Guía Práctica ESPEN: nutrición clínica en las enfermedades del hígado / ESPEN Practical Guideline: clinical nutrition in liver disease

Introducción: la Guía Práctica se basa en la actual guía científica de la ESPEN sobre nutrición clínica en las enfermedades hepáticas. Métodos: se ha reducido y transformado en diagramas de flujo para facilitar su uso en la práctica clínica. La guía está dedicada a todos los profesionales, incluidos médicos, dietistas, Nutriciónistas y enfermeras, que trabajan con pacientes con enfermedad hepática crónica. Resultados: la guía presenta un total de 103 pronunciamientos y recomendaciones con breves comentarios para el manejo Nutricional y metabólico de pacientes con (i) insuficiencia hepática aguda grave, (ii) esteatohepatitis alcohólica, (iii) enfermedad hepática grasa no alcohólica, (iv) cirrosis hepática, y (v) cirugía o trasplante de hígado. Conclusión: las recomendaciones relacionadas con enfermedades están precedidas por recomendaciones generales sobre el diagnóstico del estado Nutricional en los pacientes hepáticos y sobre las complicaciones hepáticas asociadas a la nutrición médica (AU)

Background: the Practical Guideline is based on the current scientific ESPEN guide on Clinical Nutrition in Liver Disease Methods: it has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. Results: a total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. Disease-related recommendations are preceded by general recommendations on the diagnosis of nutritional status in liver patients and on liver complications associated with medical nutrition. Conclusion: this Practical Guideline gives guidance to health care providers involved in the management of liver disease on how to offer optimal nutritional care (AU)

Meta-analysis of single-port versus conventional laparoscopic cholecystectomy comparing body image and cosmesis.

BACKGROUND: The purpose of this study was to evaluate improvements in cosmetic results and postoperative morbidity for single-incision laparoscopic cholecystectomy (SILC) in comparison with multiport laparoscopic cholecystectomy (MLC). METHODS: A literature search was undertaken for RCTs comparing SILC with MLC in adult patients with benign gallbladder disease. Primary outcomes were body image and cosmesis scores at different time points. Secondary outcomes included intraoperative and postoperative complications, postoperative pain and frequency of port-site hernia. RESULTS: Thirty-seven RCTs were included, with a total of 3051 patients. The body image score favoured SILC at all time points (short term: mean difference (MD) -2·09, P < 0·001; mid term: MD -1·33, P < 0·001), as did the cosmesis score (short term: MD 3·20, P < 0·001; mid term: MD 4·03, P < 0·001; long-term: MD 4·87, P = 0·05) and the wound satisfaction score (short term: MD 1·19, P = 0·03; mid term: MD 1·38, P < 0·001; long-term: MD 1·19, P = 0·02). Duration of operation was longer for SILC (MD 13·56 min; P < 0·001) and SILC required more additional ports (odds ratio (OR) 6·78; P < 0·001). Postoperative pain assessed by a visual analogue scale (VAS) was lower for SILC at 12 h after operation (MD in VAS score -0·80; P = 0·007). The incisional hernia rate was higher after SILC (OR 2·50, P = 0·03). All other outcomes were similar for both groups. CONCLUSION: SILC is associated with better outcomes in terms of cosmesis, body image and postoperative pain. The risk of incisional hernia is four times higher after SILC than after MLC.

[Hand replantation: differences in functional outcome considering patient age and sociomedical aspects]. / Handreplantation: Unterschiede im funktionellen Ergebnis in Anbetracht von Alter und sozialmedizinischem Aspekt.

By presenting 2 cases of successful hand replantation with similar trauma mechanism, level of amputation and ischaemia time of an 18-year-old female patient and a 48-year-old depressive male patient, the influence of age and sociomedical status on the postoperative outcome is discussed. DASH- (disabilities of the arm, shoulder and hand) score and Biometrics E-LINK power and sensitivity measurement were used to evaluate the outcomes.

Comparing single-frequency bioelectrical impedance analysis against deuterium dilution to assess total body water.

