Adequação calórico proteica da terapia nutricional enteral em pacientes críticos / Caloric-protein adequacy of enteral nutritional therapy in critical patients

A doença crítica promove um estado hipercatabólico associado a uma resposta inflamatória intensa. Admite-se que essas alterações contribuem para o aumento do gasto de energia e para a elevação do catabolismo proteico. Objetivo: analisar a adequação calórico-proteica da terapia de nutrição enteral e o seu impacto no desfecho clínico de pacientes críticos. Método: Trata-se de um estudo longitudinal prospectivo realizado com 36 pacientes internados em unidades de terapia intensiva. A adequação da oferta calórico-proteica foi obtida pela relação percentual a partir do quarto dia de implementação da terapia nutricional. Realizou-se o teste de Shapiro Wilk para averiguar a normalidade dos dados e a partir disso, foi aplicado o teste de Mann-Whitney ou de t-Student não pareado. Foi realizada a análise de regressão logística com estimativa de seu coeficiente. Para a regressão estimou-se o intervalo de confiança de 95% e nível de significância de 5%. Foi utilizado o software STATA® versão 14.0 nesta análise. Resultados: Ao avaliar 36 pacientes verificou-se que a sobrevida foi menor entre os indivíduos que apresentaram o menor percentual de adequação calórica (p=0,010) e proteica (p=<0,001). Observou-se que oferta proteica impactou mais expressivamente os desfechos clínicos, ao aumento de 1% na média de adequação proteica as chances de óbito diminuíram 21%. Conclusão: O menor percentual de adequação calórico-proteica foi associado a menor sobrevida de pacientes críticos. Ainda, observou-se que o percentual de adequação proteica se associou mais expressivamente aos desfechos clínicos nessa amostra

The critical illness promotes a hypercatabolic state associated with an intense inflammatory response. It is recognized that those changes contribute to the rise of consumption of energy expenditure and to protein metabolism rise. Objective: to analyze the adequacy caloric-protein of enteral nutrition therapy and its impact on the clinical outcome of critical patients. Method: This is a prospective longitudinal study conducted with 36 hospitalized patients in intensive care units. The caloric-protein adequacy was acquired by percent ratio from the fourth day of nutritional therapy implementation. The Shapiro Wilk test was performed to check the data normality and based on that the Mann-Whitney test or unpaired Student t test was applied. The logistic regression analysis was performed with an estimate of its coefficient. For regression, it was estimated the confidence interval of 95% and significance level of 5%. In this analysis was utilized the STATA® software version 14.0. Results: In the evaluation of 36 patients, it was found that survival was lower among the individuals who had the lower percentage of caloric adequacy (p=0,010) and protein (p=<0,001). It was observed that the protein supply impacted expressively the clinical outcome with an increase of 1% in the average protein adequacy, the chances of death decreased by 21%. Conclusion: The lower percentage of caloric-protein adequacy was associated with lower mortality of critical patients. In addition, in this sampling, it was observed that the protein adequacy percentual joined expressively in the clinical outcome

Inadequação calórica e proteica e fatores associados em pacientes graves / Inadequate energy and protein and associate factors in critically ill patients

RESUMO Objetivo: Investigar a adequação calórico-proteica de pacientes em terapia nutricional enteral exclusiva internados nas Unidades de Terapia Intensiva de um hospital universitário. Métodos: Estudo longitudinal realizado entre abril e novembro de 2014 nas Unidades de Terapia Intensiva de um hospital universitário. Foram avaliados no período de 14 dias: percentual de adequação calórico-proteica, calculada pelas médias dos valores prescritos e administrados; condições clínicas (unidade e diagnóstico de internação, escore prognóstico Acute Physiology and Chronic Health Evaluation II, estado nutricional, tempo de internação); complicações gastrointestinais; e motivo de interrupção da dieta. Valores inferiores a 80% de adequação calórica e proteica foram considerados inadequados. Realizou-se análise multivariada por Regressão de Poisson com nível de significância de 5%. Resultados: O estudo contou com uma amostra de 38 pacientes, sendo 52,63% desnutridos. As médias de adequação calórica e proteica foram de 76,47% e 69,11%, respectivamente. A prevalência de inadequação calórica foi de 55,26% e de proteica, 68,42%. O jejum para procedimentos foi a causa mais frequente de interrupção da dieta. O volume residual gástrico e a diarreia foram as complicações gastrointestinais mais comuns. A inadequação calórica associou-se ao tempo de permanência ≤14 dias e ao volume residual elevado. A inadequação proteica associou-se ao tempo de permanência ≤14 dias, ao volume residual gástrico elevado e à saída ou obstrução da sonda. Conclusão: A prevalência de inadequação calórica e proteica ocorreu em mais da metade dos pacientes avaliados. Estratégias como a elaboração de protocolos por equipe multiprofissional devem ser implantadas para minimizar interrupções da dieta administrada, estabelecer medidas de controle para complicações gastrointestinais e, assim, garantir um aporte nutricional adequado durante o período de internação.

