Eficacia y seguridad de la fórmula nutricional con bajo contenido lipídico y alto contenido de triglicéridos de cadena media para el tratamiento de pacientes menores de 18 años con linfangiectasia intestinal primaria / Efficacy and safety of nutritional formula with low lipid content and high content of medium chain triglycerides for the treatment of patients under 18 years of age with primary intestinal lymphangiectasia

ANTECEDENTES: En el marco de la metodología ad hoc para evaluar solicitudes de tecnologías sanitarias, aprobada mediante Resolución de Institución de Evaluación de Tecnologías en Salud e Investigación N° 111-IETSI-ESSALUD-2021, se ha elaborado el presente dictamen, el que expone la evaluación de tecnología acerca de la eficacia y seguridad de la fórmula nutricional con bajo contenido lipídico y alto contenido de triglicéridos de cadena media (TCM) para el tratamiento de pacientes menores de 18 años con linfangiectasia intestinal primaria (LIP). Así, el Dr. Marco Morales Acosta, médico especialista en pediatría del Hospital Nacional Edgardo Rebagliati Martins perteneciente a la Red Prestacional Rebagliati, siguiendo la Directiva N° 003-IETSI-ESSALUD-2016, envía al Instituto de Evaluación de Tecnologías en Salud e Investigación - IETSI la solicitud de uso, por fuera del petitorio, del producto fórmula nutricional con bajo contenido lipídico y alto contenido de TCM. ASPECTOS GENERALES: La linfangiectasia intestinal primaria (LIP) es una condición causada por una deformidad congénita del sistema linfático del intestino delgado; la cual se caracteriza por la dilatación (local o difusa) de los vasos linfáticos de la mucosa y submucosa del intestino delgado (Suresh et al., 2009; Vignes & Bellanger, 2008; Waldmann et al., 1961). Esta dilatación de vasos linfáticos conduciría a la fuga de la linfa hacia el intestino delgado (enteropatía perdedora de proteínas); ocasionando hipoproteinemia, hipogammaglobulinemia, hipoalbuminemia, linfopenia; los que, a su vez, conducen a edema, pérdida de peso, entre otros (Abramowsky et al., 1989; Vignes & Bellanger, 2008). Aunque también se ha sugerido que el paso de la linfa hacia el lumen del intestino delgado podría deberse a una ruptura directa de los vasos linfáticos a través de la mucosa (Waldmann et al., 1961). La LIP es una enfermedad infrecuente que suele presentarse en menores de 3 años; aunque también se han reportado casos en la adultez (Freeman & Nimmo, 2011; Vignes & Bellanger, 2008). A la fecha, la prevalencia e incidencia mundial de LIP sigue siendo desconocida. En el Perú, solo se ha identificado un reporte de caso publicado en el año 2019 (Usnayo et al., 2019). Los médicos especialistas en pediatría del Servicio de Nutrición Pediátrica del Hospital Nacional Edgardo Rebagliati Martins reportan que en los últimos 10 años han atendido a tres pacientes con LIP. METODOLOGÍA: Se llevó a cabo una búsqueda bibliográfica exhaustiva con el objetivo de identificar la mejor evidencia sobre la eficacia y seguridad la fórmula nutricional con bajo contenido lipídico y alto contenido de TCM para el tratamiento de pacientes menores de 18 años con LIP. La búsqueda bibliográfica se realizó en las bases de datos PubMed, The Cochrane Library y LILACS. Asimismo, se realizó una búsqueda manual dentro de las páginas web pertenecientes a grupos que realizan evaluación de tecnologías sanitárias y guías de práctica clínica (GPC) incluyendo el National Institute for Health and Care Excellence (NICE), Canadian Agency for Drugs and Technologies in Health (CADTH), Scottish Medicines Consortium (SMC), Scottish Intercollegiate Guidelines Network (SIGN), Institute for Clinical and Economic Review (ICER), Instituto de Calidad y Eficiencia en la Atención de la Salud (IQWiG, por sus siglas en alemán), Agency for Healthcare Research and Quality (AHRQ), Guidelines International Network (GIN), National Health and Medical Research Council (NHMRC), Haute Autorité de Santé (HAS), International HTA Database, la Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas (BRISA), la Organización Mundial de la Salud (OMS), el Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) y la Agencia de Evaluación de Tecnologías Sanitarias del País Vasco. Asimismo, se realizó una búsqueda de GPC de las principales sociedades o instituciones especializadas en enfermedades raras como la National Organization for Rare Disorders (NORD) y Orphanet. Finalmente, se realizó una búsqueda en la página web de registro de ensayos clínicos (EC) www.clinicaltrials.gov, para identificar EC en curso o que no hayan sido publicados aún. RESULTADOS: Luego de la búsqueda bibliográfica, realizada hasta el 25 de setiembre del 2021, se incluyeron tres estudios. El primero fue un estudio observacional que comparó tres dietas en pacientes con linfangiectasia intestinal (Aoyagi et al., 2005). El segundo fue un estudio observacional que realizó un análisis pre-post de una dieta alta en proteínas (1.5 ­ 3.0 g/Kg/día) y baja en lípidos (15 ­ 20 % del total de calorías); de los cuales el 60 % fueron TCM, en pacientes menores de 18 años con LIP (Prasad et al., 2019). El tercer estudio fue una revisión de evidencia científica en la cual se compararon los reportes de pacientes tratados con TCM y pacientes que recibieron otros tratamientos (Desai et al., 2009). Adicionalmente, se incluyó una ETS realizada por el Ministerio de Sanidad, Servicios Sociales e Igualdad de España (Güemes et al., 2013). CONCLUSIÓN: Por lo expuesto, el Instituto de Evaluación de Tecnologías en Salud e Investigación 9.~ aprueba el uso de la fórmula nutricional con bajo contenido lipídico (25 % del requerimiento calórico) y alto contenido de TCM (mayor o igual al 56 %) para el tratamiento de los pacientes con LIP, como producto farmacéutico no incluido en el Petitorio Farmacológico de EsSalud, según lo establecido en el Anexo N° 1. La vigencia del presente dictamen preliminar es de un año a partir de la fecha de publicación. Así, la continuación de dicha aprobación estará sujeta a la evaluación de los resultados obtenidos y de mayor evidencia que pueda surgir en el tiempo.

