Manejo quirúrgico en la colitis ulcerosa grave: alternativas técnicas / Severe ulcerative colitis: surgical options

Surgical options for treatment of severe ulcerative colitis are presented. The preferred treatment should consider clinical presentation (elective or emergency), age, co-morbidities, functional status, previous continence and acceptance of a temporary or permanent ostomy. In emergency condition the alternative is subtotal colectomy with end ileostomy and closure of the rectal stump. This removes the extended disease, can optimize medical therapy and leads the patient to an optimal condition for elective surgery. In the case of elective condition the patient’s functional status and continence becomes more important. The most commonly used option is the proctocolectomy with ileal reservoir and anal anastomosis and loop ileostomy. Functional results are appropriate and even though morbidity is high, there is an adequate control of the disease with an overall 8 percent failure of the reservoir. Other alternatives include proctocolectomy with permanent ileostomy, the continent ileostomy and total colectomy with ileo rectal anastomosis.

Se presentan las alternativas quirúrgicas para el tratamiento de la colitis ulcerosa grave. La elección del tratamiento debe considerar la forma de presentación clínica (electiva o urgencia), la edad del paciente, su comorbilidad y estatus funcional, la continencia previa a la cirugía y la aceptación del paciente de una ostomía transitoria o definitiva. En condición de urgencia o emergencia la alternativa recomendada es la colectomía total o subtotal con ileostomía terminal y cierre del muñón rectal. Con esto se logra la remoción de la mayor parte de la enfermedad, permite optimizar la terapia médica y llevar al paciente a una condición óptima para la cirugía electiva. En condición electiva cobra mayor importancia el estado funcional del paciente y su continencia. La opción más utilizada es la proctocolectomía con reservorio ileal, anastomosis reservorio anal e ileostomía en asa transitoria de protección. Los resultados funcionales son adecuados y aunque la morbilidad es alta, existe un adecuado control de la enfermedad, con una falla global del reservorio de 8%. Otras alternativas incluyen la proctocolectomía con ileostomía definitiva, la ileostomía continente y la colectomía total con anastomosis íleo rectal.

First report of the toxin profile of Dinophysis sacculus Stein from LC-MS analysis of laboratory cultures.

Dinophysis sacculus is associated with DSP outbreaks especially in the Mediterranean Sea and is supposed to be mildly toxic based on few toxin results from field samples. First report of LC-MS analysis of D. sacculus cultures from Galicia (NW Spain) showed moderate amounts of OA (7.8 pg cell(-1)) comparable to those found in Dinophysis acuminata from the same region, PTX2 (13.2 pg cell(-1)) and trace amounts of DTX1 (0.8 pg OA equiv. cell(-1)). The contribution of D. sacculus to DSP outbreaks in the Galician Northern Rías should not be underestimated.

[Importance of water in the hydration of the Spanish population: FESNAD 2010 document]. / Importancia del agua en la hidratación de la población española: documento FESNAD 2010.

For any healthy individual, thirst is an appropriate sign to drink water, except for babies, sportsmen, and most of ill and elderly people. In these instances, it is convenient to schedule appropriate times to drink water since great demands and the physiological mechanisms that determine thirst in these situations may condition water unbalances with important consequences for health and the physical and intellectual performance. The human body has a number of mechanisms that allow keeping constant the water content by adjusting intakes and wastes. Water balance is determined by intake (consumed water, beverages, and water contained in foods) and wastes (urine, stools, the skin, and expired air from the lungs). Failure of these mechanisms and subsequent impairments in water balance may produce severe disarrangements that may threaten somebody's life. In the present document, we analyze the evidences regarding the factors conditioning water needs in the different life stages and physiological situations, as well as the consequences of water unbalance under different situations. A proper hydration may be achieved by feeding and the use of water and other liquids. Although water is the beverage by excellence and represents the ideal way of restoring the losses and get hydrated, we should be aware that, from the very beginning, we have sought other liquid sources with hydration properties. In the last decades we have increased the consumption of different beverages, with a proliferation of sugar-containing beverages. Since excessive sugar consumption has been related to obesity and other chronic conditions, it is evident that the use of these caloric beverages should be rationalized, especially in children. In this document all the considerations regarding hydration are presented and different recommendations are exposed.

