Nutritional care routines in Italy: results from the PIMAI (Project: Iatrogenic MAlnutrition in Italy) study.

BACKGROUND/OBJECTIVES: Disease-related malnutrition is a common comorbidity at hospital admission. The purpose of the present report was to describe the data on nutritional care routines collected during the Project: Iatrogenic MAlnutrition in Italy (PIMAI) study, as these may be helpful to avoid iatrogenic malnutrition and improve nutritional policies. SUBJECTS/METHODS: Standards of nutritional care were assessed on the basis of (1) adherence to study protocol (completeness of data collected); (2) attitude in assessing the nutritional status; (3) prescription of nutritional therapy (within 3 days) at least in patients presenting with overt malnutrition (body mass index (BMI) <18.5 kg/m(2) or significant weight loss (>or=10% in 3 months and/or >or=5% in the last month)), regardless of its adequacy, and adherence to current guidelines and (4) attitude in monitoring nutritional status during the stay (number of weight measurements performed compared with those expected). RESULTS: In total, 1583 subjects were assessed. A minimum data set for performing the Nutritional Risk Screening 2002 tool was available in 1284 patients (81.1%), but nutritional screening was possible in every patient by alternative analytical criteria related to food intake, anthropometry and biochemistry. However, several missing values were recorded, particularly in biochemical parameters due to lack of prescription by admission wards. According to ward practices, only 38.2% of the patients had the BMI calculated. A nutritional support was prescribed only to 26/191 patients (13.6%) presenting with overt malnutrition. Finally, we recorded that only 21.6% of the patients (207/960 were randomly selected) had their weight monitored on a scheduled basis. This reality was worse in surgical rather than medical departments (17 vs 26%; P<0.001). CONCLUSION: Present results confirm that in Italy, nutritional care routines are still poor and need improvements.

Alpha-lipoic acid supplementation: a tool for obesity therapy?

Lipid peroxidation has supposed as the major biochemical alteration underling oxidant-induced cell injury in stress including numerous diseases. One of the natural molecules know to prevent or retard oxidation is alpha-lipoic acid (LA) and, therefore, the lipoic acid/dihydrolipoic acid (LA/DHLA) redox couple has received considerable attention. Recent studies have highlighted the potential of free LA and DHLA as powerful metabolic antioxidants that are able to scavenge the reactive oxygen species, to recycle other antioxidants. Our aim was to investigate the beneficial effects of LA in the treatment of Italian pre-obese and obese subjects. We screened 1612 subjects for enrollment; of these, 1127 subjects (445 men and 682 women, 18-60 age) met enrolment criteria and were enrolled in the study. According to body mass index (BMI) the 53% was obese and the 43% was pre-obese. The subjects were treated for 4 month with 800 mg/day of LA. In pre-obese subject significant reduction (p<0.001) of weight (8%, both gender), BMI (2 points), blood pressure, and abdominal circumference (female 6 cm, male 7 cm) were observed. In obese subjects significant reductions (p<0.001) of weight (9%, both gender), BMI (female 3 point, male 4 point), blood pressure and abdominal circumference (female 9 cm, male 11 cm) were observed. Our study indicated that LA is an ideal antioxidant candidate for the therapy of obesity related diseases. Further clinical studies should be considered to highlight the role and efficacy of LA treatment.

Continuous care in the treatment of obesity: an observational multicentre study.

OBJECTIVES: To investigate weight loss and reasons for attrition in obese patients on long-term continuous care. DESIGN: Observational study with 36 months of follow-up. Setting. Fifteen Italian obesity centres applying a continuous care model of medical treatment. SUBJECTS: One thousand treatment-seeking obese subjects (785 females, median age 45.1 years, median BMI 37.4 kg m(-2)). Weight loss expectations were systematically recorded at baseline. INTERVENTIONS: An initial intensive treatment period (3-6 months) was followed by a less intensive continuous care (a follow-up control every 2-4 months). Main outcome measures. Attrition, reasons for treatment interruption and BMI change. Data were recorded by telephone interview in dropouts. RESULTS: Only 157 patients (15.7%) were in continuous treatment at 36 months. The main reasons of attrition were logistics, unsatisfactory results and lack of motivation. The only basal predictor for continuous care was lower Expected One-Year BMI Loss (P = 0.016). The probability of dropout increased systematically for any 5% expected BMI loss (Hazard ratio, 1.05; 96% confidence interval, 1.01-1.09). The mean percentage weight loss was greater in continuers (5.2% vs. 3.0% in dropouts; P = 0.016). However, the dropouts satisfied with the results or confident to lose additional weight without professional help reported a mean weight loss of 9.6% and 6.5% respectively. DISCUSSION: Continuous care produces long-term weight loss only in a subgroup of obese patients seeking treatment in medical centres. The finding that subgroups of dropouts report long-term weight loss has implication for the treatment of obesity.

Body composition modification in obese patients treated with intragastric balloon.