Technology-Supported Self-Guided Nutrition and Physical Activity Interventions for Adults With Cancer: Systematic Review.

BACKGROUND: Nutrition and physical activity interventions are important components of cancer care. With an increasing demand for services, there is a need to consider flexible, easily accessible, and tailored models of care while maintaining optimal outcomes. OBJECTIVE: This systematic review describes and appraises the efficacy of technology-supported self-guided nutrition and physical activity interventions for people with cancer. METHODS: A systematic search of multiple databases from 1973 to July 2018 was conducted for randomized and nonrandomized trials investigating technology-supported self-guided nutrition and physical activity interventions. Risk of bias was assessed using the Cochrane Risk of Bias tool. Outcomes included behavioural, health-related, clinical, health service, or financial measures. RESULTS: Sixteen randomized controlled trials representing 2684 participants were included. Most studies were web-based interventions (n=9) and had a 12-week follow-up duration (n=8). Seven studies assessed dietary behaviour, of which two reported a significant benefit on diet quality or fruit and vegetable intake. Fifteen studies measured physical activity behaviour, of which eight studies reported a significant improvement in muscle strength and moderate-to-vigorous physical activity. Four of the nine studies assessing the health-related quality of life (HRQoL) reported a significant improvement in global HRQoL or a domain subscale. A significant improvement in fatigue was found in four of six studies. Interpretation of findings was influenced by inadequate reporting of intervention description and compliance. CONCLUSIONS: This review identified short-term benefits of technology-supported self-guided interventions on the physical activity level and fatigue and some benefit on dietary behaviour and HRQoL in people with cancer. However, current literature demonstrates a lack of evidence for long-term benefit. TRIAL REGISTRATION: PROSPERO CRD42017080346; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=80346.

A portable sensor sheet for measuring the eating pace in meal assistance care.

In this paper, we introduce the development of a new sensing device for measuring the pace, time, order, and intake of meal consumption for the elderly in a nursing home. The developed device is a portable sensor sheet which is suitable for use in nursing homes because it is designed not to disturb meal consumption and can be used conveniently. We first describe the measurement method of food intake using the proposed device such as the pace, time, order of meal. Finally, we report an experiment that we conducted about eating behavior in the nursing home while using the proposed device together with a sensing device for swallowing activities.

How we use the Internet matters for health: The relationship between various online health-related activities and preventive dietary behaviors.

This study identified specific types of online health-related activities that may promote preventive dietary behaviors. Two cycles (Cycles 1 and 3) of the Health Information National Trends Survey 4 were analyzed (N = 2606 and 2284, respectively; Internet users only). Similar types of activities were grouped to create three types of online activities: information seeking, engagement in health information technology, and social media use. In both cycles, online health information seeking and the engagement in health information technology were positively associated with two dietary behaviors (fruit/vegetable consumption and using menu information on calories) but not with soda consumption. Individuals may be exposed to new information or become more aware of their current health status through information seeking or health information technology engagement. However, social media use for health was not related to any of the dietary behavior. The results suggest that "how we use the Internet" may make a difference in health outcomes.

Use of nutritional devices in Cornelia de Lange syndrome: Data from a large Italian cohort.

Cornelia de Lange syndrome (CdLS) is a genetic condition characterized by intellectual disability, peculiar facial dysmorphisms, multiorgan malformations, and growth problems. Majority cases of CdLS are caused by mutations in genes of Cohesin pathway. Although feeding problems are a well-known feature, no specific data have been published about the use of nutritional devices. We analyzed use, type, time of introduction, and duration of nutritional devices in 73 CdLS patients. In total, 29/73 (40%) used a device; nasogastric tube (NGT) in 28/73 (38%) and percutaneous endoscopic gastrostomy (PEG) in 7/73 (10%). NGT was placed during the first days/weeks of life. 19/28 (68%) maintained it for less than 3 months, 7/28 (25%) for a period between 3 and 12 months, while 2/28 (7%) for more than 1 year. PEG was placed within the first year in 4/7 (57%) and removed in two patients after 4 years These data have been matched with a wide number of genetic and clinical variables. Presence of upper limb malformations is positively correlated with the need of a device. From the opposite side, the use of a device positively correlates with a more severe prognosis as regard growth, intellectual development and disease severity. Our data show that nutritional devices are frequently used by CdLS patients, also if the majority of them (93.1%) succeed with time in achieving a normal oral nutrition. Finally, the need, the type of device used and the duration of NGT or/plus PEG can be considered a further sign of worse prognosis of the disease itself.