Mouse bioassay for palytoxin. Specific symptoms and dose-response against dose-death time relationships.

Nowadays, a variety of protocols are applied to quantitate palytoxin. However, there is not desirable agreement among them, the confidence intervals of the basic toxicological parameters are too wide and the formal descriptions lack the necessary generality to establish comparisons. Currently, the mouse bioassay is the most accepted one to categorize marine toxins and it must constitute the reference for other methods. In the present work, the mouse bioassay for palytoxin is deeply analyzed and carefully described showing the initial symptoms of injected mice which are presented here in the first time. These symptoms clearly differ from the more common marine toxins described up to now. Regarding to the toxicological aspects two considerations are taking into account: (i) the empiric models based in the dose-death time relationships cause serious ambiguities and (ii) the traditional moving average method contains in its regular use any inaccuracy elements. Herein is demonstrated that the logistic equation and the accumulative function of Weibull's distribution (with the modifications proposed) generate satisfactory toxicological descriptions in all the respects.

[Colectomy management]. / Manejo de la colectomía.

Colorectal surgery is one of the most frequently performed surgical procedures on the gastrointestinal tract. The large bowel plays an important role in maintaining water and electrolyte balance due to its high capacity of water absorption that may be altered with surgery. Artificial nutritional support should be administered, whenever possible, and is well managed with through the enteral route. PN is indicated only at post-surgery when there are major complications associated with intestinal failure. Early post-surgery EN, or oral supplements, seems to be beneficial. Pouchitis occurs after proctocolectomy with ileoanal anastomosis with the creation of a reservoir in patients with ulcerative colitis, and is well managed with antibiotic therapy, steroids, and probiotics. The implementation of a specific nutritional support protocol allows for decreasing PN and shortens hospital stay.

Manejo de la colectomía / colectomy management

La cirugía colorrectal es uno de los procedimientos quirúrgicos sobre el tracto digestivo que se realizan con mayor frecuencia. El colon juega un papel importante para mantener el equilibrio hidroelectrolítico, ya que tiene una gran capacidad de absorción de agua, que puede verse alterada con la cirugía. En relación con el soporte nutricional artificial, debería ser administrado, siempre que fuera posible, a través de la vía enteral. La NP solo está indicada en el postoperatorio cuando se producen complicaciones mayores en asociación con fallo intestinal. La NE precoz postcirugía, o los suplementos orales, parecen ser beneficiosos. La pouchitis se produce tras la proctocolectomía con anastomosis íleo-anal con formación de reservorio, en pacientes con colitis ulcerosa, y responde al tratamiento con antibióticos, esteroides y probióticos. La implantación de un protocolo específico de soporte nutricional, permite disminuir la NP y acorta la estancia hospitalaria

Colorectal surgery is one of the most frequently performed surgical procedures on the gastrointestinal tract. The large bowel plays an important role in maintaining water and electrolyte balance due to its high capacity of water absorption that may be altered with surgery. Artificial nutritional support should be administered, whenever possible, and is well managed with through the enteral route. PN is indicated only at post-surgery when there are major complications associated with intestinal failure. Early post-surgery EN, or oral supplements, seems to be beneficial. Pouchitis occurs after proctocolectomy with ileoanal anastomosis with the creation of a reservoir in patients with ulcerative colitis, and is well managed with antibiotic therapy, steroids, and probiotics. The implementation of a specific nutritional support protocol allows for decreasing PN and shortens hospital stay

Recommendations from SPNS/GEAM/SENBA/SENPE/AEDN/SEDCA/GESIDA on nutrition in the HIV-infected patient.

