Evidence of the effect of immunonutrition on the prevention of surgical site infection.

Surgical candidates are often immunosuppressed patients. Immunodeficiency associated with malnutrition are risk factors for developing postoperative SSI. The term "immunonutrition" refers to the addition of omega-3 fatty acids, glutamine and arginine to liquid nutritional supplements. Diverse studies have shown a reduction in septic complications after perioperative use of immunonutrition, but these results could not be confirmed by other authors. In this issue, we will review the actual evidence about the effect of immunonutrition on the prevention of SSI.

Dexamethasone intravitreal implant in the treatment of macular edema secondary to necrotizing retinitis.

PURPOSE: To describe our experience with the use of a sustained-release dexamethasone implant in three patients with recalcitrant macular edema that developed after necrotizing retinitis in the context of the previously treated virus. CASE DESCRIPTION: Two immunocompetent patients presented with unilateral acute retinal necrosis (ARN) due to Varicella-Zoster (VZV). The other, an immunocompromised patient, presented with unilateral cytomegalovirus (CMV) necrotizing retinitis. The diagnoses were confirmed by anterior chamber polymerase chain reaction (PCR) and all were treated with oral valganciclovir and intravitreal ganciclovir (2 mg/0.1 ml). Infection was controlled but two of them required pars plana vitrectomy. Between 2 and 4 months after the resolution of signs of infection, resistant macular edema (RME) developed, and an intravitreal dexamethasone device was implanted after anterior chamber PCR had been negative. Functional and anatomical improvement was achieved, with the resolution of the edema accompanied by improvement in visual acuity in all patients. There was no evidence of reactivation at two years. No cataract or ocular hypertension was observed. One patient required two additional dexamethasone implants. CONCLUSION: Dexamethasone intravitreal implant could be considered as an option for the treatment of macular edema developed after ARN. Care should be taken to avoid reactivation and patients need to be properly informed.

Autologous Pericranium Graft for Necrotizing Scleritis.

PURPOSE: The purpose of this study was to describe the clinical outcome of scleral staphyloma secondary to necrotizing scleritis treated with autologous pericranial grafting. CASE REPORT: A 63-year-old woman with necrotizing scleritis and choroidal protrusion underwent homologous scleral grafting, which failed. The patient's medical management was optimized for control of her systemic inflammation, and she underwent a second surgery consisting of autologous pericranium grafted to the parietal region. A 3- × 2-cm tissue patch was harvested and sutured over the staphyloma borders with 8/0 polyglactin sutures. Complete re-epithelialization was observed at 3 weeks, the graft was well integrated, and no signs of inflammation were observed at 18 months. CONCLUSIONS: The pericranium offers a viable alternative for scleral thinning because of necrotizing scleritis.

Treatment of COVID-19 during the Acute Phase in Hospitalized Patients Decreases Post-Acute Sequelae of COVID-19.

BACKGROUND: The post-acute sequelae of SARS-CoV-2 (PASC) infection have caused a significant impact on our health system, but there is limited evidence of approved drugs focused on its prevention. Our objective was to identify risk factors that can determine the presence of PASC, with special attention to the treatment received in the acute phase, and to describe the profile of persistent symptoms in a multidisciplinary Post-Coronavirus Disease-19 (COVID-19) Unit. METHODS: This one-year prospective observational study included patients following an acute COVID-19 infection, irrespective of whether they required hospital admission. A standardized symptom questionnaire and blood sampling were performed at the first follow-up visit, and demographic and clinical electronic data were collected. We compared subjects with PASC with those who had fully recovered. Multivariate logistic regression was performed to identify factors associated with PASC in hospitalized patients, and Kaplan-Meier curves were used to assess duration of symptoms according to disease severity and treatments received in the acute phase. RESULTS: 1966 patients were evaluated; 1081 had mild disease, 542 moderate and 343 severe; around one third of the subjects had PASC, and were more frequently female, with obesity, asthma, and eosinophilia during acute COVID-19 disease. Patients who received treatment with dexamethasone and remdesivir during the course of the acute illness showed a lower median duration of symptoms, compared with those who received none of these treatments. CONCLUSION: Treatment with dexamethasone and/or remdesivir may be useful to reduce the impact of PASC secondary to SARS-CoV-2 infection. In addition, we identified female gender, obesity, asthma, and disease severity as risk factors for having PASC.

EGFR and KRAS Mutations in Lung Parenchyma of Subjects With EGFR/KRAS Wild-Type Lung Adenocarcinoma.

