Prognostic value of energy expenditure and respiratory quotient measuring in patients with liver cirrhosis.

BACKGROUND & AIMS: Resting energy expenditure (REE) and respiratory quotient (RQ) as measured by indirect calorimetry (IC) may correlate with muscle mass and represent prognostic indicators in treating patients with liver cirrhosis. We aimed to assess the correlation of IC-measured REE and RQ with skeletal muscle mass (SM), mortality, and REE values as estimated by Harris-Benedict, European guidelines (EG), and Brazilian guidelines-DITEN (BG) equations in patients with liver cirrhosis. METHODS: In this prospectively designed study, REE was measured in 126 male patients with liver cirrhosis by IC and predicted by Harris-Benedict, EG (35 kcal/kg current weight), and BG (30 kcal/kg current weight) guidelines. Measurements were obtained at the time of admission to the study. Body composition was determined by whole-body dual-energy X-ray absorptiometry. The association between REE and 3-year survival was investigated. RESULTS: Cirrhosis etiology was classified as alcohol related (59.0%), viral (20.1%), cryptogenic (11.8%), or other (9.0%). Mean Child-Pugh and MELD indexes were 8.30 ± 2.0 and 14.38 ± 6.12, respectively. RQ showed a moderate correlation with SM (r = 0.64), while IC-measured REE was inversely associated with mortality (multivariate Cox Regression, HR = 0.88, 95% CI: 0.78; 1, p = 0.04). Among the predictive equations for REE, only Harris-Benedict yielded values close to the IC, with a positive Pearson correlation (r = 0.77), excellent accuracy (Cb = 0.98), and positive Lin's concordance correlation (CCC = 0.75). However, a large standard deviation was observed; HB-measured REE did not correlate with mortality. CONCLUSIONS: RQ and REE, as measured by IC, may be valuable tools for evaluating the severity of cirrhosis, by reflecting SM and predicting mortality, respectively. The predictive equations for REE included in this study cannot replace IC for this purpose. REGISTERED AT: www.clinicalTrials.gov (NCT02421848).

Home parenteral nutrition program and referral of potential candidates for intestinal and multivisceral transplantation in a single Brazilian center.

Intestinal failure is a multifaceted condition that may require high-complexity treatment and a multidisciplinary program, including home parenteral nutrition therapy (HPNT) and intestinal transplantation. In this article, we profile a Brazilian single-center experience with 128 cases of HTPN followed for the last 30 years and appraise the referral for potential intestinal and multivisceral transplantation.

[Hospital hyponutrition]. / Desnutrición hospitalaria.

Identifying hyponutrition is essential at the hospital setting to avoid or minimize the impact on the patients' clinical course and its association with more severe complications, longer hospital staying, and increased mortality, and all of this is associated with increased costs for the institution and the society. The aims of this study were to disbelieve the epidemiology of hospital hyponutrition, the types of hyponutrition, the body response to fasting, the clinical course of the patient with hyponutrition and the consequences of hyponutrition in the different live stages and, thus, we carried out a review on hospital hyponutrition. We found that hyponutrition prevalence is high in the hospital setting, hyponutrition influences genetic, metabolic, and hormonal factors of the human being and leads to harmful effects from the intrauterine fetal development until the adulthood. There are also different types of hyponutrition, the differentiation being important to decide the best therapy. We also found that hyponutrition is related to inflammation. When inflammation is chronic and mild to moderate (such as in organ failure, pancreatic cancer, obesity, rheumatoid or sarcopenic arthritis), the term "hyponutrition-related chronic disease", and when inflammation is acute and severe (severe infection, burns, trauma or head trauma), the preferred term is "hyponutrition-related acute disease or hyponutrition-related lesions". Finally, the patient with hyponutrition has worse clinical course than the patient with an appropriate nutritional status.

Cell activation state influences the modulation of HLA-DR surface expression on human monocytes/macrophages by parenteral fish oil lipid emulsion.