OBJECTIVE: to make recommendations on the approach to nutritional problems (malnutrition, cachexia, micronutrient deficiency, obesity, lipodystrophy) affecting HIV-infected patients. METHODS: these recommendations have been agreed upon by a group of expertes in the nutrition and care of HIV-infected patients, on behalf of the different groups involved in drafting them. Therefore, the latest advances in pathophysiology, epidemiology, and clinical care presented in studies published in medical journals or at scientific meetings were evaluated. RESULTS: there is no single method of evaluating nutrition, and diferent techniques--CT, MRI, and DXA--must be combined. The energy requirements of symptomatic patients increase by 20-30%. There is no evidence to support the increase in protein or fat intake. Micronutrient supplementation in only necessary in special circumstances (vitamin A in children and pregnant woman). Aerobic and resistance excercise is beneficial both for cardiovascular health and for improving lean mass and muscular strength. It is important to follow the rules of food safety at every stage in the chain. Therapeutic intervention in anorexia and cachexia must be tailored, by combining nutritional and pharmacological support (appetite stimulants, anabolic steroids, and, in some cases, testosterone). Artificial nutrition (oral supplementation, enteral or parenteral nutrition) is safe and efficacious, and improves nutritional status and response to therapy. In children, nutritional recommendations must be made early, and are a necessary component of therapy. CONCLUSION: appropriate nutritional evaluation and relevant therapeutic action are an essential part of the care of HIV-infected patients.

Recommendations from SPNS/GEAM/SENBA/SENPE/AEDN/SEDCA/ GESIDA on nutrition in the HIV-infected patient / Recomendaciones de SPNS/GEAM/SENBA/SENPE/AEDN/SEDCA/GESIDA sobre nutrición en el paciente con infección por VIH

Objective: to make recommendations on the approach to nutritional problems (malnutrition, cachexia, micronutrient deficiency, obesity, lipodystrophy) affecting HIV-infected patients. Methods: these recommendations have been agreed upon by a group of expertes in the nutrition and care of HIV-infected patients, on behalf of the different groups involved in drafting them. Therefore, the latest advances in pathophysiology, epidemiology, and clinical care presented in studies published in medical journals or at scientific meetings were evaluated. Results: there is no single method of evaluating nutrition, and diferent techniques —CT, MRI, and DXA— must be combined. The energy requirements of symptomatic patients increase by 20-30%. There is no evidence to support the increase in protein or fat intake. Micronutrient supplementation in only necessary in special circumstances (vitamin A in children and pregnant woman). Aerobic and resistance excercise is beneficial both for cardiovascular health and for improving lean mass and muscular strength. It is important to follow the rules of food safety at every stage in the chain. Therapeutic intervention in anorexia and cachexia must be tailored, by combining nutritional and pharmacological support (appetite stimulants, anabolic steroids, and, in some cases, testosterone). Artificial nutrition (oral supplementation, enteral or parenteral nutrition) is safe and efficacious, and improves nutritional status and response to therapy. In children, nutritional recommendations must be made early, and are a necessary component of therapy. Conclusion: appropriate nutritional evaluation and relevant therapeutic action are an essential part of the care of HIV-infected patients

Objetivo: realizar recomendaciones sobre el abordaje de los problemas nutricionales (malnutrición, caquexia, déficit de micronutrientes, obesidad, lipodistrofia) presentes en la infección VIH. Métodos: estas recomendaciones se han consensuado por un grupo de expertos en nutrición y en atención al enfermo VIH, en representación de las distintas sociedades firmantes. Para ello se han revisado los últimos avances fisiopatológicos, epidemiológicos y clínicos recogidos en estudios publicados en revistas médicas o presentados en congresos. Resultados: no existe un único método de valoración nutricional, debiendo combinarse cuestionarios y técnicas como TAC, RNM y DEXA. Los requerimientos energéticos en enfermos sintomáticos aumentan en un 20-30%. No existe evidencia que respalde el incremento del aporte proteico o graso. La suplementación de micronutrientes sólo es necesaria en circunstancias especiales (Vitamina A en niños y embarazadas). El ejercicio aeróbico de resistencia es beneficioso tanto para la salud cardiovascular como para mejorar la masa magra y la fuerza muscular. Es importante seguir normas de seguridad en toda la cadena alimentaria. La intervención terapéutica en la anorexia y caquexia debe ser individualizada, combinando soporte nutricional y farmacológico (estimulantes del apetito, agentes anabolizantes y testosterona en algún caso). La nutrición artificial (suplementación oral, nutrición enteral o parenteral) es segura y eficaz, mejorando el estado nutricional y la respuesta al tratamiento. En niños, las recomendaciones nutricionales deben ser muy precoces, formando necesariamente parte del tratamiento. Conclusión: La adecuada valoración nutricional y la pertinente actuación terapéutica son parte esencial de la asistencia del enfermo VIH