ABSTRACT Objective: To investigate the energy and protein adequacies of intensive care unit of a university hospital patients in exclusive enteral nutrition. Methods: This longitudinal study was conducted between April and November 2014 in the adult intensive care unit of a university hospital. The following items were assessed during 14 days: percentage of protein energy adequacy, based on the mean prescribed and administered values; clinical conditions (unit and diagnosis on admission, Acute Physiology and Chronic Health Evaluation II, nutritional status, and length of stay); gastrointestinal complications; and reason for diet interruption. Values below 80% of the caloric and protein adequacies were considered inadequate. Multivariate analysis was performed by Poisson Regression at a significance level of 5%. Results: The sample consisted of 38 patients, and 52.63% were undernourished. The mean caloric and protein adequacies were 76.47% and 69.11%, respectively. The prevalences of caloric and protein inadequacies were 55.26% and 68.42%, respectively. Fasting for procedures was the most frequent cause for diet interruption. Residual gastric volume and diarrhea were the most common gastrointestinal complications. Caloric inadequacy was associated with length of stay ≤14 days and high residual gastric volume. Protein inadequacy was associated with length of stay ≤14 days, high residual gastric volume, and catheter displacement or obstruction. Conclusion: More than half of the patients had caloric and protein inadequacies. Strategies, such as the development of protocols for multidisciplinary teams, should be created to minimize disruption of the administered diet, establish measures to control gastrointestinal complications, and thus ensure adequate nutritional intake during intensive care unit stay.

Severe protein malnutrition in a morbidly obese patient after bariatric surgery.

The aim of this study was to describe the clinical course of a morbidly obese patient who underwent Roux-en-Y gastric bypass (RYGB) surgery and, in the late postoperative period, presented the expected loss of weight, but also presented severe protein malnutrition (PM). A patient with morbid obesity, who in March 2012, presented PM (serum albumin = 2.4 g/dL) 2 y after the completion of RYGB surgery (loss of 52.7% of usual body weight). During the hospitalization, the patient received partial volumes of commercial semi-elemental, high-protein, low-fat diet by tube feeding with gastric positioning, associated with an oral low-fat, low-sodium, and bland-consistency diet. The patient presented a temporary clinical improvement, however, outpatient monitoring identified the need for subsequent hospitalizations due to the recurrence of severe hypoalbuminemia (e.g., 1.39 g/dL), anasarca (increase of 15 kg in 79 d), and normocytic and normochromic anemia (e.g., hemoglobin 9.2 g/dL). In July 2013 the RYGB partial reversal technique was performed with a reduction of 100 cm in the Roux-en-Y arm. Seventy days after surgery, the patient was asymptomatic (albumin 3.7 g/dL), however, she presented rapid and progressive recovery of the body weight (increase of 10.3 kg in 60 d, without edema). The effective treatment of morbid obesity is still a major challenge in clinical practice. Restrictive, malabsorptive bariatric techniques are associated with nutritional deficiencies. Severe PM is rarely reported as a late postoperative complication of RYGB, however, due to the serious consequences associated with this, it requires early diagnosis and treatment.

Clinical outcome of protein-energy malnourished patients in a Brazilian university hospital.

Protein-energy malnutrition (PEM) is a treatable disease with high prevalence among hospitalized patients. It can cause significant increases in the duration of hospitalization and costs. PEM is especially important for health systems since malnourished patients present higher morbidity and mortality. The objective of the present study was to assess the evolution of nutritional status (NS) and the effect of malnutrition on clinical outcome of patients at a public university hospital of high complexity in Brazil. Patients hospitalized in internal medicine (n = 54), oncology (n = 43), and infectious diseases (n = 12) wards were included. NS was evaluated using subjective global assessment up to 48 h after admission, and thereafter at intervals of 4-6 days. On admission, patients (n = 109) were classified as well-nourished (n = 73), moderately malnourished or at risk of malnutrition (n = 28), and severely malnourished (n = 8). During hospitalization, malnutrition developed or worsened in 11 patients. Malnutrition was included in the clinical diagnosis of only 5/36 records (13.9% of the cases, P = 0.000). Nutritional therapy was administered to only 22/36 of the malnourished patients; however, unexpectedly, 6/73 well-nourished patients also received commercial enteral diets. Complications were diagnosed in 28/36 malnourished and 9/73 well-nourished patients (P = 0.000). Death occurred in 12/36 malnourished and 3/73 well-nourished patients (P = 0.001). A total of 24/36 malnourished patients were discharged regardless of NS. In summary, malnutrition remains a real problem, often unrecognized, unappreciated, and only sporadically treated, even though its effects can be detrimental to the clinical course and prognosis of patients. The amount of public and private funds unnecessarily dispersed because of hospital malnutrition is significant.