The acquisition of driver mutations in non-tumoral cells appears to be very important during the carcinogenesis of adenocarcinoma (ADC). Recent studies suggest that cancer-related mutations may not necessarily be present only in malignant cells, but also in histologically "healthy cells". Objective: to demonstrate the presence of EGFR or KRAS mutations in non-tumoral lung cells in subjects with ADC and negative mutational status. Results: mutations in EGFR or KRAS oncogenes were identified in the normal lung in 9.7% of the subjects. Exon 21 substitution L858R in EGFR was detected in two cases while the exon 19 deletion E746-A750 in the EGFR, the G12C and G12D substitutions in the KRAS were detected once. One patient presented three different mutations in the normal lung parenchyma (EGFR_L858R, KRAS_G12C and KRAS_G12D). The negative-mutation status of the tumor and the mutations detected in the "normal lung" were confirmed using highly sensitive and specific TaqMan PCR (CAST-PCR). No differences were found in terms of progression, progression-free survival or overall survival during the 18 months follow-up. Conclusions: These results confirm the presence of driver mutations in the histologically normal lung parenchyma cells in the absence of mutations coexisting with the primary tumor.

Incidence of pulmonary embolism in patients with non-invasive respiratory support during COVID-19 outbreak.

While the incidence of thrombotic complications in critically ill patients is very high, in patients under non-invasive respiratory support (NIS) is still unknown. The specific incidence of thrombotic events in each of the clinical scenarios within the broad spectrum of severity of COVID-19, is not clearly established, and this has not allowed the implementation of thromboprophylaxis or anticoagulation for routine care in COVID-19. Patients admitted in a semi-critical unit treated initially with NIS, especially Continuous-Positive Airway Pressure (CPAP), were included in the study. The cumulative incidence of pulmonary embolism was analyzed and compared between patients with good response to NIS and patients with clinical deterioration that required orotracheal intubation. 93 patients were included and 16% required mechanical ventilation (MV) after the NIS. The crude cumulative incidence of the PE was 14% (95%, CI 8-22) for all group. In patients that required orotracheal intubation and MV, the cumulative incidence was significantly higher [33% (95%, CI 16-58)] compared to patients that continued with non-invasive support [11% (CI 5-18)] (Log-Rank, p = 0.013). Patients that required mechanical ventilation were at higher risk of PE for a HR of 4.3 (95%CI 1.2-16). In conclusion, cumulative incidence of PE is remarkably higher in critically patients with a potential impact in COVID-19 evolution. In this context, patients under NIS are a very high-risk group for developing PE without a clear strategy regarding thromboprophylaxis.

[Impact of early nutritional support and presence of diabetes mellitus in patients with acute stroke]. / Influencia del soporte nutricional precoz y la presencia de diabetes mellitus en pacientes con ictus agudo.

INTRODUCTION: Introduction: the data in the medical literature are conflicting regarding the nutritional support of patients with stroke and the most appropriate time to start it. Objective: to analyze the effect of a nutritional intervention and of nutritional parameters on the clinical evolution of patients with stroke. Material and methods: this was an observational, retrospective study in 43 patients. The following baseline data were collected: tricipital skinfold (TS), mid-upper arm circumference (MUAC), muscular arm circumference (MAC), albumin, prealbumin, total cholesterol, lymphocytes, diabetes mellitus (DM), nutritional support onset, duration and type of supplementation, nutrition care plan, neurological dysfunction according to the National Institute of Health Stroke Scale (NIHSS) both at baseline and discharge, and mortality. Mortality within the first month and neurological deficit at discharge are identified as poor prognostic factors, and are related to nutritional parameters. Results: age 67.2 ± 12.5 years; 53.5% males and 34.9% females. Presence of DM: 34.88%. Nutritional parameters: TS: 18.7 ± 7.8 mm; MUAC: 30.2 ± 3 cm; MAC: 24.4 ± 3.1 cm; serum albumin 3.39 ± 0.3 g/dl; prealbumin: 22.3 ± 6.9 mg/dl; total cholesterol: 177.1 ± 46.4 mg/dL; lymphocytes: 1742 ± 885/mm3. Enteral nutritional support was started at 4.3 ± 5.8 days after the acute event, with a duration of 17.8 ± 23.2 days. Fifty percent of patients had severe neurological deficits at discharge. As markers of worse prognosis we identified a delay in the start of nutritional support of over 7 days, and the presence of DM. Conclusions: the late start of nutritional support was related to worse clinical prognosis. DM is a marker of poor prognosis in patients with stroke.