Application of semi-automated ultrasonography on nutritional support for severe acute pancreatitis.

OBJECTIVE: To evaluate the application value of semi-automated ultrasound on the guidance of nasogastrojejunal tube replacement for patients with acute severe pancreatitis (ASP), as well as the value of the nutritional support for standardized treatment in clinical practice. METHODS: The retrospective research was performed in our hospital, and 34 patients suffering from ASP were enrolled into this study. All these identified participants ever received CT scans in order to make definitive diagnoses. Following, these patients received semi-automated ultrasound examinations within 1 days after their onset, in order to provide enteral nutrititon treatment via nasogastrojejunal tube, or freehand nasogastrojejunal tube replacement. In terms of statistical analysis, the application value of semi-automated ultrasound guidance on nasogastrojejunal tube replacement was evaluated, and was compared with tube replacement of no guidance. After cathetering, the additional enteral nutrition was provided, and its therapeutic effect on SAP was analyzed in further. RESULTS: A total of 34 patients with pancreatitis were identified in this research, 29 cases with necrosis of pancreas parenchyma. After further examinations, 32 cases were SAP, 2 cases were mild acute pancreatitis. When the firm diagnosis was made, additional enteral nutrition (EN) was given, all the patient conditions appeared good, and they all were satisfied with this kind of nutritional support. According to our clinical experience, when there was 200-250 ml liquid in the stomach, the successful rate of intubation appeared higher. Additionally, the comparison between ultrasound-guided and freehand nasogastrojejunal tube replacement was made. According to the statistical results, in terms of the utilization ratio of nutritional support, it was better in ultrasound-guided group, when compared with it in freehand group, within 1 day, after 3 days and after 7 days (7/20 versus 2/14; P < 0.05; 14/20 versus 6/14; P < 0.05; 20/20 versus 12/14; P < 0.05). Besides, the complications caused by cathetering between two groups was not statistically different (P > 0.05). CONCLUSIONS: It can be indicated that semi-automated ultrasound guidance is a reliable method for nasogastrojejunal tube replacement, and should be substituted for no guidance of cathetering. In terms of therapeutic effect of EN, additional nutritional support contributed to significantly improve the prognosis of SAP patients, and should be widely recommended in clinical practice. Surely, this conclusion should be evaluated in further, by means of randomized controlled trials and economic evaluation.

Overview of Intensive Care Unit-Related Physical and Functional Impairments and Rehabilitation-Related Devices.

Rehabilitation after critical illness requires a multidisciplinary effort. Nutrition support of critically ill patients aims to correct the imbalance between protein synthesis and protein degradation to maximize strengthening and muscle mass, whereas physical and occupational therapists focus on optimizing strength and mobility through functional activity to help intensive care (ICU) patients return to their precritical illness level of function and improve quality of life. Early mobility has become the new standard of care for ICU patients. Therapists utilize various devices and technologies to increase the feasibility of early mobility and enhance the rehabilitation process to ensure that patients reach their rehabilitation goals. Tools such as electrical stimulation, cycle ergometers, dynamic tilt tables, and resistive bands aid in strengthening. Therapists use safe patient-handling equipment and ambulation aids to address gait impairments. Adaptive toileting, dressing, bathing, and feeding tools facilitate greater independence with activities of daily living. Augmentative and alternative communication devices promote well-being and communication of basic needs. Splints prevent joint contracture and maintain functional range of motion. Overall, many rehabilitation devices are safe and feasible for use in an ICU setting and serve to maximize strength and functional independence. The purpose of this narrative review is to discuss the benefits and limitations of available rehabilitation devices in the context of critical illness rehabilitation goals.

Nutritional intra-amniotic therapy increases survival in a rabbit model of fetal growth restriction.

OBJECTIVE: To evaluate the perinatal effects of a prenatal therapy based on intra-amniotic nutritional supplementation in a rabbit model of intrauterine growth restriction (IUGR). METHODS: IUGR was surgically induced in pregnant rabbits at gestational day 25 by ligating 40-50% of uteroplacental vessels of each gestational sac. At the same time, modified-parenteral nutrition solution (containing glucose, amino acids and electrolytes) was injected into the amniotic sac of nearly half of the IUGR fetuses (IUGR-T group n = 106), whereas sham injections were performed in the rest of fetuses (IUGR group n = 118). A control group without IUGR induction but sham injection was also included (n = 115). Five days after the ligation procedure, a cesarean section was performed to evaluate fetal cardiac function, survival and birth weight. RESULTS: Survival was significantly improved in the IUGR fetuses that were treated with intra-amniotic nutritional supplementation as compared to non-treated IUGR animals (survival rate: controls 71% vs. IUGR 44% p = 0.003 and IUGR-T 63% vs. IUGR 44% p = 0.02), whereas, birth weight (controls mean 43g ± SD 9 vs. IUGR 36g ± SD 9 vs. IUGR-T 35g ± SD 8, p = 0.001) and fetal cardiac function were similar among the IUGR groups. CONCLUSION: Intra-amniotic injection of a modified-parenteral nutrient solution appears to be a promising therapy for reducing mortality among IUGR. These results provide an opportunity to develop new intra-amniotic nutritional strategies to reach the fetus by bypassing the placental insufficiency.