Insulinización en el paciente diabético en tratamiento con nutrición enteral y parenteral / Insulin therapy in the diabetic patient receiving enteral or parenteral nutrition

La nutrición enteral o parenteral en pacientes con diabetes es frecuente en la práctica clínica. La valoración nutricional, las indicaciones del soporte nutricional y el cálculo de los requerimientos calóricos son similares a los de los pacientes no diabéticos, a excepción de las situaciones clínicas de gastroparesia diabética y de sobrepeso. Se debe evitar la sobrealimentación, por lo que el peso usado para calcular los requerimientos calóricos debería ser uno intermedio entre el ideal y el real. Las fórmulas de nutrición enteral con menor contenido en hidratos de carbono y más ricas en grasas se asocian con un mejor control glucémico que las fórmulas estándares usadas. No hay evidencias científi cas para la nutrición enteral continua en pacientes hospitalizados. Cuando se inicia nutrición enteral por sonda, se recomienda el uso de insulinas de acción rápida hasta que la perfusión llega a 40 mL/h, a partir de la cual el empleo de insulina NPH o análogos de insulina de acción prolongada (glargina o detemir) suele ser seguro. Se pueden usar hipoglucemiantes orales en pacientes diabéticos tipo 2 bien controlados y estables. Antes de la administración de nutrición parenteral, debería realizarse un control de glucemia y añadir una cantidad basal de insulina rápida a la solución de nutrición parenteral en los casos de glucemia >150 mg/dL o en pacientes en tratamiento previo con insulina o hipoglucemiantes orales. Se suele iniciar con 0,1 UI/g de glucosa administradas en la solución y suplementos de insulina rápida subcutánea ante situaciones de hiperglucemia, pero cuando ésta es importante, se requiere la instauración de perfusión de insulina intravenosa (i.v.)

In clinical practice, enteral or parenteral nutrition is frequently administered to diabetic patients. Nutritional assessment, indications for nutritional support and the estimation of nutritional needs are similar to those of nondiabetic patients, except that diabetic gastroparesis and excess weight are specific clinical conditions associated with diabetes. To avoid overfeeding, the weight used to estimate caloric requirements should be intermediate between the ideal and the current weight. Enteral formulas with less carbohydrate and more fat content are associated with better glycemic control than standard formulas. There is no evidence to support continuous enteral feeding in hospitalized patients. When initiating tube feeding, the administration of short-acting insulin is recommended, but once the infusion rate has reached 40 mL/h, the use of NPH or long-acting insulin analogues (insulin glargine or detemir) is generally safe. Oral hypoglycemic agents can be used in well-controlled type 2 diabetic patients. Before initiation of parenteral nutrition, capillary blood glucose should be measured. If glucose values are higher than 150 mg/dL or the patient had previously been treated with insulin or oral hypoglycemic agents, the addition of short-acting insulin to the parenteral nutrition solution is recommended. A common starting dose is 0.1 IU/g of dextrose in the solution and subcutaneous short-acting insulin supplements for elevated glucose values. When hyperglycemia is marked and persistent, intravenous insulin infusion is required

[Nutritional support in haemodialysis]. / Soporte nutricional en hemodiálisis.

Malnutrition is a common severe problem in dialysis. The prevalence of malnutrition has been estimated as between 30% and 70%. Although malnutrition is not normally listed among the most frequent causes of mortality in these patients, it contributes to cardiovascular mortality through the MIA syndrome (Malnutrition, inflammation and arteriosclerosis) and the severity of infections. The cause of malnutrition in dialysis is frequently due to a multiplicity of factors. The use of the term malnutrition has been criticized when the cause is not scant dietary intake, for practical reasons: if the cause is not a lack of food intake, the treatment will not be an increase in the provision of nutrients. The therapeutic approach to malnutrition in dialysis has recently been reviewed. In this sense, the multifactorial origin requires the problem to be approached from different angles. The case reported is an undernourished dialysis patient in which a chronic gradual deterioration in nutritional status is treated through a multiple therapy approach.

