Multidisciplinary consensus statement on the clinical management of patients with pancreatic cancer.

Pancreatic cancer (PC) remains one of the most aggressive tumors with an increasing incidence rate and reduced survival. Although surgical resection is the only potentially curative treatment for PC, only 15-20% of patients are resectable at diagnosis. To select the most appropriate treatment and thus improve outcomes, the diagnostic and therapeutic strategy for each patient with PC should be discussed within a multidisciplinary expert team. Clinical decision-making should be evidence-based, considering the staging of the tumor, the performance status and preferences of the patient. The aim of this guideline is to provide practical and evidence-based recommendations for the management of PC.

[Enteral nutrition in neurological patients: is there enough vitamin D content in commonly used formulas?]. / Nutrición enteral en el paciente neurológico: ¿es suficiente el contenido en vitamina D en las fórmulas de uso habitual?

INTRODUCTION: Vitamin D deficiency produces inadequate bone mineralization, proximal muscle weakness, abnormal gait and increased risk of falls and fractures. Moreover, in epidemiological studies, has been associated with increased risk of cancer, autoimmune diseases, type 1 and 2 diabetes, rheumatoid arthritis, multiple sclerosis, infectious diseases, cardiovascular diseases and depression. When synthesis through the skin by sun exposure is not possible and the patient can not eat by mouth, as in the advanced stages of various neurological diseases, the supply of vitamin D has to be done by enteral nutrition. OBJECTIVES: The aim of this study is to review the role of vitamin D in a common group of neurological conditions that often require artificial nutrition and analyze whether the vitamin D of different enteral nutrition formulas is adequate to meet the needs of this group of patients. RESULTS: Numerous studies have shown the association between vitamin D deficiency and increased incidence of dementia, stroke and other neurodegenerative diseases. Interventions aimed to increase levels of vit. D and its effects on functional (falls, pain, quality of life) and cardiovascular goals (cardiovascular death, stroke, myocardial infarction, cardiovascular risk factors) have obtained as highlight data a clear reduction of falls and fractures, while the evidence for the other parameters studied is still limited and inconsistent. The content of calcium and vitamin D of enteral formulas is legislated in our country. The total amount of vitamin D for a daily intake of 1,500-2,000 kcal ranges between 300 and 1,600 IU/d (mean ± SD: 32.9 ± 8.5 mg/100 kcal) in the complete formulas for enteral nutrition most commonly used. 50% of the diets studied, for an intake of 2,000 kcal/d, and 90% for an intake of 1,500 kcal/d, provide less than 600 IU/d of vitamin D. DISCUSSION: Some revised recently guidelines published recommendations of daily intake of vitamin D. The document published by the U.S. Institute of Medicine recommended for adults between 19 and 70 years, 600 IU/d and up from 70, proposes 800 IU/d of vitamin D. These amounts are deemed insufficient by other scientific societies to state that to achieve blood levels of 25 (OH) D equal or greater than 30 ng/ml may be required a daily intake of 1,500-2,000 IU and a number two or three times higher if previous deficiency exists. CONCLUSIONS: Further controlled studies are needed to ascertain which is the appropriate dose of vitamin D in advanced stages of neurological disease, where sun exposure is difficult and unlikely. We suggest that the vitamin D content should probably be reconsidered in enteral nutrition formulas, which, in light of recent publications appear as clearly insufficient for standard energy intakes (1,500-2,000 kcal).

Nutrición enteral en el paciente neurológico; ¿es suficiente el contenido en vitamina D en las fórmulas de uso habitual? / Enteral nutrition in neurological patients; is there enough vitamin D content in commonly used formulas?

