Nutritional support and parenteral nutrition in cancer patients: an expert consensus report.

BACKGROUND: Malnutrition is a frequent medical problem of cancer patients that negatively impacts their quality of life. METHODS: A multidisciplinary group of experts in Medical Oncology, Pharmacy, and Nutrition convened to discuss the management of the nutritional support in cancer patients. RESULTS: Of the 18 questions addressed, 9 focused on nutritional support, 5 were related to parenteral nutrition (PN) and 4 about home PN (HPN). The panel of experts recommends using nutritional screening routinely, at diagnosis and throughout the disease course, for detecting the risk of malnutrition and, if it is positive, to perform a complete nutritional assessment, to diagnose malnutrition. Currently, there are different screening tools and methods that allow us to detect nutritional risk. Based on the evidence and experience, the panel stated that PN is indicated mainly when it is not possible to use the digestive tract and/or oral feeding and/or enteral nutrition is not sufficient or possible. The nutritional needs of the cancer patients, except in those cases where individualized measures are required, should be considered similar to healthy individuals (25-30 kcal/kg/day). The panel considers that the nutritional monitoring of the cancer patient should be multidisciplinary and adapted to the characteristics of each center. Additionally, the objective of the HPN is to improve or maintain the nutritional status of a patient at home. CONCLUSIONS: This document seeks to lay down a set of recommendations and to identify key issues that may be useful for the nutritional management of cancer patients.

[Satisfaction with weight and characteristics of eating disorders in high school]. / Satisfacción con el peso y rasgos de trastorno del comportamiento alimentario en secundaria.

INTRODUCTION: The prevalence of diseases related to eating behaviour disorders has increased among adolescents. The objective of this study is to analyse the satisfaction with body weight of schoolchildren as regards their body mass index and the strategies used to control the diet. METHOD: A total of 1197 students from secondary education (12-18 years) answered a questionnaire on eating habits and body weight control. Their weight and height was measured and body mass index was calculated. RESULTS: More than two-thirds (68.1%) of students who had an adequate BMI were satisfied with their weight. Greater dissatisfaction with the weight is associated with overweight (OR=10.23) and obesity (OR=16.60). Students with overweight are on a diet consulting an expert such as a physician or even the family, whereas among schoolchildren with normal weight there is a large percentage on a diet on their own. A 13.87% of the schoolchildren have been undertaken Compensatory activities before excessive eating has been undertaken by 13.87% of the schoolchildren. An overweight BMI is associated, with more than twice the risk (OR>2.00), with the use of measures such as physical activity, vomiting, or fasting to compensate an excessive intake. CONCLUSIONS: Overweight and obese schoolchildren are more likely to be dissatisfied with their body, and are more likely to use ploys such as vomiting, in order to compensate for the excess intake.

Home enteral nutrition in Spain; NADYA registry 2011-2012.

OBJECTIVE: To describe the results of the home enteral nutrition (HEN) registry of the NADYA-SENPE group in 2011 and 2012. MATERIAL AND METHODS: We retrieved the data of the patients recorded from January 1st 2011 to December 31st 2012. RESULTS: There were 3021 patients in the registry during the period from 29 hospitals, which gives 65.39 per million inhabitants. 97.95% were adults, 51.4% male. Mean age was 67.64 ± 19.1, median age was 72 years for adults and 7 months for children. Median duration with HEN was 351 days and for 97.5% was their first event with HEN. Most patients had HEN because of neurological disease (57.8%). Access route was nasogastric tube for 43.5% and gastrostomy for 33.5%. Most patients had limited activity level and, concerning autonomy, 54.8% needed total help. Nutritional formula was supplied from chemist's office to 73.8% of patients and disposables, when necessary, was supplied from hospitals to 53.8% of patients. HEN was finished for 1,031 patients (34.1%) during the period of study, 56.6% due to decease and 22.2% due to recovery of oral intake. CONCLUSIONS: Data from NADYA-SENPE registry must be explained cautiously because it is a non-compulsory registry. In spite of the change in the methodology of the registry in 2010, tendencies regarding HEN have been maintained, other than oral route.