BACKGROUND/OBJECTIVES: In this study, we aimed to validate the accuracy of single-frequency bioelectrical impedance analysis (SF-BIA) at 50 kHz to assess total body water (TBW) against the reference technique deuterium dilution (D(2)O) and to explore if the simple clinical parameters extracellular fluid (ECF) composition and body shape explain individual differences between D(2)O and SF-BIA (Diff(BIA-D(2)O)). SUBJECTS/METHODS: We assessed TBW with D(2)O and SF-BIA in 26 women and 26 men without known disease or anomalous body shapes. In addition, we measured body shape with anthropometry and ECF composition (osmolality, albumin, glucose, urea, creatinine, sodium and potassium). RESULTS: On group average, SF-BIA to predict TBW agreed well with D(2)O (SF-BIA, 39.8 ± 10.1 l; D(2)O, 40.4 ± 10.2 l; and Diff(BIA-D(2)O) -0.7 l). In four individuals ('outliers'; 15% of the study population), Diff(BIA-D(2)O) was high (-6.8 to +3.8 l). Diff(BIA-D(2)O) was associated with individual variations in body shape rather than ECF composition. Using gender-specific analysis, we found that individual variability of waist circumference in men and arm length in women significantly contributed to Diff(BIA-D(2)O). When removing the four 'outliers', these associations were lost. CONCLUSIONS: In the majority of our sample, BIA agreed well with D(2)O. Adjusting for individual variability in body shape by anthropometrical assessment could possibly improve the accuracy of SF-BIA for individuals who deviate from mean values with respect to body shape. However, further studies with higher subject numbers are needed to confirm our findings.

Distinct gender-related sleep pattern in an acute model of TMJ pain.

Since it is recognized that acute inflammation of the temporomandibular joint results in sleep disturbances in male rats, and that the orofacial region may display a site-specific effect of ovarian hormones on nociception, we hypothesized that distinct genders would respond differently when subjected to this inflammatory acute orofacial pain. Sleep was monitored after injection of saline/Freund's adjuvant into the temporomandibular joint in male and female (proestrus and diestrus phases) rats. Progesterone and stress-related hormones were also assessed. In males, Freund's adjuvant induced a significant nociceptive response and sleep disturbances. Behavior and sleep architecture in the females remained unaffected. Our results suggest that females and males present distinct responses to an acute model of orofacial pain.

Effects of COX-2 inhibitor in temporomandibular joint acute inflammation.

Since it is recognized that cyclo-oxygenase-2 mediates nociception and the sleep-wake cycle as well, and that acute inflammation of the temporomandibular joint (TMJ) results in sleep disturbances, we hypothesized that cyclo-oxygenase-2 inhibitor would restore the sleep pattern in this inflammatory rat model. First, sleep was monitored after the injection of Freund's adjuvant (FA group) or saline (SHAM group) into the rats' temporomandibular joint. Second, etoricoxib was co-administered in these groups. The Freund's adjuvant group showed a reduction in sleep efficiency, in rapid eye movement (REM), and in non-REM sleep, and an increase in sleep and REM sleep latency when compared with the SHAM group, while etoricoxib substantially increased sleep quality in the Freund's adjuvant group. These parameters returned progressively to those found in the SHAM group. Etoricoxib improved the sleep parameters, suggesting the involvement of the cyclo-oxygenase-2 enzyme in acute inflammation of the TMJ, specifically in REM sleep.

[ESPEN guidelines on enteral nutrition--summary]. / ESPEN-Leitlinien Enterale Ernährung--Zusammenfassung.

Under the auspices of the European Society for Clinical Nutrition and Metabolism (ESPEN) clinical practice guidelines were systematically developed by 88 experts from 20 different countries between spring 2004 and winter 2005 in a predefined evidence and consensus based process. Evidence was gathered by a structured literature search, and the quality and strength of the evidence was graded according to published standards. On this basis recommendations were formulated which were then finalised in a consensus conference. The recommendations and their grades were summarized in table form. The German translation of these tables is now published for the following chapters: Intensive care, surgery including organ transplantation, non-surgical oncology, gastroenterology, pancreas, liver disease, adult renal failure, cardiology and pulmonology, wasting in HIV and chronic infectious diseases, geriatrics. The full text and the comments are available in ,,Clinical Nutrition" as well as on the internet under www.espen.org and www.dgem.de. The ESPEN guidelines enteral nutrition reflect the current medical knowledge in the field of enteral nutrition therapy and may help to decide when enteral nutrition is indicated and which therapeutic goals can be reached.