INTRODUCCIÓN: Introducción: en la literatura actual se describen datos contradictorios en relación con el soporte nutricional en los pacientes con ictus y el momento idóneo de comenzar el mismo. Objetivo: analizar el impacto de los parámetros y la intervención nutricional en la evolución clínica de los pacientes afectos de ictus. Material y métodos: estudio observacional, retrospectivo y descriptivo de 43 pacientes con diagnóstico de ictus agudo. Se recogen los siguientes parámetros nutricionales: pliegue tricipital (PT), circunferencia del brazo (CB), circunferencia muscular del brazo (CMB), albúmina, prealbúmina, colesterol total, linfocitos, diabetes mellitus (DM), inicio de soporte nutricional, duración y tipo de suplemento, y abordaje digestivo. También se registra la afectación neurológica según la escala National Institute of Health Stroke Scale (NIHSS) tanto en el momento basal como en el momento del alta. Se identifican la mortalidad en el primer mes y el déficit neurológico al alta como factores de mal pronóstico y se relacionan con los parámetros nutricionales. Resultados: edad de 67,2 ± 12,5 años; 53,5% de varones y 34,9% de mujeres. Presencia de DM: 34,88%. Media de parámetros nutricionales: PT: 18,7 ± 7,8 mm; CB: 30,2 ± 3 cm; CMB: 24,4 ± 3,1 cm; albúmina: 3,39 ± 0,3 g/dl; prealbúmina: 22,3 ± 6,9 mg/dl; colesterol total: 177,1 ± 46,4 mg/dl; linfocitos: 1742 ± 885/mm3. Se inició el soporte nutricional enteral a los 4,3 ± 5,8 días del evento agudo, siendo su duración de 17,8 ± 23,2 días. El 50% de los pacientes presentaban al alta un déficit neurológico grave. Se identificaron como marcadores de peor pronóstico los siguientes: un retraso en el inicio del soporte nutricional superior a 7 días y la presencia de DM. Conclusiones: el inicio tardío del soporte nutricional se relacionó con un peor pronóstico clínico. La DM constituye un marcador de mal pronóstico en los pacientes con ictus.

COVID-19 and multiple sclerosis: A description of two cases on alemtuzumab.

BACKGROUND: Alemtuzumab is a treatment for highly active multiple sclerosis (MS). Immunosuppression is considered a risk factor for SARS-CoV-2 infection and there is still lack of evidence to guide MS practice. METHODS/RESULTS: We describe the clinical and immunological evolution of two MS patients under alemtuzumab treatment who were affected by COVID-19, one of them only one week after receiving her last dose, and both recovered without sequelae. CONCLUSION: In selected patients (young, without comorbidities, and with high activity), MS itself could be more dangerous than COVID-19, so we should consider continuing MS treatment as previously planned, including alemtuzumab.

Efficacy in type 2 diabetes mellitus remission in patients undergoing bariatric surgery. / Eficacia en la remisión de la diabetes mellitus tipo 2 en pacientes sometidos a cirugía bariátrica en nuestro medio.

OBJECTIVES: To assess remission of type 2 diabetes mellitus (T2DM) after bariatric surgery, to analyze potential conditioning factors, and to compare Spanish and American remission criteria. MATERIAL AND METHODS: A retrospective study of diabetic patients undergoing Roux-en-Y gastric bypass from 2009 to 2015. Data collected included age, sex, time since T2DM diagnosis, antidiabetic drugs, insulin (type and dose), weight and BMI, percent excess weight lost, HbA1c, blood glucose levels, and course of T2DM after surgery according to Spanish and American criteria, including a descriptive analysis and correlation between both. RESULTS: The study sample consisted of 106 patients. Outcomes one year after surgery was as follows (Spanish criteria): complete remission 65.9%, partial remission 5.5%, improvement 18.9%, no change 9.7% (at 5 years: 68.4, 5.3, 10.5, and 15.8%, respectively). Outcomes according to ADA criteria were as follows: complete remission 61.5%, partial remission 5.3%, and no remission 28.6% (after 5 years, complete remission 68.4%). There was a good correlation between both classifications (Rho=0.974; P<.001). Mean HbA1c levels: 7.3±1.8% at baseline; 5.7±1% at one year; 6.3±1.2% at 5 years. Chance of remission was lower in patients aged over 50 years (54.4 vs. 88.2%; P=.001), with T2DM diagnosed more than 10 years before (26.3 vs. 81.8%; P<.001), on insulin treatment (31.3 vs. 87.9%; P<.001), and with HbA1c levels≥8% (40 vs. 77%; P=.001). CONCLUSIONS: At our hospital, bariatric surgery is associated to a high remission rate of T2DM in patients with morbid obesity, with a good correlation between Spanish and American criteria. Age over 50 years old, long T2DM duration, poorer baseline metabolic control, and previous insulin treatment are markers of poorer response.

Validity of the new nutrition screening tool Control of Food Intake, Protein, and Anthropometry (CIPA) in non-surgical inpatients.

INTRODUCTION: There is no gold-standard method for hospital nutrition screening. The new screening tool termed Control of Food Intake, Protein, and Anthropometry (CIPA) gives positive results when at least one of the following parameters is met: control of food intake for 72 h < 50%, serum albumin < 3 g/dl, body mass index < 18.5 kg/m2 or mid-upper arm circumference ≤ 22.5 cm. This method was validated in comparison with Subjective Global Assessment (SGA) in hospitalized patients with non-surgical pathologies. MATERIAL AND METHODS: A prospective, longitudinal study was performed on 221 consecutively enrolled patients. Prevalence or risk of malnutrition was estimated with CIPA vs. SGA screening at hospital admission and the concordance (k index - K) between the two methods and their sensitivity (S) and specificity (SP) were studied. Mean length of stay (LOS), mortality, and rate of early readmission were analyzed. RESULTS: The prevalence or risk of malnutrition identified by CIPA and SGA was 35.7% and 23.1%, respectively. K was 0.401 (p < 0.001); S and SP of CIPA vs. SGA were 72.5% and 75.3%, respectively. In contrast to SGA, CIPA-positive patients had an increased mean LOS compared to the negative ones (19.53 vs. 12.63 days, p < 0.001). Both methods detected a major risk of mortality in positive patients, but no difference in early readmission. CONCLUSIONS: The CIPA and the SGA screening tools detect patients with a higher risk of mortality, but only CIPA identifies patients with an increased mean LOS. CIPA screening proved valid for use in non-surgical inpatients.

