Investigación en nutrición clínica y generación de nuevas evidencias: el programa NutriCOVer / Investigation in clinical nutrition and generation of new evidence: the NutriCOVer program

NutriCOVer es un programa de investigación impulsado por Nutricia a nivel global para apoyar iniciativas de investigación clínica en 16 países de todo el mundo. El programa tiene como objetivo adaptar el cuidado nutricional a las necesidades de los pacientes con COVID-19 dados de alta de la unidad de cuidados intensivos. En España se están desarrollando tres proyectos de investigación, siendo un país de referencia dentro del programa NutriCOVer. Estos estudios analizan la evolución de los pacientes tras una COVID-19 grave desde el punto de vista nutricional, evaluando aspectos relevantes como la prevalencia y evolución de la desnutrición y la sarcopenia (estudio NUTRICOVID), la prevalencia y el impacto de la disfagia (estudio COVID-19-DN-OD) y los cambios de la composición corporal medida por ecografía nutricional y bioimpedanciometría (estudio NUTRIECOMUSCLE). En este artículo, los investigadores que lideran estos tres proyectos discuten todos los pasos que han seguido para el desarrollo de los estudios en el contexto de una pandemia mundial: desde la idea inicial, el diseño y el reclutamiento de pacientes hasta los problemas de ejecución que se han encontrado en el día a día o la política de publicación de los resultados. Además, ofrecen algunas impresiones sobre los resultados iniciales y las implicaciones que pueden tener estos estudios para cambiar la práctica clínica habitual (AU)

NutriCOVer is a global research program sponsored by Nutricia to support initiatives in clinical investigation in 16 countries worldwide. The program's objective is to adapt nutritional care to the needs of patients with COVID-19 who have been discharged from the intensive care unit. In Spain — a reference country for the NutriCOVer program — three research projects are being carried out. These studies analyze the clinical course of COVID-19 patients from a nutritional point of view, evaluating relevant aspects such as the prevalence and evolution of malnutrition and sarcopenia (the NUTRICOVID study), the prevalence and impact of dysphagia (the COVID-19-DN-OD study), or changes in corporal composition measured through nutritional ultrasound and bioimpedance analysis (the NUTRIECOMUSCLE study). In this article, the principal investigators of the three projects discuss the steps taken to develop these studies in the context of a worldwide pandemic: from initial concept, study design, and patient recruitment to problems in the execution of the project in day-to-day practice and publication policies. Also, they offer some insights on the initial results and the implications which these studies may have for current clinical practice (AU)

Bronquiectasias y nutrición / Bronchiectasis and nutrition

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Síntomas depresivos y ansiosos en pacientes con fibrosis quística: influencia sobre la calidad de vida relacionada con la salud / Symptoms of depression and anxiety in patients with cystic fibrosis: their influence on the quality of living with regards to health

Objetivo y finalidad del estudio: La FQ es una enfermedad crónica con impacto en la CVRS. Se ha comunicado una prevalencia elevada de síntomas depresivos y ansiosos en estos sujetos. La finalidad del estudio fue evaluar los síntomas de depresión y ansiedad en una muestra de adultos con FQ con la Hospital Anxiety and Depression Scale (HADS) y su posible relación con la CVRS medida con el Cystic Fibrosis Questionnaire Revised para adolescentes y adultos versión Spain (CFQ-R14+ Spain). Material y método: Estudio transversal con selección prospectiva de pacientes adultos con FQ. Se recogieron datos demográficos, clínicos, radiológicos y espirométricos y completaron la escala HADS y el CFQ-R14+. Resultados: Se incluyeron 43 pacientes. El cribado fue positivo para síntomas depresivos en el 21,5% y para síntomas ansiosos en el 31%. Los síntomas psicológicos se asociaron a una edad mayor y a peor situación respiratoria. La presencia de síntomas depresivos y ansiosos se asoció a una peor calidad de vida. Tras controlar por variables demográficas (edad, sexo) y clínicas (gravedad según FEV1) se observó que el cribado positivo para depresión y para ansiedad explicó un porcentaje importante de la varianza del dominio percepción de la salud (CFQ-R14+). Conclusiones: El cribado para síntomas depresivos y/o ansiosos fue elevado en los pacientes con FQ y se asoció a una peor percepción de la salud independientemente de la función pulmonar (AU)

Objective of the study: Cystic fibrosis (CF) is a chronic disease that impacts on quality of life with regards to health (QLRH). A high prevalence of depressive and anxiety type symptoms has been reported in CF patients. The objective of this study was to assess the symptoms of depression and anxiety in an adult sample with CF using the Hospital Anxiety and Depression Scale (HADS) and its possible relationship with QLRH, measured with the Cystic Fibrosis Questionnaire Revised for adolescents and adults in Spain (CFQ-R14+ Spain). Material and method: Transversal study with a prospective selection of adult, CF patients. Demographic, clinical, radiological and spirometric data was collected and all participants answered the HADS and CFQ-R14+ scales. Results: 43 patients were included. The group was positive for symptoms of depression in 21.5% and for symptoms for anxiety in 31%. The psychological symptoms were associated with increased age and a poor respiratory situation. The presence of depression and anxiety-related symptoms was associated to a worse quality of living. After verifying demographic (age, sex) and clinical (seriousness according to FEV1) data, it was observed that the group that was positive for depression and anxiety showed an important percentage in the variance of the perception of health (CFQ-R14+). Conclusions: The group for depression and/or anxiety-related symptoms was higher in patients with CF and was associated to an inferior perception of health, independently of pulmonary function (AU)

[Analysis of the relevance and feasibility of quality indicators in nutrition support]. / Análisis de la relevancia y factibilidad de indicadores de calidad en las unidades de nutrición.

