Nutrition education in medical schools (NEMS) project: Joining ESPEN and university point of view.

BACKGROUND & AIMS: Nutrition education is not well represented in the medical curriculum. The aim of this original paper was to describe the Nutrition Education in Medical Schools (NEMS) Project of the European Society for Clinical Nutrition and Metabolism (ESPEN). METHODS: On 19 January 2020, a meeting was held on this topic that was attended by 51 delegates (27 council members) from 34 countries, and 13 European University representatives. RESULTS: This article includes the contents of the meeting that concluded with the signing of the Manifesto for the Implementation of Nutrition Education in the Undergraduate Medical Curriculum. CONCLUSION: The meeting represented a significant step forward, moved towards implementation of nutrition education in medical education in general and in clinical practice in particular, in compliance with the aims of the ESPEN Nutrition Education Study Group (NESG).

Assessment of drug administration via feeding tube and the knowledge of health-care professionals in a university hospital.

BACKGROUND/OBJECTIVES: The use of drugs via feeding tube is problematic. Appropriate techniques must be used during the administration to prevent obstruction of a feeding tube, to avoid inadequate drug effects and to minimize the risk of toxicity of the given pharmaceuticals. SUBJECTS/METHODS: In this study, medications of all the patients in a University Hospital with 1100 beds were monitored to identify the appropriateness of administration. The study was performed on 5 days each in 5 consecutive weeks to observe the current practice. After evaluation of practice, a questionnaire was given to doctors, nurses and pharmacists to determine the health-care professionals' attitudes on drug administration through a feeding tube. RESULTS: A total of 225 drugs (out of 13 935) were administered via feeding tube during the study period and 40.5% (n=91) were not administered in appropriate dosage forms. Only 86% of the doctors and 98% of the nurses stated that they pay attention to the suitability of drugs when they prescribe or administer drugs via feeding tube. Only 58% of pharmacists, 17% of nurses and 24% of doctors were aware of the fact that enteric-coated tablets should not be crushed owing to the risk of tube occlusion and lack of efficacy when they are administered via feeding tube. CONCLUSIONS: This study demonstrated the discordance between the theoretical knowledge and the practical performance of the health-care professionals in drug administration. In patients with feeding tubes, assessment of drug dosage forms by a pharmacist would be beneficial for appropriate administration and to prevent drug interactions.

Co-existence of Echinococcus granulosus infection and cancer metastasis in the liver correlates with reduced Th1 immune responses.

A possible relationship between cancer and Echinococcus granulosus infection has been postulated. As T cells are critical players in immune responses against both infections and malignancies, in an experimental model of secondary echinococcosis and breast cancer, this study aims to observe the progression of cancer and to determine the characters of T-cell responses. 4T1 breast tumour cells were subcutaneously injected into mammary region, whereas protoscoleces were intraperitoneally inoculated into the mice. Hydatid cysts, tumours and metastases were determined with macroscopic and histopathological evaluation. T cells found in spleen, liver and tumour were characterised by flow cytometric analysis of CD3, CD4, CD8, CD25, CCR5, CCR3, IL-4 and IFN-γ. In the mice inoculated both with protoscoleces and with breast tumour cells, increased frequency of cancer metastasis was observed in the liver. The amount of CD4(+) T cells was increased in the liver and in the spleen of mice infected with E. granulosus. However, co-existence of echinococcosis and metastatic lesions in the liver was associated with significant reduction in the IFN-γ(+) and CCR5(+) Th1 cells and increase in the CD25(+) T cells. Our results may indicate an immunological link between cystic echinococcosis and cancer that allows tumour metastasis to flourish in the liver.

Is surgical treatment of liver hemangiomas effective for pain relief?

