[Immunonutrition, evidence and experiences]. / Inmunonutrición, evidencias y experiencias.

Introduction: Immunonutrition is a science that encompasses aspects related to nutrition, immunity, infection, inflammation and tissue damage. Immunomodulatory formulas have shown benefits in a wide variety of clinical situations. The objective of this work was to review the available evidence in immunonutrition (IN). For this, a bibliographic search has been carried out with the keywords: immunonutrition, arginine, glutamine, nucleotides, omega-3 fatty acids, ERAS, fast-track. Clinical trials, reviews and clinical practice guidelines have been included. IN has been shown to reduce postoperative fistulae in head and neck cancer patients and in gastric and esophageal cancer patients, infectious complications and hospital stay. Other clinical situations that benefit from the use of IN are pancreatic cancer surgery, colorectal cancer surgery and major burns. More controlled, prospective, and randomized studies are necessary to confirm the potential benefits of IN in other clinical situations such as non-esophageal thoracic surgery, bladder cancer, gynecological surgery, hip fracture, liver pathology and COVID-19, among others.

Introducción: La inmunonutrición es una ciencia que engloba aspectos relacionados con la nutrición, la inmunidad, la infección, la inflamación y el daño tisular. Las fórmulas inmunomoduladoras han demostrado beneficios en una amplia variedad de situaciones clínicas. El objetivo de este trabajo es revisar la evidencia disponible en inmunonutrición (IN). Para ello, se ha realizado una búsqueda bibliográfica con las palabras clave: inmunonutrición, arginina, glutamina, nucleótidos, ácidos grasos omega-3, ERAS, fast-track. Se han incluido ensayos clínicos, revisiones y guías de práctica clínica. La IN ha demostrado reducir las fístulas en el postoperatorio en pacientes con cáncer de cabeza y cuello. En pacientes con cáncer gástrico y cáncer de esófago, la IN se asocia a una disminución de las complicaciones infecciosas y la estancia hospitalaria. Otras situaciones clínicas que se benefician del uso de la IN son la cirugía del cáncer de páncreas, la cirugía del cáncer colorrectal y los grandes quemados. Son necesarios más estudios controlados, prospectivos y aleatorizados para confirmar los potenciales beneficios de la IN en otras situaciones clínicas como la cirugía torácica no esofágica, el cáncer vesical, la cirugía ginecológica, la fractura de cadera, la patología hepática y la COVID-19, entre otros.

[Nutrition in palliative care: guidelines from the Working Group on Bioethics, Spanish Society of Clinical Nutrition and Metabolism (SENPE)]. / Nutrición en cuidados paliativos: resumen de recomendaciones del Grupo de Trabajo de Ética de la SENPE.

Introduction: Palliative care provides a holistic approach and care for patients with a terminal illness and their families. In palliative care physical complaints as well as emotional, social and spiritual aspects are considered. Nutritional care should be also considered within palliative support. For those working in the nutritional support field, to withhold or withdraw nutritional support may be an ethical dilemma in this scenario. The controversy starts when considering nutrition and hydration as basic care or a treatment. The goals of nutrition support in palliative care patients differ from common ones, aiming to improve quality of life, survival or both. The decision should be based on a consideration of prognosis (length of survival), quality of life, and risks-benefits ratio. Regarding oral nutrition (with or without oral supplements) the idea prevails of "comfort feeding", based on providing oral feeding till discomfort or avoidance develop. There is no evidence on the benefit of specific nutrients, despite the fact that omega-3 FAs may have some positive effects in patients with cancer. Regarding nutritional support (enteral or parenteral), no scientific evidence is present, so the decision needs to be agreed according to the desires and beliefs of the patient and their family, and based on a consensus with the interdisciplinary team on the aims of this support.

