Searching for a nutritional screening tool. The value of an analytical method when staff trained in clinical nutrition is not available.

INTRODUCTION: Disease-related malnutrition (DRM) is highly prevalent. Various European resolutions urge to screen and treat DRM. No policy in this regard has yet been developed in Extremadura (Spain). OBJECTIVES: To assess the prevalence of DRM (defined as NRS 2002≥3) using an analytical method (FILNUT), and to compare it with the official rate. RESULTS: FILNUT scores≥3 showed values of sensitivity (S) and positive predictive value (PPV) of 82.3% and 72.3% respectively. No statistically significant differences were found between men and women using this tool. FILNUT showed a significantly higher sensitivity for detecting malnutrition in medical - as compared to surgical - diseases when low scores were used. The estimated prevalence of DRM was 21.4%. Prevalence of DRM is much greater than officially reported. CONCLUSIONS: FILNUT scores≥3 show high sensitivity and PPV for detecting DRM, and is a good alternative as a nutritional screening tool to detect malnutrition at our center.

Impacto del empleo de umbrales específicos de referencia en el diagnóstico de las alteraciones funcionales tiroideas en la mujer gestante / Impact of using specific reference intervals on the diagnosis of thyroid dysfunction during pregnancy

Objetivo: Establecer los umbrales específicos de referencia de cada uno de los parámetros de función tiroidea en cada trimestre de la gestación y determinar el impacto del uso de umbrales no específicos en el diagnóstico de las alteraciones funcionales en el primer trimestre. Métodos: Entre enero y septiembre de 2014 se contactaron 759 mujeres embarazadas con edad mayor de 18 años y sin alteraciones funcionales tiroideas conocidas. Tras excluir a todas las pacientes que no completaron el seguimiento durante toda la gestación y las que presentaron inmunidad tiroidea positiva, 411 gestantes configuraron nuestra población de referencia. Se determinaron los niveles de TSH, T4L y T3L en cada trimestre, los anticuerpos antiperoxidasa tiroidea y antitiroglobulina en el primero y se recogió una muestra de orina en los trimestres primero y tercero para la determinación del yodo urinario. Resultados: Un total de 411 gestantes completaron el seguimiento en los 3 trimestres. Un 38,69% consumían sal yodada y un 72,20% suplementos yodados. Los valores de referencia de TSH expresados como mediana y percentiles 2,5 y 97,5 fueron: 1,53 μUI/ml (0,26-3,95), 1,90 μUI/ml (0,78-3,85) y 1,89 μUI/ml (0,71-3,61) en el primer, segundo y tercer trimestre, respectivamente. El nivel de yoduria fue de 171,31 μg/l (90,7-274,9) en el primer trimestre y de 190,37 μg/l (96,44-360,38) en el tercero. La aplicación en el primer trimestre de los umbrales propuestos por las sociedades internacionales ocasionaría una clasificación errónea del 19,8% de las gestantes en relación con su función tiroidea, mientras que los umbrales no específicos de nuestro laboratorio lo harían en el 8,52%. Conclusiones: La utilización de umbrales no específicos para el diagnóstico de las alteraciones funcionales tiroideas durante la gestación ocasiona un importante porcentaje de errores de clasificación, contribuyendo a una atención inadecuada.

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Benefits of early specialized nutritional support in malnourished patients. / Beneficios del soporte nutricional especializado precoz en pacientes con criterios de desnutrición.

INTRODUCTION AND OBJECTIVE: Disease related malnutrition (DRM) is highly prevalent in Spain, affecting 23% of in-hospital patients, and is associated with clinical complications. Specialized nutritional support (SNS) can reduce these complications. MATERIAL AND METHODS: Prospective study carried out in standard clinical practice conditions to test if SNS during the first 5 days of hospitalization, or subsequently, was associated to a lower length of stay or reduced complications in patients with a NRS-2002 score≥3 points. RESULTS: In the group of patients who initiated early SNS, the length of stay was 8.83 days shorter than in the group with a later introduction (95% CI 3.55-14.10); nevertheless, the higher prevalence of male and oncological patients in this group could have impacted the results. A tendency towards a statistically significant lower mortality rate and a reduced amount of total complications was described. CONCLUSION: The early introduction of SNS (within the first 5 days of hospitalization) in patients with DRM was associated with a 32.4% reduction in the length of stay.

Glutamina: su papel en el paciente crítico / Glutamine: the role in critically ill patients

La glutamina es un aminoácido condicionalmente esencial considerado actualmente como un importante fármaco-nutriente. Niveles plasmáticos bajos de glutamina han demostrado comportarse como un factor independiente de mortalidad en el paciente crítico, y su adición al soporte nutricional ha probado disminuir las complicaciones infecciosas, la mortalidad y la estancia hospitalaria. En los últimos años han aparecido nuevos estudios que indicanla necesidad de individualizar la vía de acceso y la dosis y el período de suplementación para determinados grupos de pacientes candidatos a la suplementación con glutamina, y por otra parte, a tenor de los resultados, es aconsejable evitarla en situaciones deshock hipovolémico inestable, fallo multiorgánico o insu¬ciência renal no sometida a técnicas de depuración.

