[Commitment of Asunción. A call to action]. / Compromiso de Asunción. Un llamado a la acción.

Introduction: The Latin American Federation of Nutritional Therapy, Clinical Nutrition, and Metabolism - FELANPE, was founded in 1988. It brings together interdisciplinary societies and associations in Clinical Nutrition and Nutritional Therapy from Latin America and the Caribbean, as well as Spain and Portugal. Currently, it comprises representations from 18 countries. The objectives of the Federation are described, taking into account the assumed commitment. This is an observational cross-sectional, multicenter study that included 132 hospitals with more than 100 beds, of high complexity, both state-owned and private, from 14 countries in Latin America that are members of FELANPE. The study assessed hospital characteristics, implementation of nutritional assessment, nutritional diagnosis of patients, the team responsible for nutritional therapy, nutritional therapy (oral, enteral, and parenteral), monitoring, and nutritional follow-up. For this purpose, a digital questionnaire and an explanatory video were designed and validated to ensure the quality of the collected data. Validation was carried out through a pilot study conducted in Paraguay, approved by the Ethics Committee for Research at the Faculty of Medical Sciences of the National University of Asunción. The current research has the approval of the Research Ethics Committee of the Faculty of Chemical Sciences of the National University of Asunción and the Ethics Committee of FELANPE. The results presented at the XVIII Latin American Congress of FELANPE in Asunción, Paraguay, on October 12, 2023, serve as a basis for characterizing the implementation of Parenteral and Enteral Nutritional Therapy (medical nutritional therapy) in hospitals in Latin America and are used as technical support for the present Asunción Commitment.

Introducción: La Federación Latinoamericana de Terapia Nutricional, Nutrición Clínica y Metabolismo ­ FELANPE, fue fundada en el año 1988. Reúne a Sociedades y Asociaciones Interdisciplinarias de Nutrición Clínica y Terapia Nutricional de América Latina y el Caribe, además de España y Portugal. Actualmente la conforman representaciones de 18 países. Se describen los objetivos de la Federación teniendo en cuenta el compromiso asumido. Se trata de estudio observacional transversal, multicéntrico en que se incluyeron 132 hospitales con más de 100 camas, de alta complejidad, estatales y privados de 14 países de Latinoamérica miembros de FELANPE. Se evaluaron las características del hospital, la implementación de la valoración nutricional, el diagnóstico nutricional de pacientes, el equipo responsable de la terapia nutricional, la terapéutica nutricional (oral, enteral y parenteral), la monitorización y el seguimiento nutricional. Para tal, se diseñó y validó un cuestionario digital y un video explicativo para garantizar la calidad de los datos recolectados. La validación se efectúo mediante un estudio piloto realizado en Paraguay, aprobado por el Comité de Ética en la Investigación de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción. La investigación actual cuenta con la aprobación del Comité de Ética de Investigación de la Facultad de Ciencias Químicas de la Universidad Nacional de Asunción y del Comité de Ética de FELANPE. Los resultados presentados en el XVIII Congreso Latinoamericano de FELANPE, en Asunción del Paraguay, el 12 de octubre del 2023, sirven como base para caracterizar la implementación de la Terapia Nutricional Parenteral y Enteral (terapia nutricional médica) en Hospitales de Latinoamérica y son utilizados como sustento técnico del presente Compromiso de Asunción.

Perfil nutricional de pacientes ostomizados. Hospital General del segundo departamento de San Pedro Paraguay ­ Corea. 2022 / Nutritional profile of ostomized patients. General Hospital of the second department of San Pedro Paraguay ­ Korea. 2022

El perfil nutricional de los pacientes ostomizados adquiere especial atención debido a las condiciones que podrían predisponer a una malnutrición. El objetivo del estudio fue determinar el perfil nutricional de pacientes ostomizados que reciben atención ambulatoria en el Hospital General del Segundo Departamento de San Pedro-Paraguay - Corea, en el año 2022, se realizó un estudio observacional de corte transversal. Los datos obtenidos fueron cargados en una planilla electrónica Microsoft-Excel, para el análisis se utilizó estadística descriptiva. Para describir el estado nutricional de los pacientes se emplearon indicadores antropométricos y el Screening de Riesgo Nutricional (NRS-2002), aplicados mediante entrevista y evaluación clínica nutricional. El estudio tuvo una duración global de 9 meses, fueron incluidos 20 pacientes ostomizados atendidos en el Programa Nacional de Atención Integral al Paciente Ostomizado provisto por el Hospital General Paraguay-Corea que cumplieron con los criterios de inclusión. Se respetaron los principios éticos de investigación. El grupo etario más representativo fue el de 41 a 64 años o más, seguido del grupo etario de 20 a 40 años; mayor proporción de sexo masculino, procedencia rural. El tipo de ostomía más frecuente fue colostomía terminal seguido de colostomía laterales; enfermedad de base más frecuente fue el de tipo oncológico, seguida de obstrucción intestinal, trauma y por último fistulas y enfermedad diverticular. En conclusión, la apreciación global del estado nutricional evaluada mediante la herramienta NRS-2002 indicó que el perfil nutricional de los pacientes ostomizados presenta riesgo de malnutrición en todos los casos evaluados.