Soporte nutricional en hemodiálisis / Nutritional support in haemodialysis

La malnutrición es un problema frecuente y grave en diálisis. La prevalencia de malnutrición se ha estimado entre 30 y 70 por ciento1. Si bien la malnutrición no suele enumerarse entre las causas más frecuentes de mortalidad de estos pacientes, contribuye a la mortalidad cardiovascular, a través del síndrome MIA (Malnutrición, inflamación, arteriosclerosis2 y a la gravedad de las infecciones. La causa de la malnutrición en diálisis es, con frecuencia, multifactorial. Se ha criticado el empleo del término malnutrición cuando la causa no es una escasa ingesta dietética, con un sentido práctico: si la causa no es una ingesta escasa, el tratamiento no será un incremento en el aporte de nutrientes3. El abordaje terapéutico de la malnutrición en diálisis ha sido revisado recientemente1, 4, 5 . En este sentido, la multicausalidad requiere abordar el problema desde varios ángulos diferentes. Presentamos el caso de un paciente malnutrido en hemodiálisis, en el cual un deterioro crónico progresivo del estado nutricional es tratado con un abordaje terapéutico múltiple (AU)

Malnutrition is a common severe problem in dialysis. The prevalence of malnutrition has been estimated as between 30% and 70%. Although malnutrition is not normally listed among the most frequent causes of mortality in these patients, it contributes to cardiovascular mortality through the MIA syndrome (Malnutrition, inflammation and arteriosclerosis) and the severity of infections. The cause of malnutrition in dialysis is frequently due to a multiplicity of factors. The use of the term malnutrition has been criticized when the cause is not scant dietary in-take, for practical reasons: if the cause is not a lack of food intake, the treatment will not be an increase in the provision of nutrients. The therapeutic approach to malnutrition in dialysis has recently been reviewed. In this sense, the multifactorial origin requires the problem to be approached from different angles. The case reported is an undernourished dialysis patient in which a chronic gradual deterioration in nutritional status is treated through a multiple therapy approach (AU)

[Obesity in women]. / Obesidad en la mujer.

Obesity has become an important problem of public health in all developed countries. It has slightly different connotations in women because, apart from its greater prevalence, low socio-economic level is a risk factor solely for women. As well as a cardiovascular risk factor in women, it is associated with an increased risk of breast cancer, cancer of the endometrium, ovarian polycystosis and infertility. Weight control in women has a large aesthetic motivation and eating has considerable emotional components. On the other hand, women consume more drugs (contraceptives, painkillers, migraine treatments, anxiolytics, anti-depressants) which seem to favour obesity. The role played in the pathogenesis of obesity by cyclical hormonal changes, pregnancy, the consumption of oral contraceptives and the menopause remains to be clarified. The effect of replacement hormone therapy as a cause of weight gain is doubtful.

Obesidad en la mujer / Obesity in women

La obesidad se ha convertido en un importante problema de salud pública en todos los países desarrollados. En las mujeres adquiere unas connotaciones ligeramente diferentes debido, además de a la mayor prevalencia, a que el bajo nivel socioeconómico es factor de riesgo sólo en la mujer. Además de ser factor de riesgo cardiovascular en la mujer se asocia a una aumento del riesgo de cáncer de mama y de endometrio y a poliquistosis ovárica e infertilidad. En las mujeres el control de peso tiene una fuerte motivación estética y presenta importantes componentes emocionales en relación con la comida. Por otra parte, la mujer es mayor consumidora de fármacos (anticonceptivos, analgésicos, antimigrañosos, ansiolíticos, antidepresivos), que parecen favorecer la obesidad. Queda por aclarar el papel que tienen en la patogénesis de la obesidad los cambios hormonales cíclicos, el embarazo, la ingesta de anticonceptivos orales y la menopausia. El efecto del tratamiento hormonal sustitutivo como causa de la ganancia de peso es dudoso (AU)

