Nutritional assessment in hepatic cirrhosis; clinical, anthropometric, biochemical and hematological parameters.

INTRODUCTION: Since malnutrition is common in patients with hepatic cirrhosis (HC) is necessary to investigate the interference of the pathophysiological changes of liver in the methods of diagnosis of the nutritional status. OBJECTIVE: To evaluate the frequency of malnutrition among patients with HC outpatients, using different assessment methods of the nutritional state. METHODS: Nutritional state was determined by subjective global assessment (SGA); body mass index (BMI); percentage of ideal body weight (%BW); triceps skinfold thickness (%TST), mid-arm circumference (%MAC) and of the ideal mid-arm muscle circumference (%MAMC); serum albumin (ALB) and total lymphocyte count (TLC). RESULTS: Seventy-eight patients were evaluated, 56.4% were male and mean age were 53.0 ± 7.7 years. The HC etiology was alcoholic in 56.4% of the cases. According to the classification of Child-Pugh, 48.7% were A, 26.9% were B and 24.4% were C. Variable degrees of malnutrition were diagnosed in 61.5% (SGA), 16.7% (BMI), 17.9% (%BW), 93.6% (%TST), 62.8% (%MAC) and 38.5% (%MAMC) of the patients. The levels of ALB and TLC were compatible with malnutrition diagnosis in 43.6% and 69.2% of the patients, respectively. The frequency of diagnosis of malnutrition increased according to the severity of HC and it also increased in patients with alcoholic etiology. A greater depletion of adipose tissue in women and of muscular tissue in men was demonstrated. CONCLUSIONS: The diagnostic frequency of malnutrition in ambulatory-treated patients varies according to the nutritional evaluation method used. The prevalence of malnutrition is greater in the more advanced stages of HC and in alcoholic etiology.

Introducción: Desde la malnutrición es común en pacientes con cirrosis hepática (CH) es necesario investigar la interferencia de los cambios fisiopatológicos de hígado en los métodos de diagnóstico del estado nutricional. Objetivo: Evaluar la frecuencia de desnutrición en los pacientes con CH ambulatoria, utilizando diferentes métodos de evaluación del estado nutricional. Métodos: El estado nutricional se determinó mediante la valoración global subjetiva (VGS), índice de masa corporal (IMC), porcentaje de peso corporal ideal (% PCI), el pliegue del tríceps (% PT), circunferencia del brazo (% CB) y de la ideales mediados de circunferencia muscular del brazo (% CMB), albúmina de suero (ALB) y recuento total de linfocitos (RTL). Resultados: Setenta y ocho pacientes fueron evaluados, el 56,4% eran varones y la edad media fue 53,0 ± 7,7 años. La etiología fue alcohólica CH en el 56,4% de los casos. De acuerdo con la clasificación de Child-Pugh, el 48,7% eran A, el 26,9% fueron el B y el 24,4% fueron C. Grados variables de desnutrición fueron diagnosticados en un 61,5% (VGS), 16,7% (IMC), 17,9% (% PCI), 93,6% (% PT), 62,8% (% CB) y 38,5% (CMB%) de los pacientes. Los niveles de ALB y RTL fueron compatibles con el diagnóstico de la desnutrición en 43,6% y 69,2% de los pacientes, respectivamente. La frecuencia de diagnóstico de la malnutrición aumenta de acuerdo con la gravedad de CH y también aumentó en los pacientes con etiología alcohólica. Una disminución mayor de tejido adiposo en las mujeres y de tejido muscular en los hombres fue demostrada. Conclusiones: La frecuencia de diagnóstico de la malnutrición en ambulatorio de pacientes tratados varía de acuerdo con el método de evaluación nutricional utilizado. La prevalencia de desnutrición es mayor en las etapas más avanzadas de la CH y de etiología alcohólica.