Introducción: La carencia de vitamina D produce una mineralización ósea inadecuada, debilidad muscular de predominio proximal, alteración de la marcha y aumento del riesgo de caídas y de fracturas. Por otra parte, en estudios epidemiológicos, se ha asociado al aumento en el riesgo de cáncer, enfermedades autoinmunes, diabetes tipo 1 y 2, artritis reumatoide, esclerosis múltiple; así como, enfermedades infecciosas, cardiovasculares y depresión. Cuando no es posible la síntesis cutánea a través de la exposición solar y el paciente no puede ingerir alimentos por vía oral, como ocurre en las fases avanzadas de diversas enfermedades neurológicas, el aporte de vitamina D ha de hacerse mediante la nutrición enteral. Objetivos: El objetivo del presente estudio es revisar el papel de la vitamina D en un grupo frecuente de enfermedades neurológicas que precisan nutrición artificial y analizar si el contenido de vitamina D de las diferentes fórmulas de nutrición enteral es adecuado para cubrir las necesidades de este grupo de pacientes. Resultados: Numerosos estudios han puesto en evidencia la asociación entre el déficit de vitamina D y el aumento en la incidencia de demencia, ictus y otras enfermedades neurodegenerativas. Las intervenciones encaminadas a incrementar los niveles de vit. D y sus efectos sobre objetivos funcionales (caídas, dolor, calidad de vida) y cardiovasculares (muerte de origen cardiovascular, ictus, infarto de miocardio, factores de riesgo cardiovascular) han obtenido como dato más destacado una clara reducción de caídas y fracturas, mientras que la evidencia para el resto de parámetros estudiados todavía es escasa y poco consistente. El contenido de calcio y vitamina D de las distintas fórmulas completas de nutrición enteral está regulado en nuestro país. La cantidad total de vitamina D para un aporte diario de 1.500-2.000 kcal oscila entre 300 y 1.600 UI/d (media ± SD: 32,9 ± 8,5 mg/100 kcal) en las fórmulas completas de nutrición enteral de uso más común. El 50% de las dietas estudiadas, para una ingesta de 2.000 kcal/d, y el 90%, para una ingesta de 1.500 kcal/d, aportan menos de 600 UI/d de vitamina D. Discusión: Algunas guías publicadas recientemente han revisado las recomendaciones de ingesta diaria de vitamina D. El documento publicado por el Instituto de Medicina de EE.UU recomienda para los adultos, entre 19 y 70 años, 600 UI/d y, por encima de los 70 a, se proponen 800 UI/d de vitamina D. Estas cantidades son consideradas insuficientes por otras sociedades científicas que establecen que para conseguir unos niveles sanguíneos de 25(OH)D iguales o superiores a 30 ng/ml puede requerirse un aporte diario de 1.500-2.000 UI y una cantidad dos o tres veces mayor si existe deficiencia previa. Conclusiones: Se necesitan más estudios controlados para averiguar cual es la dosis adecuada de vitamina D en fases avanzadas de la enfermedad neurológica, donde es difícil e improbable la exposición solar. Sugerimos que el contenido en vitamina D probablemente debería ser reconsiderado en las fórmulas de nutrición enteral, que, a la luz de las publicaciones recientes, aparecen como claramente insuficientes para aportes energéticos estándar (1.500-2.000 kcal) (AU)

Introduction: Vitamin D deficiency produces inadequate bone mineralization, proximal muscle weakness, abnormal gait and increased risk of falls and fractures. Moreover, in epidemiological studies, has been associated with increased risk of cancer, autoimmune diseases, type 1 and 2 diabetes, rheumatoid arthritis, multiple sclerosis, infectious diseases, cardiovascular diseases and depression. When synthesis through the skin by sun exposure is not possible and the patient can not eat by mouth, as in the advanced stages of various neurological diseases, the supply of vitamin D has to be done by enteral nutrition. Objectives: The aim of this study is to review the role of vitamin D in a common group of neurological conditions that often require artificial nutrition and analyze whether the vitamin D of different enteral nutrition formulas is adequate to meet the needs of this group of patients. Results: Numerous studies have shown the association between vitamin D deficiency and increased incidence of dementia, stroke and other neurodegenerative diseases. Interventions aimed to increase levels of vit. D and its effects on functional (falls, pain, quality of life) and cardiovascular goals (cardiovascular death, stroke, myocardial infarction, cardiovascular risk factors) have obtained as highlight data a clear reduction of falls and fractures, while the evidence for the other parameters studied is still limited and inconsistent. The content of calcium and vitamin D of enteral formulas is legislated in our country. The total amount of vitamin D for a daily intake of 1,500-2,000 kcal ranges between 300 and 1,600 IU/d (mean ± SD: 32.9 ± 8.5 mg/100 kcal) in the complete formulas for enteral nutrition most commonly used. 50% of the diets studied, for an intake of 2,000 kcal/d, and 90% for an intake of 1,500 kcal/d, provide less than 600 IU/d of vitamin D. Discussion: Some revised recently guidelines published recommendations of daily intake of vitamin D. The document published by the U.S. Institute of Medicine recommended for adults between 19 and 70 years, 600 IU/d and up from 70, proposes 800 IU/d of vitamin D. These amounts are deemed insufficient by other scientific societies to state that to achieve blood levels of 25 (OH) D equal or greater than 30 ng/ml may be required a daily intake of 1,500-2,000 IU and a number two or three times higher if previous deficiency exists. Conclusions: Further controlled studies are needed to ascertain which is the appropriate dose of vitamin D in advanced stages of neurological disease, where sun exposure is difficult and unlikely. We suggest that the vitamin D content should probably be reconsidered in enteral nutrition formulas, which, in light of recent publications appear as clearly insufficient for standard energy intakes (1,500-2,000 kcal) (AU)

Estrategias nutricionales ante el estreñimiento y la deshidratación en las personas mayores / Nutritional strategies towards constipation and dehydration in older people