Clinical outcome of protein-energy malnourished patients in a Brazilian university hospital

Protein-energy malnutrition (PEM) is a treatable disease with high prevalence among hospitalized patients. It can cause significant increases in the duration of hospitalization and costs. PEM is especially important for health systems since malnourished patients present higher morbidity and mortality. The objective of the present study was to assess the evolution of nutritional status (NS) and the effect of malnutrition on clinical outcome of patients at a public university hospital of high complexity in Brazil. Patients hospitalized in internal medicine (n = 54), oncology (n = 43), and infectious diseases (n = 12) wards were included. NS was evaluated using subjective global assessment up to 48 h after admission, and thereafter at intervals of 4-6 days. On admission, patients (n = 109) were classified as well-nourished (n = 73), moderately malnourished or at risk of malnutrition (n = 28), and severely malnourished (n = 8). During hospitalization, malnutrition developed or worsened in 11 patients. Malnutrition was included in the clinical diagnosis of only 5/36 records (13.9% of the cases, P = 0.000). Nutritional therapy was administered to only 22/36 of the malnourished patients; however, unexpectedly, 6/73 well-nourished patients also received commercial enteral diets. Complications were diagnosed in 28/36 malnourished and 9/73 well-nourished patients (P = 0.000). Death occurred in 12/36 malnourished and 3/73 well-nourished patients (P = 0.001). A total of 24/36 malnourished patients were discharged regardless of NS. In summary, malnutrition remains a real problem, often unrecognized, unappreciated, and only sporadically treated, even though its effects can be detrimental to the clinical course and prognosis of patients. The amount of public and private funds unnecessarily dispersed because of hospital malnutrition is significant.

Protein-calorie adequacy of enteral nutrition therapy in surgical patients.

OBJECTIVE: To evaluate the protein-calorie adequacy of enteral nutrition therapy (ENT) in surgical patients. METHODS: A prospective study was performed in surgical patients who received ENT from March to October 2011. Patients were evaluated anthropometrically and by subjective global assessment (SGA). The amount of calories and protein prescribed and administered were recorded daily, as well as the causes of discontinuation of the diet. A 90% value was used as the adequacy reference. The difference between the prescribed and administered amount was verified by Student's t-test. RESULTS: A sample of 32 patients, aged 55.8 ± 14.9 years, showed a malnutrition rate of 40.6% to 71.9%, depending on the assessment tool used. Gastric cancer and gastrectomy were the most common diagnosis and surgery, respectively. Of the patients, 50% were able to meet their caloric and protein needs. The adequacy of the received diet in relation to the prescribed one was 88.9 ± 12.1% and 87.9 ± 12.2% for calories and proteins, respectively, with a significant difference (p < 0.0001) of 105.9 kcal/day and 5.5 g protein/day. 59.4% of the patients had adequate caloric intake and 56.2% had adequate protein intake. Causes of diet suspension occurred in 81.3%, with fasting for procedures (84.6%) and nausea/vomiting (38.5%) being the most frequently observed causes in pre- and postoperative periods, respectively. CONCLUSION: Inadequate caloric and protein intake was common, which can be attributed to complications and diet suspensions during ENT, which may have hampered the sample reached their nutritional needs. This may contribute to the decline in the nutritional status of surgical patients, who often have impaired nutrition, as observed in this study.