The nutritional profile of ostomized patients acquires special attention due to the conditions that could predispose to malnutrition. The objective of the study was to determine the nutritional profile of ostomized patients who receive outpatient care at the General Hospital of the Second Department of San Pedro-Paraguay Korea, in the year 2022, an observational study of a cross-section was conducted. The data obtained were loaded in an electronic form Microsoft-Excel, for the analysis was used descriptive statistics. To describe the nutritional status of patients, anthropometric indicators and nutritional risk screening (NRS-2002) were used, applied through nutritional clinical interview and evaluation. The study had a global duration of 9 months, 20 ostomized patients were included in the National Program for Comprehensive Care of the Ostomized Patient provided by the General Paraguay-Corea Hospital that complied with the inclusion criteria. Ethical research principles were respected. The most representative age group was 41 to 64 years or more, followed by the age group from 20 to 40 years; Greater proportion of male sex, rural origin. The most frequent type of ostomy was terminal colostomy followed by lateral colostomy; The most frequent base disease was the oncological type, followed by intestinal obstruction, trauma and finally fistulas and diverticular disease. In conclusion, the global appreciation of the nutritional status evaluated by the NRS-2002 tool indicated that the nutritional profile of ostomized patients has a risk of malnutrition in all cases evaluated.

Chitosan and nematophagous fungi for sustainable management of nematode pests.

Plants are exposed to large number of threats caused by herbivores and pathogens which cause important losses on crops. Plant pathogens such as nematodes can cause severe damage and losses in food security crops worldwide. Chemical pesticides were extendedly used for nematode management. However, due to their adverse effects on human health and the environment, they are now facing strong limitations by regulatory organisations such as EFSA (European Food Safety Authority). Therefore, there is an urgent need for alternative and efficient control measures, such as biological control agents or bio-based plant protection compounds. In this scenario, chitosan, a non-toxic polymer obtained from seafood waste mainly, is becoming increasingly important. Chitosan is the N-deacetylated form of chitin. Chitosan is effective in the control of plant pests and diseases. It also induces plants defence mechanisms. Chitosan is also compatible with some biocontrol microorganisms mainly entomopathogenic and nematophagous fungi. Some of them are antagonists of nematode pests of plants and animals. The nematophagous biocontrol fungus Pochonia chlamydosporia has been widely studied for sustainable management of nematodes affecting economically important crops and for its capability to grow with chitosan as only nutrient source. This fungus infects nematode eggs using hyphal tips and appressoria. Pochonia chlamydosporia also colonizes plant roots endophytically, stimulating plant defences by induction of salicylic and jasmonic acid biosynthesis and favours plant growth and development. Therefore, the combined use of chitosan and nematophagous fungi could be a novel strategy for the biological control of nematodes and other root pathogens of food security crops.

Comprehensive geriatric assessment: Influence on clinical results after colorectal surgery in advanced age patients. / Valoración geriátrica integral: influencia en los resultados clínicos de la cirugía colorrectal en pacientes de edad muy avanzada.

INTRODUCTION: The objective of this work was to analyse the postoperative clinical results of patients surgically treated for colorectal cancer in relation to the results of the preoperative comprehensive geriatric evaluation. METHODS: Observational study in which postoperative morbidity and mortality at 30 and 90 days were analysed in a cohort of patients surgically treated for colorectal cancer according to age groups: group 1) between 75 and 79 years old; group 2) between 80 and 84 years old, and group 3) ≥85 years old. In addition to the anaesthetic risk assessment, patients were assessed with the Karnofsky, Barthel and Pfeiffer indexes. Mortality at 30 and 90 days after surgery was analysed in relation to the results of the comprehensive evaluation. RESULTS: A total of 227 patients with colorectal cancer were included in the study period: 91 in group 1, 89 in group 2 and 47 in group 3. There were statistically significant differences in mortality at 30 days (p=0,029) but not at 90 days after surgery, according to age groups. Mortality at 90 days was significantly higher in patients with worse scores on the Karnofsky and Barthel scales. CONCLUSIONS: Comprehensive geriatric assessment using different scales is a good tool to assess postoperative mortality in the mid-term postoperative period.

The Role of Liver Transplantation in Propionic Acidemia.