Incidencia de hipofosfatemia en pacientes ingresados no críticos con nutrición enteral / Incidence of hypophosphatemia in not critically ill patients with enteral feeding

Introducción: se ha descrito una incidencia de hipofosfatemia en pacientes con soporte nutricional especializado (SNE) de hasta el 30-40%. La hipofosfatemia leve y la moderada son generalmente asintomáticas, mientras que la severa es el hecho fundamental del síndrome de realimentación. Objetivo: evaluar la incidencia y gravedad de la hipofosfatemia en pacientes hospitalizados no críticos con nutrición enteral (NE). Material y métodos: se diseñó un estudio observacional y prospectivo en condiciones de práctica clínica habitual. Se recogieron datos clínicos, antropométricos y analíticos de 181 pacientes a los que se les inició nutrición enteral. El seguimiento fue de siete días. Resultados: el 51,9% de los pacientes estaban en riesgo de desarrollar síndrome de realimentación según las guías del United Kingdom National Institute for Health and Clinical Excellence (NICE). La incidencia de hipofosfatemia fue del 31,5% y la de la hipofosfatemia severa, del 1,1%. De todos los parámetros clínicos, antropométricos y analíticos analizados, solo la edad y unas proteínas séricas más bajas se correlacionaron de forma estadísticamente significativa con el aumento en la incidencia de hipofosfatemia. Conclusión: la incidencia de hipofosfatemia grave en nuestra serie es muy baja, lo que hace imposible extraer conclusiones específicas para este grupo de pacientes (AU)

Background: Up to 30-40% of the patients starting artificial nutritional support develop hypophosphatemia. In general, patients with mild and moderate hypophosphatemia do not have symptoms, but severe hypophosphatemia is the hallmark of refeeding syndrome. Aim: To determine the incidence of hypophosphatemia in not critically ill patients receiving enteral feeding. Material and methods: Prospective study. We assessed during seven days 181 not critically ill patients started on enteral artificial nutrition support during seven days. Results: 51.9% of the patients were considered to be at risk of developing refeeding syndrome (United Kingdom National Institute for Health and Clinical Excellence criteria). The incidence of hypophosphatemia was 31.5%, but only 1.1% of the patients developed severe hypophosphatemia. Older age and lower plasma proteins were significantly associated with hypophosphatemia. Conclusion: The incidence of severe hypophosphatemia in our study is low, so we can’t offer robust conclusions about the risk of hypophosphatemia in the type of patients receiving enteral nutrition (AU)

The two sides of superior mesenteric artery syndrome treatment: conservative or surgical management? / Las dos caras del tratamiento del síndrome de la arteria mesentérica superior: ¿manejo conservador o quirúrgico?

Introduction: Superior mesenteric artery syndrome (SMAS) is a rare condition characterized by vascular compression of the duodenum. There is controversy regarding the optimal treatment. Case report: In case 1, we describe the case of a 21-year-old woman (body mass index [BMI] 16.9 kg/m2) with high-level obstructive symptoms three months prior, with computed tomography scan (TC) showing a superior mesenteric artery aorta angle (SMAA) of 13° and compression of the third portion of the duodenum (D3), for this reason a nasojejunal tube was placed for enteral feeding. In case 2, enteral nutrition was initiated for feeding a 17-year-old female with anorexia nervosa (BMI 8.3 kg/m2). She presented macrohematuria, vomiting, epigastralgia, abdominal distension and acute abdomen when oral feeding was reinitiated. TC reported a SMAA of 15°, in addition to compression of the left renal vein (Nutcracker syndrome) and gastro duodenal expansion, surgical management was necessary. Discussion: Both cases had favorable evolution, being the nutritional support fundamental. SMAS should be suspected in all people with high-level obstructive symptoms and recent weight loss (AU)