El estreñimiento puede ser definido por defecación infrecuente y esfuerzo defecatorio excesivo. Las causas más habituales son la deshidratación, la dieta pobre en fibra, el consumo de determinados fármacos y las enfermedades debilitantes, circunstancias especialmente frecuentes en la edad geriátrica. El estreñimiento en anciano puede asociarse a complicaciones derivadas de la impactación fecal y otras derivadas del excesivo esfuerzo para conseguir la defecación. Para que se produzca deshidratación, virtualmente en todos los casos, debe existir una alteración en la percepción de la sed o en la capacidad de ingerir agua. Cuando el déficit de agua supera al de sodio el paciente desarrolla un síndrome clínico de hipernatremia/hiperosmolaridad que siempre está asociada a un aumento de la osmolaridad plasmática efectiva y, por tanto, con una disminución del volumen intracelular. Las causas desencadenantes en el anciano son la infección, el uso excesivo de diuréticos, el ictus, tratamiento con corticoides, situación de postoperatorio, la suspensión de un tratamiento antidiabético o la diabetes insípida. El tratamiento de rehidratación debe realizarse preferiblemente por vía oral y de forma lenta para evitar el daño neurológico. La corrección debe incluir agua y electrolitos (sales de sodio y potasio) y obliga a un cálculo preciso del aporte, sobre todo cuando está alterado el estado de conciencia y precisamos de tratamiento intravenoso, para evitar la sobrehidratación y las alteraciones electrolíticas. El tratamiento del estreñimiento incluye, además de la rehidratación, la educación del paciente en un patrón horario, postural y de ejercicio físico para reforzar la prensa abdominal. Un cambio en los hábitos alimentarios para aumentar el contenido en fibra alimentaria en la dieta aumenta el tamaño del bolo fecal, mejora la consistencia de las heces y disminuye las molestias abdominales. Así mismo, el uso de prebióticos, complementado con fibra fermentable, logra aumentar la masa fecal. Los alimentos de uso común ricos en fibra son el salvado de trigo, legumbres, harinas integrales, frutas y verduras. Las recomendaciones sobre el consumo de fibra son de 10 a 13 g/1.000 kcal siendo el 70-75% de fibra insoluble y un 25-30% de fibra soluble. El uso juicioso de fármacos con efecto laxante tiene un papel en el tratamiento del estreñimiento cuando éste no responde a las medidas higiénico-dietéticas. Existen cuatro grupos farmacológicos de uso habitual: laxantes con efecto osmótico, estimulantes del peristaltismo, emolientes y aumentadores del bolo fecal con distintas indicaciones. En el paciente de edad avanzada, podemos iniciar el tratamiento con lactulosa o lactitiol o recurrir directamente a fármacos estimulantes como bisacodilo, picosulfato sódico o senósidos. Los azúcares osmóticos serán los laxantes recomendados para el uso crónico. Debemos usar con precaución los laxantes estimuladores del peristaltismo, ya que la secreción de agua y electrolitos a la luz intestinal es responsable de episodios de hipotensión ortostática que pueden ocasionar caídas en el paciente anciano (AU)

Constipation can be defined as infrequent defecation and straining at stool. The most common causes are dehydration, low-fiber diet, use of certain drugs and debilitating disease, particularly common conditions in geriatric patients. Constipation in the elderly may be associated with fecal impaction and other complications deriving from excessive straining to pass stools. Dehydration occurs, in virtually all cases, with an alteration in the perception of thirst or water intake capacity. When the water deficit exceeds that of sodium, the patient develops clinical signs and symptoms of hypernatremia/hyperosmolality, always associated with an increase in effective plasma osmolality and consequent decrease in intracellular volume. Precipitating causes in the elderly are infection, excessive use of diuretics, stroke, treatment with corticosteroids, postoperative status, suspension of antidiabetic drugs or diabetes insipidus. Rehydration should preferably be oral and done slowly to prevent neurological damage. Treatment should include water and electrolytes (sodium and potassium salts) and requires accurate calculation of input to prevent overload and electrolyte imbalance, especially in the case of altered consciousness with the patient needing intravenous therapy. In addition to rehydration, the treatment of constipation includes educating the patient about bowel training to establish a regular pattern, posture and physical exercise to strengthen the muscles in the abdominal wall. A change in eating habits to increase dietary fiber content increases the size of the feces, improves stool consistency and reduces abdominal discomfort. Likewise, the use of prebiotics, supplemented with fermentable fiber, helps increase fecal mass. Commonly-used foods rich in fiber are wheat bran, beans, whole flour, fruit and vegetables. Recommended fiber intake is 10 to 13 g/1,000 kcal with 70-75% insoluble fiber and 25-30% soluble fiber. Judicious use of laxative drugs does have a role in the treatment of constipation if patients do not respond to the toileting / dietary measures. There are four commonly used drug classes: osmotic laxatives, peristalsis stimulants, emollients and fecal enhancers, with different indications. In the older patient, we can begin treatment with lactulose or lactitiol or go directly to stimulant drugs such as bisacodyl, cassia extracts or sodium picosulfate. Sugar osmotic laxatives are recommended for long-term use. Stimulating peristalsis laxatives have to be used with caution since secretion of water and electrolytes into the intestinal lumen can be responsible for orthostatic hypotension, causing falls in the elderly (AU)