ESPEN Guidelines on Enteral Nutrition: Geriatrics.

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Methodology for the development of the ESPEN Guidelines on Enteral Nutrition.

Under the auspices of the European Society for Clinical Nutrition and Metabolism (ESPEN) clinical practice guidelines on enteral nutrition were systematically developed between spring 2004 and winter 2005 in a both evidence and consensus based process. A steering committee implemented 13 disease-specific working groups with a total of 88 experts in clinical nutrition from 20 countries. Evidence was gathered by conducting a structured literature search applying a defined search strategy, inclusion criteria and specified keywords. The quality and strength of the supporting evidence was then graded according to published standards. On this basis recommendations were spelled out which were not only based on the evidence levels of the studies but also on the judgement of the working groups concerning the consistency, clinical relevance and validity of the evidence. Preparation of the drafts was accomplished in interactive small group work processes. The voting of statements took place in a consensus conference and final refinements and voting were done using the Delphi technique. The ESPEN guidelines enteral nutrition reflect the current medical knowledge in the field of enteral nutrition therapy and summarize the evidence when enteral nutrition is indicated and which goals can be reached in regard to nutritional state, quality of life and outcome.

ESPEN Guidelines on Enteral Nutrition: Gastroenterology.

Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.

Influence of temporomandibular joint pain on sleep patterns: role of nitric oxide.

Since nitric oxide is related to nociception and the sleep-wake cycle, this study sought to determine its involvement in the altered sleep pattern in a temporomandibular joint pain model by investigating the effect of the inhibitor of nitric oxide synthase (L-NAME) and that of its precursor (L-arginine). The temporomandibular joints of test animals were injected with Freund's adjuvant or saline, and their sleep was recorded. The procedure was repeated after the administration of L-NAME and L-arginine. L-NAME increased rapid eye movement (REM) sleep in the control group. The orofacial pain group showed a reduction in total sleep time and an increase in sleep latency compared with the SHAM group. L-NAME increased sleep time, non-rapid eye movement (NREM), and REM sleep and reduced sleep latency in the orofacial pain group. L-arginine did not alter sleep parameters. Thus, L-NAME improved sleep efficiency, whereas L-arginine did not modify it, suggesting the involvement of nitric oxide in painful temporomandibular joint conditions.

[Fractures of the lower leg in professional skiers]. / Die Unterschenkelfraktur im professionellen Skisport.

Fractures of the lower leg due to skiing accidents remain an important concern. Few studies have focussed on the special demands of professional athletes who sustain these injuries. We present our experience with three cases of lower leg fractures in competitive professional downhill skiers and discuss management and treatment concepts. We performed limited reamed compression nailing in all the patients presented because it offers the advantages of high mechanical stability and optimized fragment apposition. Plate osteosynthesis of the fibula is not required in most typical fractures. All patients resumed ski training. Two of them returned to World Cup. Only one achieved her pre-injury World Cup level of performance and success. In conclusion, a successful return for professional skiers with lower leg fractures is feasible using an optimized treatment strategy.

Sleep alterations in an experimental orofacial pain model in rats.

