Diet in Scleroderma: Is There a Need for Intervention?

Systemic sclerosis (SSc) patients exhibit a plethora of risk factors for nutritional decline, including the presence of chronic inflammation and the progressive nature of disease-related multisystem involvement. The prevalence and consequences of nutritional decline in scleroderma are frequently underestimated, its management currently remaining a subject of debate. The main objective of the present study was to perform a detailed assessment of scleroderma patients' diet as well as their eating habits and to describe the relationships with weight loss and malnutrition risk in the absence of professional nutritional counseling. METHODS: We used a translated and validated version of the EPIC-Norfolk FFQ (European Prospective Investigation into Cancer and Nutrition Norfolk Food Frequency Questionnaire) to evaluate the patients' diet and MUST (Malnutrition Universal Screening Tool) to investigate the risk of malnutrition. Disease activity was estimated using the EUSTAR-AI (European Scleroderma Trials and Research group Activity Index). RESULTS: We included 69 patients with SSc, of which 42 underwent a detailed dietary assessment. Dietary factors were connected to body composition and digestive symptoms. We found high sodium intake and frequent suboptimal energy consumption in our study group, including patients with cardiopulmonary involvement. Liver transaminases were inversely correlated with the consumption of nuts and seeds. Malnutrition and weight loss were significantly associated with pulmonary hypertension, heart failure, albumin levels, and the extent of skin fibrosis, but not advanced age. Although the patients with EUSTAR-AI ≥ 2.5 were more frequently included in the moderate and high malnutrition risk categories, these results did not reach statistical significance. CONCLUSIONS: Currently, there is an unmet need for longitudinal and interventional research focusing on the long-term significance, ramifications, and management of nutritional impairment in SSc patients with various clinical manifestations. Our results indicate that scleroderma patients could benefit from personalized nutritional counseling in an interdisciplinary setting.

The relationship between lifestyle components and dietary patterns.

We conducted a narrative review on the interaction between dietary patterns with demographic and lifestyle variables in relation to health status assessment. The food pattern has the advantage of taking into account the correlations that may exist between foods or groups of foods, but also between nutrients. It is an alternative and complementary approach in analysing the relationship between nutrition and the risk of chronic diseases. For the determination of dietary patterns one can use indices/scores that evaluate the conformity of the diet with the nutrition guidelines or the established patterns (a priori approach). The methods more commonly used are based on exploratory data (a posteriori): cluster analysis and factor analysis. Dietary patterns may vary according to sex, socio-economic status, ethnicity, culture and other factors, but more, they may vary depending on different associations between these factors. The dietary pattern exerts its effects on health in a synergistic way or even in conjunction with other lifestyle factors, and we can therefore refer to a 'pattern of lifestyle'.

Is Liver Biopsy Necessary in Patients With Nonalcoholic Fatty Liver Disease?

Nonalcoholic fatty liver disease is the most common cause of liver disease in the Western world. Liver biopsy is considered the gold standard in the diagnosis and progression of the disease and its usefulness cannot be neglected in terms of research. But in current clinical practice, liver biopsy tends to be replaced by less expensive and noninvasive methods allowing the identification of cardiovascular and metabolic risks. Given the fact that a small percentage of individuals with nonalcoholic fatty liver disease will progress to cirrhosis, attention will be focused more on cardiovascular risk as nonalcoholic fatty liver is now regarded as a distinct component of the metabolic syndrome. The aim of the clinician is to identify the early stages of fatty liver, using in this purpose simple and easily accessible methods. Many techniques have been proposed for the diagnosis of nonalcoholic fatty liver, from simple clinical factors (anthropometric indices measuring,blood pressure) laboratory biomarkers, imaging methods and scores, which should allow early treatment. This review describes different methods for identifying nonalcoholic fatty liver and various stages of this disease.

Pathological aspects underlying pancreatogenous hyperinsulinemic hypoglycemia--report of three cases.

