Evaluation of Nutritional Status and the Impact of Nutritional Treatment in Patients with Pancreatic Cancer.

Patients with pancreatic cancer who develop irreversible cancer cachexia have a life expectancy of less than 3 months. Therefore, it is extremely important to evaluate the patient's nutritional status as early as possible and to implement an appropriate nutritional intervention in order to reduce the risk of further weight loss and/or muscle loss, which affect the outcomes of cancer treatment and the correct nutritional treatment in patients with pancreatic cancer. A literature review was performed by using the PubMed and Cochrane quick search methodology. The main purpose of this review was to present the current approach to nutritional treatment in pancreatic cancer. The review included publications, most of which concerned clinical nutrition as part of the phase of treatment of patients with pancreatic cancer, nutritional and metabolic disorders in pancreatic cancer, and the period after pancreatic resection. Some of the publications concerned various nutritional interventions in patients with pancreatic cancer undergoing chemotherapy or surgical treatment (nutritional support before surgery, after surgery, or during palliative treatment). There is an unmet need for integrated nutritional therapy as a key part of the comprehensive care process for PC patients. Nutritional counseling is the first line of nutritional treatment for malnourished cancer patients, but pancreatic enzyme replacement therapy also constitutes the cornerstone of nutritional treatment for relieving symptoms of indigestion and maintaining or improving nutritional status.

Antioxidant balance in plasma of patients on home parenteral nutrition: A pilot study comparing three different lipid emulsions.

BACKGROUND & AIMS: Parenteral nutrition (PN) can supply all essential nutrients to a patient with gastrointestinal insufficiency. However, the sensitivity to lipid peroxidation might increase in those receiving PN, especially home parenteral nutrition (HPN). This study aimed to investigate whether PN affects the antioxidant balance of plasma of HPN patients without comorbidities and whether this balance is influenced by comorbidities and according to the type of lipid emulsion included in the PN. METHODS: Adult patients on HPN (n = 86) received one of three types of lipid emulsion (based on 1) soyabean oil, 2) olive and soyabean oil or 3) soyabean, coconut, olive and fish oil) in all-in-one mixtures; in addition healthy controls (n = 66) were studied as comparators. HPN patients were classified to the following subgroups: 1) patients without (n = 58) or with (n = 28) comorbidities 2) patients on Intralipid (GINTRA, n = 53), ClinOleic (GCLIN, n = 17) or SMOFlipid (GSMOFn = 16). The activities of total glutathione peroxidase (GSH-Px), selenium dependent glutathione peroxidase (Se-GSHPx) and glutathione S-transferase (GST) in plasma were determined spectrophotometrically. The antioxidant potential of plasma was determined using oxygen radical absorbance capacity (ORAC). The lipid peroxidation marker malondialdehyde (MDA) was analyzed with high performance liquid chromatography. RESULTS: MDA concentration was the highest in GINTRA and the lowest in GSMOF (p < 0.05). GSMOF also had the highest activity of GSH-Px. No differences in Se-GSHPx, GST and ORAC were observed among GINTRA, GCLIN and GSMOF. Comparing with healthy controls, significantly lower GST (p = 0.0293) and ORAC (p < 0.0001) were observed in the HPN patients. Among all measured parameters only the concentration of MDA was significantly higher in patients with comorbidities compared to those without them. Comorbidities did not influence MDA level in GINTRA and GSMOF being still the lowest in GSMOF (p = 0.0033). In contrast, significantly higher MDA level was observed for GCLIN in those with vs. without comorbidities (p = 0.0262). CONCLUSIONS: Patients on HPN have lower antioxidant defenses than healthy controls. The type of lipid emulsion used in HPN affects lipid peroxidation (even after taking into account comorbidities which often involve oxidative stress) being the highest in GINTRA and the lowest in GSMOF. Thus, to minimize the risk of oxidative stress, SMOFlipid can be considered in patients in HPN especially for those with comorbidities. ClinOleic can be considered in HPN patients without comorbidities. The observation should be confirmed in larger studies.

Effect of changing the lipid component of home parenteral nutrition in adults.