Análisis del grado de satisfacción alimentaria percibido por los pacientes en un hospital de tercer nivel.

Introducción: la alimentación constituye el pilar fundamental del soporte nutricional de los pacientes hospitalizados. Evaluar el grado de aceptación de la dieta es imprescindible en aras de combatir la desnutrición hospitalaria.Objetivos: a) determinar el grado de satisfacción de los pacientes en relación con las dietas; y b) analizar posibles variables asociadas a un grado de satisfacción mayor (apetito y tipo de dieta).Material y métodos: estudio descriptivo de corte transversal. Se emplea una encuesta de 17 preguntas con datos sociodemográficos, datos cualitativos, así como la valoración general del paciente. Se comparó el grado de satisfacción global en función del apetito y el tipo de dieta (terapéutica vs.basal; con sal vs.sosa) (Test no paramétric o Krustal-Wallis y T-Student para muestras independientes, respectivamente).Resultados: mil cuatrocientos trece pacientes. Edad: 53,9 ± 19 años; 51,3% mujeres. Dieta terapéutica (34,9%). Solo el 39,4% tomó dieta con sal. El 66,8% refirió ingresos previos. La alimentación del hospital para un 43% de pacientes fue ''como esperaba'', mientras que para un 44,1% fue ''mejor de lo que esperaba''. El horario de comidas era adecuado (89,1%) y el tiempo para comer, suficiente (96,4%). En cuanto a las características de la comida servida, consideraron como buenas o muy buenas la misma el porcentaje reflejado: sabor/gusto (56.3%), olor (65,5%), cocinado (69,2%), presentación (80,4%), tamaño de ración (75,9%), calidad (73%), cantidad (77,9%), variedad (67,6%), temperatura (70,4%). La valoración global de la alimentación en una escala de 1 a 10 fue de 6,8 ± 2,3. El apetito se asoció a un aumento significativo de la satisfacción global alimentaria del paciente (p < 0,01). El tipo de dieta o la presencia de sal en la misma no se asociaron a un aumento significativo de la satisfacción con la dieta de los pacientes (p = 0,99 y 0,35, respectivamente).Conclusiones: aunque el grado de satisfacción de la dieta de nuestro hospital es aceptable, es preciso introducir mejoras que aumenten su aceptación. El apetito se asocia a un aumento significativo de la satisfacción global alimentaria. La presencia de sal y el tipo de dieta (basal versusterapéutica) no se relacionan con una mejoría significativa de la valoración global de la dieta.

Relationship between Mid-Upper Arm Circumference and Body Mass Index in Inpatients.

INTRODUCTION: Nutritional screening is a fundamental aspect of the initial evaluation of the hospitalised patient. Body Mass Index (BMI) in association with other parameters is a good marker of malnutrition (<18.5 kg/m2), but it presents the handicap that the great majority of patients cannot be weighed and measured. For this reason it is necessary to find other indicators that can be measured in these patients. OBJECTIVES: 1) Analyse the relationship between BMI and Mid-Upper Arm Circumference (MUAC); 2) establish a cut-off point of MUAC equivalent to BMI <18.5 kg/m2. MATERIALS AND METHODS: The anthropometric data of patients hospitalised over the period 2004-2013 were retrospectively revised. The following variables were collected: weight, height, BMI, MUAC, sex and age. RESULTS: 1373 patients were evaluated, who presented a mean weight of: 65.04±15.51 kg; height: 1.66±0.09 m; BMI: 23.48±5.03 kg/m2; MUAC: 26.95±4.50 cm; age: 56.24±16.77. MUAC correlates suitably to BMI by means of the following equation (simple linear regression): BMI = - 0.042 + 0.873 x MUAC (cm) (R2 = 0.609), with a Pearson r value of 0.78 (p<0.001). The area under the curve of MUAC for the diagnosis of malnutrition was 0.92 (95% CI: 0.90-0.94; p<0.001). The MUAC value ≤22.5 cm presented a sensitivity of 67.7%, specificity of 94.5%, and a correct classification of 90%. No significant statistical differences were found in the cut-off point of MUAC for the diagnosis of malnutrition based on sex (p = 0.115) and age (p = 0.694). CONCLUSIONS: 1) MUAC correlates positively and significantly with BMI. 2) MUAC ≤ 22.5 cm correlates properly with a BMI of <18.5 kg/m2, independent of the age or sex of the patient, although there are other alternatives. MUAC constitutes a useful tool as a marker of malnutrition, fundamentally in patients for whom weight and height cannot be determined.