Introducción: el síndrome de la arteria mesentérica superior (SAMS) es una condición rara caracterizada por la compresión vascular del duodeno, y existe controversia acerca de su tratamiento. Caso clínico: en el caso 1, presentamos a una mujer de 21 años (índice de masa corporal [IMC] 16,9 kg/m2) con datos de obstrucción alta y epigastralgia durante los tres meses previos, con tomografía computarizada (TC) que reporta ángulo de la arteria mesentérica superior (AAMS) de 13° y compresión de D3. Se colocó sonda nasoyeyunal para alimentarla. En el caso 2, se inició alimentación enteral por sonda nasogástrica en una mujer de 17 años con anorexia nerviosa (IMC 8,3 kg/m2). Al reiniciar la vía oral presentó hematuria, vómito, epigastralgia, distensión abdominal y abdomen agudo. La TC reportó AAMS 15°, compresión de la vena renal izquierda (síndrome de Nutcracker) y distensión gastroduodenal. Requirió tratamiento quirúrgico. Discusión: ambas pacientes tuvieron evolución favorable, siendo fundamental el soporte nutricional. Se debe sospechar el SAMS en los pacientes con datos de obstrucción intestinal alta y pérdida de peso reciente (AU)

O papel da dieta na etiologia da endometriose / The role of diet in the etiology of endometriosis

Introdução: A endometriose é uma condição inflamatória crônica e hormônio-dependente. Fatores genéticos, imunológicos e ambientais podem estar implicados na patogênese da endometriose. Nesse sentido, esse estudo tem por objetivo descrever o papel da dieta na etiologia da endometriose. Método: Foi realizada uma busca eletrônica no PubMed, no período entre 1 de janeiro de 2012 e 31 de dezembro de 2016, empregando os termos "endometriosis and diet" e "endometriosis and food". Os critérios de inclusão foram: relação direta com o tema, publicação no idioma inglês, disponibilidade da versão completa do artigo e artigo original/pesquisa. Foram selecionadas 12 publicações que cumpriram os critérios previamente estabelecidos. Resultados: Houve predomínio de estudos que avaliaram a contribuição de ácidos graxos poli-insaturados para o desenvolvimento da endometriose (6/12), seguido pelas vitaminas B, C, D, E, cálcio e magnésio (4/12) e apenas dois artigos investigaram xantohumol e café/cafeína, sendo um artigo cada. A maioria desses compostos atuou na redução das lesões endometriais, uma vez que exibiram efeitos anti-inflamatório e antiangiogênico e são antioxidantes. No entanto, as pesquisas foram conduzidas em modelos animais e, apesar dos achados promissores, é necessário cautela ao extrapolar os resultados para o estudo da endometriose em humanos. Conclusões: Foi demonstrado um papel significativo da dieta no desenvolvimento e progressão da endometriose, sendo que a maioria exibe efeito protetor. Nesse sentido, é pertinente, adequado e justificável o acompanhamento nutricional às pacientes portadoras de endometriose.

Introduction: Endometriosis is a chronic inflammatory condition and hormone dependent. Genetic, immunological, and environmental factors may be implicated in the pathogenesis of endometriosis. Thus, this study aims to describe the role of diet in the etiology of endometriosis. Methods: An electronic search was conducted in PubMed in the period from January 1, 2012 to December 31, 2016, using the terms "endometriosis and diet" and "endometriosis and food." Inclusion criteria were directly related to the subject, published in English, availability of the full version of the article and original/research article. We selected 12 publications that met the criteria previously established. Results: There was a predominance of studies have evaluated the contribution of polyunsaturated fatty acids for the development of endometriosis (6/12) followed by vitamins B, C, D, E, calcium, and magnesium (4/12) and only two articles investigated xantohumol and coffee/caffeine, one article each. Most of these compounds reduced endometrial lesions once they exhibit effects anti-inflammatory, anti-angiogenic and are antioxidants. However, studies were conducted in animal models and despite the promising findings, it is necessary to exercise caution when extrapolating the results for the study of endometriosis in humans. Conclusions: A significant role of diet in the development and progression of endometriosis was demonstrated, most of which exhibits a protective effect. In this sense, it is relevant, appropriate, and justifiable nutritional monitoring of patients with endometriosis.

Self-Expanding Metal Stents Improve Swallowing and Maintain Nutrition During Neoadjuvant Therapy for Esophageal Cancer.

BACKGROUND: Patients with locally advanced esophageal cancer can have significant dysphagia. Nutritional support during neoadjuvant therapy is often delivered via nasoenteric or percutaneous feeding tubes. These approaches do not allow for per-oral feeding. AIMS: Evaluate the safety and efficacy of fully covered self-expanding metal esophageal stents for nutritional support during neoadjuvant therapy. METHODS: This was a pilot, prospective study at a single tertiary center. From March 2012 to May 2013, consecutive patients with esophageal cancer eligible for neoadjuvant therapy were enrolled. Metal stents were placed prior to starting neoadjuvant therapy. Data were collected at baseline and predetermined intervals until an endpoint (surgery or disease progression). Outcomes included dysphagia grade, satisfaction of swallowing score, nutritional status (weight, serum albumin), impact on surgery, and adverse events. RESULTS: Fourteen stents were placed in 12 patients (59.1 ± 9.5 years, 11 men, 1 woman). Dysphagia grade (pre 3.4 ± 0.5 vs post 0.2 ± 0.4, p < 0.0001) and swallowing scores (20.2 ± 5.9 vs 6.3 ± 4.7, p < 0.0001) significantly improved after stent placement. Improvements were sustained throughout neoadjuvant therapy. Body weight and serum albumin levels remained stable. Adverse events included severe chest pain (2), food impaction (1), and delayed stent migration (2). Five patients underwent surgical resection. No significant chemoradiation or operative adverse events occurred due to the presence of a stent. CONCLUSIONS: During neoadjuvant therapy for esophageal cancer, self-expanding metal stents are safe and effective in relieving dysphagia and maintaining nutrition. They allow patients to eat orally, thereby improving patient satisfaction. The presence of an in situ stent did not interfere with surgery.