Abnormal surface expression of HLA-DR by leukocytes is associated with a poor prognosis in critical care patients. Critical care patients often receive total parenteral nutrition with lipid emulsion (LE). In this study we evaluated the influence of fish oil LE (FO) on human monocyte/macrophage (Mφ) expression of surface HLA-DR under distinct activation states. Mononuclear leukocytes from the peripheral blood of healthy volunteers (n=18) were cultured for 24 hours without LE (control) or with 3 different concentrations (0.1, 0.25, and 0.5%) of the follow LE: a) pure FO b) FO in association (1:1-v/v) with LE composed of 50% medium-chain trygliceride and 50% soybean oil (MCTSO), and c) pure MCTSO. The leukocytes were also submitted to different cell activation states, as determinate by addition time: no INF-γ addition, 18 hours before, or at the time of LE addition. HLA-DR expression on Mφ surface was evaluated by flow cytometry using specific monoclonal antibodies. In relation to controls (for 0.1%, 0.25%, and 0.5%: 100) FO decreased the expression of HLA-DR when added alone [in simultaneously-activated Mφ, for 0.1%: 70 (59 ± 73); for 0.25%: 51 (48 ± 56); and for 0.5%: 52.5 (50 ± 58)] or in association with MCTSO [in simultaneously-activated Mφ, for 0.1%: 50.5 (47 ± 61); for 25%: 49 (45 ± 52); and for 0.5%: 51 (44 ± 54) and in previously-activated Mf, for 1.0%: 63 (44 ± 88); for 0.25%: 70 (41 ± 88); and for 0.5%: 59.5 (39 ± 79)] in culture medium (Friedman p < 0.05). In relation to controls (for 0.1%, 0.25%, and 0.5%: 100), FO did not influence the expression of these molecules on non-activated Mφ [for 0.1%: 87.5 (75±93); for 0.25%: 111 (98 ± 118); and for 0.5%: 101.5 (84 ± 113)]. Results show that parenteral FO modulates the expression of HLA-DR on human Mφ surface accordingly to leukocyte activation state. Further clinical studies evaluating the ideal moment of fish oil LE infusion to modulate leukocyte functions may contribute to a better understanding of its immune modulatory properties.

Amino acids change liver growth factors gene expression in malnourished rats.

BACKGROUND: Glutamine and proline are metabolized the liver and may collaborate on its regeneration. Parenteral nutrition (PN) containing either glutamine or proline was given to partially hepatectomized rats. The total RNA content and growth factor gene expression in hepatic remnants was measured, to determine the effects of these amino acid supplementation on the expression of growth factors during liver regeneration. METHODS: Wistar rats nourished (HN) and malnourished (HM) were hepatectomized and divided in two groups: 20 receiving PN enriched with Alanyl-Glutamine (HN-Gln and HM-Gln) and 20 PN enriched with proline+alanine (HN-Pro and HM-Pro). The control groups comprised 7 nourished (CN) and 7 malnourished (CM) rats that didn't undergo surgery. Growth factor and thymidine kinase mRNA levels were measured by RT-PCR. RESULTS: In nourished rats, total hepatic RNA levels were lower in the HN-Gln and HN-Pro groups (0.75 and 0.63 microg/mg tissue, respectively) than in control group (1.67 microg/mg tissue) (P<0.05). In malnourished rats, total hepatic RNA content was higher in the HM-Pro group than HN-Pro, HM-Gln, and CM (3.18 vs. 0.63, 0.93 and 1.10 microg/mg, respectively; P<0.05). Hepatocyte growth factor mRNA was more abundant in the HM-Gln group when compared to CM (0.31 vs. 0.23 arbitrary units) and also in HM-Pro in relation to HM-Gln, HN-Pro, and CM(0.46 vs. 0.33 and 0.23, respectively, P<0.05). CONCLUSIONS: Proline or glutamine supplementation in malnourished rats improves total RNA content in the remnant hepatic tissue. Amino acids administration increased HGF gene expression after partial hepatectomy in malnourished rats, with a greater effect of proline than glutamine.

Cell activation state influences the modulation of HLA-DR surface expression on human monocytes/macrophages by parenteral fish oil lipid emulsion.