Impact of hyponatremia on mortality and morbidity in patients with COPD exacerbations.

Hyponatremia is the most common electrolyte disorder in hospitalized patients, being associated with increased morbidity and mortality in different clinical conditions. However, the prevalence and impact of this electrolytic disorder in patients hospitalized for an exacerbation of COPD still remains unknown. The aim of the present study was to clarify these points. A total of 424 patients hospitalized due to a COPD exacerbation were consecutively included, showing a frequency of hyponatremia of 15.8% (hyposmolar in most cases). Even though patients with and without hyponatremia showed a similar age, comorbidities, lung function impairment, presence of previous exacerbations, hospitalizations, most of the comorbidities and the overall severity index (APACHE II), their clinical outcomes were worse. Indeed, their hospitalization length, mechanical ventilation requirements and deaths (both during admission and within the months following discharge) were higher than those of non-hyponatremic patients. A sodium threshold lower than 129.7 mEq/L exhibited the better discriminatory power for death prediction. We conclude that hyponatremia (especially if severe) is a predictive marker for a bad clinical course in COPD exacerbations and therefore, patients with this electrolyte abnormality should be carefully monitored.

[CONCORDANCE IN THE RESULTS OF CONTROL INTAKE PERFORMANCE OF 72 H BY DIFFERENT HEALTH PROFESSIONALS IN A TERTIARY HOSPITAL]. / CONCORDANCIA EN LOS RESULTADOS TRAS LA REALIZACIÓN DE UN CONTROL DE INGESTAS DE 72 H POR DIFERENTE PERSONAL SANITARIO EN UN HOSPITAL DE TERCER NIVEL.

INTRODUCTION: the nutritional screening CIPA is positive when it fulfills one of the following parameters: Control food Intake (CI) 72 h < 50%; albumin < 3 g/dl; Body Mass Index (BMI) < 18,5 kg/m2 or Mid-Upper Arm Circumference (MUAC) ≤ 22,5 cm (if BMI cannot be determined). The only parameter no totally objective is the CI so that this study seeks to reinforce its validity. OBJECTIVES: analyze the existing concordance among different health professionals when assessing a CI of 72 h. MATERIALS AND METHOD: retrospective study of patients admitted in hospitalization wards (February-October 2014). Variables considered: age, sex, health service, CI of 72 h and type of diet. The aim of CI is to assess the amount of food consumed, differing between superior or inferior intakes to 50%. It is analyzed the concordance of the results CI determined by a doctor, a nurse and a nutritionist (gold-standard) by the coefficient Kappa (K). Subsequently the sensitivity (S) and specificity (Sp) of positive CI were computed. RESULTS: 176 control of food intake were analyzed. Age 63.70 } 14.46 years; 42% women. Units: Digestive (22.2%), Pneumology (42%), Internal Medicine (21.6%), Nephrology (9.1%), others (5.1%). Type of diet: basal (23%), therapeutic (67%), consistency (4%), progressive (3.4%), others (2.3%). It was compared the nursing CI vs. nutritionist (K = 0.798; p < 0.001), and the doctor vs. nutritionist (K = 0.823; p < 0.001). The S and Sp of nursing vs. nutritionist was 84% and 97% while between the doctor and the nutritionist was 84% and 98% respectively. CONCLUSIONS: the concordance of the results of a CI of 72 hours (intakes < or > to 50%) performed in patients hospitalized by a doctor, nurse, and nutritionist is high, minimizing subjectivity to this parameter. The CI is helpful for its use within the routine clinical practice, and particularly within the nutritional screenings, such as CIPA.

Introducción: el cribado nutricional CIPA es positivo cuando se cumple uno de los siguientes parametros: Control de Ingestas (CI) 72 h < 50%; albumina < 3 g/dl; Indice de Masa Corporal (IMC) < 18,5 kg/m2 o Circunferencia del Brazo (CB) ≤ 22,5 cm (si no se puede determinar IMC). El unico parametro no totalmente objetivo es el CI, por lo que este estudio busca reforzar la validez del mismo. Objetivos: analizar la concordancia existente entre diferentes profesionales sanitarios a la hora de evaluar un CI de 72 h. Material y métodos: estudio prospectivo de pacientes ingresados en plantas de hospitalizacion (febrero-octubre de 2014). Variables recogidas: edad, sexo, servicio medico, CI de 72 h y tipo de dieta. El objetivo del CI es valorar la cantidad de alimento consumido, diferenciando entre ingestas superiores o inferiores al 50%. Se analiza la concordancia de los resultados del CI dictaminados por un medico, una enfermera y un nutricionista (gold-standar) mediante el coeficiente Kappa (K). Posteriormente se calculo la sensibilidad (S) y la especificidad (E) de los CI positivos. Resultados: se analizaron 176 controles de ingestas. Edad: 63,70 } 14,46 anos; 42% mujeres. Servicios: Digestivo (22,2%), Neumologia (42%), Medicina Interna (21,6%), Nefrologia (9,1%), Otros (5,1%). Tipo de dieta: basal (23,3%), terapeutica (67%), consistencia (4%), progresion (3,4%), otros (2,3%). Se comparo el CI de enfermeria vs. nutricionista (K = 0,798; p < 0,001), y del medico vs. nutricionista (K = 0,823; p < 0,001). La S y E de enfermeria vs. nutricionista fue de 84% y 97%, mientras que entre medico y nutricionista fue de 84% y 98%, respectivamente. Conclusiones: la concordancia de los resultados de un CI de 72 horas (ingestas < o > al 50%) realizado en pacientes hospitalizados por un medico, una enfermera y un nutricionista es alta, restando subjetividad a este parametro. El CI resulta util para su uso dentro de la practica clinica habitual y, en concreto, dentro de cribados nutricionales, como el CIPA.

