Atrophy of the intestinal villi in a post-gastrectomy patient with severe iron deficiency anemia.

BACKGROUND & AIMS: Iron deficiency anemia is a common complication of gastric surgery that in certain patients can be refractory to treatment with oral iron and needs to be treated parenterally. METHODS: A 48-year woman underwent gastric surgery for a gastric ulcer. She was referred to the nutrition unit for the study and treatment of a 3-year iron deficiency anemia refractory to oral iron supplementation. Blood tests, endoscopy and jejunal biopsy were made to study the case. RESULTS: Intestinal villi atrophy in the absence of celiac disease was the result. She was treated with intravenous iron, resolving the villous atrophy and thus oral iron supplementation could be effective. CONCLUSION: This case illustrates that iron deficiency may cause villous atrophy. In this setting, parenteral iron administration is necessary to correct the haematological and non-hematological alterations associated with this deficiency.

[Sea-blue histiocyte syndrome associated with home parenteral nutrition]. / Síndrome del histiocito azul marino en relación a nutrición parenteral domiciliaria.

A case of a 55 years-old male with long-term Crohn's disease without response to medical treatment and many intestinal fistula is presented. After the last bowel resection, home parenteral nutrition was started. He presented chronic hepatopathy and pancytopaenia. After 9 months of home parenteral nutrition hepatic function and pancytopaenia began to deteriorate. Bone marrow examination revealed an infiltrate of sea-blue histiocytes. He made unsatisfactory progress and died due to a multiorganic failure.

[Management models in clinical nutrition: weaknesses and strengths]. / Modelos de gestión en nutrición clínica: Puntos débiles y puntos fuertes.

At the 6th Abbott-SENPE Debate Forum a multidisciplinary and multiprofessional discussion was established in order to seek for the model or the models of clinical management most appropriate for Clinical Nutrition and Dietetics Units (CNAD) in Spain. The weaknesses and strengths as well as opportunities for the current systems were assessed concluding that a certain degree of disparity was observed not only due to regional differences but also to different hospital types. It was proposed, from SENPE, the creation of a working group helping to standardize the models and promote the culture of Integral Control and Change Management.

Direct costs of a home parenteral nutrition programme.

BACKGROUND & AIMS: Home parenteral nutrition (HPN) is a lifesaving treatment for people with chronic intestinal failure and its cost has been reported to be very high. The purpose of the present paper was to study the direct healthcare and non-healthcare costs associated with the HPN programme managed by a tertiary hospital. METHODS: Observational, retrospective study of all adult patients on HPN from 11.1.2014 to 10.31.2015 treated at Gregorio Marañón University Hospital (Madrid, Spain). An economic evaluation was undertaken to calculate the direct healthcare (HPN provision, outpatient monitoring and management of complications) and non-healthcare costs (transportation process) of the HPN programme. The variables were collected from medical records, the dispensary and the hospital's financial services. The unit costs were taken from official price lists. RESULTS: Thirty-two patients met the inclusion criteria. Total direct healthcare and non-healthcare costs amounted to €13,363.53 per patient (€124.02 per patient per day). The direct healthcare costs accounted for 98.32% of overall costs, while the non-healthcare costs accounted for the remaining 1.68%. HPN provision accounted for the majority of the costs (74.25%), followed by management of complications (21.85%) and outpatient monitoring (2.23%). CONCLUSIONS: The direct healthcare costs accounted for the majority of HPN expenditure, specifically HPN provision was the category with the highest percentage.

[Nutritional management of patients with acute pancreatitis: when the past is present]. / Tratamiento nutricional de los enfermos con pancreatitis aguda: cuando el pasado es presente.

Patients with acute pancreatitis usually present nutritional status impairment. In alcoholic pancreatitis this impairment is usually presented before hospital admission. In patients with long-term complicated pancreatitis, malnutrition develops during the course of the disease. Besides, these patients present an increased stress and protein hypercatabolism. Treatment of acute pancreatitis usually maintains patients in a short period of starvation. In mild pancreatitis, starvation is needed for a few days, beginning progressively oral feeding. These patients don't need special nutritional support, unless they were previously malnourished. Patients with severe acute pancreatitis should always receive artificial nutritional support in order to preserve the nutritional status as starvation will be maintained for more than one week. In this paper, we review the nutritional treatment in these situations, trying to answer some different questions: type of nutritional support, when it should be started and when it is indicated to withdraw.