Iron deficiency and anaemia in bariatric surgical patients: causes, diagnosis and proper management / Deficiencia de hierro y anemia en pacientes de cirugía bariátrica: causas, diagnóstico y tratamiento adecuado

Obesity-induced chronic inflammation leads to activation of the immune system that causes alterations of iron homeostasis including hypoferraemia, iron-restricted erythropoiesis, and finally mild-to-moderate anaemia. Thus, preoperative anaemia and iron deficiency are common among obese patients scheduled for bariatric surgery (BS). Assessment of patients should include a complete haematological and biochemical laboratory work-up, including measurement of iron stores, vitamin B12 and folate. In addition, gastrointestinal evaluation is recommended for most patients with iron-deficiency anaemia. On the other hand, BS is a long-lasting inflammatory stimulus in itself and entails a reduction of the gastric capacity and/or exclusion from the gastrointestinal tract which impair nutrients absorption, including dietary iron. Chronic gastrointestinal blood loss and iron-losingenteropathy may also contribute to iron deficiency after BS. Perioperative anaemia has been linked to increased postoperative morbidity and mortality and decreased quality of life after major surgery, whereas treatment of perioperative anaemia, and even haematinic deficiency without anaemia, has been shown to improve patient outcomes and quality of life. However, long-term follow-up data in regard to prevalence, severity, and causes of anaemia after BS are mostly absent. Iron supplements should be administered to patients after BS, but compliance with oral iron is no good. In addition, once iron deficiency has developed, it may prove refractory to oral treatment. In these situations, IV iron (which can circumvent the iron blockade at enterocytes and macrophages) has emerged as a safe and effective alternative for perioperative anaemia management. Monitoring should continue indefinitely even after the initial iron repletion and anaemia resolution, and maintenance IV iron treatment should be provided as required. New IV preparations, such ferric carboxymaltose, are safe, easy to use and up to 1000 mg can be given in a single session, thus providing an excellent tool to avoid or treat iron deficiency in this patient population (AU)

La inflamación crónica inducida por la obesidad provoca alteraciones en la homeostasis del hierro, incluyendo hiposideremia, restricción del hierro para la eritropoyesis y anemia leve o moderada. Consecuentemente, la anemia y la deficiencia de hierro son frecuentes entre los pacientes candidatos a cirugía bariátrica (CB). El estudio preoperatorio debe incluir un hemograma completo y la evaluación del status férrico, vitamina B12 y ácido fólico. Se recomienda realizar un estudio gastrointestinal en la mayoría paciente con anemia ferropénica. Ante una anemia inexplicada, debería postergarse la cirugía hasta que se haya realizado un diagnóstico apropiado. La anemia perioperatoria se ha relacionado con aumento de morbi-mortalidad postoperatoria y disminución de la calidad de vida después de una cirugía mayor, mientras que la corrección de la anemia y la deficiencia de micronutrientes (hierro, vitamina B12, folato) mejoran el pronóstico y la calidad de vida. Sin embargo, no existen estudios de seguimiento a largo plazo en lo que respecta a la prevalencia, gravedad y causas de la anemia en pacientes CB. Tras la CB, los pacientes deben recibir suplementos de hierro, pero la tolerancia al hierro oral no es buena; una vez instaurada la situación de ferropenia, ésta podría ser refractaria al tratamiento oral. En estas situaciones, el uso de preparados IV (que evitan el bloqueo del hierro en enterocitos y macrófagos) ha surgido como una alternativa segura y efectiva en el tratamiento de la anemia perioperatoria. Los nuevos preparados de hierro IV, como la carboximaltosa férrica, son seguros, fáciles de utilizar y permiten administrar hasta 1.000 mg en una sola sesión, proporcionando así una excelente herramienta para tratar o prevenir el déficit de hierro en estos pacientes. Después de la repleción de hierro y la resolución de la anemia, deben realizarse controles periódicos de forma indefinida para realizar nuevos tratamientos de mantenimiento si fueran necesarios (AU)

Severe hypocalcemia secondary to hypomagnesaemia, successfully treated by self-administered subcutaneous magnesium.

We report the case of a patient with recurrent severe hypocalcemia, secondary to hypomagnesaemia, and prerenal renal failure, due to ileostomy losses after a colectomy, who needed several admissions to the hospital through more than one year. Finally, he was successfully treated by self-administered subcutaneous magnesium: he reached and maintained normal levels of serum calcium, magnesium and PTH, no more hospital admission were needed and he resumed a normal life.