Introducción: Los cuidados paliativos proporcionan una atención integral que tiene en cuenta los aspectos físicos, emocionales, sociales y espirituales del paciente con enfermedad terminal y su entorno familiar. El tratamiento nutricional debe formar parte activa de los equipos de cuidados paliativos. La necesidad de iniciar o no un tratamiento nutricional sigue siendo, desde hace décadas, uno de los principales problemas éticos a los que se enfrentan los profesionales dedicados a la nutrición clínica. El origen de tal controversia radica, fundamentalmente, en cómo se consideran la nutrición y la hidratación: cuidado/soporte o tratamiento médico. Los objetivos fundamentales del tratamiento nutricional en los pacientes en cuidados paliativos deben ser otros: la mejoría de la calidad de vida, de la supervivencia o de ambas. La decisión de indicar o no el tratamiento nutricional en cuidados paliativos debe tomarse tras considerar el pronóstico, la calidad de vida y la relación "riesgo/beneficio". En relación a la alimentación por vía oral (con o sin suplementos orales), prevalece la idea de la "alimentación de confort", que se basa en intentos de alimentación oral hasta que se produzcan la incomodidad y/o el rechazo del paciente. No existen evidencias que justifiquen el uso de nutrientes específicos, aunque desde hace años se señala la posibilidad de lograr beneficios cuando se utilizan ácidos grasos omega-3 en los pacientes con cáncer. En cuanto al tratamiento nutricional (enteral o parenteral), en ausencia de evidencia, las decisiones sobre si iniciar una nutrición artificial en un paciente paliativo deben tomarse teniendo en cuenta los deseos y creencias del paciente y sus familiares, y basarse en el consenso del equipo interdisciplinar sobre los objetivos que se persiguen al iniciarla.

Genetic Variants in Folate and Cobalamin Metabolism-Related Genes in Pregnant Women of a Homogeneous Spanish Population: The Need for Revisiting the Current Vitamin Supplementation Strategies.

Polymorphisms of genes involved in the metabolism and transport of folate and cobalamin could play relevant roles in pregnancy outcomes. This study assessed the prevalence of genetic polymorphisms of folate and cobalamin metabolism-related genes such as MTHFR, MTR, CUBN, and SLC19A1 in pregnant women of a homogeneous Spanish population according to conception, pregnancy, delivery, and newborns complications. This study was conducted on 149 nulliparous women with singleton pregnancies. Sociodemographic and obstetrics variables were recorded, and all patients were genotyped in the MTHFR, MTR, CUBN, and SLC10A1 polymorphisms. The distribution of genotypes detected in this cohort was similar to the population distribution reported in Europe, highlighting that more than 50% of women were carriers of risk alleles of the studied genes. In women with the MTHFR risk allele, there was a statistically significant higher frequency of assisted fertilisation and a higher frequency of preeclampsia and preterm birth. Moreover, CUBN (rs1801222) polymorphism carriers showed a statistically significantly lower frequency of complications during delivery. In conclusion, the prevalence of genetic variants related to folic acid and vitamin B12 metabolic genes in pregnant women is related to mother and neonatal outcomes. Knowing the prevalence of these polymorphisms may lead to a personalised prescription of vitamin intake.

Relevance of nutritional assessment and treatment to counteract cardiac cachexia and sarcopenia in chronic heart failure.

Chronic heart failure (CHF) is frequently associated with the involuntary loss of body weight and muscle wasting, which can determine the course of the disease and its prognosis. While there is no gold standard malnutrition screening tool for their detection in the CHF population, several bioelectrical and imaging methods have been used to assess body composition in these patients (such as Dual Energy X-Ray Absorptiometry and muscle ultrasound, among other techniques). In addition, numerous nutritional biomarkers have been found to be useful in the determination of the nutritional status. Nutritional considerations include the slow and progressive supply of nutrients, avoiding high volumes, which could ultimately lead to refeeding syndrome and worsen the clinical picture. If oral feeding is insufficient, hypercaloric and hyperproteic supplementation should be considered. ß-Hydroxy-ß-methylbutyrate and omega-3 polyunsaturated fatty acid administration prove to be beneficial in certain patients with CHF, and several interventional studies with micronutrient supplementation have also described their possible role in these subjects. Taking into account that CHF is sometimes associated with gastrointestinal dysfunction, parenteral nutritional support may be required in selected cases. In addition, potential therapeutic options regarding nutritional state and muscle wasting have also been tested in clinical studies. This review summarises the scientific evidence that demonstrates the necessity to carry out a careful nutritional evaluation and nutritional treatment to prevent or improve cardiac cachexia and sarcopenia in CHF, as well as improve its course.

[Functional recovery of the cardio-respiratory patient]. / Recuperación funcional del paciente cardiorrespiratorio.

INTRODUCTION: Heart failure (HF), chronic obstructive pulmonary disease (COPD), and most chronic diseases are associated with mild to moderate chronic or recurrent inflammation. This inflammation contributes to malnutrition through different mechanisms: anorexia, decreased intake, alteration of metabolism with increased energy expenditure at rest and increased muscle catabolism. The decrease in lean mass has been included as a phenotypic criterion in the recently coined definition of malnutrition. In addition, a greater importance is given to the evaluation of the function, together with that of the morphological parameters. The grip strength, measured with a manual dynamometer and compared to reference populations, is a simple measure of muscle strength and correlates with the strength of the legs. On the other hand, the so-called "paradox of obesity" occurs in both patients with HF and COPD, since overweight and obese patients have lower overall mortality than patients with normal or low body mass index (BMI). The nutritional treatment, with an adequate contribution of macro and micronutrients and a contribution of proteins of fast absorption, with a higher content of leucine or its metabolite ß-hydroxy-ß-methylbutyrate, seems to offer a benefit in the preservation of muscle mass and its functionality in the patient with cardiorespiratory pathology. Nutritional treatment, associated with a pulmonary or cardiac rehabilitation regimen, is essential to obtain good morphological and functional results.