BACKGROUND: Traditional treatment for liver hemangiomas is surgery. Currently, it is controversial whether hemangioma surgeries are sufficiently beneficial for the patients. In this study, we evaluated the effectiveness of surgery in patients with liver hemangiomas. METHODS: Forty-two patients who underwent surgical operations for hepatic hemangiomas were retrospectively evaluated and interviewed. RESULTS: Study population included 36 female and 6 male patients whose ages ranged between 26 and 65 years (mean age, 47.8 +-8.7 years). Their mean duration of hospitalization was 6 days (range, 3 - 59 days). The median time since surgery was 50 months (range 0-120 months). There was a statistically significant decrease in numerical rating and adjective rating pain scale scores (p 0.05). Postoperatively, pain did not cease in 10 patients (peptic ulcers requiring medical treatment in four patients, cholelithiasis in four patients, and nephrolithiasis in two patients). CONCLUSION: Patients with cavernous hemangiomas of the liver who require surgical treatment have significant benefits in terms of pain relief following surgery. The lack of pain relief after the surgery in some patients may be related to concomitant medical problems other than the hemangioma.

Malnutrition in Turkish nursing homes: a correlate of short term mortality.

OBJECTIVE: Elderly nursing home residents are under high risk of malnutrition. Early interventions to prevent malnutrition may play a critical role in malnutrition-mortality correlation. This study aimed to obtain insight into the prevalence of malnutrition in nursing homes in the capital city of Turkey and the role of malnutrition in predicting the risk for short-term mortality. DESIGN: This study was conducted in seven different residential care facilities in Ankara. MEASUREMENTS: Nutritional status was evaluated by Mini Nutritional Assessment-Short Form. RESULTS: The mean age of the 534 participants was 79.46±7.22 years. Nutritional assessment revealed that 15.9% of all older adults suffered from malnutrition and another 53.6% were at risk of malnutrition. The mortality rate for all subjects was 118 (22.1%) over 18 months, which was significantly higher in participants with malnutrition. CONCLUSIONS: We noted a high prevalence of malnutrition and a strong correlation of increased mortality with malnutrition in nursing home residents. Given the negative impact of malnutrition on mortality and morbidity, an emphasis should be placed on an effective nutritional policy in nursing homes.

The postoperative analgesic efficacy of intraperitoneal tramadol compared to normal saline or intravenous tramadol in laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVE: The aim of this study was to compare the postoperative analgesic efficacy of intraperitoneal tramadol with intravenous tramadol or normal saline in patients undergoing laparoscopic cholecystectomy. METHODS: Sixty-one patients undergoing laparoscopic cholecystectomy were randomized to one of three groups in a double-blind manner via coded syringes. All patients received an intravenous and an intraperitoneal injection after installation of the pneumoperitoneum and again before removal of the trocars. In the control group, all injections were with normal saline. In the intravenous tramadol group, patients received intravenous tramadol 100 mg and intraperitoneal saline. In the intraperitoneal tramadol group, patients received intravenous saline and intraperitoneal tramadol 100 mg. All patients had a standard anaesthetic. Postoperative analgesia was with morphine. Postoperatively, numeric pain scores for parietal and visceral pain, 1 h and 24 h morphine consumption, and adverse effects were recorded. RESULTS: Parietal and visceral pain scores were lowest in the intravenous tramadol group during the first postoperative hour (P < 0.016 compared with control). The delay until the first analgesic administration was longest in the intravenous tramadol group (median 23 min, range 1-45), when compared with the intraperitoneal tramadol group (10, 1-120 min, P = 0.263) or with the control group (1, 1-30 min, P = 0.015). One-hour morphine consumption was significantly lower in the intravenous tramadol group (mean +/- SD; 3.4 mg +/- 2.5) and in the intraperitoneal tramadol group (4.4 +/- 4.3 mg) compared with the control group (6 +/- 2 mg) (P = 0.044). There was no difference between the three groups regarding pain scores, morphine consumption and incidence of shoulder pain or adverse effects at 24 h. CONCLUSION: Intravenous tramadol provides superior postoperative analgesia in the early postoperative period after laparoscopic cholecystectomy compared with an equivalent dose of tramadol administered intraperitoneally and with normal saline in patients undergoing laparoscopic cholecystectomy.

Renal safety and extrahepatic defluorination of sevoflurane in hepatic transplantations.