Objetivos: Describir los resultados del registro de nutrición enteral domiciliaria (NED) del grupo NADYASENPE de los años 2011 y 12. Material y métodos: Se recopilaron los datos introducidos en el registro desde el 1 de enero de 2011 al 31 de diciembre de 2012. Resultados: Hubo 3021 pacientes en el registro durante el periodo, procedentes de 29 hospitales, lo que da una prevalencia de 65,39 casos por millón de habitantes. 97.95% fueron adultos, 51,4% varones. La edad media fue 67,64 ± 19,1 años y la mediana 72 años para los adultos y 7 meses para los niños. La duración media de la NED fue 351 días y para el 97,5% fue el primer episodio con NED. La mayoría de pacientes tenían NED por una enfermedad neurológica (57,8%). La vía de acceso fue sonda nasogástrica para el 43,5% y gastrostomía para el 33,5%. La mayoría de pacientes tuvieron un nivel de actividad física limitado y, respecto a la autonomía, 54,8% necesitaba ayuda total. La fórmula de nutrición se suministró desde las oficinas de farmacia para el 73,8% y los fungibles, cuando fueron necesarios, desde los hospitales para el 53,8%. La NED se suspendió en 1.031 pacientes (34,1%) durante el periodo de estudio, 56,6% debido a fallecimiento y 22,2% debido a recuperación de la vía oral. Conclusiones: Los datos del registro NADYA-SENPE deben ser interpretados con precaución ya que se trata de un registro voluntario. A pesar del cambio de metodología del registro en 2010, las tendencias en NED se han mantenido, salvo la importancia cuantitativa de la vía oral.

Incidencia de la diabetes tipo 1 infantil en Extremadura, 2003-2007 / Incidence of childhood type I diabetes in Extremadura, Spain, 2003-2007

Fundamento y objetivo: Existen datos de una evolución creciente de la incidencia de la diabetes tipo 1 infantil en Europa en los últimos 20 a˜nos. El presente trabajo analiza la incidencia y la evolución de la diabetes tipo 1 en menores de 15 a˜nos en Extremadura durante el periodo 2003 a 2007. Material y método: Estudio de captura-recaptura que utiliza como fuente primaria la base de datos nacional de altas hospitalarias. Se seleccionaron los ingresos del periodo con diagnóstico de diabetes en menores de 15 a˜nos. Como fuente secundaria se utilizaron los datos de recetas de insulina del sistema público de salud. Se estandarizaron las tasas y se realizó una regresión de Poisson para evaluar la evolución en el periodo. Resultados: La tasa de incidencia ajustada fue de 25,2/100.000 (IC 95%: 21,8-28,6), con una exhaustividad del 100%; no se encontraron diferencias por sexos ni por provincias. Las tasas de incidencia por grupos de 0-4, 5-9 y 10-14 a˜nos fueron, respectivamente, de 20,2/100.000 (IC 95%: 10,1-30,3), 24,8/100.000 (IC 95%: 20,1-29,4) y 30,0/100.000 (IC 95%: 25,8-34,1), con un RR de 1,67 (IC 95%: 1,18-2,36; p = 0,004) en edades de 10-14 respecto a 0-4 a˜nos. En el grupo de 0-4 a˜nos los casos aumentaron de 5 en 2003 a 15 en 2006, aunque este incremento no llega a ser significativo. Conclusiones: La incidencia es más elevada de lo esperado para la región de Extremadura. Es necesaria una atenta vigilancia del grupo de 0-4 a˜nos para confirmar la tendencia observada (AU)