Abnormal surface expression of HLA-DR by leukocytes is associated with a poor prognosis in critical care patients. Critical care patients often receive total parenteral nutrition with lipid emulsion (LE). In this study we evaluated the influence of fish oil LE (FO) on human monocyte/macrophage (Mphi) expression of surface HLA-DR under distinct activation states. Mononuclear leukocytes from the peripheral blood of healthy volunteers (n=18) were cultured for 24 hours without LE (control) or with 3 different concentrations (0.1, 0.25, and 0.5%) of the follow LE: a) pure FO b) FO in association (1:1-v/v) with LE composed of 50% medium chain triglyceride and 50% soybean oil (MCTSO), and c) pure MCTSO. The leukocytes were also submitted to different cell activation states, as determinate by INF-gamma addition time: no INF-gamma addition, 18 hours before, or at the time of LE addition. HLA-DR expression on Mphi surface was evaluated by flow cytometry using specific monoclonal antibodies. In relation to controls (for 0.1%, 0.25%, and 0.5%: 100) FO decreased the expression of HLA-DR when added alone [in simultaneously-activated Mphi, for 0.1%: 70 (59+/-73); for 0.25%: 51 (48+/-56); and for 0.5%: 52.5 (50+/-58)] or in association with MCTSO [in simultaneously-activated Mphi, for 0.1%: 50.5 (47+/-61); for 25%: 49 (45+/-52); and for 0.5%: 51 (44+/-54) and in previously-activated Mphi, for 1.0%: 63 (44+/-88); for 0.25%: 70 (41+/-88); and for 0.5%: 59.5 (39+/-79)] in culture medium (Friedman p<0.05). In relation to controls (for 0.1%, 0.25%, and 0.5%: 100), FO did not influence the expression of these molecules on non-activated Mphi [for 0.1%: 87.5 (75+/-93); for 0.25%: 111 (98+/-118); and for 0.5%: 101.5 (84+/-113)]. Results show that parenteral FO modulates the expression of HLA-DR on human Mphi surface accordingly to leukocyte activation state. Further clinical studies evaluating the ideal moment of fish oil LE infusion to modulate leukocyte functions may contribute to a better understanding of its immune modulatory properties.

Resting energy expenditure in white and non-white severely obese women.

This study aimed to compare the resting energy expenditure (REE) of white and non-white severely obese Brazilian women. REE was examined in 83 severely obese Brazilian women (n = 58 white and 25 non-white) with mean (+/- SD) age 42.99 +/- 11.35 and body mass index 46.88 +/- 6.22 kg/m(2) who were candidates for gastric bypass surgery. Body composition was assessed by air displacement plethysmography (ADP) BOD PODO body composition system (Life Measurement Instruments, Concord, CA) and REE was measured, under established protocol, with an open-circuit calorimeter (Deltatrac II MBM-200, Datex-Ohmeda, Madison, WI, USA). There was no significant difference between the REE of white and non-white severely obese women (1,953 +/- 273 and 1,906 +/- 271 kcal/d, respectively; p = 0.48). However, when adjusted for fat free mass (MLG), REE was significantly higher in nonwhite severely obese women (difference between groups of 158.4 kcal, p < 0.01). REE in white women was positively and significantly correlated to C-reactive protein (PCR) (r = 0.418; P < 0.001) and MLG (r = 0.771; P < 0.001). In the non-white women, REE was only significantly correlated to MLG (r = 0.753; P < 0.001). The multiple linear regression analysis showed that skin color, MLG and PCR were the significant determinants of REE (R(2) = 0.55). This study showed that, after adjustment for MLG, non-white severely obese women have a higher REE than the white ones. The association of body composition inflammation factors and REE in severely obese Brazilian women remains to be further investigated.

Detection of nosocomial malnutrition is improved in Amazon region by a standard clinical nutrition education program.