How accurate are predictive formulas calculating energy expenditure in adolescent patients with anorexia nervosa?

BACKGROUND & AIMS: To compare resting energy expenditure, measured by indirect calorimetry, to values estimated by different predictive formulas in adolescent patients with anorexia nervosa. METHODS: We studied 22 female in-patients with a mean age of 14.7 years (SD 1.2). Resting energy expenditure was measured by indirect calorimetry (Deltatrac II MBM-200). We compared measured resting energy expenditure to values estimated by several predictive formulas [Fleisch, Harris-Benedict, FAO, Schofield-HW, Schebendach] using the intraclass correlation coefficient and the Bland-Altman method. RESULTS: Body mass index increased significantly (P<0.001). Measured resting energy expenditure increased during hospitalization (P<0.05). All formulas overestimated resting energy expenditure with respect to indirect calorimetry except the Schebendach formula. The intraclass correlation between indirect calorimetry and the formulas were poor (0.09-0.20). We observed a poor clinical agreement (Bland-Altman). CONCLUSIONS: Body mass index and resting energy expenditure increased during hospitalization. The majority of the predictive formulas overestimate resting energy expenditure in adolescent patients with anorexia nervosa. Therefore, indirect calorimetry may be a very useful tool for calculating caloric requirements in these patients.

[Evolution in the knowledge on fiber]. / Evolución en el conocimiento de la fibra.

Fiber is an essential nutrient in a healthy diet, contributing to health maintenance and preventing the occurrence of different disease. The classification of fiber according to its degree of fermentation within the large bowel categorizes it into two different types, completely fermentable fiber and partially fermentable fiber. The level of fermentability of each fiber will give it characteristic properties. Besides the known effects of fiber on transit and bowel movement regulation, the recent advance on the knowledge on the metabolism of some fermentable fibers, such as inulin, fructo-oligosaccharides, and galacto-oligosaccharides, has shown its prebiotic effect. Because of this fermentation, short chain fatty acids with important colonic and systemic functions are produced. Therefore, it is essential to perform a balanced diet with adequate fiber consumption.

[Gastric surgery as a nutritional risk factor]. / Cirugía gástrica como factor de riesgo nutricional.

BACKGROUND: The stomach has a role in the digestion and absorption of nutrients, so patients are in nutritional risk after gastric resection. The aim of this work was to study the nutritional status of postgastrectomy outpatients followed in our hospital. METHODS: We retrospectively studied 54 patients (27 M, 27 F) followed more than 12 months postgastrectomy. Mean age was 61 +/- 14 yr and median follow-up was 35 months. The nutritional assessment included anthropometry, biochemical data and measurement of bone mineral density by dual-energy X-ray absorptiometry. The statistical analysis was performed by non-parametric tests. RESULTS: Malignancy was the most frequent indication (85%), 63% of patients had total gastrectomy. Patients were supplemented with iron (43%), B12 (87%), calcium (18%) and vitamin D (17%). 13% of patients had a BMI < 18.5. The incidence of 25 OH vitamin D deficiency and secondary hyperparathyroidism was 45% and 76%, respectively. The incidence of osteoporosis at lumbar spine was 46%. Matched with same age-sex people patients had 85.6% of bone mineral density. CONCLUSIONS: The loss of weight and the metabolic bone disease were the most prevalent impairments after gastric resection. These impairments point to the importance of a nutritional surveillance of patients after gastric resection.

[IV Debate Forum of the SENPE: questions on nutrition research]. / IV Foro de Debate SENPE: problemática de la investigación en nutrición.

