A case of autochthonous human Dirofilaria infection, Germany, March 2014.

In March 2014, an infection with the nematode Dirofilaria repens was diagnosed in a German citizen in the federal state of Saxony-Anhalt. The patient had developed an itching subcutaneous nodule containing a female worm, which was identified as D. repens by 12S ribosomal ribonucleic acid (rRNA) gene sequencing. Autochthonous human D. repens infections have not been described in Germany so far, but this finding is consistent with the recent detection of D. repens in mosquitoes from east Germany.

ESPEN Guidelines on Enteral Nutrition: Liver disease.

Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in patients with liver disease (LD). It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for patients with chronic LD in whom undernutrition is very common. ONS improve nutritional status and survival in severely malnourished patients with alcoholic hepatitis. In patients with cirrhosis, TF improves nutritional status and liver function, reduces the rate of complications and prolongs survival. TF commenced early after liver transplantation can reduce complication rate and cost and is preferable to parenteral nutrition. In acute liver failure TF is feasible and used in the majority of patients.

Relationship between impaired pulmonary diffusion and cardiopulmonary exercise capacity after heart transplantation.

STUDY OBJECTIVES: Diffusion impairment and reduced performance in cardiopulmonary exercise testing (CPX) have been found in patients after heart transplantation. The pathogenesis of these abnormalities is unclear. In particular, the contribution of pulmonary interstitial changes has not yet been verified. DESIGN: We analyzed pulmonary function tests, high-resolution CT (HRCT), echocardiography, left heart catheterization, and CPX in transplanted patients. PATIENTS: Forty long-term survivors were studied at a median of 47 months (range, 12 to 89 months) after heart transplantation. RESULTS: Diffusion was impaired in 40% (transfer factor for carbon monoxide) or 82.5% (carbon monoxide transfer coefficient) of the patients. Diffusion impairment was caused by a decreased diffusing capacity of the alveolar capillary membrane in 89% and/or by a decreased blood volume of the alveolar capillaries in 46% of cases. In five patients (12.5%), CT revealed interstitial lung changes. These patients did not have different values of diffusion capacity. Maximal oxygen uptake and ventilatory efficiency during exercise (minute ventilation/carbon dioxide output slope) were impaired in 92% and 46% of the cases, respectively. CONCLUSIONS: Our data show that the diffusion abnormalities are caused by an impaired diffusion status of the alveolar capillary membrane. Interstitial changes detectable in HRCT were found not to be involved in this process. The reduced performance in CPX in our long-term survivors is caused by pulmonary perfusion abnormalities and low tidal volume, which is due to the deconditioning of respiratory muscle, rather than by interstitial changes or diffusion abnormalities.

ESPEN guidelines for nutrition screening 2002.

AIM: To provide guidelines for nutrition risk screening applicable to different settings (community, hospital, elderly) based on published and validated evidence available until June 2002. NOTE: These guidelines deliberately make reference to the year 2002 in their title to indicate that this version is based on the evidence available until 2002 and that they need to be updated and adapted to current state of knowledge in the future. In order to reach this goal the Education and Clinical Practice Committee invites and welcomes all criticism and suggestions (button for mail to ECPC chairman).

Dipeptide metabolism in the isolated perfused rat small intestine.

The purpose of the present study was to investigate the utilisation of vascularly administered leucyl-leucine (Leu-Leu), alanyl-glutamine (Ala-Gln) and glycyl-glutamine (Gly-Gln) by the isolated vascularly perfused rat small intestine. Fractional extraction rates were 49%, 35.5%, and 12% for Leu-Leu, Ala-Gln, and Gly-Gln (0.15mM) corresponding to a net uptake of -63.5, -31.5, and -17 nmol/min/g wet weight. Nitrogen metabolism in terms of glutamine uptake and release of alanine and ammonia was not different when perfusion with dipeptides or with free amino-acids were compared. No soluble dipeptidase activity was released into the plasma- and cell-free synthetic vascular perfusate. No dipeptide could be recovered from the luminal perfusate. Considering the high fractional extraction rate for Leu-Leu, it is conceivable that dipeptide assimilation may occur also in extramucosal gut tissue. Although dipeptide transport cannot be excluded, dipeptide assimilation in small intestine may involve membrane bound peptidase(s), as in liver.