Severe hypocalcemia secondary to hypomagnesaemia, successfully treated by self-administered subcutaneous magnesium / Hipocalcemia severa, secundaria a hipomagnesemia, tratada con éxito mediante auto-administración subcutánea de magnesio

We report the case of a patient with recurrent severe hypocalcemia, secondary to hypomagnesaemia, and prerenal renal failure, due to ileostomy losses after a colectomy, who needed several admissions to the hospital through more than one year. Finally, he was successfully treated by self-administered subcutaneous magnesium: he reached and maintained normal levels of serum calcium, magnesium and PTH, no more hospital admission were needed and he resumed a normal life (AU)

Se trata de un paciente con hipocalcemia severa recurrente, secundaria a hipomagensemia, y fracaso renal agudo prerrenal secundario a perdidas digestivas a través de una ileostomía, tras una colectomía. Por este motivo necesitó varios ingresos hospitalarios a lo largo de más de un año. Finalmente fue tratado con éxito mediante autoadministración subcutánea de magnesio. Con este tratamiento mantuvo niveles normales de calcio, magnesio y PTH, no requirió más ingresos hospitalarios y recuperó una vida normal (AU)

[Impact of the implementation of parenteral nutrition program by the clinical nutrition unit in surgical patients]. / Impacto de la introducción de un programa de nutrición parenteral por la unidad de nutrición clínica en pacientes quirúrgicos.

INTRODUCTION: The creation of a Nutrition Unit (NU), with a specialized professional establishing homogenous criteria and standardized proceedings for the use of parenteral nutrition (PN) may improve the clinical course of the patients and decrease the number of technique-related complications. OBJECTIVES: To describe the clinical characteristics of the patients submitted to PN at our Center. To assess the effect that the implementation of a NU has on the patients clinical course, and to know the frequency of mortality and hospital stay duration after the implementation of the NU at the University Hospital Complex of Albacete. MATERIAL AND METHODS: We reviewed the clinical charts of the patients receiving PN during the two years before and the two years after the creation of the NU by means of a two-period cohort study. RESULTS: Of the 390 patients, 100 belonged to the cohort before the NU and 290 to the following cohort. 61.3% of the patients were admitted at the surgery department. 25% of the patients had a personal history of digestive pathology. Among the reasons for ordering PN to the NU, surgical complications were the most common (66.7%). Oncologic abdominal surgery was the most common category (39.3%) out of the six in which the patients have been categorized. The mortality rate for the first cohort was 29% and for the second cohort 12.8% (p < 0,00). The average of stay days for the first cohort was 29.53 days and 27.67 days for the second one (p = 0.41). CONCLUSIONS: The implementation of a NU has a positive impact on the clinical course of hospitalized patients submitted to PN.

[Enteral feeding of critical patients]. / Nutrición enteral en el paciente crítico.

Artificial nutrition support forms part of the basic care of critical patients. Enteral feeding has been shown to be better than total parenteral nutrition at improving morbidity (infectious complications) and reducing the length of hospital stays, number of days with mechanical ventilation, and costs. As with any other treatment, enteral feeding has associated complications and side effects which should be understood and treated in order to obtain the greatest benefit from it and reduce possible adverse effects. In this review, we attempt to provide a practical summary of the use of enteral feeding in critical patients. We cover the management of the most frequent associated complications, based on new studies and current scientific evidence. The review is intended to serve as a practice guide for the routine care of severely ill patients.

Impacto de la introducción de un programa de nutrición parenteral por la unidad de nutrición clínica en pacientes quirúrgicos / Impact of the implementation of a parenteral nutrition program by the clinical nutrition unit in a surgical patients

Introducción: La creación de una Unidad de Nutrición (UN), con un especialista en la materia que establezca criterios homogéneos y procedimientos estandarizados de uso de la nutrición parenteral (NP) puede mejorar el curso clínico de los pacientes y disminuir las complicaciones relacionadas con la técnica. Objetivos: Describir las características clínicas de los pacientes sometidos a NP en nuestro centro. Evaluar el efecto que la introducción de una UN tiene en el curso clínico de los pacientes y conocer la frecuencia de mortalidad y duración la estancia tras la introducción de una UN en el Complejo Hospitalario Universitario de Albacete. Material y métodos: Se estudiaron las historias clínicas de los pacientes que recibieron NP durante los dos años previos y los dos años posteriores a la creación de la UN mediante un estudio de cohortes con doble temporalidad. Resultados: De 390 pacientes, 100 pertenecen a la cohorte previa a la UN y 290 a la posterior. Un 61,3% de los pacientes estaban ingresados en cirugía. Un 25% de los pacientes presentaba antecedentes de patología digestiva. Respecto a los motivos por los que se solicitó la NP a la UN, las complicaciones quirúrgicas fueron los más frecuentes (66,7%). La cirugía abdominal tumoral fue la categoría más frecuente (39,3%) de las seis en las que se han clasificado a los pacientes. La mortalidad en la primera cohorte fue 29% y en la segunda 12.8% (p < 0,00). 29,53 días fue la media de los días de estancia en la primera cohorte y 27,67 días en la segunda (p = 0,41). Conclusiones: La introducción de una UN tiene un impacto positivo en la evolución de los pacientes hospitalizados sometidos a NP (AU)