The IV Debate Forum of the SENPE values from a multidisciplinary and multi-professional perspective the questions on clinical research in nutrition in Spain, focusing on enteral nutrition due to the lack of legislation on this issue. The concluding remarks point out the SENPE commitment with promoting quality, education and facilitation of research, greater help to emergent groups, looking for financial support, and timely information on the several summons from public systems and reference centers

[Avascular necrosis of both hips and knees in a patient with ulcerative colitis treated for a long term with high-dose corticosteroids]. / Necrosis avascular de ambas caderas y rodillas en una paciente con colitis ulcerosa tratada prolongadamente con corticoides a dosis altas.

INTRODUCTION: Avascular necrosis represents the bone tissue death from vascularization failure, and it is mainly associated with the use of high-dose corticosteroids for a long time. CLINICAL CASE: A 25 years old female patient treated with high-dose corticosteroids for 7 months for ulcerative colitis presents with both knees pain and limited hip and knee motility. In a plain X-ray and in nuclear magnetic resonance imaging (MRI) avascular necrosis was observed at these joints. Bone densitometry showed osteopenia at the femoral head and lumbar osteoporosis. DISCUSSION: We present a striking case for its large involvement of the joints (both knees and hips) with simultaneous osteoporosis and osteopenia in a young patient treated with corticosteroids for ulcerative colitis. It is necessary to recommend the judicious use of glucocorticoids, prescribing the minimal necessary dose and for the least amount of time necessary to control the underlying disease.

[Conclusions of the III SENPE Debate Forum on specialized nutritional support: ethical issues]. / Conclusiones del III Foro de Debate SENPE. Soporte nutricional especializado: aspectos eticos.

Conclusions of the III SENPE-Abbott Debate Forum on several ethical issues of specialized nutritional support in hospitalized patients and outpatients. An insight in the principle of equity is given depending on geographical location, in its indications both as a primary therapy and palliative care, and in informed consent.

Effect of inulin and fructo-oligosaccharide on the prevention of acute radiation enteritis in patients with gynecological cancer and impact on quality-of-life: a randomized, double-blind, placebo-controlled trial.

BACKGROUND/OBJECTIVES: The pathogenesis of enteritis after abdominal radiotherapy (RT) is unknown, although changes in fecal microbiota may be involved. Prebiotics stimulate the proliferation of Lactobacillus spp and Bifidobacterium spp, and this may have positive effects on the intestinal mucosa during abdominal RT. SUBJECTS/METHODS: We performed a randomized, double-blind, placebo-controlled trial involving patients with gynecological cancer who received abdominal RT after surgery. Patients were randomized to receive prebiotics or placebo. The prebiotic group received a mixture of fiber (50 inulin and 50% fructo-oligosaccharide), and the placebo group received 6 g of maltodextrin twice daily from 1 week before to 3 weeks after RT. The number of bowel movements and stool consistency was recorded daily. Diarrhea was evaluated according to the Common Toxicity Criteria of the National Cancer Institute. Stool consistency was assessed using the 7-point Bristol scale. Patients' quality-of-life was evaluated at baseline and at completion of RT using the EORTC-QLQ-C30 (European Organization for Research and Treatment of Cancer quality-of-life Questionnaire C30) test. RESULTS: Thirty-eight women with a mean age of 60.3±11.8 years participated in the study. Both groups (prebiotic (n=20) and placebo (n=18)) were comparable in their baseline characteristics. The number of bowel movements per month increased in both groups during RT. The number of bowel movements per day increased in both groups. The number of days with watery stool (Bristol score 7) was lower in the prebiotic group (3.3±4.4 to 2.2±1.6) than in the placebo group (P=0.08). With respect to quality-of-life, the symptoms with the highest score in the placebo group were insomnia at baseline and diarrhea toward the end of the treatment. In the prebiotic group, insomnia was the symptom with the highest score at both assessments, although the differences were not statistically significant. CONCLUSIONS: Prebiotics can improve the consistency of stools in gynecologic cancer patients on RT. This finding could have important implications in the quality-of-life of these patients during treatment.

Nutritional support and quality of life in stable chronic obstructive pulmonary disease (COPD) patients.