Despite optimal medical treatment and strict low-protein diet, the prognosis of propionic acidemia (PA) patients is generally poor. We aim to report our experience with liver transplantation (LT) in the management of PA patients. Six patients with PA received a LT at a mean age of 5.2 years (1.3-7.5 years). The indications for LT were frequent metabolic decompensations in the first 4 patients and preventative in the last 2 patients. Two patients presented hepatic artery thromboses that were solved through an interventional radiologist approach. These patients showed a very high procoagulant state that was observed by thromboelastography. Arterial vasospasm without thrombus was observed in 2 patients during the LT surgery. In order to avoid hepatic artery thrombosis, an arterial conduit from the recipient aorta to the hepatic artery of the donor was used in the fifth patient. After LT, patients presented improvement in propionyl byproducts without complete normalization, but no decompensations have been observed. In conclusion, LT could be a good therapeutic option to improve the metabolic control and the quality of life of PA patients. Improved surgical strategies along with new techniques of interventional radiology allow us to perform the LT minimizing the complications derived from the higher risk of hepatic artery thrombosis.

Predictive biomarkers for death and rehospitalization in comorbid frail elderly heart failure patients.

BACKGROUND: Heart failure (HF) is associated with a high rate of readmissions within 30 days post-discharge and in the following year, especially in frail elderly patients. Biomarker data are scarce in this high-risk population. This study assessed the value of early post-discharge circulating levels of ST2, NT-proBNP, CA125, and hs-TnI for predicting 30-day and 1-year outcomes in comorbid frail elderly patients with HF with mainly preserved ejection fraction (HFpEF). METHODS: Blood samples were obtained at the first visit shortly after discharge (4.9 ± 2 days). The primary endpoint was the composite of all-cause mortality or HF-related rehospitalization at 30 days and at 1 year. All-cause mortality alone at one year was also a major endpoint. HF-related rehospitalizations alone were secondary end-points. RESULTS: From February 2014 to November 2016, 522 consecutive patients attending the STOP-HF Clinic were included (57.1% women, age 82 ± 8.7 years, mean Barthel index 70 ± 25, mean Charlson comorbidity index 5.6 ± 2.2). The composite endpoint occurred in 8.6% patients at 30 days and in 38.5% at 1 year. In multivariable analysis, ST2 [hazard ratio (HR) 1.53; 95% CI 1.19-1.97; p = 0.001] was the only predictive biomarker at 30 days; at 1 year, both ST2 (HR 1.34; 95% CI 1.15-1.56; p < 0.001) and NT-proBNP (HR 1.19; 95% CI 1.02-1.40; p = 0.03) remained significant. The addition of ST2 and NT-proBNP into a clinical predictive model increased the AUC from 0.70 to 0.75 at 30 days (p = 0.02) and from 0.71 to 0.74 at 1 year (p < 0.05). For all-cause death at 1 year, ST2 (HR 1.50; 95% CI 1.26-1.80; p < 0.001), and CA125 (HR 1.41; 95% CI 1.21-1.63; p < 0.001) remained independent predictors in multivariable analysis. The addition of ST2 and CA125 into a clinical predictive model increased the AUC from 0.74 to 0.78 (p = 0.03). For HF-related hospitalizations, ST2 was the only predictive biomarker in multivariable analyses, both at 30 days and at 1 year. CONCLUSIONS: In a comorbid frail elderly population with HFpEF, ST2 outperformed NT-proBNP for predicting the risk of all-cause mortality or HF-related rehospitalization. ST2, a surrogate marker of inflammation and fibrosis, may be a better predictive marker in high-risk HFpEF.

Assessing the efficacy over time of the addition of industrial by-products to remediate contaminated soils at a pilot-plant scale.

The effect of the addition of industrial by-products (gypsum and calcite) on the leaching of As and metals (Cu, Zn, Ni, Pb and Cd) in a soil contaminated by pyritic minerals was monitored over a period of 6 months at a two-pit pilot plant. The contaminated soil was placed in one pit (non-remediated soil), whereas a mixture of the contaminated soil (80% w/w) with gypsum (10% w/w) and calcite (10% w/w) was placed in the other pit (remediated soil). Soil samples and leachates of the two pits were collected at different times. Moreover, the leaching pattern of major and trace elements in the soil samples was assessed at laboratory level through the application of the pHstat leaching test. Addition of the by-products led to an increase in initial soil pH from around 2.0 to 7.5, and it also provoked that the concentration of trace elements in soil extracts obtained from the pHstat leaching test decreased to values lower than quantification limits of inductively coupled plasma optical emission spectrometry and lower than the hazardous waste threshold for soil management. The trace element concentration in the pilot-plant leachates decreased over time in the non-remediated soil, probably due to the formation of more insoluble secondary minerals containing sulphur, but especially decreased in pit of the remediated soil, in agreement with laboratory data. The pH in the remediated soil remained constant over the 6-month period, and the X-ray diffraction analyses confirmed that the phases did not vary over time, thus indicating the efficacy of the addition of the by-products. This finding suggests that soil remediation may be a feasible option for the re-use of non-hazardous industrial by-products.