Nutritional assessment in hepatic cirrhosis; clinical, anthropometric, biochemical and hematological parameters / Evaluación nutricional en cirrosis hepática; los parámetros clínicos, antropométricos, bioquímicos y hematológicos

Introduction: Since malnutrition is common in patients with hepatic cirrhosis (HC) is necessary to investigate the interference of the pathophysiological changes of liver in the methods of diagnosis of the nutritional status. Objective: To evaluate the frequency of malnutrition among patients with HC outpatients, using different assessment methods of the nutritional state. Methods: Nutritional state was determined by subjective global assessment (SGA); body mass index (BMI); percentage of ideal body weight (%BW); triceps skinfold thickness (%TST), mid-arm circumference (%MAC) and of the ideal mid-arm muscle circumference (%MAMC); serum albumin (ALB) and total lymphocyte count (TLC). Results: Seventy-eight patients were evaluated, 56.4% were male and mean age were 53.0 ± 7.7 years. The HC etiology was alcoholic in 56.4% of the cases. According to the classification of Child-Pugh, 48.7% were A, 26.9% were B and 24.4% were C. Variable degrees of malnutrition were diagnosed in 61.5% (SGA), 16.7% (BMI), 17.9% (%BW), 93.6% (%TST), 62.8% (%MAC) and 38.5% (%MAMC) of the patients. The levels of ALB and TLC were compatible with malnutrition diagnosis in 43.6% and 69.2% of the patients, respectively. The frequency of diagnosis of malnutrition increased according to the severity of HC and it also increased in patients with alcoholic etiology. A greater depletion of adipose tissue in women and of muscular tissue in men was demonstrated. Conclusions: The diagnostic frequency of malnutrition in ambulatory-treated patients varies according to the nutritional evaluation method used. The prevalence of malnutrition is greater in the more advanced stages of HC and in alcoholic etiology (AU)

Introducción: Desde la malnutrición es común en pacientes con cirrosis hepática (CH) es necesario investigar la interferencia de los cambios fisiopatológicos de hígado en los métodos de diagnóstico del estado nutricional. Objetivo: Evaluar la frecuencia de desnutrición en los pacientes con CH ambulatoria, utilizando diferentes métodos de evaluación del estado nutricional. Métodos: El estado nutricional se determinó mediante la valoración global subjetiva (VGS), índice de masa corporal (IMC), porcentaje de peso corporal ideal (% PCI), el pliegue del tríceps (% PT), circunferencia del brazo (% CB) y de la ideales mediados de circunferencia muscular del brazo (% CMB), albúmina de suero (ALB) y recuento total de linfocitos (RTL). Resultados: Setenta y ocho pacientes fueron evaluados, el 56,4% eran varones y la edad media fue 53,0 ± 7,7 años. La etiología fue alcohólica CH en el 56,4% de los casos. De acuerdo con la clasificación de Child-Pugh, el 48,7% eran A, el 26,9% fueron el B y el 24,4% fueron C. Grados variables de desnutrición fueron diagnosticados en un 61,5% (VGS), 16,7% (IMC), 17,9% (% PCI), 93,6% (% PT), 62,8% (% CB) y 38,5% (CMB%) de los pacientes. Los niveles de ALB y RTL fueron compatibles con el diagnóstico de la desnutrición en 43,6% y 69,2% de los pacientes, respectivamente. La frecuencia de diagnóstico de la malnutrición aumenta de acuerdo con la gravedad de CH y también aumentó en los pacientes con etiología alcohólica. Una disminución mayor de tejido adiposo en las mujeres y de tejido muscular en los hombres fue demostrada. Conclusiones: La frecuencia de diagnóstico de la malnutrición en ambulatorio de pacientes tratados varía de acuerdo con el método de evaluación nutricional utilizado. La prevalencia de desnutrición es mayor en las etapas más avanzadas de la CH y de etiología alcohólica (AU)

Enteral nutrition therapy for critically ill adult patients; critical review and algorithm creation.

INTRODUCTION: Undernutrition directly affects critically ill patient's clinical outcome and mortality rates. OBJECTIVE: Interdisciplinar algorithm creation aiming to optimize the enteral nutrition therapy for critically ill adult patients. DATA SOURCE: Pubmed, SciELO, Scholar Google, Web of Science, Scopus, with research of these key words: protocols, enteral nutrition, nutritional support, critical care, undernutrition, fasting. SETTING: Intensive Care Unit, Hospital de Clínicas, Federal University of Uberlándia, MG, Brazil. MEASUREMENTS AND MAIN RESULTS: Were established in the algorithm a following sequential steps: After a clinical-surgical diagnosis, including the assessment of hemodynamic stability, were requested passage of a feeding tube in post-pyloric position and a drainage tube in gastric position. After hemodynamic stability it should be done the nutritional status diagnosis, calculated nutritional requirements, as well as chosen formulation of enteral feeding. Unless contraindicated, aiming to increase tolerance was started infusion with small volumes (15 ml/h) of a semi-elemental diet, normocaloric, hypolipidic (also hyperproteic, with addition of glutamine). To ensure infusion of the diet, as well as the progressive increase of infusion rates, the patient was monitored for moderate or severe intestinal intolerance. The schedule and infusion rates were respected and diet was not routinely suspended for procedures and diagnostic tests, unless indicated by the medical team. CONCLUSIONS: For nutrition therapy success it is essential routine monitoring and extensive interaction between the professionals involved. Nutritional conducts should be reevaluated and improved, seeking complete and specialized care to the critically ill patients. Adherence to new practices is challenging, though instruments such as protocols and algorithms help making information more accessible and comprehensible.