Meta proteica versus disfunção renal na Unidade de Terapia Intensiva / Protein goal and renal dysfunction in the Intensive Care Unit

Introdução: As atuais recomendações de oferta proteica para o doente crítico orientam uma grande quantidade, sendo a orientação entre 1,2 e 2,0 g/kg/dia. Todavia, os grandes estudos demonstram que esta oferta proteica não é atingida, trazendo prejuízos à evolução dos pacientes. A utilização de uma oferta proteica alta frente a uma disfunção renal instalada também é tema de discussão na condução da terapia nutricional. Objetivo: Este artigo busca discutir os principais pontos dos estudos atuais relacionados ao tema. Método: Foram avaliados artigos de 2010 até 2016, na base de dados PubMed e LILACS, que relatavam a oferta proteica oferecida aos doentes críticos, embora nem sempre este fosse o principal dado do estudo. Resultados: A maioria dos estudos tinha desenho observacional, sendo possível notar que, em grande parte destes estudos, a oferta proteica mínima recomendada não foi atingida, tanto no grupo intervenção como controle. Outro ponto importante é que com o aumento da oferta para 1,5 g/kg/dia a 2 g/kg/dia ocorre aumento significativo do balanço nitrogenado, sem alterar a função renal. Não foram encontrados estudos randomizados que mostrem melhora do desfecho com uma oferta proteica mais elevada. Conclusões: Pacientes críticos apresentam geralmente elevado catabolismo proteico, desta forma existe um racional de recomendação de elevada oferta proteica. Entretanto, a maioria dos estudos mostra que tal recomendação não é cumprida na prática clínica. Dúvidas persistem em relação à meta proteica, particularmente na primeira semana da doença grave de pacientes com lesão renal aguda.(AU)

Introduction: The current recommendations of protein supply for the critical patient guide a great quantity, being the orientation between 1.2 and 2.0 g/kg/day. However, the large studies show that this protein supply is not reached, bringing losses to the evolution of the patients. The use of a high protein supply facing an established renal dysfunction is also a topic of discussion in the conduction of nutritional therapy. Objective: This article aims to discuss the main points of the current studies related to the theme. Methods: Articles from 2010 to 2016 were evaluated in the PubMed and LILACS databases, which reported the protein supply offered to critically ill patients, although this was not always the main data of the study. Results: Most of the studies had an observational design, being possible to observe that in the majority of these studies, the recommended minimum protein supply was not reached, both in the intervention and in the control group. Another important point is that with the increasing supply to 1.5 g/kg/day at 2 g/kg/day there is a significant increase in the nitrogen balance, without altering renal function. No randomized trials were found to show improvement in outcome with a higher protein supply. Conclusions: Critical ill patients generally present high protein catabolism in thus there is a rational recommendation of high protein supply. However,the majority of the studies show that this recommendation is not fulfilled in clinical practice. Doubts persist regarding the protein target, particularly in the first week of severe disease in patients with acute kidney injury.(AU)

Nutritional/Growth Status in a Large Cohort of Medically Fragile Children Receiving Long-Term Enteral Nutrition Support.

OBJECTIVE: The aim of the present study was to assess the nutritional status and growth of medically fragile children receiving long-term enteral nutritional support (ENS). METHODS: A retrospective cross-sectional survey was conducted at a tertiary-level pediatric hospital. Growth features and nutritional intake of children (n = 287) receiving ENS were evaluated. During a period of 5 years (2009-2013), study patients in the age group of 1 to 36 months had been referred for the explicit reason of tube weaning. Data were documented with the help of ARCHIMED (version 46.2) and analyzed using SPSS for Windows version 21. Nutritional/growth status was determined by using World Health Organization growth standard tables. RESULTS: Anthropometric parameters of children were compared with World Health Organization standards, and the prevalence of underweight, wasting, and stunting was very high despite being exclusively or predominantly on ENS. Results revealed that the age of a child, inadequate amount of caloric supply/day, the diagnosis of small-for-gestational age, and the type of tube (nasogastric tube) were significantly associated with growth/nutritional status (P < 0.05). Duration of ENS in the percentage of the cohort's lifetime and the main diagnosis were not associated with nutritional/growth outcomes. CONCLUSIONS: In medically fragile children, ENS does not ensure adequate growth per se. ENS requires highly specialized and individually tailored management and in many cases regular adjustments. Long-term tube feeding plans often seem unable to ensure the required amount of nutritional support, which surely compromise the individual efficacy of ENS.