Improved assessment of body cell mass by segmental bioimpedance analysis in malnourished subjects and acromegaly.

BACKGROUND: Estimation of body cell mass (BCM) has been regarded valuable for the assessment of malnutrition. AIM: To investigate the value of segmental bioelectrical impedance analysis (BIA) for BCM estimation in malnourished subjects and acromegaly. METHODS: Nineteen controls and 63 patients with either reduced (liver cirrhosis without and with ascites, Cushing's disease) or increased BCM (acromegaly) were included. Whole-body and segmental BIA (separately measuring arm, trunk, leg) at 50 kHz was compared with BCM measured by total-body potassium. Multiple regression analysis was used to develop specific equations for BCM in each subgroup. RESULTS: Compared to whole-body BIA equations, the inclusion of arm resistance improved the specific equation in cirrhotic patients without ascites and in Cushing's disease resulting in excellent prediction of BCM (R(2) = 0.93 and 0.92, respectively; both P<0.001). In acromegaly, inclusion of resistance and reactance of the trunk best described BCM (R(2) = 0.94, P<0.001). In controls and in cirrhotic patients with ascites, segmental impedance parameters did not improve BCM prediction (best values obtained by whole-body measurements: R(2)=0.88 and 0.60; P<0.001 and <0.003, respectively). CONCLUSION: Segmental BIA improves the assessment of BCM in malnourished patients and acromegaly, but not in patients with severe fluid overload.

Controlled clinical trial of doxorubicin and tamoxifen versus tamoxifen monotherapy in hepatocellular carcinoma.

OBJECTIVES: Treatment results of advanced hepatocellular carcinoma have remained unsatisfactory; the response rates to intravenous doxorubicin are no better than 20%. Oral tamoxifen has been proposed on the basis of beneficial results in some trials. The aim of this study was to evaluate whether the addition of doxorubicin to oral tamoxifen improves survival compared to oral tamoxifen alone. METHODS: Thirty-two consecutive patients with a priori defined contra-indications against surgery (transplantation, resection) or chemo-embolization were evaluated to receive chemotherapy. All patients received oral tamoxifen 30 mg bid; 16 also received intravenous doxorubicin 50 mg/m2 every 4 weeks. The control group consisted of the remaining 16 patients who either were considered unfit for doxorubicin because of a Karnofsky index < 50% (n = 5), cardiac disease (n = 6) or who refused to have cytotoxic drug therapy (n = 5). RESULTS: Median survival time was 148 days (95% CI 89.2-206.8) in the doxorubicin group and 96 days (95% CI 49.0-143.0) in the control group, and this was not significantly different (P= 0.408), regardless of the presence or absence of cirrhosis. CONCLUSIONS: In conclusion, the results of our study indicate that combination therapy using doxorubicin and tamoxifen is unlikely to considerably improve survival compared to tamoxifen alone in patients with advanced hepatocellular carcinoma.

Nutrition of liver transplant patients.

Good cooperation between the hepatologist, surgeon and anesthesiologist is required to determine the appropriate perioperative nutritional management for the liver transplant patient. For preoperative risk stratification, nutritional assessment according to resting energy expenditure by indirect calorimetry, and body cell mass by bioelectrical impedence analysis, may be superior to anthropometric parameters. When considering impaired glucose tolerance in the early postoperative period, requirements of energy intake and macronutrients are no different from those established in major abdominal surgery. Preference should be made to use the enteral route whenever possible. Fat emulsions containing medium- and long-chain triglycerides have neither a negative impact on reticulo-endothelial system recovery of the graft, nor any obvious metabolic advantages. There is no evidence for the routine use of branched-chain amino acids. Even in the case of good graft function, long term dietary evaluation and counselling may be useful. Impaired glucose tolerance, hyperlipidemia and hypercholesterolemia should be considered carefully. The role of preoperative nutritional therapy using oral supplements and the value of immune-enhancing substrates should be evaluated with special regard to a decrease in postoperative septic complications and for possible impact on immune tolerance after transplantation.