Pancreatogenous hyperinsulinemic hypoglycemia (PHH) is a rare disorder determined by an abnormally high secretion of insulin in the pancreas, in the absence of other medical or pharmacological factors. Either ß-cell tumors (insulinomas) or ß-cell hyperplasia (nesidioblastosis) can determine this pathology. Most publications on insulinomas or nesidioblastosis approached these subjects from a clinical point of view. This paper aims to analyze pathological aspects underlying pancreatogenous hyperinsulinemic hypoglycemia. We present two cases of insulinomas with unusual pancreatic localization and size, one of them showing amyloid deposits in the stroma. In both cases, immunohistochemistry confirmed the clinical and imagistic supposition. The third reported case refers to a 57-year-old patient with nesidioblastosis with isolated disposition of endocrine cells and areas of focal organization, both morphological aspects being extremely rare in adults. Although clinical and laboratory data are usually identical in the two forms of PHH, histopathological and immunohistochemical diagnosis is essential in differentiating insulinomas from nesidioblastosis, as the surgical management is different: enucleation for insulinomas and total or subtotal pancreatectomy for nesidioblastosis.

The evaluation of preoperative nutritional status in patients undergoing thoracic surgery.

AIM: The aim of this study was to assess the preoperative nutritional status of patients undergoing thoracic surgery using different nutritional tools. MATERIAL AND METHOD: . We conducted a prospective study on a sample of 43 thoracic patients, including 23 with neoplasms and 20 with non-neoplastic pathology who underwent thoracic surgery procedures between July-September 2011, in the Thoracic Surgery Clinic in Iasi. Weight and height were measured and body mass index (BMI) was calculated. WHO classification for BMI categories was used. Preoperative serum level of transthyretin (TTR) and demographic data (gender, age) were also assessed. All patients were examined by the Subjective Global Assessment (SGA) and the Nutritional Risk Screening 2002 (NRS 2002). RESULTS: After performing SGA, 67.9% of the patients were well-nourished, 21.4% were moderately or suspected of being malnourished and 10.7% were severely malnourished. The level of TTR was significantly lower in the moderately or severely malnourished group, compared to those considered well-nourished. According to NRS-2002, 42.9% of the patients were considered at nutritional risk. The level of TTR of these patients was lower than the level of TTR of the patients without nutritional risk, but without statistical significance. CONCLUSIONS: Subjective Global Assessment (SGA) and the Nutritional Risk Screening 2002 (NRS 2002) are useful in identifying patients with nutritional risk, so that appropriate nutritional management could be initialised even before surgery.

The role and interactions of ghrelin concerning the nutritional and inflammatory status.

Ghrelin is an important neuroendocrine peptide having as main purpose the stimulation of growth hormone (GH) secretion. It is also an important regulator of the long-term energy balance and short-term nutritional intake. Ghrelin has several other biological actions, among which the capacity to regulate gastrointestinal motility, to modulate the reproductive and stress axes as well as the glucose metabolism, and other well-defined actions within the cardiovascular and renal physiology. Due to its numerous effects, ghrelin is considered on one hand a potential target in the treatment of obesity and on the other, a therapeutic option in other dysfunctions and illnesses.

[Surgical treatment of tarsal tunnel syndrome in diabetic neuropathy]. / Tratamentul chirurgical al sindromului de canal tarsian în neuropatia periferica diabetica.