Adequação calórico-proteica da terapia nutricional enteral em pacientes cirúrgicos / Protein-calorie adequacy of enteral nutrition therapy in surgical patients

OBJETIVO: Avaliar a adequação calórico-proteica da terapia nutricional enteral (TNE) empregada em pacientes cirúrgicos. MÉTODOS: Estudo prospectivo, realizado em pacientes cirúrgicos que receberam TNE de março a outubro de 2011. Os pacientes foram avaliados antropometricamente e pela avaliação subjetiva global (ASG). Os valores de calorias e proteínas prescritos e administrados e as causas de interrupção da dieta foram registrados diariamente. O valor de 90% foi utilizado como referencial de adequação. A diferença entre o prescrito e o administrado foi verificada pelo teste t de Student. RESULTADOS: Uma amostra de 32 pacientes, com idade de 55,8 ± 14,9 anos, apresentou 40,6 a 71,9% de desnutrição dependendo da ferramenta utilizada. A neoplasia gástrica e as gastrectomias foram o diagnóstico e as cirurgias mais frequentes. Dos pacientes, 50% conseguiram atingir suas necessidades calórico-proteicas. A adequação da dieta recebida em relação à prescrita foi de 88,9 ± 12,1% e de 87,9 ± 12,2% para calorias e proteínas, respectivamente, com um déficit significativo (p < 0,0001) de 105,9 Kcal/dia e de 5,5 g de proteína/dia. Dos pacientes, 59,4% estavam adequados quanto a calorias e 56,2% quanto a proteínas. As causas de suspensão da dieta ocorreram em 81,3%, sendo o jejum para procedimentos (84,6%) e náuseas/vômitos (38,5%) as causas mais observadas no pré e no pós-operatório, respectivamente. CONCLUSÃO: A inadequação calórico-proteica foi frequente, podendo ser atribuída às intercorrências e suspensões da dieta durante a TNE, o que pode ter dificultado que a amostra atingisse suas necessidades nutricionais. Isto pode contribuir para o declínio do estado nutricional do paciente cirúrgico, que frequentemente já está comprometido, conforme observado neste estudo.

OBJECTIVE: To evaluate the protein-calorie adequacy of enteral nutrition therapy (ENT) in surgical patients. METHODS: A prospective study was performed in surgical patients who received ENT from March to October 2011. Patients were evaluated anthropometrically and by subjective global assessment (SGA). The amount of calories and protein prescribed and administered were recorded daily, as well as the causes of discontinuation of the diet. A 90% value was used as the adequacy reference. The difference between the prescribed and administered amount was verified by Student's t-test. RESULTS: A sample of 32 patients, aged 55.8 ± 14.9 years, showed a malnutrition rate of 40.6% to 71.9%, depending on the assessment tool used. Gastric cancer and gastrectomy were the most common diagnosis and surgery, respectively. Of the patients, 50% were able to meet their caloric and protein needs. The adequacy of the received diet in relation to the prescribed one was 88.9 ± 12.1% and 87.9 ± 12.2% for calories and proteins, respectively, with a significant difference (p < 0.0001) of 105.9 kcal/day and 5.5 g protein/day. 59.4% of the patients had adequate caloric intake and 56.2% had adequate protein intake. Causes of diet suspension occurred in 81.3%, with fasting for procedures (84.6%) and nausea/vomiting (38.5%) being the most frequently observed causes in pre- and postoperative periods, respectively. CONCLUSION: Inadequate caloric and protein intake was common, which can be attributed to complications and diet suspensions during ENT, which may have hampered the sample reached their nutritional needs. This may contribute to the decline in the nutritional status of surgical patients, who often have impaired nutrition, as observed in this study.

Desnutrição energético-proteica grave durante a hospitalização: aspectos fisiopatológicos e terapêuticos: [revisão] / Protein-energy malnutrition during hospital stay: physiopathology and treatment: [review]

OBJETIVOS: Apresentar a conduta para o tratamento da desnutrição energético-proteica grave e os principais aspectos fisiopatológicos da doença. FONTES DE DADOS: Tomando como base o Manual da Organização Mundial da Saúde (OMS, 1999), realizou-se uma busca por trabalhos publicados em inglês, espanhol e português sobre o tratamento hospitalar de crianças com desnutrição grave, nas bases de dados Lilacs, Medline e SciELO, publicados nos últimos dez anos, utilizando-se as palavras-chave: desnutrição, criança, hospitalização, terapia nutricional, diretrizes, OMS. SÍNTESE DE DADOS: Foram abordadas as principais características fisiopatológicas da desnutrição grave e a conduta recomendada para o tratamento. Identificaram-se as principais complicações clínico-metabólicas, como a hipotermia, a hipoglicemia, a desidratação e as infecções recorrentes, além da má absorção e a fase de estabilização ou de recuperação do desnutrido grave. A compreensão de todos esses conceitos relacionados à fisiopatologia da desnutrição energético-proteica, associada ao adequado planejamento e execução da terapia nutricional, pode reduzir o risco de morbimortalidade em crianças com idade inferior a cinco anos. CONCLUSÕES: As diretrizes da OMS devem ser implantadas levando-se em consideração a realidade de cada região e a capacitação do profissional da saúde quanto ao conhecimento da complexidade e fisiopatologia da desnutrição energético-proteica grave, para adequado diagnóstico e tratamento. O sucesso do tratamento está associado ao cuidado e à atenção ao paciente.