RATIONALE: Nutritional depletion is a common problem in chronic obstructive pulmonary disease (COPD) patients. It is caused, to a large extent, by an imbalance between low-energy intake and high-energy requirements. This problem adversely affects morbidity and mortality. However, the use of nutritional supplements to reach their energy necessities requires optimisation between positive and adverse effects on outcome before being used systematically as part of their comprehensive care. PURPOSE: The aim of our study was to investigate the effects of oral nutritional repletion on quality of life in stable COPD patients. METHODS: Prospective, randomised and multi-centre study. Stable COPD patients with a body mass index 22, a fat-free mass index 16, and/or a recent involuntary weight loss (5% during last month, or 10% during the last 3 months) were studied. Exclusion criteria were to present signs of an airway infection, to have a cardiovascular, neurological, or endocrine disease, to be treated with oral steroids, immunosuppressors or oxygen therapy at home, and to receive nutritional supplements. During 12 weeks, patients were encouraged to ingest a total daily defined energy intake. Randomly, in patients from group A the total daily energy load was Resting Energy Expenditure (REE)x1.7, and those from group B, REE x1.3. Total daily energy intake was achieved with regular food plus, if necessary, oral nutritional supplement rich in proteins (with 50% of whey protein), with predominance of carbohydrates over fat, and enriched in antioxidants. Primary end-point variable was quality of life. Secondary end-point outcomes included body weight, body composition, lung function, handgrip strength, and compliance with the energy intake previously planned. Data were treated with a SAS System. Student's test, Wilcoxon's rank sum test, and Mann-Whitney's test were used. RESULTS: At baseline both groups of patients were comparable. All patients needed oral nutritional supplements to achieve total daily defined energy intake. After 12 weeks of follow-up, patients in both groups significantly increased energy intake. Patients in group A increased body weight (P=0.001), triceps skin fold thickness (P=0.009) and body fat mass (P=0.02), and decreased body fat-free mass index (P=0.02). In this group a marked increase in airflow limitation was observed. A tendency to increase body weight and handgrip strength, and to decrease airflow limitation was observed in patients from group B. Furthermore, patients in the later group showed a significant improvement in the feeling of control over the disease (P=0.007) and a tendency to better the other criteria in a quality of life scale. CONCLUSIONS: According to our results, total daily energy intake of REE x 1.3 is preferable to REE x 1.7 in mild stable COPD patients. The administration of oral nutritional supplements, rich in proteins (with 50% of whey protein), with predominance of carbohydrates over fat, and enriched in antioxidants, to achieve total daily defined energy intake in patients in group B was followed by a significant improvement of one criteria (mastery) among many others in a quality of life scale.

[Osteoporosis and inflammatory bowel disease]. / Osteoporosis y enfermedad inflamatoria intestinal.

Inflammatory bowel disease is a chronic disease with an unknown ethiology although multiple factors intervene such as individual, genetic and immunologic susceptibility, as well as different environmental factors. Like other multisystemic diseases, its clinical manifestations are diverse and it may affect other organs besides the gastrointestinal tract. In the last few years there is a growing interest for one of these extraintestinal manifestations, osteoporosis and osteopenia that may affect up to 42% of patients and can condition an important increase in morbility. Inactivity, prolonged corticosteroid treatment, nutritional deficiencies and the disease per se have an important role in the development of this complication. This article reviews clinical and ethiological aspects of inflammatory bowel disease associated osteoporosis and offers a strategy for diagnosis and treatment.

[Study of energy expenditure in anorexia nervosa: agreement between indirect calorimatry and several equations]. / Estudio del gasto energético en la anorexia nerviosa: concordancia entre calorimetria indirecta y diferentes ecuaciones.