BACKGROUND: The effect of different lipid emulsions (LEs) within the parenteral nutrition (PN) regimen of adult home PN (HPN) patients is not clear. This study investigated the effect of changing adult HPN patients from a soybean oil based LE (Intralipid) to either a fish oil containing LE (providing n-3 fatty acids) (SMOFLipid) or an olive oil based LE (ClinOleic). METHODS: Thirty two adults receiving long-term HPN with Intralipid as the LE were transferred to receive either SMOFLipid (n = 13) or ClinOleic (n = 19) for 60 days. Liver function markers, cholesterol, triglycerides, a full profile of fatty acids, and several cytokines were measured at study entry and after 60 days. RESULTS: SMOFLipid did not affect liver function markers, blood lipids or plasma cytokines. ClinOleic lowered both gamma-glutamyltranspeptidase (P = 0.044) and interleukin-8 (P = 0.030) concentrations. Both LEs induced marked changes in the fatty acid profile of plasma. SMOFLipid resulted in significant decreases in the proportions of linoleic acid, several other n-6 fatty acids and the essential fatty acid (EFA) deficiency indicator mead acid and significant increases in the proportions of the n-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid. ClinOleic resulted in significant decreases in the proportions of some saturated fatty acids, linoleic acid, several n-6 fatty acids, all n-3 fatty acids and mead acid and a significant increase in the proportion of oleic acid. The ratio of mead to arachidonic acid in plasma was not altered by either SMOFLipid or ClinOleic. No patient had a mead acid to arachidonic acid ratio of >0.2, the cut-off used to indicate EFA deficiency. CONCLUSION: Both SMOFLipid and ClinOleic significantly alter the fatty acid profile of plasma in adult HPN patients previously using Intralipid. Neither LE induces EFA deficiency in these patients. SMOFLipid did not alter liver function markers or inflammation. In contrast, ClinOleic decreased some, though not all, markers of liver function and inflammation. SMOFLipid and ClinOleic may both be considered for use in adult HPN patients.

Home parenteral nutrition with an omega-3-fatty-acid-enriched MCT/LCT lipid emulsion in patients with chronic intestinal failure (the HOME study): study protocol for a randomized, controlled, multicenter, international clinical trial.

BACKGROUND: Home parenteral nutrition (HPN) is a life-preserving therapy for patients with chronic intestinal failure (CIF) indicated for patients who cannot achieve their nutritional requirements by enteral intake. Intravenously administered lipid emulsions (ILEs) are an essential component of HPN, providing energy and essential fatty acids, but can become a risk factor for intestinal-failure-associated liver disease (IFALD). In HPN patients, major effort is taken in the prevention of IFALD. Novel ILEs containing a proportion of omega-3 polyunsaturated fatty acids (n-3 PUFA) could be of benefit, but the data on the use of n-3 PUFA in HPN patients are still limited. METHODS/DESIGN: The HOME study is a prospective, randomized, controlled, double-blind, multicenter, international clinical trial conducted in European hospitals that treat HPN patients. A total of 160 patients (80 per group) will be randomly assigned to receive the n-3 PUFA-enriched medium/long-chain triglyceride (MCT/LCT) ILE (Lipidem/Lipoplus® 200 mg/ml, B. Braun Melsungen AG) or the MCT/LCT ILE (Lipofundin® MCT/LCT/Medialipide® 20%, B. Braun Melsungen AG) for a projected period of 8 weeks. The primary endpoint is the combined change of liver function parameters (total bilirubin, aspartate transaminase and alanine transaminase) from baseline to final visit. Secondary objectives are the further evaluation of the safety and tolerability as well as the efficacy of the ILEs. DISCUSSION: Currently, there are only very few randomized controlled trials (RCTs) investigating the use of ILEs in HPN, and there are very few data at all on the use of n-3 PUFAs. The working hypothesis is that n-3 PUFA-enriched ILE is safe and well-tolerated especially with regard to liver function in patients requiring HPN. The expected outcome is to provide reliable data to support this thesis thanks to a considerable number of CIF patients, consequently to broaden the present evidence on the use of ILEs in HPN. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03282955. Registered on 14 September 2017.

Occipital C1-C2 neuromodulation decreases body mass and fat stores and modifies activity of the autonomic nervous system in morbidly obese patients--a pilot study.

BACKGROUND: Autonomic and vagal neuromodulation has been suggested for the treatment of morbid obesity. Occipital nerves remain in close anatomical relation to vagal nerve roots at the entrance to medulla oblongata. The aim of the study was to evaluate the effect of C1-C2 occipital neuromodulation on autonomic activity, body mass, and composition. METHODS: Five obese patients were included in the study (three women and two men, BMI 43-49, average age 43.3, range 24-55). Two electrodes were placed bilaterally in the C1-C2 region subcutaneously under local anesthesia. Stimulation was started 24 h after implantation and continued for 8 weeks. Patients activated stimulators for 12 h every day and turned the stimulators off at night. No other treatment including diet or change in lifestyle was introduced during the study. The following parameters were evaluated: body mass (0, 4th, and 8th week), body composition (bioimpedance study), food intake, quality of life, and heart rate variability (HRV) (0 and 8th week). RESULTS: No adverse events were observed in this group. One patient reported amelioration of constipation and one reported two incidents of salivation. The average body mass decrease was 5.6 kg in 4 weeks and 8.7 kg in 8 weeks. Body composition study showed a 2-month decrease in body fat of 7.9 kg on average. HRV revealed increased parasympathetic tone (LF/HF 4.4 ± 4.3 SD vs. 1.6 ± 1.7 SD). CONCLUSIONS: C1-C2 occipital stimulation seems being capable of decreasing body mass and affecting a positive shift in body composition and significantly increases the activity of the autonomic nervous system.

Does vagal nerve stimulation affect body composition and metabolism? Experimental study of a new potential technique in bariatric surgery.