Perfil, critérios de indicação e desfecho da inserção de gastrostomia em um hospital pediátrico universitário / Profile, recommendation criteria, and outcome of gastrostomy tube insertions in a pediatric teaching hospital

Objetivo: Descrever o perfil dos pacientes submetidos à gastrostomia, os critérios de indicação e o desfecho dessa inserção em um hospital pediátrico universitário. Método: Estudo retrospectivo, quantitativo e descritivo, através de pesquisa em prontuários de pacientes submetidos à gastrostomia no período entre janeiro/2010 e dezembro/2012. Resultados: As doenças e condições de base mais frequentes foram: encefalopatia crônica da infância (77,5%), pneumonia (67,5%), crise convulsiva (57,5%) e desnutrição (42,5%). Apesar da maioria dos pacientes apresentar história de disfagia (62,5%), observou-se como via de nutrição mais frequente antes da inserção da gastrostomia a via oral (42,5%), seguida pela nasoenteral (40%). A introdução de dieta pela gastrostomia foi bem sucedida e ocorreu em média 2,82(± 1,19) dias após a sua inserção. Após seis meses de realização da gastrostomia, 80% dos pacientes permaneceram alimentando-se exclusivamente através desta via e somente 2,5% retirou a gastrostomia. 45% dos participantes apresentaram complicações da gastrostomia, sendo extravasamento do material gástrico (15%) e inflamação local (15%) as mais frequentes. Conclusão: O perfil dos pacientes submetidos à gastrostomia é de indivíduos, em sua maioria, com doença neurológica e respiratória, sem suporte respiratório, do sexo masculino e alimentando-se por via oral ou sonda nasoenteral por período prolongado. Os principais critérios de indicação foram doença neurológica e disfagia. Em relação ao desfecho, a introdução de dieta pela gastrostomia é bem sucedida, a maioria dos indivíduos permanece com este suporte nutricional a longo prazo e as complicações mais frequentes são extravasamento do material gástrico e inflamações na área da gastrostomia.

Objective: To describe the profile of patients undergoing a gastrostomy, the recommendations and outcome of this insertion in a Pediatric Teaching Hospital. Method: This was a retrospective, quantitative, and descriptive study that researched the records of patients who underwent a gastrostomy between January 2010 and December 2012. Results: The diseases and conditions most frequent were chronic infantile encephalopathy (77.5%), pneumonia (67.5%), seizures (57.5%), and malnutrition (42.5%). Although most patients presented a history of dysphagia (62.5%), oral feeding was observed most frequently as the most common form of nutrition, before the gastrostomy insertion (42.5%), followed by nasoenteric tube (40%). The introduction of nutrition by gastrostomy was successful and occurred an average of 2.82 (± 1.19) days after insertion. Six months after their gastrostomy, 80% of patients continued feeding only through this access tube and only 2.5% had removed the gastrostomy; 45% of the participants had gastrostomy complications, with extravasation of gastric material (15%) and local inflammation (15%) being the most frequent. Conclusion: The profile of patients undergoing gastrostomy is mostly of individuals with neurological and respiratory diseases, without respiratory support, of the male gender, and feeding by oral cavity or nasoenteric tube for a prolonged period. The main recommendation criteria were dysphagia and neurological diseases. Regarding the outcome, the introduction of nutrition by gastrostomy was successful; most individuals remained with this long-term nutritional support and the most common complications were gastric material extravasation and local inflammations.

Migrability of PVC plasticizers from medical devices into a simulant of infused solutions.

Medical devices (MD) for infusion and artificial nutrition are essentially made of plasticized PVC. The plasticizers in the PVC matrix can leach out into the infused solutions and may enter into contact with the patients. In order to assess the risk of patient exposure to these plasticizers we evaluated the migration performance of DEHP, DEHT, DINCH, and TOTM using a model adapted to the clinical use of the MDs. Each PVC tubing sample was immersed in a simulant consisting of a mixture of ethanol/water (50/50v/v) at 40°C and migration tests were carried out after 24h, 72h, and 10 days.DEHP had the highest migration ability, which increased over time. The amount of TOTM released was more than 20 times less than that of DEHP, which makes it an interesting alternative. DEHT is also promising, with a migration level three times smaller than DEHP. However, the migration ability of DINCH was similar to DEHP, with the released amounts equaling 1/8th of the initial amount in the tubing after 24h of contact. Taking into account the available toxicological data, TOTM and DEHT appear to be of particular interest. However, these data should be supplemented and correlated with clinical and toxicological studies on plasticizers and their metabolites.

Intake of energy and nutrients; harmonization of Food Composition Databases

Food composition databases (FCDBs) provide detailed information about the nutritional composition of foods. The conversion of food consumption into nutrient intake need a Food composition database (FCDB) which lists the mean nutritional values for a given food portion. The limitations of FCDBs are sometimes little known by the users. Multicentre studies have raised several methodology challenges which allow to standardize nutritional assessments in different populations and geographical areas for food composition and nutrient intake. Differences between FCDBs include those attributed to technical matters, such as description of foods, calculation of energy and definition of nutrients, analytical methods, and principles for recipe calculation. Such differences need to be identified and eliminated before comparing data from different studies, especially when dietary data is related to a health outcome. There are ongoing efforts since 1984 to standardize FCDBs over the world (INFOODS, EPIC, EuroFIR, etc.). Food composition data can be gathered from different sources like private company analysis, universities, government laboratories and food industry. They can also be borrowed from scientific literature or even from the food labelling. There are different proposals to evaluate the quality of food composition data. For the development of a FCDB it is fundamental document in the most detailed way, each of the data values of the different components and nutrients of a food. The objective of AECOSAN (Agencia Española de Consumo Seguridad Alimentaria y Nutrición) and BEDCA (Base de Datos Española de Composición de Alimentos) association was the development and support of a reference FCDB in Spain according to the standards to be defined in Europe. BEDCA is currently the only FCDB developed in Spain with compiled and documented data following EuroFIR standards (AU)