Glutamine is a conditionally essential aminoacid which is nowadays considered an important pharmaco nutrient. Low serum levels of glutamine have proven to be an independent predictor of mortality in the critically ill patient. Supplementation with glutamine as a part of a nutritional therapy has demonstrated to reduce infectious complications, length of stay in hospital and mortality. Recent new published data show the need to individualize the route, dose, length of supplementation for determined groups of candidate patients to glutamine administration. On the other hand, according to results, glutamine is not recommended in case of unstable hypovolemic shock, multiorgan faillure, or renal failure not subjected to depuration techniques.

Action of obestatin in skeletal muscle repair: stem cell expansion, muscle growth, and microenvironment remodeling.

The development of therapeutic strategies for skeletal muscle diseases, such as physical injuries and myopathies, depends on the knowledge of regulatory signals that control the myogenic process. The obestatin/GPR39 system operates as an autocrine signal in the regulation of skeletal myogenesis. Using a mouse model of skeletal muscle regeneration after injury and several cellular strategies, we explored the potential use of obestatin as a therapeutic agent for the treatment of trauma-induced muscle injuries. Our results evidenced that the overexpression of the preproghrelin, and thus obestatin, and GPR39 in skeletal muscle increased regeneration after muscle injury. More importantly, the intramuscular injection of obestatin significantly enhanced muscle regeneration by simulating satellite stem cell expansion as well as myofiber hypertrophy through a kinase hierarchy. Added to the myogenic action, the obestatin administration resulted in an increased expression of vascular endothelial growth factor (VEGF)/vascular endothelial growth factor receptor 2 (VEGFR2) and the consequent microvascularization, with no effect on collagen deposition in skeletal muscle. Furthermore, the potential inhibition of myostatin during obestatin treatment might contribute to its myogenic action improving muscle growth and regeneration. Overall, our data demonstrate successful improvement of muscle regeneration, indicating obestatin is a potential therapeutic agent for skeletal muscle injury and would benefit other myopathies related to muscle regeneration.

Perioperative nutritional support.

The relationship between preoperative malnutrition and morbi-mortality has been documented for years. Despite the existence of tools that allow its detection, and therefore treat this entity, their introduction into clinical practice is not wide-spread. Both perioperative insulin resistance and hyperglycemia are associated with increased perioperative morbidity and length of hospital stay. The intake of carbohydrate-rich drinks 2-4h prior to surgery reduces insulin resistance. In the immediate postoperative period, the enteral route is safe and well tolerated and its early use reduces hospital stay and postoperative complications compared with parenteral nutritional support. Inmunonutrition has been proven effective to decrease postoperative complications and hospital stay. In view of these data we opted for the adoption of these measures replacing bowel rest and the indiscriminate use of postoperative parenteral nutrition.

The open mesh repair of Spigelian hernia.

BACKGROUND: Spigelian hernias are rare defects of the abdominal wall usually appearing between the abdominal muscles, lateral to the rectus abdominis and through a debilitated Spigelian aponeurosis. Recently, mesh repair has been introduced for the treatment of these types of hernias and different approaches have been proposed. METHODS: Nine patients with Spigelian hernia were prospectively treated by placing a mesh prosthesis between the external oblique and the internal oblique muscles, based on principles of mesh repair established by the Lichtenstein group. RESULTS: Five women and 4 men, mean age 75.7 years, were operated on. In 1 patient the Spigelian hernia was an incidental finding during an inguinal hernia repair. Two patients were operated on an emergency basis. Elective operations were undertaken in ambulatory facilities in 3. Two patients had postoperative ecchymosis with no associated morbidity. No recurrences have been observed during follow-up. CONCLUSIONS: Open mesh repair of Spigelian hernias placing the mesh between the external and internal oblique muscles is a simple and safe approach that can prevent morbidity related to other techniques.

Stress fractures of the femur after ACL reconstruction with transfemoral fixation.

The ACL reconstruction with hamstring tendons has become increasingly popular, in part because it is assumed that the complication rate associated with the technique and their severity are lower than with patellar tendon. Two cases of stress reaction of the medial supracondylar area of the femur after ACL reconstruction with hamstring tendons using BioTransfix (Arthrex, Naples, FL, USA) devices for fixation within femur are presented. Both patients were professional athletes (one soccer and one basketball player), and it is hypothesized that the accelerated rehabilitation program used might have represented a risk factor for stress fractures when associated with the guide pin exit hole in the medial femoral cortex. To our knowledge, no such cases have been published to date, but it is important to consider this possibility if an unexplained pain arises in the rehabilitation process of an ACL reconstruction using transfemoral fixation.

The role of antibiotic prophylaxis on wound infection after mesh hernia repair under local anesthesia on an ambulatory basis.

Mesh prosthesis, local anesthesia, and ambulatory care have been widely introduced in recent decades in the treatment of inguinal hernia. The use of antibiotic prophylaxis during open inguinal hernia repair has been controversial. No prospective trial has been conducted to assess the role of antibiotic prophylaxis in patients operated on for inguinal hernia under the above-mentioned conditions. A prospective, randomized, double-blinded trial was initiated to assess the efficacy of antibiotic prophylaxis in the prevention of wound infection during open mesh inguinal hernia repair under local anesthesia on an ambulatory basis. Ninety-nine consecutive hernia repairs were randomized to receive 1 g of parenteral Cefazolin preoperatively or a placebo. No wound infections existed in the therapeutic group (0/50). Four infections appeared in the control group (4/49), and the study was suspended for ethical reasons when differences reached values close to statistical significance ( P=0.059). We conclude that a single dose of intravenous Cefazolin decreases the risk of wound infection during open mesh inguinal hernia repair under local anesthesia on an ambulatory basis.