Early Postdischarge STOP-HF-Clinic Reduces 30-day Readmissions in Old and Frail Patients With Heart Failure.

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is associated with a high rate of readmissions within 30 days postdischarge. Strategies to lower readmission rates generally show modest results. To reduce readmission rates, we developed a STructured multidisciplinary outpatient clinic for Old and frail Postdischarge patients hospitalized for HF (STOP-HF-Clinic). METHODS: This prospective all-comers study enrolled patients discharged from internal medicine or geriatric wards after HF hospitalization. The intervention involved a face-to-face early visit (within 7 days), HF nurse education, treatment titration, and intravenous medication when needed. Thirty-day readmission risk was calculated using the CORE-HF risk score. We also studied the impact of 30-day readmission burden on regional health care by comparing the readmission rate in the STOP-HF-Clinic Referral Area (∼250000 people) with that of the rest of the Catalan Health Service (CatSalut) (∼7.5 million people) during the pre-STOP-HF-Clinic (2012-2013) and post-STOP-HF-Clinic (2014-2015) time periods. RESULTS: From February 2014 to June 2016, 518 consecutive patients were included (age, 82 years; Barthel score, 70; Charlson index, 5.6, CORE-HF 30-day readmission risk, 26.5%). The observed all-cause 30-day readmission rate was 13.9% (47.5% relative risk reduction) and the observed HF-related 30-day readmission rate was 7.5%. The CatSalut registry included 65131 index HF admissions, with 9267 all-cause and 6686 HF-related 30-day readmissions. The 30-day readmission rate was significantly reduced in the STOP-HF-Clinic Referral Area in 2014-2015 compared with 2012-2013 (P < .001), mainly driven by fewer HF-related readmissions. CONCLUSIONS: The STOP-HF-Clinic, an approach that could be promptly implemented elsewhere, is a valuable intervention for reducing the global burden of early readmissions among elder and vulnerable patients with HF.

Influence of multidrug resistance and appropriate empirical therapy on the 30-day mortality rate of Pseudomonas aeruginosa bacteremia.

Infections due to multidrug-resistant (MDR) Pseudomonas aeruginosa are increasing. The aim of our study was to evaluate the influences of appropriate empirical antibiotic therapy and multidrug resistance on mortality in patients with bacteremia due to P. aeruginosa (PAB). Episodes of PAB were prospectively registered from 2000 to 2008. MDR was considered when the strain was resistant to ≥3 antipseudomonal antibiotics. Univariate and multivariate analyses were performed. A total of 709 episodes of PAB were studied. MDR PAB (n = 127 [17.9%]) was more frequently nosocomial and associated with longer hospitalization, bladder catheter use, steroid and antibiotic therapy, receipt of inappropriate empirical antibiotic therapy, and a higher mortality. Factors independently associated with mortality were age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002 to 1.033), shock (OR, 6.6; 95% CI, 4 to 10.8), cirrhosis (OR, 3.3; 95% CI, 1.4 to 7.6), intermediate-risk sources (OR, 2.5; 95% CI, 1.4 to 4.3) or high-risk sources (OR, 7.3; 95% CI, 4.1 to 12.9), and inappropriate empirical therapy (OR, 2.1; 95% CI, 1.3 to 3.5). To analyze the interaction between empirical therapy and MDR, a variable combining both was introduced in the multivariate analysis. Inappropriate therapy was significantly associated with higher mortality regardless of the susceptibility pattern, and there was a trend toward higher mortality in patients receiving appropriate therapy for MDR than in those appropriately treated for non-MDR strains (OR, 2.2; 95% CI, 0.9 to 5.4). In 47.9% of MDR PAB episodes, appropriate therapy consisted of monotherapy with amikacin. In conclusion, MDR PAB is associated with a higher mortality than non-MDR PAB. This may be related to a higher rate of inappropriate empirical therapy and probably also to amikacin as frequently the only appropriate empirical therapy given to patients with MDR PAB.

[Prokinetic agents as a cause of granulomatous interstitial nephritis]. / Procinéticos como causantes de nefritis intersticial granulomatosa.

Granulomatous interstitial nephritides are uncommon entities in routine clinical practice. These entities are usually associated with infectious diseases such as tuberculosis, or immune diseases, such as sarcoidosis, systemic lupus erythematosus or cryoglobulinemia. However, these diseases are most frequently associated with drug intake, especially antibiotics, proton pump inhibitors and nonsteroidal anti inflammatory drugs. An association with prokinetic agents has not previously been reported. We report the case of a 64-year-old woman who developed acute renal failure with this histological pattern after taking the motility promoter cinitapride without her physician's knowledge.