OBJECTIVE: To identify the main physiopathological aspects of severe protein-energy malnutrition and its treatment. DATA SOURCE: Based on the World Health Organization guidelines (WHO, 1999), an electronic search for papers on hospital treatment of children with severe malnutrition was performed on Lilacs, Medline and SciELO databases. Studies in English, Spanish and Portuguese published in the last ten years were searched by the following key-words: malnutrition, child, hospitalization, nutrition therapy, practice guidelines, WHO. DATA SYNTHESIS: The main pathological aspects of severe malnutrition and its specific treatment were reviewed. The main clinical and metabolic complications of severe malnutrition were identified such as hypothermia, hypoglycemia, dehydration, usual infections, intestinal malabsorption, as well as stabilization and recovery phases, were defined. Understanding the main concepts of the physiopathology of this condition, associated with appropriate nutrition support planning, can decrease morbidity and mortality risks of children younger than five years old. CONCLUSIONS: The implementation of the 1999 WHO guidelines should take into consideration local economic and cultural aspects, as well as the professional health care training. Due to the complexity of severe malnutrition, adequate knowledge about basic aspects of this condition helps providing adequate diagnosis and treatment.

Soporte nutricional en la insuficiencia renal aguda / Nutritional support in acute renal failure

La insuficiencia renal aguda (IRA) se presenta frecuentemente en distintas condiciones clínicas y es especialmente frecuente en unidades de cuidados intensivos. La presencia de IRA se considera como un factor de riesgo independiente de morbilidad y mortalidad hospitalaria. De ahí la importancia de evaluar los diversos factores determinantes de su evolución,entre los que cuenta la desnutrición calórico-proteica.El propósito de esta revisión es analizar la literatura más relevante hasta la actualidad en este tema.

Acute renal failure is frequently present in patients with different clinical settings, and especially in the intensives care units. Acute renal failure is considered an independent risk factor to increased hospital morbidity and mortality. Hence, the importance of evaluating the various determinants of its evolution, including account protein-calorie malnutrition. The purpose of this review is to examine the relevant literature to date on this issue.

Suporte nutricional após ressecções intestinais extensas / Nutritional support after massive intestinal resection

Os pacientes submetidos à ressecção intestinal extensa apresentam sintomatologia decorrente da insuficiência intestinal. Desenvolvem complicações nutricionais e infecciosas, apresentam síndrome de má absorção e distúrbios do equilíbrio hidrossalino e ácido-basico e muitas vezes desnutrição. O suporte nutricinal apresenta-se como terapêutica fundamental para uma boa evolução. Com o advento do transplante de intestino delgado, um maior número de portadores de síndrome do intestino curto poderá ser beneficiado.

Short bowel syndrome (SBS) is the clinical entity that results from an effective reduction in the functioning intestinal absorptive surface, with leads to malabsorption and an inability to maintain an adequate nutritional status. Before the introduction of parenteral nutrition, survival of patients with SBS was exceptional. The article reviews the pathophysiology of intestinal resection and the metabolic derangements and nutritional deficits that occur in SBS. Nutrition support for SBS is also discussed.

Desnutrição calórico-proteica do tipo kwashiorkor desencadeada por alergia à proteína do leite de vaca / Kwashiorkor-type malnutrition due to cow's milk protein allergy

A enteropatia induzida por proteína alimentar, uma das formas de apresentação de hipersensibilidade alimentar, tem na alergia à proteína do leite de vaca a causa mais comum dessa síndrome. Ocorre comumente em lactentes, e o diagnóstico depende de uma anamnese minuciosa associada a uma resposta clínica favorável à retirada do antígeno. No presente relato, paciente do sexo feminino de 1 ano e 8 meses, interna para investigação de desnutrição calórico-proteica grave com história de vômitos, diarreia sanguinolenta e perda ponderal pronunciada a partir dos 8 meses de idade. Amamentação exclusiva no primeiro mês de vida e fórmula láctea do segundo ao quarto mês; desde então, com leite de vaca integral. Na admissão, chorosa, irritada, emagrecida, desidratada, cabelos despigmentados e quebradiços, em anasarca e com hepatomegalia. Exames laboratoriais revelaram anemia megaloblástica, leucocitose e hipoalbuminemia. Hipóteses diagnósticas: doença celíaca, fibrose cística e alergia à proteína do leite de vaca. Realizada endoscopia digestiva alta com biópsia: discreto aumento de eosinófilos na lâmina própria em mucosa gástrica e duodenal e esofagite crônica discreta com raros eosinófilos intraepiteliais. Teste do suor negativo. Estabelecido o diagnóstico de alergia à proteína do leite de vaca desencadeando um quadro de desnutrição calórico-proteica grave do tipo kwashiorkor e iniciada dieta com hidrolisado proteico. A alergia à proteína do leite de vaca é uma apresentação clínica frequente de alergia alimentar em lactentes e pré-escolares, sendo as repercussões gastrintestinais e nutricionais significativas nessa faixa etária. Dessa forma, o diagnóstico de alergia à proteína do leite de vaca deve ser considerado em pacientes com desnutrição calórico-proteica, uma vez que a desnutrição primária, por ingestão insuficiente, tenha sido excluída.