INTRODUCTION: The quality assessment in health activities requires the choice of indicators in line with the results we want to measure. Of all possible, we should prioritize those that allow us to obtain the most relevant information without overloading the regular work of our units. OBJECTIVE: To determine the opinion of the members of SENPE regarding the relevance and feasibility of using a selection of quality indicators designed for use in clinical nutrition. METHODS: E-mail survey sent to members of SENPE asking them their views on 12 quality indicators, evaluating each in terms of their relevance and feasibility of implementation in their environment. RESULTS: 40 respondents answered from 40 centers in 12 different regions. In general, the indicators were considered more relevant than feasible. The indicators best rated were: "identification in artificial nutrition bags, "semi-recumbent position in patient with nasogastric tube feeding" and "basic clinical protocols". Considering the type of indicator: "patient identification in the bags of artificial nutrition (structure)," a semi-incorporated "and" basic clinical protocols (process), and "fulfillment of the caloric goal" (result). CONCLUSION: The results of the survey can make a selection of indicators that could be considered for first-line introduction in a Nutrition Unit.

Eficacia, coste-efectividad y efectos sobre la calidad de vida de la suplementación nutricional / Efficacy, cost-effectiveness, and effects on quality of life of nutritional supplementation

El presente artículo resume los resultados y conclusiones presentados en el Simposio “Suplementación nutricional: evidencias y experiencias” celebrado en el XXIII Congreso Nacional de la SENPE (2008).La malnutrición calórico-proteica, que puede afectar al 30-50% de los pacientes hospitalizados, aumenta el tiempo de hospitalización y el coste de la atención médica en aquellos que la padecen. Un importante volumen de evidencias científicas avala que la administración de suplementos nutricionales (SN) mejora el estado nutricional o previene la aparición de malnutrición en pacientes que no cubren sus necesidades nutricionales con la dieta convencional o con la dieta adaptada, sin que, por ello, se produzca desplazamiento de la ingesta. Todo ello viene reforzado por los resultados que evidencian el papel de los SN en la mejora de parámetros tanto nutricionales como funcionales. La revisión de la literatura existente en determinados contextos clínicos (geriatría uoncología), evidencia que los SN reducen la aparición de complicaciones propias, tanto de la patología de base como del estado de desnutrición, así como que favorecen la reducción de la estancia hospitalaria y de la mortalidad. A pesar de ello, son necesarios más estudios sobre la eficacia de los SN orales en los que se realice un seguimiento más prolongado de lo que ofrecen las publicaciones disponibles actualmente. Más allá de su eficacia, los SN constituyen una intervención terapéutica segura y sin efectos adversos clínicos relevantes que, según la literatura, mejoran la funcionalidad del paciente y su calidad de vida. Cabe añadir que los SN pueden ser coste-efectivos en ciertos perfiles de paciente (ancianos malnutridos o en riesgo de desnutrición y en pacientes quirúrgicos hospitalizados). La revisión de la literatura evidencia la necesidad de realizar más estudios, con la metodología (..) (AU)

This article summarizes the main results and conclusions presented in the Symposium “Nutritional supplementation: evidences and experiences” that took place in the XXIIIrd SENPE Congress (2008).Protein energy malnutrition, that can affect 30-50%of hospitalized patients, increases both time of hospitalization and costs of medical care of this kind of patients. There is a lot of scientific evidences demonstrating that the use of nutritional supplementation improves nutritional status or prevents malnutrition in those patients who do not meet their nutritional needs with a conventional diet or an adapted one with no replacing intake from normal food. This is strengthened by the results that demonstrate the rol of nutritional supplements improving nutritional and functional parameters. Current bibliographic reviews focused on certain clinical frameworks (i.g. geriatrics, oncology),prove that nutritional supplements reduce complications related to pathology and to nutritional status, and also reduce length of hospitalization and mortality. More studies regarding to efficacy of oral nutritional supplements are needed. These studies should be carried out with a period of follow-up longer than the current published studies have. As well as effective, nutritional supplements become a save therapeutic intervention with no important adverse events that, according to bibliography, improve patient’s functionality and quality of life. It is worth mentioning that nutritional supplements can be effective on certain kind of patients, for instance, malnourished elderly or elderly in risk of malnourishment, and hospitalized surgical patients. Scientific literature refers that it is necessary to carry out more studies, with an accurate methodology, which assess the effect of nutritional supplements on quality of life and its cost-effectiveness on malnourished patients regarding specific clinical situations (..) (AU)