This study sought to assess sleep patterns in rats injected with Freund's adjuvant (FA) in the temporomandibular joint (TMJ) as a potential experimental orofacial pain model. Pain response to indomethacin was also assessed. Rats were implanted with electrodes to record electrocorticogram and eletromyogram signals. After a baseline (B) recording, they were injected with Freund's adjuvant (orofacial pain group, n=8) or saline (sham group, n=8) in the temporomandibular joint, and their sleep was monitored over two 12-h light periods. In the second phase of the study, after injecting Freund's adjuvant, indomethacin was administered (1 mg/kg p.o.) at 12- intervals, and sleep patterns were recorded for two additional light periods. The orofacial pain group showed a reduction in sleep efficiency during the two light periods compared with the baseline recording and with the sham group (p<0.001). Increases in sleep and paradoxical sleep (PS) latencies of approximately 200% and 420%, respectively, were observed, as well as an increase in the number of awakenings during both periods (p<0.001). Treatment with indomethacin increased sleep efficiency (p<0.001) and paradoxical sleep time (p<0.001). The number of awakenings (p<0.001) and sleep (p<0.001) and paradoxical sleep latencies (p<0.001) were reduced reestablishing the normal sleep pattern. The results showed the reliability and usefulness of the temporomandibular joint pain model to characterize sleep disturbances related to pain and its response to indomethacin.

[Ankle arthrodesis with intramedullary compression nailing]. / Die Technik der tibiotalaren Arthrodese mit Kompressionsmarknagel.

Tibiotalar arthrodesis still remains the primary choice of treatment for disabling ankle arthropathy since the results of ankle arthroplasty are not yet convincing. Numerous operative techniques have been described, with an increasing trend towards the use of internal fixation and compression. Using an intramedullary compression nailing technique, 137 tibiotalar fusions were performed at our hospital. The special design of the nail allows distal interlocking in the talus and dynamic axial compression with high primary stability. With correct joint axis, only the cartilage joint surfaces were removed. For axis correction the corresponding bony joint surfaces were also resected. We also performed a dowel technique with bone grafting from the lateral malleolus. We examined 110 of the 137 patients during follow-up. A primary union could be achieved in 99 cases (90.0%). A further six cases (5.5%) healed after recompression and bone grafting. Nonunion remained in five cases (4.5%). Operative complications included one tibial shaft fracture and one hematoma. Septic complications were three superficial and eight deep infections. Sufficient pain relief after arthrodesis was reported by 70 (63.6%) patients; in 37 (33.6%) patients the symptoms remained unchanged and 3 (2.7%) patients found their pain to be worse than before the procedure. Intramedullary compression nailing is shown to be an effective technique for tibiotalar arthrodesis in severe ankle arthropathy. The main advantages of the technique are limited soft tissue damage in the ankle area and high primary stability allowing early weight bearing.

Improved assessment of body cell mass by segmental bioimpedance analysis in malnourished subjects and acromegaly.

BACKGROUND: Estimation of body cell mass (BCM) has been regarded valuable for the assessment of malnutrition. AIM: To investigate the value of segmental bioelectrical impedance analysis (BIA) for BCM estimation in malnourished subjects and acromegaly. METHODS: Nineteen controls and 63 patients with either reduced (liver cirrhosis without and with ascites, Cushing's disease) or increased BCM (acromegaly) were included. Whole-body and segmental BIA (separately measuring arm, trunk, leg) at 50 kHz was compared with BCM measured by total-body potassium. Multiple regression analysis was used to develop specific equations for BCM in each subgroup. RESULTS: Compared to whole-body BIA equations, the inclusion of arm resistance improved the specific equation in cirrhotic patients without ascites and in Cushing's disease resulting in excellent prediction of BCM (R(2) = 0.93 and 0.92, respectively; both P<0.001). In acromegaly, inclusion of resistance and reactance of the trunk best described BCM (R(2) = 0.94, P<0.001). In controls and in cirrhotic patients with ascites, segmental impedance parameters did not improve BCM prediction (best values obtained by whole-body measurements: R(2)=0.88 and 0.60; P<0.001 and <0.003, respectively). CONCLUSION: Segmental BIA improves the assessment of BCM in malnourished patients and acromegaly, but not in patients with severe fluid overload.

[Psoas abscess after anterior spinal fusion]. / Psoasabszess nach ventraler Spondylodese.