At the Centre for the Therapy of Morbid Obesity, a multidisciplinary team attends severely obese patients in a day-care hospital setting. The patients' psychological and nutritional profiles are studied and their body composition investigated with bioelectrical impedance. After the diagnosis, several approaches are proposed; among them, the insertion of a Bioenterics Intragastric Balloon (BIB). For 6 months after insertion, patients were periodically examined and followed a strict personal regimen, behaviour schedule and physical activity programme compatible with the BIB. The results obtained from the first 20 subjects are encouraging. No severe complications have been reported, and after the BIB removal, subjects are maintaining the obtained results with some of them continuing to lose weight.

Estimation of intra-abdominal pressure by bladder pressure measurement: validity and methodology.

BACKGROUND: Increased intra-abdominal pressure (IAP) is an adverse complication seen in critically ill, injured, and postoperative patients. IAP is estimated via the measurement of bladder pressure. Few studies have been performed to establish the actual relationship between IAP and bladder pressure. The purpose of this study was to confirm the association between intravesicular pressure and IAP and to determine the bladder volume that best approximates IAP. METHODS: Thirty-seven patients undergoing laparoscopy had intravesicular pressures measured with bladder volumes of 0, 50, 100, 150, and 200 mL at directly measured intra-abdominal pressures of 0, 5, 10, 15, 20, and 25 mm Hg. Correlation coefficients and differences were then determined. RESULTS: Across the IAP range of 0 to 25 mm Hg using all of the tested bladder volumes, the difference between IAP and intravesicular pressures (bias) was -3.8 +/- 0.29 mm Hg (95% confidence interval) and measurements were well correlated (R2 = 0.68). Assessing all IAPs tested, a bladder volume of 0 mL demonstrated the lowest bias (-0.79 +/- 0.73 mm Hg). When considering only elevated IAPs (25 mm Hg), a bladder volume of 50 mL revealed the lowest bias (-1.5 +/- 1.36 mm Hg). A bladder volume of 50 mL in patients with elevated IAP resulted in an intravesicular pressure 1 to 3 mm Hg higher than IAP (95% confidence interval). CONCLUSION: Intravesicular pressure closely approximates IAP. Instillation of 50 mL of liquid into the bladder improves the accuracy of the intravesicular pressure in measuring elevated IAPs.

Hypothermia in critically ill trauma patients.

OBJECTIVE: To determine the incidence and mortality of hypothermia in trauma patients. METHODS: Retrospective review of patients admitted to the Surgical Intensive Care Unit (SICU) over 4 1/2 years. Hypothermia was defined as a temperature < 35 degrees C. RESULTS: There were 7045 admissions to the SICU, of which 661 (9.4%) had a recorded temperature of < 35 degrees C. Over half (395) were trauma patients, with a mortality of 52.7%. The temperature ranged from 27.1 to 34.9 degrees C, with a mean for survivors of 34.0 degrees C and 33.1 degrees C for those that died. There was a significant difference in Apache II scores (16.6 vs 25.4) and Injury Severity Scores (26.1 vs 33.4) between survivors and non-survivors. CONCLUSIONS: The incidence of hypothermia in trauma patients is significant and is independent of the month of admission. Mortality is high but there is no threshold below which mortality is assured. Unlike historical data, 13 patients survived temperatures < 32 degrees C.

Traction injury to the liver during laparoscopic cholecystectomy.

We describe an intraoperative complication of laparoscopic cholecystectomy and make recommendations to avoid its occurrence. We describe a case in which the liver was lacerated during a routine laparoscopic cholecystectomy. The laceration occurred when the gallbladder was retracted into the suprahepatic space, causing a traction injury of the quadrate lobe, 2 cm lateral to the falciform ligament. The placement of the epigastric trocar through the falciform ligament fixed the liver to the abdominal wall, facilitating the injury. When placing the epigastric trocar, care should be taken to avoid placement through the falciform ligament. If this is not possible, retraction of the gallbladder into the suprahepatic space should be accomplished while observing the liver edge. If the liver edge seems to be under tension, division of the falciform ligament to allow for easy retraction of the liver is recommended.

Abdominal wall recurrence after laparoscopic-assisted colectomy for adenocarcinoma of the colon. Report of a case.

PURPOSE: To report an unusual mode of colorectal carcinoma recurrence after laparoscopic-assisted right hemicolectomy. METHODS: Retrospective case review. RESULTS: Laparoscopic-assisted colectomy has been shown in a variety of settings to be safe and technically feasible. The question of its efficacy in treating colorectal carcinoma remains uncertain. We report a case of a 71-year-old male who presented with a trocar site abdominal wall recurrence 10 months after a laparoscopic-assisted right hemicolectomy. To our knowledge, this represents the first such reported case in the literature. CONCLUSION: Questions surrounding the efficacy of laparoscopic colectomy in eradicating colorectal carcinoma support the need for rigorous prospective study of this new technique.

Munchausen's syndrome: report of case.

A patient with Munchausen's syndrome received treatment from at least 25 dental practitioners in the New York metropolitan area. The patient and the syndrome are described to alert the dental community about this patient who is still presumed to be living in the New York area.