Suplementación con ácidos grasos poliinsaturados a largo plazo en pacientes con fibrosis quística / Long term polyunsaturated fatty acid supplement in patients with cystic fibrosis

Objetivo: valorar el efecto de la suplementación oral de una combinación a dosis bajas de diversos ácidos grasos sobre parámetros respiratorios e inflamatorios en pacientes adultos con fibrosis quística(FQ).Método: 17 pacientes recibieron diariamente: 324 mg de ácido eicosapentaenoico (EPA), 216 mg de docosahexaenoico (DHA),480 mg de linoleico (LIN) y 258 mg de gammalinolénico (GLA)durante un año. Se valoraron parámetros espirométricos, número y gravedad de las reagudizaciones respiratorias, uso de antibióticos y marcadores inflamatorios. Resultados: se ha observado un incremento de parámetros espirométricos, así como una reducción estadísticamente significativa en el número de reagudizaciones (totales y graves) y en los días totales de tratamiento antibiótico, comparado con el año previo a la suplementación. Concomitantemente se observó una reducción significativa de los niveles del factor de necrosis tumoral alfa (TNF alfa)así como un incremento de los receptores solubles del TNF alfa. Conclusiones: la suplementación con una mezcla definida de ácidos grasos durante un año parece mejorar parámetros espirométricos, clínicos (menor número de reagudizaciones y tandas de antibióticos)e inflamatorios en pacientes adultos con FQ (AU)

Objective: to evaluate the effect of a combination of low doses oral supplement of various fatty acids on respiratory and inflammatory parameters in adult patients with cystic fibrosis (CF). Method: 17 patients received: 324 mg of eicosapentaenoic acid(EPA), 216 mg of docosahexaenoic acid (DHA), 480 mg of linoleicacid (LIN) and 258 mg of gamma-linolenic acid (GLA) daily during a one-year period. The parameters evaluated included spirometry, number and severity of the acute respiratory attacks, use of antibiotics and inflammatory markers. Results: an increase in spirometry parameters was observed, as well as a statistically significant reduction in the number of acute respiratory attacks (total and severe) and in the total number of days of antibiotic treatment, compared with the year prior to taking the supplement. At the same time, there was a reduction in the levels of the alpha tumor necrosis factor (alpha TNF), as well as an increase of the soluble receptors of alpha TNF. Conclusions: supplements with a specific mix of fatty acids for the period of one year appears to improve spirometry, clinical (lower number of the acute respiratory attacks and rounds of antibiotics) and inflammatory parameters in adults with CF (AU)

Incidence of obesity is lower in persons who consume olive oil.

We undertook a population-based cohort study in Pizarra (Spain). Anthropometric and nutritional variables were recorded for 613 persons. The type of fat used was determined by measurement of the fatty acids contained in cooking oil. Serum fatty acid was used as a biological marker of the type of fat consumed. Obesity incidence in persons who were not obese at baseline was greater in those who consumed sunflower oil (Group 1: 41.5 (95% CI, 25.4-67.8) cases per 1000 person-years) than in those who consumed olive oil or a mixture of oils (Group 2: 17.3 (95% CI, 11.6-25.8) cases per 1000 person-years). The risk of developing obesity over 6 years, adjusted for age, sex, physical activity, smoking, instruction level, energy intake and baseline BMI, was 2.3 (95% CI, 1.06-5.02) in group 1 compared with that in group 2. The increase in the prevalence of obesity in the free-living population is associated with the type of fatty acids in the diet.

[Influence of temperature on food intake in hospitalized patients]. / Influencia de la temperatura en la ingesta de pacientes hospitalizados.

BACKGROUND AND OBJECTIVES: Prevalence of hyponutrition in hospitalized patients is very high and it has been shown to be an important prognostic factor. Most of admitted patients depend on hospital food to cover their nutritional demands being important to assess the factors influencing their intake, which may be modified in order to improve it and prevent the consequences of inadequate feeding. In previous works, it has been shown that one of the worst scored characteristics of dishes was the temperature. The aim of this study was to assess the influence of temperature on patient's satisfaction and amount eaten depending on whether the food was served in isothermal trolleys keeping proper food temperature or not. MATERIAL AND METHODS: We carried out satisfaction surveys to hospitalized patients having regular diets, served with or without isothermal trolleys. The following data were gathered: age, gender, weight, number of visits, mobility, autonomy, amount of orally taken medication, intake of out-of-hospital foods, qualification of food temperature, presentation and smokiness, amount of food eaten, and reasons for not eating all the content of the tray. RESULTS: Of the 363 surveys, 134 (37.96%) were done to patients with isothermal trays and 229 (62.04%) to patients without them. Sixty percent of the patients referred having eaten less than the normal amount within the last week, the most frequent reason being decreased appetite. During lunch and dinner, 69.3% and 67.7%, respectively, ate half or less of the tray content, the main reasons being as follows: lack of appetite (42% at lunch time and 40% at dinner), do not like the food (24.3 and 26.2%) or taste (15.3 and 16.8%). Other less common reasons were the odor, the amount of food, having nausea or vomiting, fatigue, and lack of autonomy. There were no significant differences in the amount eaten by gender, weight, number of visits, amount of medication, and level of physical activity. The food temperature was classified as adequate by 62% of the patients, the presentation by 95%, and smokiness by 85%. When comparing the patients served with or without isothermal trays, there were no differences with regards to baseline characteristics analyzed that might have had an influence on amount eaten. Ninety percent of the patients with isothermal trolley rated the food temperature as good, as compared with 57.2% of the patients with conventional trolley, the difference being statistically significant (P = 0.000). Besides, there were differences in the amount of food eaten between patients with and without isothermal trolley, so that 41% and 27.7% ate all the tray content, respectively, difference being statistically significant (P = 0.007). There were no differences in smokiness or presentation rating. CONCLUSIONS: Most of the patients (60%) had decreased appetite during hospital admission. The percentage of hospitalized patients rating the food temperature as being good is higher among patients served with isothermal trolleys. The amount of food eaten by the patients served with isothermal trolleys is significantly higher that in those without them.