Introduction: The creation of a Nutrition Unit (NU), with a specialized professional establishing homogenous criteria and standardized proceedings for the use of parenteral nutrition (PN) may improve the clinical course of the patients and decrease the number of technique-related complications. Objectives: To describe the clinical characteristics of the patients submitted to PN at our Center. To assess the effect that the implementation of a NU has on the patients clinical course, and to know the frequency of mortality and hospital stay duration after the implementation of the NU at the University Hospital Complex of Albacete. Material and methods: We reviewed the clinical charts of the patients receiving PN during the two years before and the two years after the creation of the NU by means of a two-period cohort study. Results: Of the 390 patients, 100 belonged to the cohort before the NU and 290 to the following cohort. 61.3% of the patients were admitted at the surgery department. 25% of the patients had a personal history of digestive pathology. Among the reasons for ordering PN to the NU, surgical complications were the most common (66.7%). Oncologic abdominal surgery was the most common category (39.3%) out of the six in which the patients have been categorized. The mortality rate for the first cohort was 29% and for the second cohort 12.8% (p < 0,00). The average of stay days for the first cohort was 29.53 days and 27.67 days for the second one (p = 0.41). Conclusions: The implementation of a NU has a positive impact on the clinical course of hospitalized patients submitted to PN (AU)

Nutrición enteral en el paciente crítico / Enteral feeding of critical patients

El soporte nutricional artificial forma parte del cuidadobásico del paciente crítico. La nutrición enteral(NE) se ha mostrado superior a la nutrición parenteraltotal (NPT) en la mejoría de la morbilidad (complicacionesinfecciosas), y en la reducción de la estancia hospitalaria,días de ventilación mecánica y costes.Como cualquier otro tratamiento, la NE no está exentade complicaciones y efectos secundarios, que debemosconocer y tratar para obtener el máximo beneficio deésta y disminuir en lo posible los efectos adversos.En esta revisión intentamos resumir de manera prácticael uso de la NE en el paciente crítico, así como elmanejo de las complicaciones más frecuentes que podemosencontrar en relación con dicha nutrición en base alas nuevas publicaciones y la evidencia científica existente,de manera que pueda servir como Guía de actuaciónal profesional en la asistencia diaria al paciente gravementeenfermo (AU)

Artificial nutrition support forms part of thebasic care of critical patients. Enteral feeding has beenshown to be better than total parenteral nutrition atimproving morbidity (infectious complications) andreducing the length of hospital stays, number of days withmechanical ventilation, and costs. As with any othertreatment, enteral feeding has associated complicationsand side effects which should be understood and treatedin order to obtain the greatest benefit from it and reducepossible adverse effects. In this review, we attempt toprovide a practical summary of the use of enteral feedingin critical patients. We cover the management of the mostfrequent associated complications, based on new studiesand current scientific evidence. The review is intended toserve as a practice guide for the routine care of severely illpatients (AU)

Iron deficiency and anaemia in bariatric surgical patients: causes, diagnosis and proper management.

Obesity-induced chronic inflammation leads to activation of the immune system that causes alterations of iron homeostasis including hypoferraemia, iron-restricted erythropoiesis, and finally mild-to-moderate anaemia. Thus, preoperative anaemia and iron deficiency are common among obese patients scheduled for bariatric surgery (BS). Assessment of patients should include a complete haematological and biochemical laboratory work-up, including measurement of iron stores, vitamin B12 and folate. In addition, gastrointestinal evaluation is recommended for most patients with iron-deficiency anaemia. On the other hand, BS is a long-lasting inflammatory stimulus in itself and entails a reduction of the gastric capacity and/or exclusion from the gastrointestinal tract which impair nutrients absorption, including dietary iron. Chronic gastrointestinal blood loss and iron-losingenteropathy may also contribute to iron deficiency after BS. Perioperative anaemia has been linked to increased postoperative morbidity and mortality and decreased quality of life after major surgery, whereas treatment of perioperative anaemia, and even haematinic deficiency without anaemia, has been shown to improve patient outcomes and quality of life. However, long-term follow-up data in regard to prevalence, severity, and causes of anaemia after BS are mostly absent. Iron supplements should be administered to patients after BS, but compliance with oral iron is no good. In addition, once iron deficiency has developed, it may prove refractory to oral treatment. In these situations, IV iron (which can circumvent the iron blockade at enterocytes and macrophages) has emerged as a safe and effective alternative for perioperative anaemia management. Monitoring should continue indefinitely even after the initial iron repletion and anaemia resolution, and maintenance IV iron treatment should be provided as required. New IV preparations, such ferric carboxymaltose, are safe, easy to use and up to 1000 mg can be given in a single session, thus providing an excellent tool to avoid or treat iron deficiency in this patient population.

[Nutritional repercussions and management of chronic pancreatitis]. / Repercusiones nutricionales y manejo de la pancreatitis crónica.