BACKGROUND: In Brazil hospital malnutrition is highly prevalent, physician awareness of malnutrition is low, and nutrition therapy is underprescribed. One alternative to approach this problem is to educate health care providers in clinical nutrition. The present study aims to evaluate the effect of an intensive education course given to health care professionals and students on the diagnosis ability concerning to hospital malnutrition. MATERIALS AND METHODS: An intervention study, based on a clinical nutrition educational program, offered to medical and nursing students and professionals, was held in a hospital of the Amazon region. Participants were evaluated through improvement of diagnostic ability, according to agreement of malnutrition diagnosis using Subjective Global Assessment before and after the workshop, as compared to independent evaluations (Kappa Index, k). To evaluate the impact of the educational intervention on the hospital malnutrition diagnosis, medical records were reviewed for documentation of parameters associated with nutritional status of in-patients. The SPSS statistical software package was used for data analysis. RESULTS: A total of 165 participants concluded the program. The majority (76.4%) were medical and nursing students. Malnutrition diagnosis improved after the course (before k = 0.5; after k = 0.64; p < 0.05). A reduction of false negatives from 50% to 33.3% was observed. During the course, concern of nutritional diagnosis was increased (chi2 = 17.57; p < 0.001) and even after the course, improvement on the height measurement was detected (chi2 = 12.87; p < 0.001). CONCLUSIONS: Clinical nutrition education improved the ability of diagnosing malnutrition; however the primary impact was on medical and nursing students. To sustain diagnostic capacity a clinical nutrition program should be part of health professional curricula and be coupled with continuing education for health care providers.

Nutritional recommendation alone does not change the obesity profile of health professionals.

OBJECTIVE: To evaluate the frequency of overweight and obesity in health professionals, before and after a single specialized dietary recommendation. METHODS: Anthropometric measures of 579 workers of a general hospital in the city of São Paulo, Brazil were taken. The weight (f), height (h) and waist circunference (wc) were interpreted according to the WHO and NCEP ATP III guidelines. Nutrition specialist provided dietary and behavioral recommendations. The entire sample underwent a new evaluation one year later. RESULTS: At the first evaluation, 79 employees presente WC > or = 102 cm (male) or WC > or = 88 cm (female). The association between WC > or = 102 cm (men) or WC > or = 88 cm (women) and BMI > or = 30 kg/m2 was found in 12.8% (69 subjects). The BMI distribution per age group indicated that the increase in overweight and obesity was directly proportional to the age increase. Physical activities were not practiced by 75% of the subjects studied. A year later, the evaluation indicated lack of statistical differences regarding the BMI and waist circumference of the sample and only 2.8% started to practice a physical activity. CONCLUSION: Dietary recommendation alone failed to promote changes in the eating habits of health professionals who work at a general hospital or to encourage them to practice exercise.

The impact of malnutrition on morbidity, mortality and length of hospital stay in trauma patients.

BACKGROUND AND AIM: To asses the nutritional status of hospitalised trauma patients and the repercussion on the clinical follow up. METHODS: In a prospective way 161 adult patients admitted to the units of Intensive Care (ICU), General Surgery, Maxillofacial Surgery and Orthopedics of the Centro de Emergencias Médicas in Asunción, Paraguay, from March 2002 to March 2004 were evaluated at admission by using the Subjective Global Assessment (SGA). Patients were followed to determine length of hospital stay, complications and in-hospital mortality. RESULTS: From the trauma patients median age was 27 (14-92) years and 94% were males. Most patients (74%) were from the countryside. The most frequent anatomic sites of trauma were: head 25%, thorax 16.6%, limbs 15.4%, abdomen 14%. The median Injury Severity Score (ISS) was 20 (1-39). From this population of patients, 40% were malnourished or at risk of malnutrition according to the SGA. Multivariate analysis identified as significant risk factors for mortality: malnutrition according to the SGA (p = 0.04, RR = 4 (1-15), and admission to the ICU (p = 0.0001, RR 53 (12-234). Risk factors for complications were malnutrition according to the SGA (p = 0.003, RR 2.9 (1.4-5.8) and ISS over 20 (p = 0.001, RR = 8.4 (2.3-29.9). The risk factors for length of stay were malnutrition according to the Subjective Global Assesment (p = 0.01, RR = 2.3 (1.2-4.7) and Injury Severity Score over 20, p = 0.03, RR = 2.8 (1-7.3). CONCLUSIONS: In the conditions of this study, malnutrition is frequent on admission in trauma patients, and is an independent risk factor for morbidity, mortality, and prolongs the length of hospitalisation. Efforts should be made to quickly assess the nutritional status of these patients and early start nutritional intervention.