Influencia de la temperatura en la ingesta de pacientes hospitalizados / Influence od temperatura on food intake in hospitalizad patients

Antecedentes y objetivos: La prevalencia de desnutrición en los pacientes hospitalizados es muy elevada y se ha demostrado que constituye un factor pronóstico importante. La mayoría de los pacientes ingresados dependen de la comida hospitalaria para cubrir sus requerimientos nutricionales siendo importante el análisis de los factores que influyen en la ingesta y que se puedan modificar, para conseguir mejorarla y así evitar las consecuencias derivadas de una nutrición inadecuada. En anteriores trabajos se ha demostrado que una de las características de la comida peor valoradas por los pacientes es la temperatura. El objetivo de este trabajo fue evaluar la influencia de la temperatura en la satisfacción y cantidad ingerida en función de que se sirviese o no en carros isotérmicos que mantienen una temperatura adecuada de la comida. Material y métodos: Se realizaron encuestas de satisfacción a pacientes del hospital con y sin carros isotérmicos con dietas basales. Se recogieron los siguientes datos: edad, sexo, peso, número de visitas, movilidad, autonomía, cantidad de medicación por vía oral, ingestión de alimentos traídos de fuera del hospital, calificación de la temperatura, presentación y humedad, cantidad de comida ingerida y motivos por los que no se ingirió todo el contenido del carro isotérmico. Resultados: De las 363 encuestas, 134 de ellas (37,96%) se realizaron en pacientes con bandeja térmica y 229 (62,04%) en pacientes sin ella. El 60% de los pacientes referían haber comido menos de lo normal en la última semana siendo la causa más frecuente la disminución de apetito. En el almuerzo y cena comieron la mitad o menos del contenido de la bandeja el 69,3% y 67,7% respectivamente, siendo las causas más frecuentes las siguientes: la falta de apetito (42% en almuerzo y 40% en cena), no gustarles la comida (24,3 y 26,2%) y el sabor (15,3 y 16,8%). Otras causas menos frecuentes fueron el olor, la cantidad de comida, presentar náuseas o vómitos, cansancio y falta de autonomía. No hubo diferencias significativas en la cantidad de ingesta en función del sexo, peso, número de visitas, cantidad de medicación y grado de actividad. La temperatura de la comida fue clasificada como buena por el 62% de los pacientes, la presentación por el 95% y la humedad por el 85%. Al comparar a los pacientes con y sin carro isotérmico, no hubo diferencias en las características basales analizadas que pudiesen influir en la cantidad ingerida. Calificaron la temperatura como buena un 90% de los pacientes con carro isotérmico y un 57,2% sistema tradicional, siendo esta diferencia estadísticamente significativa (P = 0,000). Además hubo diferencias en la cantidad de comida ingerida entre los pacientes con y sin carro isotérmico, de modo que se lo comieron todo un 41% frente al 27,7% respectivamente siendo esta diferencia estadísticamente significativa (P = 0,007). No hubo diferencias en la calificación de humedad y presentación. Conclusiones: La mayoría de los pacientes (60%) presentan disminución de apetito durante el ingreso. La proporción de ingresados que califican la temperatura como buena es mayor en los pacientes con el sistema de carros isotérmicos. La cantidad ingerida por los pacientes con carros isotérmicos es significativamente mayor que en los pacientes sin ellos (AU)