UNLABELLED: Nutritional management is essential in anorexia nervosa (AN), although nutrient replenishment must be done progressively to prevent the occurrence of re-alimentation syndrome. OBJECTIVE: to compare resting enengy expenditure (REE) by means of indirect calorimetry and by different equations in AN female patients. MATERIAL AND METHODS: we studied 21 women admitted for AN (DSM-IV), mean age 17 years (SD 5.9), range 12-34 years. Admission stay was 55.1 +/- 20.7 days (21-91). Initial nutritional assessment included anthropometrics (BMJ, TSF, SSE, MAC, MAMC) and tetrapolar bioimpedance (HoltainBC). Indirect calorimetry (IC) was done after overnight fasting (Deltatrac II MBM-200). In 9 patients, the same study was repeated before hospital discharge. We compared REE (Kcal/24 h) measured by IC with that obtained by several equations [Fleish, Harris- Benedict, FAO, Schofield-HW (SHW), Schebendach] through the intraclass correlation coefficient (ICC) and the Bland-Altman method. RESULTS: Nutritional status significantly improved during hospital admission. Fifty percent of the recovered weight was fat mass. REE significantly increased during admission. The equations overestimated REE as compared to IC (p < 0.05), except for the Schebendach equation that underestimated REE. The agreement between direct measurement of REE by IC and its estimation through equations was poor [Fleish (ICC = 0.21); HB (ICC = 0.21), SHW (ICC = 0.19), Schebendach (ICC = 0.15)]. Through the Bland-Altman method, we observed that there was a variable bias between IC and equations, with a clinically acceptable agreement for REW values of around 1200 Kcal/day. CONCLUSIONS: 1) In our study we obtained a poor agreement between REW values measured by indirect calorimetry and those estimated by equations. 2) Through the Bland-Altman method, we observed that all equations present a variable bias as for IC, the agreement being clinically acceptable for REE values of around 1200 Kcal/day. 3) Thus, indirect calorimetry seems to be a very useful tool to calculate the energy requirements of anorexia nervosa patients.

Nutritional support in chronic renal failure: systematic review.

BACKGROUND AND AIMS: The purpose of this systematic review was to locate and assess in patients with chronic renal disease the quality of scientific evidence to establish graded recommendations based on the efficacy and effectiveness of nutritional support. METHODS: Computerized and online versions of MEDLINE (from 1989 through March 1999) and EMBASE (from 1988 through January 1999) were consulted. The Cochrane Library and the online Healthstar (from 1975) databases were also searched for clinical trials. A total of 593 studies were assessed. Following methodological review (primary reviewer), only 45 studies reviewed met criteria for selection and were analyzed by a group of experts (secondary reviewer). A final consensus was reached between the co-ordinators, experts and methodologists. RESULTS AND CONCLUSIONS: Low and very low-protein diets associated with specific enteral supplements are indicated in most patients with chronic renal disease and in patients with incipient diabetic nephropathy to slow progression of disease and to improve their overall status, contributing to improved survival (grade A recommendation). The use of protein-restricted diets in diabetic nephropathy is only indicated in type I diabetes mellitus (grade A recommendation). An improvement in nutritional parameters was found when specific diets were given in chronic renal disease (grade C recommendation).

Enteral nutrition in patients with tumours of the head and neck.

An evaluation is presented of the nutritional status of 30 patients out of the 45 submitted to head and neck surgery, involving the buccal cavity, in the Maxillofacial Surgery Service of the General Hospital "Gregorio Marañón" of Madrid, between October 1985 and December 1986, before and after being submitted to excision of a tumour in the head or neck, by administration, in the postoperative period, of a liquid comprehensive diet via a nasogastric catheter. Neither in the postoperative period nor after stopping the enteral nutrition was the existence of malnutrition detected, in any of the parameters studied. One patient inhaled gastric juice with a fatal outcome, while the rest of the patients had no severe complications. Therefore, we think that the administration of enteral nutrition in this kind of patient is very useful and is indeed necessary to avoid energy-protein malnutrition during the postoperative period. At the same time it avoids possible infection by food remaining in the oral cavity.

[Response of prolactin to thyrotrophin-RH(TRH) and chlorpromazine stimulation in the syndrome of hypogonadism and anosmia (author's transl)]. / Respuesta de la prolactina a los estímulos de torotrofina-RH(TRH) y clorpromacina en el síndrome hipogonadismo-anosmia.