Dietary protein-induced enteropathy is one of the presentations of food allergy, and cow's milk protein allergy (CMPA) is its most common cause, frequently affecting infants. Diagnosis depends on thorough history associated with favorable clinical response to the antigen with drawal. This case report describes the case of a twenty-month-old female patient admitted to investigate protein-energy malnutrition (PEM) with severe vomiting, bloody diarrhea and significant weight loss since eight months of age. She was breastfed during the first month of life, receiving infant formula up to the fourth month and, since then, whole cow's milk. At admission, the patient was very irritable, crying, angry, dehydrated, with severe weight loss, brittle and depigmented hair, edema and hepatomegaly. Laboratory tests showed megaloblastic anemia, leukocytosis and hypoalbuminemia. Diagnostic hypotheses: celiac disease, cystic fibrosis and CMPA. Esophagogastroduodenoscopy with biopsy showed slight increase in intra-epithelial eosinophils in the duodenum and chronic mild esophagitis with rare eosinophil infiltrate. Sweat test was negative. Diagnosis of kwashiorkor-type malnutrition triggered by CMPA was made, and hydrolyzed protein diet was started with favorable clinical outcome. CMPA is a prevalent clinical presentation of food allergy in infants and preschool children, and nutritional consequences are also important in these age groups. Therefore, CMPA diagnosis should always be considered in patients with PEM, provided the primary malnutrition secondary to insufficient food intake is excluded.

Muscle mass gain observed in patients with short bowel syndrome subjected to resistance training.

Few studies are available about the evaluation of resistance training in patients with protein-energy malnutrition. To assess the effects of resistance training on the recovery of nutritional status of patients with short bowel syndrome, with a small bowel remnant of less than 100 cm, 9 patients of both sexes with protein-energy malnutrition after extensive resection of the small bowel were submitted to resistance training of progressive intensity consisting of concentric and eccentric work exercises for the upper limbs, trunk, and lower limbs, with the individuality and limitations of each patients being respected. Food consumption was monitored by 24-hour food recall performed during the initial phase of the study, before and 7 and 14 weeks after physical training, and by a dietary record for a period of 3 days of oral feeding. The nutrients administered by the enteral and parenteral route were recorded. A significant increase in total arm area (P < or = .01) and fat-free mass (P < or = .01) was observed as determined by computed tomography. An increase in total energy ingestion and carbohydrate consumption (P < or = .01) was also observed. In addition, the activity of the enzyme carnosinase was increased after resistance training (P < or = .01). The present results show that resistance training in patients with short bowel syndrome and protein-energy malnutrition can be considered to be a part of the nonmedicamentous treatment of these patients, leading to better nutrient use and to a gain of lean mass.

[Effect of the nutritional recovery on the concentration of Interleukin-2 in severely malnourished children]. / Efecto de la recuperación nutricia sobre la concentración de Interleucina-2 en niñios con desnutrición grave.

The severely malnourished child has dysfunction of the immune response that may increase the risk of morbidity or mortality due to infectious diseases, therefore, the purpose of this study was to demonstrate the effect of intensive nutritional support on the cellular and serum concentration of IL-2 and CD4+, as well as CD8+ T cells in children with severe protein energy malnutrition. A clinical assay was carried out in a tertiary care hospital. 10 severely malnourished children < 48 months of age who received formula without lactose via enteral feeding for two weeks and ad libitum for an additional two weeks were included. Cellular and serum concentrations of IL-2 and the subpopulation of CD4+ and CD8+ were obtained. A control group (n = 13) was included. A paired student t test for initial-final determinations and the Mann-Whitney Test for comparison with control group were used, and null hypothesis was rejected with a p value < 0.05. There was a noteworthy increase in the comparison between the initial vs. final percentage of the cellular expression of IL-2 (p < 0.001) and in the serum concentration of IL-2 (p = 0.001). Therefore, four weeks of nutritional recovery significantly restored the production of IL-2, independently of the nutrients involved in the process, although, the rate of restoration seems to depend on the severity of the children primary PEM.