INTRODUCCIÓN: La insuficiencia cardíaca (IC), la enfermedad pulmonar obstructiva crónica (EPOC) y la mayoría de las enfermedades crónicas se asocian con una inflamación crónica o recurrente de grado ligero o moderado. Dicha inflamación contribuye a la malnutrición a través de diferentes mecanismos: anorexia, disminución de la ingesta, alteración del metabolismo con elevación del gasto energético en reposo y el aumento del catabolismo muscular. En la definición de malnutrición acuñada recientemente se ha incluido como criterio fenotípico: la disminución de masa magra. Además, cada vez se concede una mayor importancia a la evaluación de la función, junto a la de los parámetros morfológicos. La fuerza de prensión, medida con un dinamómetro manual y comparada con poblaciones de referencia, es una medida sencilla de la fuerza muscular y se correlaciona con la fuerza de las piernas. Por otra parte, tanto en los pacientes con IC como con EPOC se produce la llamada "paradoja de la obesidad", ya que los pacientes con sobrepeso y obesidad tienen una menor mortalidad global que los pacientes con un índice de masa corporal (IMC) normal o bajo. El tratamiento nutricional, con un aporte adecuado de macronutrientes y micronutrientes y un aporte de proteínas de absorción rápida, con un mayor contenido en leucina o su metabolito ß-hidroxi-ß- metilbutirato, parece ofrecer un beneficio en la preservación de la masa muscular y su funcionalidad en el paciente con patología cardiorrespiratoria. El tratamiento nutricional, asociado a una pauta de rehabilitación pulmonar o cardíaca, es fundamental para obtener buenos resultados morfológicos y funcionales.

[Clinical guideline for the diagnosis and treatment of subclinical thyroid dysfunction in pregnancy. Working Group on Subclinical Thyroid Dysfunction of the Spanish Endocrinology Society]. / Guía clínica para el diagnóstico y el tratamiento de la disfunción tiroidea subclínica en la gestación. Grupo de Trabajo sobre la Disfunción Tiroidea Subclínica de la Sociedad Española de Endocrinología.

Subclinical thyroid disease is a biochemical diagnosis and is common during pregnancy. Because of the physiological hormonal changes that take place during pregnancy and the absence of normal ranges for thyroid hormones during this period, subclinical thyroid disease is difficult to interpret during pregnancy. Subclinical hyperthyroidism during pregnancy has few clinical consequences and no treatment is required. In contrast, subclinical hypothyroidism seems to improve with thyroxine treatment. Iodine supplements during pregnancy and lactation, even in iodine-sufficient areas, are also indicated.

Guía clínica para el diagnóstico y el tratamiento de la disfunción tiroidea subclínica en la gestación / Clinical guideline for the diagnosis and treatment of subclinical thyroid dysfunction in pregnancy

La disfunción tiroidea subclínica es de diagnóstico bioquímico y es una entidad frecuente durante la gestación. Los cambios hormonales fisiológicos que acontecen durante la gestación, junto con la falta de valores de referencia de las hormonas tiroideas en este periodo, hacen que la disfunción tiroidea subclínica sea de difícil interpretación. Mientras el hipertiroidismo subclínico en la gestación carece de repercusión clínica y no requiere una actuación específica, el hipotiroidismo subclínico, en ese periodo, parece beneficiarse del tratamiento sustitutivo con tiroxina. Los suplementos de yodo en la gestación y lactación son necesarios incluso en zonas de yodosuficiencia (AU)

Subclinical thyroid disease is a biochemical diagnosis and is common during pregnancy. Because of the physiological hormonal changes that take place during pregnancy and the absence of normal ranges for thyroid hormones during this period, subclinical thyroid disease is difficult to interpret during pregnancy. Subclinical hyperthyroidism during pregnancy has few clinical consequences and no treatment is required. In contrast, subclinical hypothyroidism seems to improve with thyroxine treatment. Iodine supplements during pregnancy and lactation, even in iodine-sufficient areas, are also indicated (AU)