[Clinical nutrition knowledge in health care members of University Hospitals of Paraguay]. / Nivel de conocimiento en nutrición clínica en miembros del Equipo de Salud de Hospitales Universitarios del Paraguay.

BACKGROUND: Adequate clinical nutrition care is an integral part of the complete treatment of hospitalised patients, requiring specific knowledge from the health care team. The aim of this study is to assess, in Paraguay, the health care team ability in clinical care nutrition. MATERIALS AND METHODS: A survey was made including 174 people of Paraguay university hospitals (29% physicians, 29% medicine graduating students, 11% pharmaceutics, 24% nurses, 7% dieticians), by answering voluntarily a multiple choice questionnaire of 20 items. RESULTS: The median score of the 20 questions was 6 (0-15). Physicians obtained a median of 6 (2-15), graduating students 7 (2-14), pharmaceutics 7 (0-15), nurses 3 (0-11), and dieticians 9 (4-13). The dieticians obtained a significantly higher score than the other groups (p < 0.005). CONCLUSIONS: The knowledge about clinical nutrition in the health care members from university hospitals is not adequate. The level of education in clinical nutrition is better in the dietician.

Nutritional intervention improves the caloric and proteic ingestion of head and neck cancer patients under radiotherapy.

Malnutrition is commonly associated with head and neck cancer, due especially to anorexia, which is aggravated by radiotherapy. The objective of this study was to evaluate modifications to nutritional ingestion following three types of nutritional intervention. Sixty-four male out-patients (62.1 +/- 1.5 years) were divided into three groups: oral group, (n=32) that received an adapted oral diet; feeding tube group, (n=16) under home enteral nutrition via a nasoenteral feeding tube (6x/day); and supplement group, (n=16) with oral diet associated to oral alimentary supplement between meals (3x/day). The groups were homogeneous and counseled to maintain a caloric ingestion of 40 kcal/kg. The diet for the oral group was adapted to the age and to the side effects of radiotherapyThe nutritional state of the three groups was evaluated for the caloric-proteic ingestion, anthropometric indicators (body weight, body mass index, triceps skinfold thickness, midarm muscle area), laboratorial indicators (total proteins, albumin, hematocrit, hemoglobin and total lymphocytes count), The results showed that all of the groups presented an increase in the ingestion of calories and proteins (p < 0.001). The nutritional therapy support for patients with head and neck cancer under radiotherapy, whether exclusive oral diet, enteral through a feeding tube, or with alimentary supplement associated to an oral diet achieved a significant increase in the total caloric ingestion. It is recommended that programs be implemented-to improve the ingestion of foods among these patients.

[Degree of nutritional training of intensive care physicians. A survey in public hospitals of Asunción]. / Nivel de formación en nutrición de médicos intensivistas. Encuesta en hospitales púiblicos de Asunción.