La conversión de consumo de alimentos a ingesta de nutrientes necesita una base de datos de composición de alimentos (FCDB) que recoge los valores nutricionales medios de una porción dada de alimento. Las limitaciones de las FCDBs son, en ocasiones, poco conocidas por los usuarios. Los estudios multicéntricos han planteados varios retos metodológicos que permitan estandarizar la composición de alimentos y la ingesta de nutrientes para la evaluación nutricional en diferentes poblaciones y áreas geográficas. Las diferencias entre FCDBs incluyen las atribuibles a aspectos técnicos, como la descripción de los alimentos, cálculo de energía y definición de los nutrientes, métodos analíticos y principios para el cálculo de recetas. Estas diferencias necesitan ser identificadas y eliminadas antes de comparar los datos obtenidos de diferentes estudios, especialmente cuando dichos datos dietéticos se relacionan con resultados de salud. Desde 1984 se han realizado diversas iniciativas para estandarizar los FCDBs en el mundo (INFOOD, EPIC, EUROFIR, etc.). Los datos de composición de alimentos pueden ser obtenidos de diferentes fuentes como análisis de empresas privadas, universidades, laboratorios gubernamentales e industria alimentaria. También pueden tomarse prestados de la literatura científica o incluso del etiquetado nutricional. Existen diferentes propuestas para evaluar la calidad de los datos de composición de alimentos. Para el desarrollo de una FCDB es fundamental documentar, lo más detallado posible, cada uno de los valores de los diferentes componentes y nutrientes de un alimento. El objetivo de la AECOSAN y la asociación BEDCA fue el desarrollo y mantenimiento en España de una FCDB de acuerdo con los estándares definidos para Europa. BEDCA es actualmente la única FCDB desarrollada en España con datos compilados y documentados siguiendo los estándares de EuroFIR (AU)

Gráfica alimentaria para la población bariátrica argentina / Nutritional graph for Argentina’s bariatric population

Introducción: Una gráfica alimentaria es una guía que ayuda a los individuos a controlar y a mejorar la calidad de su alimentación; ofrece pautas sobre lo que debe comer una determinada población en términos de alimentos dando un marco para la correcta selección de los nutrientes a consumir. Objetivo: El objetivo de la presente publicación fue crear una herramienta de educación alimentaria destinada a pacientes de cirugía bariátrica para el postoperatorio en el largo plazo. Métodos: Se convocó a participar en mesas de trabajo a licenciados en nutrición y médicos especialistas en nutrición en un congreso realizado en el 2011. Se tomó como base científica el Primer Consenso Argentino de Nutrición en Cirugía Bariátrica y las «Guías alimentarias para la Población Argentina normal». De esta forma se adapta la misma a la población argentina con cirugía bariátrica sumada a la experiencia de los profesionales. Resultado: Como resultado se obtuvo un gráfica alimentaria en forma de óvalo, adaptación de la gráfica de las «Guías alimentarias para la población argentina», 12 mensajes o recomendaciones dirigidas a individuos con CB, una sugerencia de menú que responde a un valor calórico promedio de 1.273 calorías diarias, 145 g de carbohidratos, 76 g de proteínas y 43,2 g de grasas; 45,5% de calorías proveniente de los carbohidratos, 24% de calorías proveniente de las proteínas y 30,5 % de calorías proveniente de las grasas, 1.160 mg de calcio (AU)

Introduction: A food graph is a guide that helps individuals controlling and improving their feeding quality; it provides recommendations on what should a particular population eat with a correct selection of the nutrients to be consumed. Objective: The aim of this publication was to create a food education tool for bariatric surgery patients in the long run of the post-surgical period. Methods: Graduates in nutrition and physicians specialized in nutrition were invited to participate in workshops at a meeting that took place in 2011. The scientific bases were the First Argentinean Consensus on Nutrition in Bariatric Surgery and the Feeding Guidelines for Normal Argentinean Population. In this way, these guidelines are adapted to the Argentinean population submitted to bariatric surgery, together with the experience of the healthcare professionals. Result: This yielded an oval-shaped food graph, an adaptation of the Feeding Guidelines for Normal Argentinean Population, 12 messages or recommendations focused on individuals with bariatric surgery, a recommended menu with a mean energetic value of 1,273 calories per day, 145 g of carbohydrates, 76 g of proteins and 43.2 g of fat; 45.5% of the calories coming from carbohydrates, 24% from proteins, and 30.5% from fat, with 1,160 mg of calcium (AU)