The pancreas is a retroperitoneal organ that releases water, bicarbonate and digestive enzymes by the main pancreatic duct (MPD) into the duodenum. Chronic pancreatitis (CP) is typically caused, in adults, by chronic alcohol abuse and, less frequently hypertriglyceridemia, primary hyperparathyroidism or cystic fibrosis. Exocrine dysfunction results in malabsorption of fat and subsequent steatorrhea. Damage to pancreatic endocrine function is a late finding in CP and results in hyperglycaemia or overt diabetes mellitus. Care of patients with CP principally involves management of pain. A significant change in the pain pattern or the sudden onset of persistent symptoms suggests the need to rule out other potential etiologies, including peptic ulcer disease, biliary obstruction, pseudocysts, pancreatic carcinoma, and pancreatic duct stricture or stones, then is important to establish a secure diagnosis. Management of pain should then proceed in a judicious stepwise approach avoiding opioids dependence. Patients should be advised to stop alcohol intake. Fat malabsorption and other complications may also arise. Management of steatorrhea should begin with small meals and restriction in fat intake. Pancreatic enzyme supplements can relieve symptoms and reduce malabsorption in patients who do not respond to dietary restriction. Enzymes at high doses should be used with meals. Treatment with acid suppression to reduce inactivation of the enzymes from gastric acid are recommended. Supplementation with medium chain triglycerides and fat soluble vitamin replacement may be required. Management of other complications (such as pseudocysts, bile duct or duodenal obstruction, pancreatic ascites, splenic vein thrombosis and pseudoaneurysms) often requires aggressive approach with the patient kept on total parenteral nutrition to minimize pancreatic stimulation.

Repercusiones nutricionales y manejo de la pancreatitis crónica / Nutritional repercussions and management of chronic pancreatitis

El páncreas es un órgano retroperitoneal que segrega agua, bicarbonato y enzimas digestivos a través del conducto pancreático principal (CPP) al duodeno. La pancreatitis crónica (PC) está causada típicamente en el adulto por abuso crónico de alcohol, y, con menor frecuencia, hipertrigliceridemia, hiperparatiroidismo primario o fibrosis quística. La disfunción exocrina ocasiona malabsorción grasa y la consiguiente esteatorrea. El daño en la función endocrina es un hallazgo tardío que se presenta como hiperglucemia o diabetes mellitus franca. El cuidado de pacientes con PC conlleva, de forma primordial, el tratamiento del dolor. Un cambio significativo en su patrón o la aparición súbita y persistente de otros síntomas obligan a descartar otras entidades, incluyendo úlcera péptica, obstrucción biliar, pseudoquistes, cáncer de páncreas, estenosis de conductos pancreáticos o litiasis. Por tanto es importante asegurar el diagnóstico. El manejo del dolor debe realizarse de forma escalonada y prudente tratando de evitar la dependencia de opiáceos. Debe advertirse a los pacientes que interrumpan la ingesta de alcohol. El tratamiento de la mal absorcióngrasa comienza con pequeñas tomas de alimento y restricción grasa. El uso de suplementos de enzimas pancreáticos puede mejorar los síntomas y reducir la mala absorción en pacientes que no respondan al tratamiento dietético. Deben usarse dosis elevadas de enzimas con cada comida. Se recomienda tratamiento supresor dela acidez gástrica para evitar la inactivación de los enzimas. Puede ser necesaria la suplementación con triglicéridos de cadena media (MCT) y vitaminas liposolubles. El manejo de otras complicaciones (como pseudoquistes, obstrucción biliar o duodenal, ascitis pancreática, trombosis de la vena esplénica y pseusoaneurismas) con frecuencia requiere maniobras agresivas manteniendo al paciente bajo nutrición parenteral para minimizar la estimulación pancreática

The pancreas is a retroperitoneal organ that releaseswater, bicarbonate and digestive enzymes by the mainpancreatic duct (MPD) into the duodenum. Chronic pancreatitis (CP) is typically caused, in adults, by chronic alcohol abuse and, less frequently hypertriglyceridemia, primary hyperparathyroidism or chystic fibrosis. Exocrine dysfunction results in malabsorption of fat and subsequent steatorrhea. Damage to pancreatic endocrine function is a late finding in CP and results in hyperglycaemia or overt diabetes mellitus. Care of patients with CP principally involves management of pain. A significant change in the pain pattern or the sudden onset of persistent symptoms suggests the need to rule out other potentialetiologies, including peptic ulcer disease, biliaryobstruction, pseudocysts, pancreatic carcinoma, andpancreatic duct stricture or stones, then is important toestablish a secure diagnosis. Management of pain shouldthen proceed in a judicious stepwise approach avoidingopioids dependence. Patients should be advised to stopalcohol intake. Fat malabsorption and other complicationsmay also arise. Management of steatorrhea shouldbegin with small meals and restriction in fat intake. Pancreatic enzyme supplements can relieve symptoms andreduce malabsorption in patients who do not respond todietary restriction. Enzymes at high doses should be usedwith meals. Treatment with acid suppression to reduceinactivation of the enzymes from gastric acid are recommended. Supplementation with medium chain triglycerides and fat soluble vitamin replacement may be required. Management of other complications (such as pseudocysts, bile duct or duodenal obstruction, pancreatic ascites, splenic vein thrombosis and pseudoaneurysms)often requires aggressive approach with the patient kept on total parenteral nutrition to minimize pancreatic stimulation (AU)

Assessment of carotenoid status and the relation to glycaemic control in type I diabetics: a follow-up study.