[Value of rapid sequential computed tomography for the diagnosis of liver cirrhosis]. / Bedeutung der schnellen sequentiellen Computertomographie für die Diagnostik der Leberzirrhose.

Thirty-eight patients with cirrhosis of the liver and thirty-seven controls were examined by dynamic computer tomography in a prospective study. Time-density difference curves for the liver, spleen, portal vein, aorta and vena cava were treated mathematically ('gamma fit'). Comparison of the values of the difference curves of liver, spleen and portal vein showed significantly lower and delayed peaks in patients with cirrhosis than in normal people. The time-density difference curves of the liver showed a highly significant shallow decline in the presence of cirrhosis. Discriminant analysis of the curve parameters using the spleen showed differentiation between normals and cirrhosis patients of 90.2%, and using the liver curve a separation of 83%. Combining these parameters of liver and spleen curves improved the separation between cirrhotic patients and normals to 94%.

Characteristic pattern of free amino acids in plasma and skeletal muscle in stable hepatic cirrhosis.

Free amino acid (AA) concentrations in plasma and quadriceps femoris muscle were determined in 19 healthy volunteers and in 16 patients with hepatic cirrhosis and portal hypertension. Nutritional state was impaired as judged by overt muscle wasting (9/16), triceps skinfold thickness less than 70% of normal in 8/14 (57%), and creatinine-height index below 70% in 5/12 (42%). In the plasma of patients the typical amino acid pattern of cirrhosis was to be observed: Elevation of tyrosine and methionine (p less than 0.01), uniform reduction of branched chain amino acids (p less than 0.001) resulting in a decreased molar ratio of BCAA/AAA from 2.85 +/- 0.05 in normal individuals to 1.35 +/- 0.12 in cirrhotics (p less than 0.001). Levels of the gluconeogenic AA glutamine, glutamate, aspartate, alanine, glycine, threonine, serine and lysine were lowered (p less than 0.05). In muscle of cirrhotics, intracellular AA concentrations exhibited a similar pattern with two major exceptions: Tyrosine and phenylalanine were augmented (p less than 0.001). Surprisingly, BCAA levels were altered heterogeneously; those of gluconeogenic BCAA decreased: Valine from 0.34 +/- 0.03 to 0.20 +/- 0.03 mmol/l (p less than 0.001), isoleucine 0.09 +/- 0.01 to 0.05 +/- 0.02 mmol/l. However, the concentration of ketogenic leucine remained unaltered in muscle. Nevertheless, the molar ratio of BCAA/AAA was considerably reduced from 3.70 +/- 0.04 to 0.81 +/- 0.08 (p less than 0.001). Most of the gluconeogenic AA exhibited reduced intramuscular concentrations, but glutamine levels were normal. The pattern of plasma and muscle free AA in hepatic cirrhosis is thus characterized by accumulation of aromatic AA and by depletion of gluconeogenic AA, especially BCAA.(ABSTRACT TRUNCATED AT 250 WORDS)

[Nutrition and liver failure]. / Ernährung und Leberversagen.

In the critically ill liver patient, nutrition support is not very different from that given for other illnesses. In hyperacute liver failure, nutrition support is of less importance than in the other subtypes of acute liver failure that take a more protracted course. Nasoenteral tube feeding using a polymeric standard formula should be the first-line approach, while parenteral nutrition giving glucose, fat, amino acids, vitamins, and trace elements is initiated when enteral nutrition is insufficient or impracticable. In chronic liver disease, notably cirrhosis, there is frequently protein malnutrition indicating a poor prognosis and requiring immediate initiation of nutrition support. Enteral nutrition ensuring an adequate provision of energy and protein should be preferred. Particular care should be taken to avoid refeeding syndrome and to treat vitamin and trace element deficiency.