Background and objectives: Studies have shown an increasing incidence of type I diabetes in children in Europe over the last 20 years. The present study was conducted to evaluate the incidence and development of type I diabetes in children under 15 years of age in Extremadura in the period 2003-2007. Material and methods: The study applied the capture-recapture method using the national hospital discharge database as primary source. Data were collected from children under 15 years of age diagnosed with diabetes type I during the study period. Secondary data source were insulin prescriptions from the public health system. Rates were standardised and a Poisson regression was used to assess the development of the disease during the study period. Results: The overall adjusted incidence rate was 25.2/100.000 (95% CI: 21.8-28.6) with 100% completeness; no significant differences were observed by sex or provinces. Age group rates were 20.2/100.000 (95% CI: 10.1-30.3) for aged 0-4 years, 24.8/100.000 (95% CI: 20.1-29.4) for aged 5-9 years, and 30.0/100.000 (95% CI: 25.8-34.1) for aged 10-14 years, with a RR of 1.67 (95% CI: 1.18-2.36; P = .004) for 10-14 year olds relative to 0-4 year olds. The number of cases among children aged 0-4 years increased from 5 cases in 2003 to 15 cases in 2006, although this increase was not significantly different. Conclusion: The overall rates of incidence of type I diabetes were higher than the expected incidence values in Extremadura. Careful surveillance is required to confirm the increased trend in the incidence of type I diabetes observed among children aged 0-4 years (AU)

[Incidence of childhood type I diabetes in Extremadura, Spain, 2003-2007]. / Incidencia de la diabetes tipo1 infantil en Extremadura, 2003-2007.

BACKGROUND AND OBJECTIVES: Studies have shown an increasing incidence of type I diabetes in children in Europe over the last 20 years. The present study was conducted to evaluate the incidence and development of type I diabetes in children under 15 years of age in Extremadura in the period 2003-2007. MATERIAL AND METHODS: The study applied the capture-recapture method using the national hospital discharge database as primary source. Data were collected from children under 15 years of age diagnosed with diabetes type I during the study period. Secondary data source were insulin prescriptions from the public health system. Rates were standardised and a Poisson regression was used to assess the development of the disease during the study period. RESULTS: The overall adjusted incidence rate was 25.2/100.000 (95%CI: 21.8-28.6) with 100% completeness; no significant differences were observed by sex or provinces. Age group rates were 20.2/100.000 (95%CI: 10.1-30.3) for aged 0-4 years, 24.8/100.000 (95%CI: 20.1-29.4) for aged 5-9 years, and 30.0/100.000 (95%CI: 25.8-34.1) for aged 10-14 years, with a RR of 1.67 (95%CI: 1.18-2.36; P=.004) for 10-14 year olds relative to 0-4 year olds. The number of cases among children aged 0-4 years increased from 5 cases in 2003 to 15 cases in 2006, although this increase was not significantly different. CONCLUSION: The overall rates of incidence of type I diabetes were higher than the expected incidence values in Extremadura. Careful surveillance is required to confirm the increased trend in the incidence of type I diabetes observed among children aged 0-4 years.

Metabolic effects of L-carnitine on type 2 diabetes mellitus: systematic review and meta-analysis.

INTRODUCTION: Carnitine is an endogenous metabolite and exogenous nutrient with a pivotal role in lipid metabolism. Plasma levels of carnitine are reduced in type 2 Diabetes Mellitus (T2DM). The aim was to evaluate the metabolic effects of the administration of L-carnitine in T2DM. METHOD: A systematic review was performed. Relevant randomized, controlled-trials trials were searched in Pubmed, Trip Database and Cochrane Library, and selected when they had enough methodological quality assessed with the Jadad scale. Article search strategy included "Carnitine" OR "L-carnitine" AND "Diabetes -Mellitus" OR "Diabetes mellitus, type 2" OR "Noninsulindependent-diabetes mellitus". Meta-analysis was performed, and the difference of means calculated with a 95% confidence interval. Heterogeneity was evaluated with the Q statistic. RESULTS: The systematic review included 4 trials with 284 patients. Oral L-carnitine lowered fasting plasma glucose [-14.3 mg/dl (CI95% - 23.2 to -5.4); p=0,002], total cholesterol [-7.8 mg/dL (95%CI -15.5 to -0.1); p=0.09], low density lipoprotein [-8.8 mg/dl (CI95% -12.2 to -8.5), p<0.0001], apolipoprotein-B100 [-7.6 mg/dl (CI95% -13.6 to -1.6); p=0.013] and apolipoprotein-A1 [-6.0 mg/dl (CI95% -10.5 a -1.5); p=0.523]. There was no significant heterogeneity. The changes in triglycerides, lipoprotein (a) or HbA(1c) were not significant. CONCLUSION: The administration of L-carnitine in type 2 diabetes mellitus is associated with an improvement in glycaemia and plasma lipids.