Background and objectives: Prevalence of hyponutrition in hospitalized patients is very high and it has been shown to be an important prognostic factor. Most of admitted patients depend on hospital food to cover their nutritional demands being important to assess the factors influencing their intake, which may be modified in order to improve it and prevent the consequences of inadequate feeding. In previous works, it has been shown that one of the worst scored characteristics of dishes was the temperature. The aim of this study was to assess the influence of temperature on patient's satisfaction and amount eaten depending on whether the food was served in isothermal trolleys keeping proper food temperature or not. Material and methods: We carried out satisfaction surveys to hospitalized patients having regular diets, served with or without isothermal trolleys. The following data were gathered: age, gender, weight, number of visits, mobility, autonomy, amount of orally taken medication, intake of out-of-hospital foods, qualification of food temperature, presentation and smokiness, amount of food eaten, and reasons for not eating all the content of the tray. Results: Of the 363 surveys, 134 (37.96%) were done to patients with isothermal trays and 229 (62.04%) to patients without them. Sixty percent of the patients referred having eaten less than the normal amount within the last week, the most frequent reason being decreased appetite. During lunch and dinner, 69.3% and 67.7%, respectively, ate half or less of the tray content, the main reasons being as follows: lack of appetite (42% at lunch time and 40% at dinner), do not like the food (24.3 and 26.2%) or taste (15.3 and 16.8%). Other less common reasons were the odor, the amount of food, having nausea or vomiting, fatigue, and lack of autonomy. There were no significant differences in the amount eaten by gender, weight, number of visits, amount of medication, and level of physical activity. The food temperature was classified as adequate by 62% of the patients, the presentation by 95%, and smokiness by 85%. When comparing the patients served with or without isothermal trays, there were no differences with regards to baseline characteristics analyzed that might have had an influence on amount eaten. Ninety percent of the patients with isothermal trolley rated the food temperature as good, as compared with 57.2% of the patients with conventional trolley, the difference being statistically significant (P = 0.000). Besides, there were differences in the amount of food eaten between patients with and without isothermal trolley, so that 41% and 27.7% ate all the tray content, respectively, difference being statistically significant (P = 0.007). There were no differences in smokiness or presentation rating. Conclusions: Most of the patients (60%) had decreased appetite during hospital admission. The percentage of hospitalized patients rating the food temperature as being good is higher among patients served with isothermal trolleys. The amount of food eaten by the patients served with isothermal trolleys is significantly higher that in those without them (AU)

Incidence of type 2 diabetes in southern Spain (Pizarra Study).

BACKGROUND: Few European studies have used an oral glucose tolerance test (OGTT) to examine the incidence of type 2 diabetes. We determined the incidence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes in a population from southern Spain. MATERIAL AND METHODS: A population-based cohort study was undertaken in Pizarra, Spain. Baseline data were recorded on age, sex, weight, height, waist and hip circumferences, and diabetes status for 1051 persons, of whom 910 were free of type 2 diabetes (at-risk sample). Of these, 714 completed the 6-year follow-up study. Body mass index, waist-to-hip ratio and weight increase since baseline were calculated. The homeostasis model assessment equations were used to estimate the indices of insulin resistance and beta-cell function. Each person received an OGTT at baseline and after 6 years. RESULTS: Type 2 diabetes developed in 81 people for a total of 4253 person-years, representing an incidence of 19.1 cases per 1000 person-years (95% confidence interval, 15.3-23.6). Age and the presence of obesity, central obesity and carbohydrate metabolism disorders [IFG (cut off = 100 mg dL(-1), capillary blood glucose level), IGT or both] at baseline were significant markers for the onset of type 2 diabetes during follow-up. After adjusting for these variables, multivariate analysis showed weight increase, waist-to-hip ratio and the indices of insulin resistance and beta-cell function were significantly associated with the risk for type 2 diabetes. CONCLUSIONS: The incidence of type 2 diabetes in a population from southern Spain is high. It is probably associated with the high prevalence of obesity and weight increase in this population.

[Probiotics and prebiotics in clinical practice]. / Probióticos y prebióticos en la práctica clínica.

This article revises the concepts of prebiotics, probiotics and symbiotics, and their use in different situations of daily clinical practice. With a high level of evidence, it is concluded that the use of certain strains of probiotics significantly reduces the risk for antibiotic-induced diarrhea. Although further studies are needed, the use of probiotics, prebiotics, and symbiotics in people suffering from inflammatory bowel disease (particularly ulcerative colitis, and pouchitis) might improve the rates of remission induction/maintenance. The administration of probiotics and symbiotics to patients with liver transplant, severe acute pancreatitis, and intensive and surgical care patients, emerges as a promising therapeutic option that seems to reduce the number of infections; however, it is currently no possible to establish evidence-based recommendations, with a need for a higher number of better designed works. About safety of probiotics and symbiotics, the benefits/risks ratio clearly favors the former since the risk for infection is low, even in immunosuppressed patients. There are, however, selected groups of patients in which caution is advised.

Probióticos y prebióticos en la práctica clínica / Probiotics and prebiotics in clinical practice

En este artículo se revisa el concepto de prebióticos, probióticos y simbióticos y su empleo en diferentes situaciones de la práctica clínica diaria. Con un grado de evidencia alto se concluye que el empleo de determinadas cepas de probióticos reduce significativamente, el riesgo de diarrea por antibióticos. Aunque son necesarios más estudios, el uso de prebióticos, probióticos y simbióticos en personas afectas de enfermedad inflamatoria intestinal (especialmente en la colitis ulcerosa y en la pouchitis) podría mejorar las tasas de inducción y/o mantenimiento de la remisión. La administración de probióticos y simbióticos en pacientes con trasplante hepático, pancreatitis aguda grave, y en pacientes de cuidados intensivos y quirúrgicos, emerge como una opción terapéutica prometedora que parece reducir el número de infecciones; no obstante, en la actualidad no es posible establecer recomendaciones basadas en la evidencia requiriendo mayor número de trabajos y mejor diseñados. Respecto a la seguridad de los probióticos y simbióticos, la balanza de beneficios frente a los riesgos está claramente inclinada hacia los primeros ya que el riesgo de infección es bajo, incluso en pacientes inmunodeprimidos. No obstante, existen grupos seleccionados de pacientes en los cuales todavía se recomienda emplear con precaución