C-peptide as a risk factor of coronary artery disease in the general population.

OBJECTIVE: To analyse the association between serum C-peptide and coronary artery disease in the general population. METHODS: Follow-up study of 6630 adults from the general population. They were stratified into group 1 (no insulin resistance: C-peptide < third tercile and glycaemia < 100 mg/dL), group 2 (initial insulin resistance: C-peptide ⩾ third tercile and glycaemia < 100 mg/dL) and group 3 (advanced insulin resistance: glycaemia ⩾ 100 mg/dL). RESULTS: After 3.5 years of follow-up, group 2 had a higher incidence of myocardial infarction (relative risk (RR) = 4.2, 95% confidence interval (CI) = 1.7-10.6) and coronary artery disease (RR = 3.5, 95% CI = 1.9-6.6) than group 1. Group 3 also had increased incidences of both diseases. In multivariable analysis of the entire population, groups 2 and 3 showed significant risks of myocardial infarction and coronary artery disease (RR > 3 and RR > 2, respectively). However, when people with diabetes were excluded, the increased risks were corroborated only in group 2 for myocardial infarction (RR = 2.8, 95% CI = 1.1-6.9; p = 0.025) and coronary artery disease (RR = 2.4, 95% CI = 1.3-4.6; p = 0.007). CONCLUSION: Elevated C-peptide is associated with the incidence of myocardial infarction and coronary artery disease in the general population. It can be an earlier predictor of coronary events than impaired fasting glucose.

[Introducing a mixed nutritional screening tool (CIPA) in a tertiary hospital]. / Introducción de un método mixto de cribado nutricional (CIPA) en un hospital de tercer nivel.

INTRODUCTION: Malnourishment in hospitalized patients is very prevalent and therefore it is important to implement screening methods. A mixed nutritional screening method (CIPA) has been developed at our center; this method includes four parameters: (a) control of intakes for 72 h; (b) BMI; (c) proteins; and (d) albumin. OBJECTIVES: (1) To know the prevalence of malnourishment at the Internal Medicine Department of our Center; (2) To analyze the variables associated to higher prevalence of malnourishment. MATERIALS AND METHOD: The results of the nutritional screening tests carried out in 305 patients admitted to the Internal Medicine Department in the period of November of 2012-October of 2013 were retrospectively reviewed. The prevalence of hospital malnourishment was analyzed, as well as the association of a positive screening test (at least one positive item) with the following variables: BMI, age, gender, underlying disease, hospital staying, early re-admittance (< 1 month) and hospital mortality. RESULTS: The test yielded a positive result in 23% of the patients. Patients with a positive screening test had lower BMI (24.9 ± 7.2 vs. 27.8 ± 6.4 kg/m; p = 0.002). Neoplastic and infectious pathologies were associated with greater positivity (35.3 and 28.9%, respectively; p = 0.006). Gender and age were not associated with a positive screening test. Patients with a positive screening test had longer mean hospital staying (26.7 ± 25 vs. 19.4 ± 16.5; p = 0.005), higher early re-admittance rates (18.6 vs. 6.8%; p = 0.003) and higher mortality (30 vs. 10.3%; p < 0.001). CONCLUSIONS: The CIPA screening test can detect malnourished patients and predict worse clinical prognosis (mortality, mean hospital staying and early readmittance).