UNLABELLED: Nutritional support in the critically ill patient is an important mainstay within the specialty of intensive care medicine. Patients at the Intensive Care Unit (ICU) are usually hypercatabolic and require an adequate nutritional support. Usually, the intensive care physician prescribes nutrition type, its amount, and follow-up of patients; however, the qualification of these physicians regarding clinical nutrition is unknown. OBJECTIVE: to investigate the degree of knowledge on artificial nutrition and the interest on nutrition of intensive care physicians. METHODOLOGY: a prospective survey was done on 60 intensive care physicians from three public hospitals of Asunción (22 staff physicians and 38 internal residents), with a mean age of 34 +/- 6 years, and a mean professional practice of 5.8 +/- 6 years. The survey contained 10 questions and multiple-choice answers to determine the degree of knowledge depending on the grade obtained, and 5 questions on personal training and attitude towards nutritional support in the ICU. RESULTS: 98.3% of surveyed physicians considered that nutritional support of the ICU-admitted patient has an effect on morbidity and mortality of patients. Nevertheless, 88.3% of physicians considered their nutritional training in the ICU as insufficient. Seventy percent do not usually read papers on nutrition on scientific journals. Only 25% of them formulate parenteral nutrition, and 30% have attended a course on nutrition in the ICU within the last 5 years. The final grade for the 10 questions, the maximum grade possible being 10, was 6.1 +/- 1.9 for staff physicians, and 5.59 +/- 2.3 for internal residents (p = 0.3). When analyzing the correct answers by years of practice, the mean grade was 5.2 +/- 2.3 in those with less than 2 years of practice versus 6.4 +/- 1.7 in those with more than 2 years of practice (p = 0.02). CONCLUSIONS: nutritional training in intensive care medicine is incomplete and the degree of knowledge on nutrition in the critically ill patient is insufficient, being lower in physicians with a limited practice in the ICU. These results suggest the urgent need for training on clinical nutrition of intensive care physicians for the care of the critically ill patient being complete.

Diet and colorectal cancer: current evidence for etiology and prevention.

The etiology of colorectal cancer (CRC) involves the interaction of cell molecular changes and environmental factors, with a great emphasis on diet components. But the paths connecting lifestyle characteristicas and the colorectal carcinogenesis remain unclear. Several risk factors are commonly found in western diets, such as high concentrations of fat and animal protein, as well as low amounts of fiber, fruits and vegetables. A large number of experimental studies have found a counteractive effect of fiber on neoplasia induction, especially in relation to fermentable fiber (wheat bran and cellulose). Epidemiological correlation studies have also indicated that a greater ingestion of vegetables, fruit, cereal and seeds is associated to a lower risk for colorectal neoplasia. Moreover, beneficial properties of fiber (especially from vegetable sources) were documented in more than half of case-control studies. Nevertheless, recent epidemiological data from longitudinal and randomized trials tended not to support this influence. Future research should evaluate what sources of fiber provide effective anti-neoplasic protection, carrying out interventional studies with specific fibers for longer periods. Red meat, processed meats, and perhaps refines carbohydrates are also implicated in CRC risk. Recommendantions to decrease red meat intake are well accepted, although the total amount and composition of specific fatty acids may have distinct roles in this setting. Current evidence favors the substitution of long and medium-chain fatty acids and arachidonic acid for short-chain fatty acids and eicosapentaenoic acid. Excess boy weight and excess energy intake inducing hyperinsulinemia have been also associated to CRC, as well as personal habits such as physical inactivy, high alcohol consumption, smoking and low consumption of folate and methionine. Thus, current recommendations for decreasing the risk of CRC include dietary measures such as increased plant food intake; the consumption of whole grains, vegetables and fruits; and reduced red meat intake.

Pre-and postoperative nutritional evaluation in patients with chagasic megaesophagus.

Chagasic megaesophagus is a chronic disease that courses with progressive dysphagia, regurgitation and protein-calorie malnutrition. Advanced or recurrent megaesophagus can be treated with Serra Dória's operation (cardioplasty, partial gastrectomy and gastrojejunal Roux-en-Y anastomosis). A nutritional evaluation was performed on 27 patients (mean age 58 +/- 10 years) with chagasic megaesophagus at admission and after postoperative day 90. The nutritional state was assessed through global subjective nutritional evaluation (GSNE), anthropometry and laboratorial exams, besides the analysis of alimentary intake. In the preoperative period, GSNE pointed to malnutrition in 2/3 patients, while the anthropometric and laboratorial evaluation revealed that over 60% of the patients had protein-calorie malnutrition of the marasmic type. The preoperative nutritional state as evaluated by GSNE did not correlate with complications or postoperative mortality. The postoperative evaluation showed an increase in the intake of proteins, recovery in the body mass index and a reduction in the hemoglobin levels of the peripheral blood.

A proposal for clinical nutrition education for health care university students and professionals in the Amazon.