Basal and stimulatory tests of FSH, LH and PRL are reported in three cases of hypogonadism-anosmia syndrome (Maestre-Kallmann-De Morsier syndrome), two of whom were brothers. Basal FSH levels were low (mean = 1.7 mU/ml) and did not respond to the first acute stimulation with intravenous LRH (x = 2.3 mU/ml), but after intramuscular LRH, 500 microgram/day for 10 days, a clear-cut response was noted in two patients (from a mean of 7.8 mU/ml to 16.8 mU/ml), while the other patient continued without response. Low basal LH levels (mean 1.8 mU/ml) responded poorly to the first LRH stimulation (mean 4.6 mU/ml), while after intramuscular LRH for 10 days there was a marked increase in all three cases (mean 29.7 mU/ml). In no case was there a response to clomiphene. With regard to PRL, all cases had a clear response to TRH, although it was subnormal in two of them. Opposite results were obtained in one case of Klinefelter's syndrome, namely, elevated basal PRL levels (44 ng/ml) with an exaggerated response to TRH. Chlorpromazine administration caused an elevation of PRL to 43 and 30 ng/ml, respectively, in the two patients with a subnormal response to TRH, while the third case responded less than to TRH. In conclusion, the response to TRH of FSH and LH with lack of response to clomiphene supports the hypothalamic nature of the hypogonadism, while the response of PRL to both TRH and chlorpromazine, along with the normal levels of the remaining pituitary hormones (ACTH, TSH and STH) demonstrate the selectivity of the hypothalamic lesion whereby only gonadotrophin control is impaired.

[Dietary fiber: concept, classification and current indications]. / Fibra: concepto, clasificación e indicaciones actuales.

Fiber is a concept that refers to or encompasses several carbohydrates and lignine that resist hydrolysis by human digestive enzymes and that are fermented by the microflora of the colon. From a practical point of view, fibers can be divided into soluble and insoluble. There is general acceptance of the concepts soluble fiber, fermentable, viscous and insoluble fiber, and non-viscous and barely fermentable fiber. The physiological effects and therefore the clinical applications of both fibers are different. In general, the insoluble fiber is barely fermentable and has a marked laxative and intestinal regulatory effect. Soluble fiber is fermented to a high degree, showing a powerful trophic effect at the colon level. Soluble fiber is also attributed a positive role in the carbohydrate and lipid metabolism due to the effects that this has at the intestinal and the systemic level on the glucose and the cholesterol metabolism. The goal of this article is to review the current concept of fiber based on the existing bibliography (it is thought that perhaps the current classification should be changed and that fiber should be talked about depending on its degree of polymerization), its physiologic effects and the possible indications that this may have from a clinical point of view, be this at the level of oral or enteral nutrition.

[Long-term follow-up of home parenteral nutrition at a general hospital: complications and quality of life]. / Seguimiento a largo plazo de la nutrición parenteral domiciliaria en un hospital general: complicaciones y calidad de vida.

OBJECTIVE: The present study assesses the septic, thrombotic and hepatic complications and also the quality of life of patients with home parenteral nutrition (NPD in its Spanish acronym). METHODS: The case histories of patients treated with NPD at our hospital were collected for the period January, 1986, to January, 2001. We had 20 patients, mean age 48 +/- 14 years (mean +/- SD), with a total catheterization time of 16,292 days. The main causes of intestinal failure were mesenteric ischaemia and radical enteritis. Quality of life was assessed by means of the Sickness Impact Profile (SIP) and the Karnofsky Index (KI). RESULTS: We found a catheter infection rate of 0.42 per 100 days of catheter, mostly produced by coagulase-negative staphylococci (63%). In 30% of the cases, it was necessary to remove the catheter, including in all cases produced by Candida. Cather occlusion rate was 0.05 per 100 days. Five patients presented an increase in transaminases and alkaline phosphatase, and one female patient developed cholestasis. Two patients died of NPD-related causes. The results of the quality of life analysis showed it was moderately affected, with SIP scores of 14.6 +/- 3.5 and KI results of 70 +/- 20 (mean +/- SD). CONCLUSIONS: Home parenteral nutrition allows a greater survival in cases of intestinal failure. The most frequent complication is an infection of the catheter. The results of the quality of life analysis in our series reveal it was moderately affected in most cases.