Estilo de vida e formação médica: impacto sobre o perfil nutricional / Lifestyle and medical education: impact on the nutritional profile

A formação do profissional médico impõe modificações nocivas ao estilo de vida, predispondo ao ganho de peso. O objetivo deste estudo foi realizar uma revisão acerca das prevalências de sobrepeso e obesidade e possíveis fatores causais destas taxas em estudantes de Medicina (EM) e médicos residentes (MR). Realizou-se uma busca nas bases de dados on-line PubMed/Medline (US National Library of Medicine), Scielo e Lilacs, com as palavras-chave: "estudantes de medicina" e "médicos residentes", associadas com cada um dos termos: "índice de massa corporal (IMC)"; "obesidade"; "sobrepeso"; "ingestão alimentar"; "sedentarismo" e "sono", e suas traduções para a língua inglesa. Foram selecionados 31 estudos, dos quais 25 foram realizados com EM, cinco com MR e um com ambas as populações. Dezesseis estudos retrataram altas prevalências de sobrepeso e obesidade (taxas de 15% a 83%). Em relação aos fatores associados ao aumento de peso, destacaram-se os hábitos alimentares inadequados. Sonolência excessiva diurna, privação do sono e sedentarismo também foram amplamente identificados. Estes resultados ressaltam a necessidade de desenvolver ações para minimizar os efeitos negativos da rotina imposta pelo processo de formação médica, em especial os aspectos relacionados a excesso de peso.

The training of the medical profession imposes harmful changes to lifestyle, which predisposes to weight gain. The aim of this study was to review the prevalence of overweight and obesity and possible causative factors in these rates in medical students (MS) and residents physicians (RP). We conducted a search of the databases online: PubMed / Medline (U.S. National Library of Medicine), Scielo and Lilacs with the keywords: "medical students" and "residents" associated with each of the terms: "body mass index (BMI)", "obesity", "overweight", "food intake", "sendentarism" and "sleep", and using the translation of these terms for the English language Thirty one studies were selected, where 25 were performed with EM, five with MR and one with both the populations. Sixteen studies indicated high prevalences of overweight and obesity (ranging between 15% and 83%). Regarding factors associated with weight gain, have stand out inadequate food intake. The excessive daytime sleepiness, sleep deprivation and sedentarism were widely identified. These results underscore the need to develop actions to minimize the negative effects of routine imposed by the process of medical training, especially those aspects related to excess weight.

Enteral nutrition therapy for critically ill adult patients; critical review and algorithm creation / Terapia nutricional enteral para pacientes adultos en estado crítico; análisis crítico de la literatura y la creación de algoritmo

Introduction: Undernutrition directly affects critically ill patient's clinical outcome and mortality rates. Objective: Interdisciplinar algorithm creation aiming to optimize the enteral nutrition therapy for critically ill adult patients. Data source: Pubmed, SciELO, Scholar Google, Web of Science, Scopus, with research of these key words: protocols, enteral nutrition, nutritional support, critical care, undernutrition, fasting. Setting: Intensive Care Unit, Hospital de Clínicas, Federal University of Uberlándia, MG, Brazil. Measurements and main results: Were established in the algorithm a following sequential steps: After a clinical-surgical diagnosis, including the assessment of hemodynamic stability, were requested passage of a feeding tube in post-pyloric position and a drainage tube in gastric position. After hemodynamic stability it should be done the nutritional status diagnosis, calculated nutritional requirements, as well as chosen formulation of enteral feeding. Unless contraindicated, aiming to increase tolerance was started infusion with small volumes (15 ml/h) of a semi-elemental diet, normocaloric, hypolipidic (also hyperproteic, with addition of glutamine). To ensure infusion of the diet, as well as the progressive increase of infusion rates, the patient was monitored for moderate or severe intestinal intolerance. The schedule and infusion rates were respected and diet was not routinely suspended for procedures and diagnostic tests, unless indicated by the medical team. Conclusions: For nutrition therapy success it is essential routine monitoring and extensive interaction between the professionals involved. Nutritional conducts should be reevaluated and improved, seeking complete and specialized care to the critically ill patients. Adherence to new practices is challenging, though instruments such as protocols and algorithms help making information more accessible and comprehensible (AU)