UNLABELLED: Changes in nutritional status are related to an increase in morbidity and mortality. It is well established that health care professionals, particularly physicians, lack formal education to recognize nutritional disorders, which malnutrition may worsen in the hospital, and that appropriate education could effectively correct this problem. AIM: To evaluate the awareness of the health care university students and professionals about the nutrition disorders in Amazon region hospitalized patients before and after a specific education program. STUDY DESIGN: An intensive Course on Clinical Nutrition, given in three weekly classes was offered to the multidisciplinary health care students and professionals of the health care tem. CASES AND METHODS: 195 participants started the course. They were 97 students of nursing, 52 students of medicine, 20 nurses, 15 resident physicians, 3 physicians, 3 dietitians, 2 others, 1 no answer. 165 participants concluded it. Precourse and postcourse tests were answered. The results of these tests are presented in this study. RESULTS AND DISCUSSION: 76.4% of the participants were graduation students. 40% of participants had no contact with patients yet. When the exposure of the participants of the course to the theme Nutrition was analyzed, 46.7% of the resident physicians considered

Nutritional assessment of adult patients admitted to a hospital of the Amazon region.

UNLABELLED: Changes in nutritional status are important in clinical practice because they relate to an increase in morbidity and mortality. Studies about nutritional problems in hospitalized adults have been reported since the 1970s. The prevalence of malnutrition has varied from 10 to 70%, depending on the diagnostic criteria used. The hospital studied and the duration of admission. AIM: To assess, in the first day of hospital stay, the nutritional status of adults admitted to undergo elective surgery in a public hospital of the State of Acre, Amazon Region, Brazil. STUDY DESIGN: Sectional study from April 7 to May 22, 2002. PATIENTS AND METHODS: 155 consecutive nutritional evaluations were performed using several parameters-global subjective assessment (GSA), anthropometric measurement and some laboratory tests. For the diagnosis of malnutrition the Index Suggestive of Malnutrition (ISM), as proposed by Waitzberg, was adopted. In the evaluation of obesity the BMI (Body Mass Index), with cutoffs suggested by WHO was used. RESULTS: 75.2% were women. Average age was 34.4 +/- 10.1 years. Mulatto (63.1%) was the prevailing racial group. Gynecological (43.6%) was the most frequent surgery. ISM disclosed a 12.1% prevalence of malnutrition. BMI classified 2.0% of the patients as grade I overweight and 15.4% as being obese. Among 76 patients classified as normal by BMI, 15 (19.7%) were considered malnourished by ISM criteria. Concordance between ISM and BMI was weak (k = 0.07). GSA classified 100% of the cases as well nourished. CONCLUSION: Lack of a golden standard to make the diagnosis of changes in nutritional status has been one of the determinants of the wide variations observed in the pertinent literature and it has hindered valid comparisons. The present study suggests that BMI should be used as an indicator of proportion and not of nutritional status. GSA underestimates the diagnosis of malnutrition. This paper concludes that establishing uniform standards for diagnostic criteria for malnutrition is urgently required and suggests preferring IMS (Index Suggestive of Malnutrition) because of its easy use, low coast and high sensitivity.

Pharmacological nutrition in inflammatory bowel diseases.

Inflammatory Bowel Diseases--ulcerative colitis and Crohn's disease--are chronic gastrointestinal inflammatory diseases of unknown etiology. Decreased oral intake, malabsorption, accelerated nutrient losses, increased requirements, and drug-nutrient interactions cause nutritional and functional deficiencies that require proper correction by nutritional therapy. The goals of the different forms of nutritional therapy are to correct nutritional disturbances and to modulate inflammatory response, thus influencing disease activity. Nutritional intervention may improve outcome in certain individuals; however, because of the costs and complications of such therapy, careful selection is warranted. Total parenteral nutrition has been used to correct and prevent nutritional disturbances and to promote bowel rest during active disease, mainly in cases of digestive fistulae with a high output. Its use should be reserved for patients who cannot tolerate enteral nutrition. Enteral nutrition is effective in inducing clinical remission of disease in adults and promoting growth in children. Recent research has focused on the use of specific nutrients as primary treatment agents. Although some reports have indicated that glutamine, short-chain fatty acids, antioxidants and immunonutrition with omega-3 fatty acids are an important therapeutic alternative in the management of inflammatory bowel diseases, the beneficial reported effects have yet to be translated into the clinical practice. The real efficacy of these nutrients still need further evaluation through prospective and randomized trials.