We present 3 cases of secondary psoas abscess after anterior spinal fusion. Psoas abscess is still a rare clinical entity. It is often associated with unspecific symptomatology and may present as late infection. A high index of suspicion is required for early diagnosis and treatment. Computed tomography is the imaging technology of choice. Treatment includes open abscess drainage and antibiotic therapy. In secondary psoas abscess causative treatment of the primary infection focus is essential. For psoas abscess after anterior spondylodesis this includes treatment of a deep wound infection. Predisposing factors for postoperative infection are large implants, bone grafting, long operating times, previous spinal surgery, immunodeficiency and metabolic disorders. Usually several operations are necessary to eradicate infection. As long as stability is guaranteed, implant materials should be removed. Continuing antibiotic therapy for 2-3 weeks after normalization of infectious parameters is suggested. Delayed therapy results in an increase of the morbidity and mortality of psoas abscess.

Bioelectrical impedance analysis is a useful bedside technique to assess malnutrition in cirrhotic patients with and without ascites.

Protein-calorie malnutrition is associated with poor prognosis in chronic liver disease, but reliable assessment is hampered by changes in body water. We prospectively evaluated the effect of fluid retention on bioelectrical impedance analysis (BIA) as a simple method for the estimation of body cell mass (BCM(BIA)) in 41 patients with cirrhosis (n = 20 with ascites; n = 21 without ascites) using total body potassium counting (BCM(TBP)) as a reference method. Arm muscle area and creatinine-derived lean body mass were compared with total body potassium data. In patients total body potassium was 24.4% lower than in controls and this loss was more severe in patients with ascites (-34.1%; P<.01). BCM(BIA) and BCM(TBP) were closely correlated in controls (r(2) =.87, P<.0001), patients without ascites (r(2) =.94, P <.0001) and patients with ascites (r(2) =.56, P<.0001). Removal of 6.2 +/- 3 L of ascites had only minor effects on BCM(BIA) (deviation of -0.18 kg/L ascites). Limits of agreement between both methods were wider in patients with ascites than in patients without (6.2 vs. 4.2 kg). In patients without ascites arm muscle area (r(2) =.64; P<.001) and lean body mass (r(2) =.55; P<.001) correlated significantly with total body potassium, but not in patients with ascites. For assessment of protein malnutrition in patients with cirrhosis, body cell mass determination by use of BIA offers a considerable advantage over other widely available but less accurate methods like anthropometry or the creatinine approach. Despite some limitations in patients with ascites, BIA is a reliable bedside tool for the determination of body cell mass in cirrhotic patients with and without ascites.

Increased intestinal permeability to macromolecules and endotoxemia in patients with chronic alcohol abuse in different stages of alcohol-induced liver disease.

BACKGROUND/AIMS: No information is yet available about the influence of alcohol abuse on the translocation of larger molecules (Mr>1200) through the intestinal mucosa in man. The present study aimed to determine the intestinal permeability to macromolecules in patients with chronic alcohol abuse and mild to more advanced stages of liver disease, and to measure the concentration of endotoxins in the plasma, as these compounds derive from the intestinal flora and are suspected to contribute to the development of alcoholic liver disease (ALD). METHODS: The permeability to polyethylene glycol Mr 400, Mr 1500, Mr 4000, and Mr 10,000 and endotoxin plasma concentrations were measured in 54 patients with alcoholic liver disease, 19 of them with cirrhosis, and in 30 non-alcoholic healthy controls. RESULTS: Permeability to polyethylene glycol Mr 400 was found to be unchanged in patients with ALD in comparison to healthy controls, whereas polyethylene glycol Mr 1500 and Mr 4000 were recovered in about twice as high concentrations in the urine of ALD patients (p<0.01). Polyethylene glycol Mr 10,000 was detected significantly less frequently in urine from healthy controls (0/30) than in urine of patients with alcoholic liver disease (20/54, p<0.01). Endotoxin concentrations in the plasma of alcoholics were increased more than 5-fold compared to healthy controls (p<0.01). CONCLUSIONS: The results of this study indicate that alcohol abuse impairs the function of the intestinal barrier, which might enhance the translocation of bacterial toxins, thereby contributing to inflammatory processes in alcoholic liver disease.