[Analysis of the relevance and feasibility of quality indicators in nutrition support]. / Análisis de la relevancia y factibilidad de indicadores de calidad en las unidades de nutrición.

INTRODUCTION: The quality assessment in health activities requires the choice of indicators in line with the results we want to measure. Of all possible, we should prioritize those that allow us to obtain the most relevant information without overloading the regular work of our units. OBJECTIVE: To determine the opinion of the members of SENPE regarding the relevance and feasibility of using a selection of quality indicators designed for use in clinical nutrition. METHODS: E-mail survey sent to members of SENPE asking them their views on 12 quality indicators, evaluating each in terms of their relevance and feasibility of implementation in their environment. RESULTS: 40 respondents answered from 40 centers in 12 different regions. In general, the indicators were considered more relevant than feasible. The indicators best rated were: "identification in artificial nutrition bags, "semi-recumbent position in patient with nasogastric tube feeding" and "basic clinical protocols". Considering the type of indicator: "patient identification in the bags of artificial nutrition (structure)," a semi-incorporated "and" basic clinical protocols (process), and "fulfillment of the caloric goal" (result). CONCLUSION: The results of the survey can make a selection of indicators that could be considered for first-line introduction in a Nutrition Unit.

Wernicke's encephalopathy induced by total parental nutrition.

Wernicke's encephalopathy is an acute neurological syndrome due to thiamine deficiency, which is characterized by a typical triad of mental status changes, oculomotor dysfunction and ataxia. Despite the fact that Wernicke's encephalopathy, in developed countries, is frequently associated with chronic alcoholism, there have been a number of published cases associating this encephalopathy with parenteral feeding without vitamin supplementation. Diagnosis is primarily a clinical one, and can be supported by laboratory tests and imaging studies; treatment should start as soon as possible, for the morbidity and mortality (almost 20%) associated with this syndrome is high. Thiamine supplementation, along with other vitamins, is recommended for patients in risk of developing this syndrome.

[Efficacy, cost-effectiveness, and effects on quality of life of nutritional supplementation]. / Eficacia, coste-efectividad y efectos sobre la calidad de vida de la suplementación nutricional.

This article summarizes the main results and conclusions presented in the Symposium "Nutritional supplementation: evidences and experiences" that took place in the XXIIIrd SENPE Congress (2008). Protein energy malnutrition, that can affect 30-50% of hospitalized patients, increases both time of hospitalization and costs of medical care of this kind of patients. There is a lot of scientific evidences demonstrating that the use of nutritional supplementation improves nutritional status or prevents malnutrition in those patients who do not meet their nutritional needs with a conventional diet or an adapted one with no replacing intake from normal food. This is strengthened by the results that demonstrate the rol of nutritional supplements improving nutritional and functional parameters. Current bibliographic reviews focused on certain clinical frameworks (i.g. geriatrics, oncology), prove that nutritional supplements reduce complications related to pathology and to nutritional status, and also reduce length of hospitalization and mortality. More studies regarding to efficacy of oral nutritional supplements are needed. These studies should be carried out with a period of follow-up longer than the current published studies have. As well as effective, nutritional supplements become a save therapeutic intervention with no important adverse events that, according to bibliography, improve patient's functionality and quality of life. It is worth mentioning that nutritional supplements can be effective on certain kind of patients, for instance, malnourished elderly or elderly in risk of malnourishment, and hospitalized surgical patients. Scientific literature refers that it is necessary to carry out more studies, with an accurate methodology, which assess the effect of nutritional supplements on quality of life and its cost-effectiveness on malnourished patients regarding specific clinical situations. That would allow physicians to make clinical decisions based on evidences and cost analysis.

[National registry of home enteral nutrition in Spain 2007]. / Registro de Nutrición Enteral Domiciliaria en España en el año 2007.