Obesity has become an important problem of public health in all developed countries. It has slightly different connotations in women because, apart from its greater prevalence, low socio-economic level is a risk factor solely for women. As well as a cardiovascular risk factor in women, it is associated with an increased risk of breast cancer, cancer of the endometrium, ovarian polycystosis and infertility. Weight control in women has a large aesthetic motivation and eating has considerable emotional components. On the other hand, women consume more drugs (contraceptives, painkillers, migraine treatments, anxiolytics, anti-depressants) which seem to favour obesity. The role played in the pathogenesis of obesity by cyclical hormonal changes, pregnancy, the consumption of oral contraceptives and the menopause remains to be clarified. The effect of replacement hormone therapy as a cause of weight gain is doubtful (AU)

[Necrotizing fasciitis as complication of percutaneous endoscopic gastrostomy]. / Fascitis necrotizante como complicación de gastrostomía endoscópica percutánea.

Necrotizing fasciitis (NF) is a rare clinical entity. We describe a case associated with a percutaneous endoscopic gastrotomy (PEG).

Colonic volvulus and ulcerative jejunoileitis due to occult celiac sprue.

Colonic volvulus is a rare complication of celiac disease. A case is reported of a 46-year-old man with a long-standing history of diarrhea and abdominal distention with a diagnosis of irritable bowel syndrome. After an elective inguinal hernia repair, a cecal volvulus and an ulcerative jejunoileitis developed in the patient that required an extensive intestinal resection. Short bowel syndrome developed and was treated with total parenteral and enteral nutrition. The patient had a poor course after reinitiation of oral diet. Subsequently, celiac sprue was diagnosed and the patient improved with a gluten-free diet.

Atrial natriuretic factor (ANF)-like immunoreactivity and secretory granules in internal gills tadpoles of South American toad Bufo arenarum (Hensel).

In this study, an ultrastructural and immunohistochemical analysis was carried out on the presence of Atrial Natriuretic Factor-like substance in the internal gills of premetamorphic larval stages of the South American toad. The results of immunohistochemical study indicate that, at larval 27 and following stages, ANF-like immunoreactive cells are seen in internal gills. At electron-microscopy level "secretory granules" similar to those ANF-immunoreactives granules of myoendocrine cells of the same species are seen only in clear cells of gill rakers. Our results reveal the occurrence of ANF-like substance in Bufo arenarum gills and may suggest that "cardiac hormones" might play a paracrine and/or autocrine role in the water and electrolyte balance at internal gills level.

Primary hyperthyroidism and associated hyperparathyroidism in a patient with myotonic dystrophy: Steinert with hyperthyroidism and hyperparathyroidism.

A patient with myotonic dystrophy and associated primary hyperthyroidism and hyperparathyroidism is described; this association has not been reported previously, to the authors' knowledge. The patient also suffered from hypergonadotropic hypogonadism and hyperinsulinism with insulin resistance. The etiology of hyperthyroidism and hyperparathyroidism is not clear. At surgery, a parathyroid adenoma was extirpated, and a subtotal thyroidectomy was performed. Postoperative course was unremarkable, with consistently normal serum calcium levels but persistently elevated serum parathyroid hormone concentrations. The possibility that the patient had a residual hyperparathyroidism could not be eliminated. Thyroid function was normal. After surgery, the patient reported subjective improvement in his muscle strength. The authors conclude that both diseases-- hyperthyroidism and hyperparathyroidism--exert a negative effect on the myotonic dystrophy and that an early recognition of these two diseases is crucial for the favorable evolution of the patient.

[Nutrition and mental function in the elderly]. / Nutrición y función mental en el anciano.

A deterioration in cognitive functions is characteristic of the ageing process and is one of the principle causes for disability in old age. It is possible that some of the neuropsychiatric alterations associated with old age may be due to certain subclinical vitamin deficiencies and, as such, may be corrected in some cases with adequate nutrition. This article presents a broad review of the various research efforts published on the subject.