This article revises the concepts of prebiotics, probiotics and symbiotics, and their use in different situations of daily clinical practice. With a high level of evidence, it is concluded that the use of certain strains of probiotics significantly reduces the risk for antibiotic-induced diarrhea. Although further studies are needed, the use of probiotics, prebiotics, and symbiotics in people suffering from inflammatory bowel disease (particularly ulcerative colitis, and pouchitis) might improve the rates of remission induction/maintenance. The administration of probiotics and symbiotics to patients with liver transplant, severe acute pancreatitis, and intensive and surgical care patients, emerges as a promising therapeutic option that seems to reduce the number of infections; however, it is currently no possible to establish evidencebased recommendations, with a need for a higher number of better designed works. About safety of probiotics and symbiotics, the benefits/risks ratio clearly favors the former since the risk for infection is low, even in immunosuppressed patients. There are, however, selected groups of patients in which caution is advised

Actualización en requerimientos nutricionales / Update on nutritional requirements

En esta revisión se pretende actualizar los conceptos y cifras de las recomendaciones nutricionales, con especial interés en las ingestas dietéticas de referencia publicadas por el Institute of Medicine de Estados Unidos, por su importancia y amplio uso internacional. También se actualizan las guías alimentarias (que hacen referencia a alimentos, no a nutrientes) más empleadas en España. Asimismo se repasan las recomendaciones de consumo de macronutrientes y micronutrientes en función de su papel en la prevención de enfermedades crónicas (AU)

This review aims to provide an update on the concepts and values of nutritional recommendations. Special emphasis is placed on the dietary reference intakes published by the Institute of Medicine in the USA because of their importance and wide international use. The dietary guidelines (referring to foodstuffs rather than nutritients) most widely used in Spain are also discussed. Likewise, the recommended intakes of macro- and micronutrients according to their roles in the prevention of chronic diseases are also reviewed (AU)

[Economic costs associated to type 1 diabetes]. / Costes económicos asociados a la diabetes tipo 1.

OBJECTIVE: The objective of our study was to determinate the health resource utilization and economic cost associated to diabetes in a patient group with type 1 diabetes. PATIENTS AND METHODS: We designed a cross-sectional study that involved 71 type 1 diabetes patients (59.4% women) with 29.2 +/- 12.2 years old mean age and 10.5 +/- 7.9 years of diabetes evolution attended in Endocrinology Service of Puerta del Mar Hospital in Cádiz. Direct and indirect cost associated to diabetes during a year period were determinated by information obtained from patient medical history and hospital, emergency, primary care and medical inspection of social insurance databases. RESULTS: Type 1 diabetes patients presented a total cost associated to diabetes of 3.311 euros/patient/year (95% IC: 2.202-4.420 euros/patient/year). Direct cost (2.104 euros/patient/year; 95% IC: 1.825-2.383 euros/patient/year) was higher than indirect cost (1.250 euros/patient/year; 95% IC: 291-2.225 euros/patient/year). Multiple regression analysis showed an independent association between total cost associated to diabetes (dependent variable) and variables number of hospitalizations related to diabetes (p = 0.006), pensioner situation (p = 0.02) and micro and macrovascular complications (p = 0.001). CONCLUSIONS: We conclude that economic cost associated to type 1 diabetes is important and presents a notable and independent increase with hospitalizations related to diabetes, pensioner situation and micro and macrovascular complications.

Fórmulas de nutrición enteral para personas con diabetes mellitus / Enteral nutrition formulas in diabetes mellitus

La diabetes mellitus es una afección crónica muy prevalente tanto en la población general como en la hospitalizada. Las indicaciones del soporte nutricional artificial en las personas con diabetes no difieren de las de las personas sin diabetes, y el número de pacientes que reciben nutrición enteral se está incrementando progresivamente en los últimos años. En el tratamiento de la diabetes, se ha demostrado que un abordaje intensivo multifactorial reduce la morbimortalidad, así como los costes asociados, tanto en pacientes ambulatorios como hospitalizados. Por ello, el objetivo de control metabólico en pacientes diabéticos que reciben nutrición enteral debe ser alcanzar los requerimientos nutricionales adecuados, pero manteniendo un perfil glucémico y lipídico óptimos. En este sentido la apropiada selección de una formulación enteral puede influir sobre el control metabólico del individuo. En los últimos años se han comercializado un gran número de fórmulas de nutrición enteral "diseñadas para diabetes" con el objetivo nutrir adecuadamente al paciente, pero sin empeorar (o incluso mejorar) el control metabólico (glucémico y lipídico). En personas con diabetes o hiperglucemia de estrés, al igual que en la dieta habitual, el uso de fórmulas enterales con un contenido moderado/alto en lípidos monoinsaturados presenta un efecto favorable sobre el control metabólico a corto y medio plazo. La adición de fibra (preferentemente fermentable), el tipo de hidratos de carbono (y probablemente de proteínas) son factores coadyuvantes en la disminución de la respuesta glucémica posprandial. No obstante, son necesarios estudios a largo plazo sobre el efecto metabólico y la morbimortalidad para poder ofrecer recomendaciones basadas en la evidencia (AU)