Introducción: La desnutrición en el paciente hospitalizado es muy prevalente, por lo que es importante incorporar métodos de depistaje. Se ha desarrollado en nuestro centro un método mixto de cribado nutricional (CIPA), que incluye cuatro parámetros: a) control de ingestas 72 h; b) IMC; c) proteínas; y d) albúmina. Objetivos: 1) conocer la prevalencia de desnutrición en pacientes hospitalizados en el servicio de Medicina Interna de nuestro centro; 2) analizar variables asociadas a mayor prevalencia de desnutrición; 3) evaluar su efecto pronóstico clínico. Material y métodos: Se revisaron retrospectivamente los resultados de los test de cribado nutricional efectuados a 305 pacientes ingresados en el servicio de Medicina Interna en el periodo noviembre/2012-octubre/2013. Se analizó la prevalencia de desnutrición hospitalaria y la asociación del resultado positivo en el cribado (al menos un ítem positivo) con las siguientes variables: IMC, edad, sexo, patología subyacente, estancia, reingreso precoz (< de 1 mes) y mortalidad. Resultados: El test fue positivo en un 23% de los pacientes. Los pacientes con cribado positivo presentaban un IMC inferior (24,9 ± 7,2 vs 27,8 ± 6,4 kg/m; p = 0,002). La patología neoplásica e infecciosa se asociaron a mayor positividad (35,3 y 28,9%, respectivamente; p=0,006). El sexo y la edad no se asociaron con el resultado del test de cribado. Los pacientes con cribado positivo presentaban mayor estancia media (26,7 ± 25 vs 19,4 ± 16,5; p = 0,005), tasa de reingresos precoces (18,6 vs 6,8%; p = 0,003) y mortalidad (30 vs 10,3%; p < 0,001). Conclusiones: El test de cribado CIPA es capaz de detectar al paciente malnutrido y predecirle un peor pronóstico clínico (mortalidad, estancia media y reingreso precoz).

Incidence of deep vein thrombosis and thrombosis of the portal-mesenteric axis after laparoscopic sleeve gastrectomy.

BACKGROUND: Venous thromboembolism is the most common postoperative medical complication after bariatric surgery. Mortality associated with thromboembolic processes can reach up to 50%-75%. The aim of this study was to determine the incidence of deep vein thrombosis (DVT) and portal-splenic-mesenteric vein thrombosis (PSMVT) in our population undergoing laparoscopic sleeve gastrectomy (LSG) as the bariatric technique, with an anti-thromboembolic dosage scheme of 0.5 mg/kg/day 12 hours preoperatively and maintained during 30 days postoperatively. PATIENTS AND METHODS: A prospective observational study was performed, including 100 consecutive patients undergoing LSG between October 2007 and September 2013. To determine the incidence of DVT and PSMVT, all patients undergo contrast-enhanced abdominal computed tomography (CT) and Doppler ultrasonography (US) of both lower limbs on the third postoperative month, whether they were asymptomatic or symptomatic. RESULTS: Contrast-enhanced CT showed 1 case of PSMVT (1%). Two patients presented DVT in the right leg (2%). All the cases were asymptomatic. CONCLUSIONS: The incidence of PSMVT and DVT after LSG with a prophylactic low-molecular-weight heparin dose of 0.5 mg/kg/day and maintained during 30 days postoperatively is 1% and 2%, respectively. According to these results, a postoperative screening with Doppler US and/or contrast-enhanced CT seems to be unnecessary.

[Validation of a method of dispensing nutritional supplements in a tertiary hospital]. / Validación de un método de dispensación de suplementos nutricionales en un hospital terciario.

INTRODUCTION: Nutritional supplements are an essential component of the management of hospital hyponutrition, although their costs are high. There exists the need for methods allowing a rational prescription of them. OBJECTIVES: To analyze the validity of the criteria for dispensing the nutritional supplements (NS) used at our center (by using as a reference the CONUT system). MATERIAL AND METHOD: We retrospectively reviewed the petition formularies of NS sent from the different departments for 15 months (April/2010-June/2011). We analyzed the following variables: petitionary department; pathology; BMI; recent weight loss; decreased intake > 50%; total proteins; albumin; lymphocytes; total cholesterol; and assessment of the hyponutrition level according to the CONUT system. We compared the validity of our dispensing criteria of NS to those of the CONUT system by means of the Kappa coefficient. RESULTS: We received 524 petitions (34.9/month). Pathologies: infectious (31.1%), tumor (26.1%), postsurgical (19%), others (23.8%). 88.9% of the patients had recent weight loss and 83.4% decreased intake > 50%. BMI: 24.8 ± 7.5 kg/m². Laboratory parameters: albumin 2.6 ± 0.7 g/dL, total proteins 5.7 ± 2.4 g/dL, total cholesterol 152 ± 172 mg/dL, lymphocytes 1,561 ± 1,842/ mm3. Assessment of the hyponutrition level according to the CONUT system: normal (12%), mild hyponutrition (23.1%), moderate (41.6%), severe (23.3%). Adherence to our hospital requisites for the dispensation of NS: none (6.3%), one (33.6%), two (43.1%), all three (17%). We compared the number of requisites to the degree of hyponutrition (CONUT system), yielding a weak agreement index (Kappa = 0.207; p < 0.001). 156 patients (29.8% of all the petitions) received a NS in spite of having a normal nutrition level or mild hyponutrition according to the CONUT system. Most of these commands (116; 74.4%) met just one criterion for dispensing a NS, and in 93.9% of them the reason alleged by the physician was a decreased intake > 50%. CONCLUSIONS: our dispensation method of NS detects a greater percentage of patients susceptible of nutritional supplementation than the CONUT system. The main advantage of our system is the assessment of a decreased intake, which is the main indication for a NS at the hospital setting.