OBJECTIVE: To communicate the results from the registry of Home-Based Enteral Nutrition of the NADYASENPE group in 2007. MATERIAL AND METHODS: We included every patient in the registry with home enteral nutrition any time from January 1st to December 31st of 2007. RESULTS: The number of patients with home enteral nutrition in 2007 was 5,107 (52% male) from 28 different hospitals. 95.4% of them were 15 yr or older, with a mean age of 67.96 +/- 18.12, and 4.2 +/- 3.38 among patients aged 14 yr or less. The most common underlying diseases were neurological (37.8%) and neoplastic diseases (29.3%). Enteral nutrition was administered p.o. in most patients (63.5%), followed by nasogastric tube (25.9%), while gastrostomy was only used in 9.2%. The mean time in enteral nutrition support was 9.4 months and the most common reasons for withdrawal were death (58.7%) and switching to oral intake (32%). Activity was limited in 31.4% of patients and 36.01% were house-bound. Most patients needed partial (26.51%) or total (37.68%) care assistance. Enteral formula was provided by hospitals to 69.14% of patients and by pharmacies to 30.17% of them, while disposable material was provided by hospitals to 81.63% and by Primary Care to the remaining patients. CONCLUSIONS: In 2007, there has been an increase of more than 30% of patients registered with home enteral nutrition comparing with 2006, without any big difference in other data, but a higher proportion of patients with enteral nutrition p.o.

[Value of nutritional support in patients with pharingocutaneous fistula]. / Utilidad del soporte nutricional en pacientes con fistula faringocutánea.

INTRODUCTION: A prospective and statistic study is presented to evaluate the efficacy of nutritional support in the postoperative care of patients with pharyngocutaneous fistula after laryngectomy. PATIENTS AND METHODS: All patients who developed pharyngocutaneous fistula after total o partial laryngectomy between 2001 and 2004 were included and assigned to the study group if a supplementary and enteral nutrition was started through the nasogastric tube, and to the control group if a conventional liquid diet was given. Nutrition of patients in the study group was controlled by an Endocrinologist. RESULTS: 32 patients were included (14 in the study group and 18 in the control group). Both groups were similar for all variables measured except for the length of hospital stay (mean difference 31.02 days) and the need for surgical closure (33% in the control group and 0% in the study group). These differences were found statistically significant. DISCUSSION AND CONCLUSIONS: Postoperative supplementary enteral nutrition controlled by the Endocrinologist reduced the need for surgical treatment of pharyngocutaneous fistula and shortened the stay in hospital of these patients. More studies are needed to prove the efficacy of preoperative nutrition in reducing the incidence of fistula after laryngectomy.

[99m-Tc sestamibi scintigraphy in primary hyperparathyroidism. Importance of lateral projections using a pin-hole collimator]. / Gammagrafía con sestamibi-Tc99m en el hiperparatiroidismo primario. Importancia de las proyecciones laterales con colimador pin-hole.

UNLABELLED: 99mTc-Sestamibi double-phase scintigraphy has been improved with digital and tomographic procedures as well as additional projections. Since two years ago, we have introduced additional early lateral views of neck to the conventional double-phase scintigraphy. We have tried to give anatomic data about the depth of the adenomas and to evaluate the possibility of obviating the late images of the double-phase study. METHOD: Two observers reviewed 50 studies performed for primary hyperparathyroidism in two different ways. The first one reviewed only conventional double-phase studies and the second one, with the additional report of the lateral views. RESULTS: in 32/50 patients (64 %) the report of the additional lateral views and the conventional early views was enough to diagnose parathyroid adenomas. No additional lesions were observed in the late views. These views did not provide any additional useful data and could have been obviated. Four ectopic adenomas were found, 1 mediastinal and 3 in paraesophagic area; three intrathyroidal focus; all of these atypical lesions were identified by lateral pinhole views. CONCLUSION: The performance of additional lateral projections of the parathyroids supplies additional information to the surgeon on the depth of the lesion in atypical sites and would have made it possible to obviate the late phase in more than half of the patients since this did not supply additional information to that of the early images that had reached a diagnosis.