Diabetes mellitus is a chronic disease that is highly prevalent among both the general population and hospitalized individuals. The indications for artificial nutritional support in diabetics do not differ from those among non-diabetics. In the last few years, the number of patients receiving enteral nutrition has progressively increased. An intensive, multifactorial approach in the treatment of diabetes has been shown to reduce morbidity and mortality, as well as associated costs, in both inpatients and outpatients. The aim of metabolic control in diabetic patients who receive enteral nutrition should be to achieve adequate nutrition while maintaining optimal lipid and glycemic profiles. In this context, the appropriate selection of enteral formula can influence metabolic control. In the last few years a large number of enteral nutrition formulas "designed for diabetes" have become available. These formulas aim to achieve adequate nutrition but without worsening (and even improving) metabolic control (glycemic and lipidic). In individuals with diabetes or stress hyperglycemia, as with the normal diet, the use of enteral formulas with a moderate/high monounsaturated lipid content has a favorable effect on metabolic control in the short and medium term. Addition of fiber (preferably fermentable) and the type of carbohydrates (and probably of proteins) are coadjuvant factors in reducing postprandial glycemic response. Nevertheless, long-term studies on the effect of these formulas on metabolic control, morbidity and mortality are required before evidence-based recommendations can be made (AU)

Costes económicos asociados a la diabetes tipo 1 / Economic costs associated to type 1 diabetes

Objetivo. Determinar el consumo de recursos sanitarios y los costes económicos asociados a la diabetes en un grupo de pacientes con diabetes tipo 1. Pacientes y métodos. Estudio observacional descriptivo de una muestra de 71 pacientes con diabetes tipo 1 (59,4% mujeres) de 29,2 ± 12,2 años de edad media y 10,5 ± 7,9 años de evolución de la diabetes atendidos en la consulta de Endocrinología del Hospital Puerta del Mar de Cádiz. Se determinan los costes directos e indirectos asociados a la enfermedad durante el período de un año en base a la información obtenida a partir de las historias clínicas y bases de datos de hospitalización, urgencias, atención primaria e inspección médica de la Seguridad Social. Resultados. Los pacientes con diabetes tipo 1 presentaron unos costes asociados a la diabetes de 3.311 e/paciente/año (IC 95%: 2.202-4.420 €/ paciente/año), siendo superior la partida de costes directos (2.104 €/paciente/año; IC 95%: 1.825-2.383 €/paciente/año) que de costes indirectos (1.250 €/paciente/año; IC 95%: 291-2.225 €/ paciente/año). El análisis de regresión múltiple mostró una asociación independiente entre los costes totales (variable dependiente) y las variables número de ingresos relacionados con la diabetes (p = 0,006), situación laboral pensionista (p = 0,02) y presencia de complicaciones micro y macrovasculares (p = 0,001). Conclusiones. El coste económico asociado a la diabetes tipo 1 es importante, incrementándose notablemente y de manera independiente con cada hospitalización relacionada con la diabetes, la situación laboral pensionista y la presencia de complicaciones micro y macrovasculares

Objective. The objective of our study was to determinate the health resource utilization and economic cost associated to diabetes in a patient group with type 1 diabetes. Patients and methods. We designed a cross-sectional study that involved 71 type 1 diabetes patients (59,4% women) with 29,2 ± 12,2 years old mean age and 10,5 ± 7,9 years of diabetes evolution attended in Endocrinology Service of Puerta del Mar Hospital in Cádiz. Direct and indirect cost associated to diabetes during a year period were determinated by information obtained from patient medical history and hospital, emergency, primary care and medical inspection of social insurance databases. Results. Type 1 diabetes patients presented a total cost associated to diabetes of 3.311 €/patient/year (95% IC: 2.202-4.420 €/patient/year). Direct cost (2.104 €/patient/year; 95% IC: 1.825-2.383 €/patient/year) was higher than indirect cost (1.250 €/patient/year; 95% IC: 291-2.225 €/ patient/year). Multiple regression analysis showed an independent association between total cost associated to diabetes (dependent variable) and variables number of hospitalizations related to diabetes (p = 0,006), pensioner situation (p = 0,02) and micro and macrovascular complications (p = 0,001). Conclusions. We conclude that economic cost associated to type 1 diabetes is important and presents a notable and independent increase with hospitalizations related to diabetes, pensioner situation and micro and macrovascular complications

Características clínicas y grado de control metabólico de paicentes hospitalizados con diabetes