Parenteral lipid emulsions and phagocytic systems.

Lipid emulsions (LE) for parenteral use are complex emulsions containing fatty acids, glycerol, phospholipids and tocopherol in variable amounts and concentrations. In clinical practice, LE have been employed for more than 30 years. Fatty acids may have different impacts on phagocytic cells according to their structure. Experimental and clinical studies have consistently shown that LE modify monocyte/macrophage and polymorphonuclear phagocytosis. The inhibitory effect of LE on the functional activity of the phagocytic system, although still clinically controversial, may have a harmful impact because total parenteral nutrition with lipids may be recommended in hypercatabolic conditions where inflammation and infection are present. LE based on triglycerides containing long chain fatty acids (termed long chain triglycerides or LCT) are the main parenteral fat source and are typically rich in n-6 polyunsaturated fatty acids. They may have adverse effects on the immune system, especially when given in high doses over a short period of time. However when administered properly they can be used safely. LE containing medium chain triglycerides (MCT) may have some advantages because of their positive effects on polymorphonuclear cells, macrophages, and cytokine production, particularly in critically ill or immunocompromised patients. New parenteral LE containing n-3 polyunsaturated fatty acids or monounsaturated olive oil are already available in Europe. Judicious use of these new LE is mandatory especially relating on their potential impact on the immune system. New experimental and clinical studies are required to further establish the role of LE in clinical nutrition.

Impact of parenteral n-3 fatty acids on experimental acute colitis.

The present study was undertaken to investigate the effects of parenteral lipid emulsions (LE) enriched with n-3 fatty acids (n-3 FA) in experimental acute colitis. Seventy-four adult male Wistar rats were randomized into six groups, five of which had acetic acid-induced colitis. The animals received a fat-free diet and water ad libitum in individual metabolic cages. By a central venous catheter, saline was infused (0.5 ml/h) into the control groups CS (without colitis) and CC (with colitis), while the test groups received specific LE for 7 days. The n-3/n-6 FA ratio and the lipidic compositions regarding long chain (LCT) and medium chain (MCT) triglycerides were: group L--1:7.7 (LCT, n = 12), M--1:7.0 (MCT and LCT, n = 12), LW-3--1:4.5 (LCT plus n-3 FA, n = 12) and MW-3--1:3.0 (MCT and LCT plus n-3 FA, n = 13). The frequency of diarrhea, oral intake/body weight ratio, intestinal alterations, macrophage cellularity were evaluated and colonic concentrations of leukotrienes (LTB4, LTC4), prostaglandins (PGE2) and thromboxanes (TXB2) were measured. Groups M, MW-3 and LW-3 had less diarrhea than the CC group (P<0.05). Average oral intake/body weight ratio in MW-3 animals was comparable to the CS and better than the CC group. n-3 FA treated rats (LW-3 and MW-3) presented less intestinal inflammatory alterations than CC rats. Mucosal ulcer formation in MW-3 group did not differ from CS rats. M and MW-3 rats had less macrophages in the colon than the CC group. Compared with CC group, lower concentrations of LTB4 in the CS, LW-3 and MW-3 groups; of PGE2 in the CS, M and MW-3 groups; and of TXB2 in the CS and MW-3 groups were found. Mean concentrations of LTC4 did not differ among the groups. Thus, a LCT-containing LE with a low n-3-n-6 ratio does not modify inflammatory colitis manifestations; LE with a high n-3-n-6 ratio reduces diarrhea, preserves oral intake-weight ratio, attenuates morphological consequences and decreases colonic concentrations of inflammatory mediators; MCT/LCT-containing LE with 1:3 n-3-n-6 ratio exerts the most profound beneficial impact on the inflammatory response.