Gammagrafía con Sestamibi-Tc99m en el HiperparatiroidismoPrimario. Importancia de las Proyecciones Laterales con ColimadorPin-Hole / 9Mtc-sestamibi scintigraphy in primary hyperparathyroidism

La gammagrafía de paratiroides con sestamibi-Tc99m en dos fases se ha ido complementando con técnicas digitales, tomográficas y proyecciones adicionales. Desde hace dos años hemos incorporado la realización selectiva de proyecciones laterales con colimador pin-hole a 90° en las imágenes precoces en un intento sencillo de proporcionar información acerca de la situación en profundidad, por un lado, para complementar el diagnóstico intentando acortar la exploración y, por otro, para facilitar el abordaje quirúrgico al cirujano en las ectopias. Método: Dos observadores revisaron los estudios de 50 hiperparatiroidismos primarios de dos formas distintas: una a partir de las proyecciones anteriores convencionales en dos fases y otra con la información adicional de las proyecciones laterales. Resultados: En 32/50 pacientes (64 por ciento) la información de las proyecciones laterales adicionales fue suficiente para diagnosticar la presencia de adenomas paratiroideos sin que las imágenes tardías aportasen datos de interés pudiéndose obviar la fase tardía. No se observaron lesiones adicionales en las imágenes tardías. Se encontraron 4 adenomas ectópicos (3 paraesofágicos y 1 mediastínico). 3 captaciones nodulares intratiroideas fueron perfectamente localizadas por las proyecciones laterales. Conclusión: La realización de proyecciones laterales adicionales de paratiroides aporta información adicional al cirujano acerca de la profundidad de la lesión en localizaciones atípicas y hubiera permitido obviar la fase tardía en más de la mitad de los pacientes ya que ésta no aportó información adicional a la de las imágenes precoces que habían alcanzado un diagnóstico (AU)

[Complications of enteral nutrition at home. Results of a multicentre trial]. / Complicaciones de la nutrición enteral domiciliaria. Resultados de un estudio multicéntrico.

AIM: In spite of the increasing number of home enteral nutrition (HEN) patients, only few articles had reported the frequency of complications related to this treatment. Our multicentric study analyzes the HEN complications in relation to access device and time of treatment. METHOD: 92 HEN patients from 8 hospitals were randomly selected. Patients were distributed in relation to the time of treatment and access device (nasogastric tube and percutaneous or surgical gastrostomies). After an educational program, they were filled in an initial questionnaire and repeated it the days 15 and 30. They received a mean of 1650 Kcal of enteral solution. A total of 2760 HEN prospective days were analyzed. RESULTS: In prospective study 42% of patients had some complication (112 episodes). The most frequent were gastrointestinal (55%) and mechanical (29%); 0.16 complications of patient-year were registered. The most common complications were: extraction (15%), constipation (13%), vomiting (12%) and diarrhoea (10%). The gastrostomy group had more gastrointestinal complications. In retrospective evaluation, percutaneous gastrostomy group had the lowest ratio of complications and nasogastric tube group required more tube replacements (4 vs 2) and had 1.96 episodes/patient (percutaneous group 1.85 and surgical gastrostomy 3.1 episodes/patient). CONCLUSION: HEN is safe with low incidence of complications. An adequate educational program is very important and we expect, in the future, to establish an proper National Home Care System.

Hipertensión arterial resistente por síndrome de Cushing cíclico / Resistant arterial hypertension due to cyclic Cushing's syndrome

Se presenta el caso de un varón de 44 años con hipertensión arterial (HTA) de 14 años de evolución, resistente a varios fármacos, que ingresó por infarto agudo de miocardio (IAM) y en el que se realizó estudio endocrinológico ante la sospecha de HTA secundaria por el fenotipo, la edad de comienzo y la resistencia al tratamiento. Se detectó un síndrome de Cushing cíclico de dudoso origen inicialmente, que resultó ser adrenal tras la realización de pruebas funcionales y de imagen. El síndrome de Cushing cíclico es una entidad clínica infrecuente que suele tener un origen hipofisario (AU)