El objetivo del estudio fue describir las principales características y el grado de control metabólico de los pacientes con diabetes mellitus que ingresan en nuestro hospital. Se diseñó un estudio descriptivo transversal que incluyese a toda la población diabética ingresada durante el período de una semana. A partir de encuestas individuales se evaluaron los antecedentes médicos, tratamientos realizados y diversos aspectos sobre los hábitos de vida y autocuidados de la enfermedad. EL nivel de control metabólico se evaluó a àrtir de la medición del nivel de hemoglobina glicosilada (HbA1c). Se estudiaron 158 pacientes con diabetes conocida (54 por ciento mujeres) con edad media de 65 +/- 13,7 años y tiempo medio de evolución de 13,5 +/-10 años. El 65,8 por ciento presentaba hipertensión arterial (HTA), el 41,7 por ciento dislipemia y el 9,5 por ciento era fumador. El 23,4 por ciento de los pacientes habían presentado úlcera o amputación distal y el 24,6 por ciento habían recibido láserterapia retiniana. La HbA1c media fue de 7,5 +/- 2,7 por ciento, no existiendo diferencias significativas entre los pacientes en seguimiento por atención primaria o especializada. En conclusión, los pacientes con diabetes mellitus ingresados en nuestro hospital presentan una elevada prevalencia de factores de riesgo cardiovascular y de complicaciones crónicas de la diabetes. Sin embargo, los porcentajes obtenidos probablemente infravaloran la prevalencia real entre la población hospitalizada con diabetes (AU)

[Pituitary apoplexy: retrospective study of 9 patients with hypophyseal adenoma]. / Apoplejía pituitaria: análisis retrospectivo en 9 pacientes con adenomas hipofisarios.

Pituitary apoplexy is an acute hemorrhage or ischemia infarction of the pituitary gland, almost invariably occurring in the presence of an pituitary adenoma. Although intratumoral bleeding occur in about 9.5 to 25% of pituitary adenomas, various series suggest that clinical apoplexy may be diagnosed in about 2% to 10% of the adenomas. In a retrospective study from 1988 to 1998 of 110 patients with hypophyseal adenomas, there were 9 cases with pituitary apoplexy, yielding an incidence of 8.2%. Their mean age was 52.4 +/- 12.8 años years, with a male to female ratio of 7:2. Symptoms observed were headache (89%), sudden visual deterioration (78%), vomiting (78%) and oculomotor nerves paresis (33%). The diagnosis of pituitary apoplexy was established by computerized tomographic scans, and hypophyseal macroadenoma with intratumoral bleeding was observed in every patient. Five patients underwent transphenoidal surgery. Improvement of visual deficit was observed in 3/4 (75%) and ocular paresis in 3/3 (100%) of affected patients. Four patients were treated conservatively with steroids. Two patients who had visual deficit recovered it completely without surgery. Two hypophyseal adenomas were resolved spontaneously after bleeding, one stayed unchanged and another presented recurrence of bleeding at six years of follow-up. Steroid and thyroid hormone replacement therapy was required in 62.5% of patients.

Homeostasis del calcio, fósforo y magnesio

Numerosos procesos biológicos son dependientes de la existencia de adecuadas concentraciones intracelulares y extracelulares de calcio, fósforo y magnesio. El organismo mantiene los niveles séricos de estos minerales dentro de unos límites estrechos y estables por un estricto balance entre la entrada y la salida de estos elementos al líquido extracelular. En la conservación de esta homeostasis están implicados principalmente tres órganos: intestino, hueso y riñón. Las denominadas hormonas calciotrópicas, parathormona, calcitonina y los metabolitos de la vitamina D regulan estos procesos (AU)

[The quality of the care in parenteral nutrition: the benefits after the incorporation of a nutritional support team]. / Calidad asistencial en nutrición parenteral: beneficios tras la incorporación de un equipo de soporte nutricional.

GOALS: The purpose of the study was to analyze the quality of the prescription and follow-up of the total parenteral nutrition (PNT) before and after the incorporation of a nutritional support team (NST). MATERIAL AND METHODS: A random sample of 96 patients was selected retrospectively, with 48 prior to the incorporation of the NST (the Non-NST group) and 48 after its incorporation (the NST group), to whom TPN was prescribed. The following points were assessed: 1. The existence of a minimum analytical and nutritional assessment, prior to the incorporation of TPN; 2. The follow-up of the same. RESULTS: The average duration of TPN per patient was 13.8 days without differences between the two groups. There is a written record of the weight and height in 15% and 10% of cases, respectively, in the Non-NST group as opposed to 100% and 99% in the NST group (p < 0.0001). Prior to the incorporation of the NST, the nutritional requirement was not verified in any patients (0%) as opposed to 97% afterwards. Statistically significant differences were detected in the measurement of albumin prior to the start of TPN (p < 0.01). During the analytical follow-up, statistically significant differences were detected in the measurement of: blood tests (p < 0.05); basic biochemistry (p < 0.01); general biochemistry, magnesium, zinc, pre-albumin, transferrin and nitrogen balance (p < 0.0001). In the TPN follow-up, the Non-NST group did not change any of the components contained in it (in terms of volume, macro or micronutrients) in 81% of patients, while 17% had one change and 2% had 2 or more changes, as opposed to 27%, 42% and 31%, respectively in the NST group (p < 0.0001). There were no significant differences in metabolic complications between the two groups. CONCLUSIONS: The implementation of a nutritional support team in charge of the prescription and follow-up of TPN has notably improved the quality of these follow-up studies.