Efecto de la recuperación nutricia sobre la concentración de Interleucina-2 en niños con desnutrición grave

El niño con desnutrición grave tiene una disfunción de la respuesta inmune que puede aumentar de manera significativa la morbilidad y la mortalidad por infecciones. Por ello, el objetivo del presente estudio fue demostrar el efecto del apoyo nutricio intensivo en la concentración en suero y celular de IL-2 y sub-poblaciones de células CD4+, y CD8+ T en niños con desnutrición proteínico-energética grave. En un ensayo clínico se incluyeron 10 niños con desnutrición primaria grave, menores de 48 meses de edad, quienes recibieron una fórmula sin lactosa por alimentación enteral continua por dos semanas y dos semanas más ad libitum. Se obtuvieron la concentración sérica y celular de IL-2 y las sub-poblaciones de linfocitos CD4+ y CD8+ en los casos y en un grupo control (n = 13). Con la prueba t de student pareada se compararon los valores inicial vs. final de los sujetos y se utilizó la prueba U-Mann-Whitney para la comparación con el grupo control. Se rechazó la hipótesis nula con una p < 0,05. Se observó un incremento notable inicial vs. final en el porcentaje de expresión celular de IL-2 (p < 0,001) y en la concentración sérica de esta citocina (p = 0,001). Por tanto, cuatro semanas de apoyo nutricio intensivo fueron suficientes para mostrar un incremento significativo en la producción de IL-2, independientemente de los nutrimentos involucrados, aunque aparentemente este incremento dependió de la gravedad de la DPE.

Effect of the nutritional recovery on the concentration of Interleukin-2 in severely malnourished children. The severely malnourished child has dysfunction of the immune response that may increase the risk of morbidity or mortality due to infectious diseases, therefore, the purpose of this study was to demonstrate the effect of intensive nutritional support on the cellular and serum concentration of IL-2 and CD4+, as well as CD8+ T cells in children with severe protein energy malnutrition. A clinical assay was carried out in a tertiary care hospital. 10 severely malnourished children < 48 months of age who received formula without lactose via enteral feeding for two weeks and ad libitum for an additional two weeks were included. Cellular and serum concentrations of IL- 2 and the subpopulation of CD4+ and CD8+ were obtained. A control group (n = 13) was included. A paired student t test for initial-final determinations and the Mann-Whitney Test for comparison with control group were used, and null hypothesis was rejected with a p value < 0,05. There was a noteworthy increase in the comparison between the initial vs. final percentage of the cellular expression of IL-2 (p < 0,001) and in the serum concentration of IL-2 (p = 0,001). Therefore, four weeks of nutritional recovery significantly restored the production of IL-2, independently of the nutrients involved in the process, although, the rate of restoration seems to depend on the severity of the children primary PEM.

The role of nutrition in hepatic encephalopathy.

PURPOSE OF REVIEW: Protein-calorie malnutrition may be observed in all clinical stages of liver disease. Nutritional management in these patients is imperative. It is crucial that protein intake is not restricted ad hoc. Administration of vegetable proteins for patients who cannot tolerate standard proteins and, if necessary, branched-chain amino acid-enriched formulae can be an option to these patients. This issue, however, remains controversial. RECENT FINDINGS: This study is an update on the nutritional management of hepatic encephalopathy based on several studies of the last decades, involving dietary protein intake and branched-chain amino acid supplementation. SUMMARY: Malnutrition is a common complication of liver disease and it adversely affects patient outcome. Inadequate dietary protein intake has a very deleterious effect on hepatic encephalopathy, nutritional status, and clinical outcome in these patients and must be avoided. The administration of branched-chain amino acids stimulates hepatic protein synthesis, reduces postinjury catabolism and therefore improves nutritional status. Conflicting results in various different trials, however, exist, and this issue remains unclear.

Treatment of severe malnutrition in children: experience in implementing the World Health Organization guidelines in Turbo, Colombia.