UNLABELLED: Posterior tibial nerve decompression surgery in tarsal tunnel syndrome in patients with diabetic neuropathy reduces pain, improves sensitivity and prevents foot ulcers and lower leg amputations. AIM: To observe and assess the recovery of plantar sensitivity recovery and the healing of ulcerative lessions of the foot, by clinical examination, exploration and analysis of quantitative neurosensory by surgical decompression of the tarsal tunnel. MATERIAL AND METHODS: We evaluated a total of 10 patients and 12 symptomatic diabetic neuropathy feet in a prospective clinical study, surgically treated in the Clinic of Plastic Surgery and Reconstructive Microsurgery Iasi, during January 2008 - June 2011, where we practiced tibial nerve decompression and neurolysis in tarsal tunnel syndrome. RESULTS: Gender distribution of patients in the study group was predominantly male (60%), the ratio M/F = 1.5/1. Posterior tibial nerve decompression surgery resulted in recovery of plantar foot sensitivity in 90% patients in the study group. Testing Semmes-Weinstein 10 g monofilament was positive in 83.3% of the feet preoperatively whereas postoperatively only 25%, distribution of statistically significant (chi2 = 6.04, GL = 1, p = 0.014). Postoperative score to test a range of Riedel-Seiffer returned to normal in all patients: score 7 to 58.3% and score 8 to 41.7% of total standing tested. CONCLUSIONS: Tarsal tunnel decompression in diabetic patients with peripheric neuropathy improves plantar sensitivity, leads to healing of ulcerative plantar lesions and improves quality of life and should be performed in all patients with diabetic peripheral neuropathy in which conservative and/or medical treatment failed.

Socio-demographic and lifestyle characteristics associated with the risk for obstructive sleep apnea syndrome in a rural population.

AIM: To evaluate socio-demographic and lifestyle characteristics in relationship to the risk for obstructive sleep apnea syndrome (OSAS). MATERIAL AND METHODS: The study was carried out on 254 subjects. Socio-demographic data (age, gender, occupation, education level, and economic status), smoking status, alcohol consumption, and hours/day spent watching TV were recorded. For physical activity assessment the international physical activity questionnaire and for identifying the risk for OSAS Berlin Questionnaire were used. RESULTS: Of the 254 subjects, 29.4% of men and 36.8% of women were at high risk for OSAS (p=0.22). Age was higher in the group at high risk for OSAS (p=0.002) and in women (p<0.001). The highest percentage (47.5%) of participants at high risk for OSAS was found among retired people, whereas farmers generated the lowest percentage (18.6 %) (p<0.001). 57.1% of retired women were at high risk for OSAS as compared to 5.6% of the farmers (p<0.001). Education level and monthly income did not influence the risk of OSAS (p=0.172, p=0.113, respectively). No differences in the risk of OSAS were found in relation with smoking (p=0.887), alcohol consumption (p=0.688), and sedentary lifestyle. We found that individuals at low risk for OSAS performed more physical activity at work (p=0.053) and significantly more vigorous physical activity (p=0.036). CONCLUSIONS: In the study rural population, age, occupation and physical activity are related to the risk for OSAS.

[Prevalence of Helicobacter pylori infection in patients with diabetes mellitus]. / Prevalenta infectiei cu Helicobacter pylori la pacientii cu diabet zaharat.

UNLABELLED: Helicobacter pylori (H. pylori) and diabetes mellitus are the most important causes of dyspepsia. The aim of this study was to evaluate the prevalence of H. pylori infection in patients with diabetes mellitus, and to assess whether the infection was associated with severity of dyspeptic syndrome and metabolic glycemic control. MATERIAL AND METHOD: 100 patients with diabetes mellitus type 1 and 2 (41 men and 59 women, mean age 58.59 ani) were included in our study. Each patient completed a self-report questionnaire to obtain information concerning the presence and severity of upper gastrointestinal tract symptoms. H. pylori status was confirmed by serological test and histophatology study of gastric biopsy or 13C-urea breath test. RESULTS: Prevalence of H. pylori infection was found not to be significantly higher in diabetics than in controls (70% vs 73% ). 49% H. pylori positive diabetics had type 2 insulinonecesitant diabetes mellitus, 27% had type 1 diabetes mellitus and 24% had type 2 diabetes mellitus, with no statistically significant difference (p > 0.05). We found no statistically significant difference in the symptoms score between H. pylori positive and H. pylori negative diabetic patients. The main value of HbA1 levels in H. pylori--infected diabetics was 7.31% and 7.47% in H. pylori non-infected diabetics, without significant difference. CONCLUSION: There was no statistically significant difference in the prevalence of H. pylori infection between diabetics and non-diabetics patients and no difference in the symptoms score between H. pylori positive and H. pylori negative diabetic patients. H. pylori in diabetics appears no influence glycemic status.