Introducción: La hiponutrición afecta directamente al pronóstico clínico y las tasas de mortalidad del paciente crítico. Objetivo: Creación de un algoritmo interdisciplinar cuyo objetivo es optimizar la terapia con nutrición enteral para los pacientes adultos críticos. Fuente de datos: Pubmed, SciELO, Scholar Google, Web of Science, Scopus, con la búsqueda de estas palabras clave: protocolos, nutrición enteral, soporte nutricional, atención crítica, hiponutrición, ayuno. Contexto: Unidad de Cuidados Intensivos, Hospital de Clínicas, Universidad Federal de Uberlándia, MG, Brasil. Medidas y principales resultados: Se establecieron en el algoritmo los siguientes pasos secuenciales: tras un diagnóstico clínico-quirúrgico, que incluía la evaluación de la estabilidad hemodinámica, se solicitaba la colocación de una sonda de alimentación en la posición post-pilórica y un tubo de drenaje en la posición gástrica. Tras la consecución de la estabilidad nutricional se realizaba el diagnóstico del estado nutricional, se calculaban las demandas nutricionales y se escogía la formulación de la nutrición enteral. A no ser que estuviese contraindicado, se iniciaba la tolerancia con la infusión de volúmenes pequeños (15 ml/h) de una dieta semielemental, normocalórica, hipolipídica (también hiperproteica con la adición de glutamina). Para asegurar la infusión de la dieta, así como el aumento progresivo de las tasas de infusión, se monitorizaba al paciente con respecto a la intolerancia intestinal moderada o grave. Se respetó el régimen y las tasas de infusión y la dieta no se interrumpía de forma rutinaria para los procedimientos y las pruebas diagnósticas, a no ser que el equipo médico lo indicase. Conclusiones: Para el éxito de la terapia nutricional, es esencial monitorizar de forma rutinaria y extensa la interacción entre los profesionales implicados. Las conductas nutritivas deberían reevaluarse y mejorarse, buscando la atención completa y especializada de los pacientes críticos. La adherencia a las nuevas prácticas es un reto, si bien los instrumentos como los protocolos y los algoritmos ayudan a hacer la información más accesible y comprensible (AU)

Intestinal permeability and systemic infections in critically ill patients: effect of glutamine.

OBJECTIVE: This article provides a critical review of the evidence indicating that an increase in intestinal permeability is associated with the installation of bacteremia, sepsis, and the multiple organ failure syndrome and that glutamine in pharmacologic doses reduces the acute increase of intestinal permeability and the infection frequency in critically ill patients. DATA SOURCE: All studies published until December 2004 about intestinal permeability, bacterial translocation, and glutamine were located by search of PubMed and Web of Science. The reference lists of review articles and primary publications were also examined to identify references not detected in the computer search. STUDY SELECTION: Clinical and experimental studies investigating the correlation between intestinal permeability, bacterial translocation, and frequency of infections, associated or not with the effect of glutamine administration. DATA EXTRACTION: Information regarding patient population, experimental design, glutamine doses and routes of administration, nutritional therapy prescribed, methods used to assess intestinal permeability, metabolic variables, and the frequency of infections were obtained from the primary literature. DATA SYNTHESIS: Intestinal permeability is increased in critically ill patients. The results have not always been consistent, but the studies whose results support the association between intestinal permeability and systemic infections have had better design and more appropriate controls. The administration of glutamine by the intravenous or oral route and at the doses recommended before or immediately after surgery, burns, or the administration of parenteral nutrition has a protective effect that prevents or reduces the intensity of the increase in intestinal permeability. Glutamine reduces the frequency of systemic infections and may also reduce the translocation of intestinal bacteria and toxins, but this has not been demonstrated. CONCLUSIONS: Glutamine administration improves the prognosis of critically ill patients presumably by maintaining the physiologic intestinal barrier and by reducing the frequency of infections.