Introducción: Los suplementos nutricionales constituyen un pilar fundamental del tratamiento de la desnutrición hospitalaria, aunque su coste es elevado. Son precisos métodos que permitan una prescripción racional de los mismos. Objetivos: Analizar la validez de los criterios de dispensación de suplementos nutricionales (SN) utilizados en nuestro centro (empleando como referencia el sistema CONUT). Material y métodos: Se revisaron retrospectivamente los formularios de solicitud de SN remitidos por los distintos servicios durante 15 meses (abril/2010-junio/2011). Se analizaron las siguientes variables: servicio solicitante, patología, IMC, pérdida de peso reciente, disminución de la ingesta mayor del 50%, proteínas totales, albúmina, linfocitos, colesterol total y valoración del grado de desnutrición según sistema CONUT. Se comparó la validez de nuestros criterios de dispensación de SN con el sistema CONUT (empleando el coeficiente Kappa). Resultados: Se recibieron 524 solicitudes (34,9/mes). Patologías: infecciosa (31,1%), tumoral (26,1%), postquirúrgica (19%), otras (23,8%). Había pérdida de peso reciente en el 88,9% de los pacientes, y una disminución de la ingesta superior al 50% en el 83,4%. IMC: 24,8 ± 7,5 kg/m2. Parámetros analíticos: albúmina 2,6 ± 0,7 g/dl, proteínas totales 5,7 ± 2,4 g/dl, colesterol total 152 ± 172 mg/dl, linfocitos 1.561 ± 1.842/mm3. Valoración del grado de desnutrición según sistema CONUT: normal (12%), desnutrición leve (23,1%), moderada (41,6%), grave (23,3%). Cumplimiento de los requisitos de nuestro centro hospitalario para la dispensación de SN: ninguno (6,3%), uno (33,6%), dos (43,1%), los tres (17%). Se comparó el número de dichos requisitos con el grado de desnutrición (sistema CONUT), obteniéndose un índice de concordancia débil (Kappa = 0,207; p < 0,001). 156 pacientes (29,8% de las solicitudes) recibieron SN, a pesar de presentar grado de nutrición normal o desnutrición leve de acuerdo al sistema CONUT. La mayor parte de dichas solicitudes (116; 74,4%) cumplían un único requisito para la dispensación de SN, y en el 93,9% de las mismas el criterio alegado por el médico solicitante era la disminución de la ingesta mayor del 50%. Conclusiones: Nuestro método de dispensación de SN detecta un mayor porcentaje de pacientes susceptibles de suplementación nutricional que el sistema CONUT. La principal ventaja de nuestro sistema es la valoración de la disminución de la ingesta, que es la principal indicación de SN en el medio hospitalario.

Prevalencia del síndrome intestino irritable en la población adulta venezolana / Prevalence of irritable bowel syndrome in venezuelan adults

El síndrome del intestino irritable (SII) es un trastorno digestivo funcional que afecta del 10 al 20% de la población general. Existen pocos estudios en Latinoamérica que muestren su prevalencia nacional, y en Venezuela no disponemos de investigación que reporte tan importante cifra. Estudio multicéntrico, descriptivo, transversal, durante los meses abril y mayo del 2011. Se utilizó el cuestionario validado de la Fundación Roma, con quienes firmamos convenio como Servicio de Gastroenterología del Hospital Vargas de Caracas. Se seleccionaron al azar 15 estados, en cada uno un municipio, y de estos lugares como iglesias, centros comerciales, reuniones de Consejos Comunales, paradas de autobuses, etc. Los valores obtenidos fueron transcritos en una base de datos en Excel y procesados con EPIDAT 3.1. De 1781 personas encuestadas, 299 presentaron criterios clínicos diagnósticos para SII de acuerdo a Roma III. La prevalencia nacional del SII fue de 16,80%, correspondiendo 81,6% a mujeres (244) y 18,4% a hombres (55). El grupo etario entre 38 y 47 años fue el más afectado (26,43%) y el subtipo mixto el más predominante. La prevalencia del SII en la población adulta venezolana según los criterios de Roma III es de 16,80%

Irritable bowel syndrome (IBS) is a functional digestive disorder that affects 10 to 20% of the general population. Few studies exist in Latin America that shows the national prevalence, and in Venezuela we don´t have investigation resources that support those numbers. Multicenter study, descriptive, transversal, during the months April and May 2011. The validated Roma Foundation questionnaire was used. This Foundation authorized its use by the Service of Gastroenterology Hospital Vargas de Caracas. 15 states were randomly selected, in each state one municipality, and in those places as churches, shopping centers, comunity meeting, bus stops, etc. The values obtained were transcribed into a database in Excel and processed EPIDAT 3.1. Of 1781 people encuested, 299 met the criteria for IBS according to Rome III. The national prevalence of IBS was 16.80%, with 81.6% women (244) and 18.4% men (55). The age group between 38 and 47 years was the most affected (26.43%) and the mix was the most predominant subtype. The prevalence of IBS in the Venezuelan adult population according to Rome III criteria is 16.80%