[Adipocytokines and nonalcoholic steatohepatitis]. / Adipocitokinele si steatohepatita nonalcoolica.

Nonalcoholic steatohepatitis is one of the most common liver diseases. It is part of the nonalcoholic fatty liver disease, which ranges from simple hepatic steatosis to necroinflammation and fibrosis of various degrees, so that many patients can evolve towards advanced liver disfunction and even cirrhosis. Insulin resistance is the main factor involved in the development of fatty liver. As the adipose tissue is the source of many metabolically active peptides (the adipocitokines), their involvement in the pathogenesis of the hepatic steatosis and steatohepatitis began to be intensively studied during the last years. The most substantial information collected until now concerns the tumor necrosis factor alpha (a proinflammatory cytokine that induces insulin resistance, fat accumulation in the liver and even fibrosis and necrosis), adiponectin (an anti-inflammatory adipokine that acts as an insulin sensitizer and a hepatic protector) and leptin (a signal from the adipose tissue mass with effects on the appetite and food intake, but also acting upon insulin secretion and action and perhaps upon the liver fat accumulation).

[Adipocitokines and nonalcoholic steatohepatitis]. / Adipocitokinele si steatohepatita nonalcoolica.

Nonalcoholic steatohepatitis is one of the most common liver diseases. It is part of the nonalcoholic fatty liver disease, which ranges from simple hepatic steatosis to necroinflammation and fibrosis of various degrees, so that many patients can evolve towards advanced liver disfunction and even cirrhosis. Insulin resistance is the main factor involved in the development of fatty liver. As the adipose tissue is the source of many metabolically active peptides (the adipocitokines), their involvement in the pathogenesis of the hepatic steatosis and steatohepatitis has begun to be intensively studied during the last years. The most substantial information collected until now concerns the tumor necrosis factor alpha (a proinflammatory cytokine that induces insulin resistance, fat accumulation in the liver and even fibrosis and necrosis), adiponectin (an anti-inflammatory adipokine that acts as an insulin sensitizer and a hepatic protector) and leptin (a signal of the adipose tissue mass with effects on the appetite and food intake, but also acting upon insulin secretion and action and perhaps upon the liver fat accumulation).

[Medical treatment in diabetic retinopathy]. / Tratamentul medicamentos al retinopatiei diabetice.

Diabetic retinopathy is a major cause of blindness worldwide with an expected increasing incidence. Tight blood sugar and blood pressure control have proven essential in preventing both appearance and evolution of retinopathy. Surgical treatments as laser therapy and vitrectomy have also been proved highly effective in preventing major visual loss in advanced stages of retinopathy. Continuous scientific research is leading to a better understanding of pathogenesis of the disease and thus an effective medical treatment is expected in both preventing and treating different stages of diabetic retinopathy. In this update we review ongoing clinical trials and also the knowledge from finalized clinical trials that were testing the clinical impact of experimental treatments or known therapies.

[The pathological mechanisms of glycoregulation disturbances in chronic hepatitis B and C]. / Mecanismele patogenice ale tulburarilor de glicoreglare în hepatopatiile cronice cu virus B si C.

Despite the abundance of reports concerning the increased frequency of diabetes and impaired glucose tolerance in chronic liver diseases, the mechanisms underlying this phenomenon have not been resolved. 30 patients with hepatitis C virus (HCV) infection and 17 with hepatitis B virus (HBV) infection who showed an altered responds to a standard oral glucose tolerance test were investigated in order to evaluate their pancreatic-endocrine features. We have also evaluated 40 patients (20 with HCV infection and 20 with HCB infection) who developed diabetes after diagnosis of liver disease. Patients with HBV infection showed signs of enhanced insulin resistance but overt diabetes develops in those who, in addition to insulin insensitivity, have a relative defect of insulin secretion. In patients with HCV infection the significantly lower plasma insulin and C-peptide levels suggest that impairment of insulin secretion is the main mechanism leading to both glucose intolerance and overt diabetes.