OBJECTIVE: To assess the carotenoid status in young type I diabetic patients and its relationship to the glycaemic control of the disease. DESIGN: A follow-up study. SETTING: Hospital Universitario Puerta de Hierro, Health Area VI of Madrid (Spain). SUBJECTS: Forty-seven type I diabetic patients, followed for 2.5 years. INTERVENTIONS: Coinciding with physical examination and laboratory tests, serum levels of carotenoids were analysed by HPLC, and dietary intake of carotenoids was evaluated by a semiquantitative food frequency questionnaire and 3-day prospective dietary records. RESULTS: In type I diabetic patients, average intake, serum levels and correlations between diet and serum levels of carotenoids were comparable to those in reference non-diabetic groups. Between-subjects seasonal variations were observed for beta-cryptoxanthin intake and serum levels (higher in winter) and serum lycopene (higher in summer). Significant within-subjects seasonal changes were shown for dietary and serum beta-cryptoxanthin and serum beta-carotene. Serum carotenoids were unrelated to glycaemic control markers. Subjects with clinically acceptable glycaemic control showed lower lycopene intake than those with unacceptable control. Intake of carotenoids did not explain variance in insulin dose, fasting glycaemia, fructosamine or HbA1c. With the exception of lycopene, serum carotenoids were predicted by dietary intake, but in no case by fasting glycaemia, HbA1c or fructosamine. CONCLUSION: In type I diabetic patients, serum carotenoid concentrations and their variance are determined by dietary intake patterns, and are unrelated to the glycaemic control of the disease, as assessed by biochemical markers.

[The effect of nutritional therapy in the treatment of laryngeal cancer]. / Influencia de la terapéutica nutricional en el tratamiento del cáncer laríngeo.

Laryngeal cancer constitutes and important problem from the nutritional point of view, both due to the effect of the tumor itself as due to the aggressive treatment to which the majority of these patients are subjected. To evaluate the incidence of nutritional support on the morbid-mortality and on the number of hospitalization days, we compare a group A of 61 patients diagnosed with laryngeal squamous cell carcinoma, who received treatment from the Department of Nutrition, with another, similar group B, who received a standard diet. a complete evaluation of the nutritional status was done (anthropometric biochemical and immunological parameters) one day prior to the surgery and two weeks after. The differences of age (61 vs 63 years), cigarette smoking (31 vs 34), excessive alcohol ingestion (34 vs 29), location of the tumor and type of surgery, were not significant. The nutritional treatment used in group A was enteral nutrition by means of a 12-F polyurethane naso-gastric tube, while in group B it was the ground up culinary diet through a large caliber naso-gastric tube. There were no significant differences in the mortality (1/0) or in the surgical complications (9/10); nevertheless, the average number of hospital days was clearly lower in group A (18 days) compared to group B (24 days) (p < 0.005). The evolution of the evaluation parameters of the nutritional status was analyzed, as well as the administered dietary formulae, added medication, and the complications of the technique. Regulated nutritional support may contribute to the decrease of the hospitalization period of patients operated on for laryngeal cancer.

[The importance of parenteral nutrition via the peripheral route in patients with inflammatory bowel diseases (IBD)]. / Importancia de la nutrición parenteral por vía periférica en pacientes con enfermedades inflamatoria intestinal (EEI).

The objective of the present study is to evaluate the effects of peripheral parenteral nutrition (PNN) in a homogeneous group of patients who had not had surgery, and to determine whether the deterioration of the nutritional state can be avoided while keeping the advantages of the administration of a peripheral route. We have included 7 patients (4 male and 3 female) with an acute episode of inflammatory bowel disease (IBD). Each received 1780 kcal/day (1500 non-protein kcal 66% as fats, and 33% as glucose), with a kcal/g of N ratio of 160 by means of the preparation technique of "all in one". The anthropometric parameters: initial and final weight (58.5 +/- 12 vs. 57.3 +/- 11); triceps skin fold (14.1 +/- 4 vs. 14.1 +/- 4), and mean circumference of the arm (25.1 +/- 3 vs. 25.0 +/- 3), did not give any significant differences during the treatment period. In the biochemical data there were no significant differences either, except for the final level of serum albumin (3.44 +/- 0.28), which was significantly higher than the initial value (3.11 +/- 0.38) (p < 0.05). The mean duration of the treatment was 12 days (range 6-18). There was no case of phlebitis.(ABSTRACT TRUNCATED AT 250 WORDS)