OBJECTIVE: To evaluate the implementation of the World Health Organization guidelines for the treatment of children with severe acute malnutrition in a class I hospital. PATIENTS AND METHODS: Descriptive and prospective study of 335 children under the age of 6, admitted between 2001 and 2005 for severe acute malnutrition (83%) and moderate acute malnutrition associated with illness (17%). The care of the children was provided by clinicians and medical staff trained under World Health Organization guidelines. RESULTS: Kwashiorkor was a common result in children with severe acute malnutrition (60.8%); 58% were younger than 1 year old. Complications upon admission were diarrhea (68.4%) and anemia (51.1%), and the most common complication during hospital stay was sepsis (9%). Overall, 61.7% attained -1 standard deviation of weight for height after an average stay of 3 weeks in the hospital; 5.1% were sent to tertiary care hospitals. Overall, mortality during the 5 years was 5.7%, with sepsis the most common cause. In the first year, the mortality rate was 8.7%; it decreased to 4.0% in the last year. The mortality rate was significantly higher in children with edema. Children with moderate acute malnutrition had similar complications and mortality when compared with children with severe acute malnutrition (5.3%). CONCLUSIONS: Once the World Health Organization guidelines were implemented, low mortality rates were achieved in children with severe acute malnutrition in class I hospitals.

Impacto obtenido sobre la morbilidad infantil suplementando vitamina A, hierro y cinc a niños <5 años de edad residentes en una zona de alta pobreza: caso: Relleno Sanitario Sector Walter Marquez / The impact obtained about infantile morbidity supplement with vitamin A, iron and zinc to children <5 years old that live in poverty places

La ciencia y la tecnología nunca resolverán todos los problemas suscitados por la insuficiencia de alimentos y la falta de servicios de salud y saneamiento, propiciantes de la desnutrición infantil. Pero los éxitos de los adelantos científicos y los conocimientos obtenidos, han dado pie a nuevas esperanzas de lograr vidas más saludables y productivas, tanto para los niños como para los adultos. Parte de estos conocimientos, como el fortalecimiento del sistema de inmunidad gracias a los efectos de la vitamina A, están bien establecidos. Con el objetivo de demostrar que la suplementación de micro nutrientes a niños en situaciones de pobreza puede propiciar una reducción en la aparición de enfermedades infecciosas más frecuentes, se diseñó un estudio experimental de campo, descriptivo y longitudinal, sobre una población integrada por niños de educación inicial ubicados en el Barrio “Hugo Rafael Chávez” del Sector Walter Márquez de San Josecito, Municipio Torbes. Luego de visitas de inducción, capacitación y censo de morbilidad, se procedió a desparasitar con albendazol y a suministrar dosis pediátricas de vitamina A en capsulas blandas 3 días, sulfato de cinc en tabletas 15 días y sulfato ferroso en jarabe 3 meses, para cumplir un plan de seguimiento mensual durante tres meses. Se incorporan 25 niños y niñas, de los cuales el 50 por ciento de los menores de 2 años de edad tenían algún grado de desnutrición aguda. Mientras que el 36 por ciento de los mayores de dos años tenían desnutrición crónica. De las enfermedades conseguidas, las del aparato respiratorio fueron las más frecuentes, seguidas por las intestinales. Dentro de las respiratorias, las gripes, rinitis y catarro fueron el 81,3 por ciento. Las diarreas fueron el 57,8 por ciento de las digestivas. Las piodermitis fueron el 50 por ciento de las infecciones de piel. Finalmente, la caries dental como enfermedad infecciosa bucal, fue el 55,8 por ciento de otras enfermedades.

Childhood malnutrition is associated with a reduction in the total melanin content of scalp hair.

Childhood malnutrition is known to be associated with visible lightening of hair colour (hypochromotrichia). Nevertheless, no systematic investigations have been carried out to determine the biochemical basis of this change. We used an HPLC method to measure melanins in the scalp hair of thirteen Jamaican children, diagnosed as having primary malnutrition, during various stages of their treatment and after recovery. During treatment for malnutrition, a progressive decrease in total melanin content along the hair shaft from tip to root (root:tip ratio: 0.62 (sd 0.31)) was observed. This ratio was significantly different (P = 0.003) from the ratio observed among children sampled several months after discharge from hospital (0.93 (sd 0.23)) and among normal control children (0.97 (sd 0.12)). Thus, it appears that a decrease in melanin content is associated with periods of malnutrition. The low root:tip ratio during malnutrition presumably arises because the tips reflect prior hair growth during 'normal' nutrition and the roots reflect hair growth during malnutrition; a return of the root:tip ratio to that seen among controls reflects 'recovery' from malnutrition. It is possible that reduced intake or availability of tyrosine, a key substrate in melanin synthesis, may play a role in the reduction of hair melanin content during periods of malnutrition. The precise mechanisms by which melanin content is reduced, and the role of aromatic amino acid availability in hair colour change and other features of childhood malnutrition remain to be explored.