BACKGROUND: It has been shown that vagal nerve stimulation (VNS) can affect body mass. The aim of this study was to evaluate effect of VNS on body mass, body composition, metabolic rate, and plasma leptin and IGF-I levels. METHODS: Eight female pigs were included in the study. Under general anesthesia, a bipolar electrode was implanted on the anterior vagal nerve by laparoscopy. Group A was treated by VNS, and group B was the control. After 4 weeks, stimulation was discontinued in group A and started in group B. The following parameters were evaluated: body mass, body composition, metabolic rate, plasma leptin and IGF-1 levels and intramuscular fat content (IMF). RESULTS: VNS attenuated body weight gain (2.28 +/- 3.47 kg vs 14.04 +/- 6.75 kg; P = .0112, for stimulation and nonstimulation periods, respectively), backfat gain (0.04 +/- 0.26 mm vs 2.31 +/- 1.12 mm) and IMF gain (-3.76 +/- 6.06 mg/g MS vs 7.24 +/- 12.90 mg/g MS; P = .0281). VNS resulted in lower backfat depth/loin muscle area ratio (0.33 +/- 0.017 vs 0.38 +/- 0.35; P = .0476). Lower plasma IGF-I concentration was found after VNS (-3.67 +/- -11.55 ng/mL vs 9.86 +/- 10.74 ng/mL; P = .0312). No significant changes in other parameters were observed. CONCLUSIONS: VNS affects body weight mainly at the expense of body fat resources; however, metabolic rate is not affected.

Gastric stimulation is effective in reversing vasopressin induced gastroparesis.

UNLABELLED: The aim of this study was to determine the most effective current parameters reversing vasopressin (VP) induced gastroparesis by gastric electrical stimulation IGES). METHODS: Twenty male healthy Wistar rats were included into the study (weight 227 +/- 24 g). Animals were subjected to gastric fistula placement and implantation of two monopolar electrodes for EGG-studies and GES. After 5 days of recovery VP was applied (terlipressin 0.1 mg/kg i.p.) The gastric motility was measured by means of balloon introduced into the stomach through the fistula. The gastric electrical and motor activity were recorded by the PowerLab/8SP system and software. Electrical signals were cleared by 3000 AC/DC differential amplifier A-M System Inc. Gastric electrical stimulation (GES) was generated by Zimmer stimulator SINUS5. The following currents: S01 (monopolar): ampl 2.2 mA, freq 29 Hz, on/off 1 s / 10 s; S02 (bipolar): ampl 2.2 mA, freq 29 Hz, on/off 1s/10s: S03 (monopolar): ampl 2.2 mA, freq 0.5 Hz: S04 (monopolar): ampl 2.2 mA, freq 34 Hz, on/off 5.5 s/15 s were used. RESULTS: The phasic contractions almost disappeared and amplitude decreased from 12 +/- 5 to 2.9 +/- 1.5 cm H20. The motility index decreased from 276,3 +/- 76.4 to 154.6 +/- 63 cm H2O x s/min. GES S01-S04 increased motility index to: 167.6 +/- 60.8: 155.1 +/- 89.3; 170.3 +/- 92.3: 301.9 +/- 70.5 cm H2O x s/min respectively. The frequency of gastric slow wave increased from 0.04 +/- 0.02 to 0.07 +/- 0.02 Hz after VP administration. GES S01-S04 reversed VP induced increase of slow wave frequency to 0.06 +/- 0.02, 0.055 +/- 0.02, 0.06 +/- 0.01 and 0.04 +/- 0.02 Hz, respectively. CONCLUSIONS: This effectiveness of local GES and the pressure pattern of induced gastroparesis suggest peripheral complex inhibitory-excitatory action of vasopressin on gastric smooth muscles. The mechanism of this action may involve the enteric nervous system, gastric and vasal smooth muscles. The most effective in reversing VP induced functional gastroparesis is high frequency current applied in timing of the natural slow wave.

Effects of vagal pacing on food intake and body mass in pigs.

UNLABELLED: In obesity patients inexpensive, non-invasive, low risk treatment remains a holy grail. The purpose of this study was to evaluate effect of long term and low frequency vagal pacing on feeding behavior in pigs. METHODS: Two groups of animals were investigated, first control with sham operation and second group with microchip (MC) on both vagal nerves placed laparoscopically. In both groups EGG was performed before and after MC implantation. Parameters of stimulation were stable (amplitude 170 mV, frequency 1 Hz, impulse duration 170 ms). RESULTS: MC group demonstrated continuous decrease in body weight gain during 8 weeks of experiment at average of 3.73 +/- 0.5 vs. 4.83 +/- 1.1 (p < 0.05). Food intake also decreased in MC group and was 16.38 +/- 1.3 vs. control 17.5 +/- 1.7 kg/w (ns). EGG recording showed decreased percent normogastria in MC group 26.66 +/- 10 vs. 76.2 +/- 16 (p < 0.05) mostly at cost of tachygastria 62.3 +/- 15 vs. 35.4 +/- 16% of the recording time. CONCLUSION: MC vagal pacing mostly decreased body weight being without significant influence on food intake causing gastric dysrhythmia.