BACKGROUND: The main metabolic pathway for defluorination of sevoflurane in the liver produces inorganic fluoride (Fl). The metabolism and effect of sevoflurane on the kidney is not clear during anhepatic phase in liver transplantation. The goal of the present study was to investigate the metabolism and renal effect of sevoflurane by measuring plasma and urine inorganic fluoride, urinary N-acetyl-glucosaminidase (NAG), and plasma creatinine levels in patients undergoing liver transplantations. METHODS: After institutional approval and informed consent, we studied nine cases of orthotopic liver transplantation after anesthesia was induced with 5 mg . kg(-1) thiopental, 1 mug . kg(-1) fentanyl intravenously, the trachea was intubated after vecuronium bromide 0.1 mg . kg(-1). Anesthesia was maintained with sevoflurane (2%), O(2), and N(2)O at a total gas flow of 6 L . min(-1) using a semiclosed circle system with a sodalime canister. Blood and urine samples were obtained to measure plasma and urine fluoride concentrations and urinary NAG excretions before induction (P0), hourly during resection (P1, P2, P3), every 15 minutes during anhepatic phase (A1, A2, A3), hourly after reperfusion (neohepatic phase) (N1, N2, N3), and postoperative first hour (Po1). Preoperative (T0) and postoperative day 1 (T1), 3 (T3), 7 (T7) plasma blood urea nitrogen (BUN) and creatinine (Cr) levels were also recorded. RESULTS: Mean duration of surgery was 9:06 +/- 0:09 hours. Mean inorganic fluoride concentrations in plasma were in the range of 0.71 +/- 0.30 to 28.73 +/- 3.31 mumole . L(-1). In P3, N1, N2, N3, increases in plasma inorganic fluoride concentrations were significant (P < .05) and reached a peak value at Po1. The mean urine inorganic fluoride concentrations were 12.49 +/- 2.04 to 256.7 +/- 49.62 mumole . L(-1). In A2, A3, N1, N2, and N3, mean urine inorganic fluoride concentrations were significantly increased (P < .05) and the peak value was observed at Po1. Mean NAG concentrations in urine varied (5.6 +/- 1.6 IU . L(-1) to 12.5 +/- 1.14 IU . L(-1)) and peak level was observed at 30 minutes of the anhepatic phase (A2), which did not exceed the normal values for urine NAG levels (1.5 to 6.1 U . L(-1)). No impairment was observed in serum BUN and creatinine levels at any time. While there was only a slight increase in NAG during anhepatic phase, there was no change in plasma F1. CONCLUSIONS: Sevoflurane seemed to have minimal effect on kidney functions of BUN and Cr levels during liver transplantation. Although urine F1 and NAG levels increased during the anhepatic phase plasma F1, BUN, and Cr levels did not, suggesting that renal F1 production may occur in the absence of hepatic function. The renal effect of sevoflurane in chronic liver disease is controversial and must be investigated in further studies.

Diarrhea in neutropenic patients: a prospective cohort study with emphasis on neutropenic enterocolitis.

BACKGROUND: Although diarrhea is a frequent complication in neutropenic patients, its true incidence, risk factors and clinical course have not been investigated prospectively. PATIENTS AND METHODS: The study was carried out at Hacettepe University Hospital for Adults and involved patients over 16 years of age. Patients with malignant diseases who were neutropenic on admission or who became neutropenic during their stay in the wards between January 2001 and February 2003 were included. They were monitored daily until discharge, exitus, or recovery from neutropenia-whichever occurred earlier-to monitor the presence of diarrhea and other infections. RESULTS: A total of 317 neutropenic episodes in 215 patients were followed. Diarrhea was observed in 18.6% episodes, and the incidence of NEC was 3.5%. The etiology in 27% episodes of diarrhea could not be identified. The use of anthracyclines and mitoxantrone increased the incidence of diarrhea. Prior use of penicillin derivatives plus beta-lactam inhibitors and N-imidazoline derivatives was associated with decreased incidence of diarrhea. CONCLUSIONS: Diarrhea is a common complication in neutropenic patients. Not only specific conditions like NEC, but also nonspecific diseases like parasitosis may be the cause of diarrhea in this patient population.

Surgical technique for closure of difficult abdomen.

Abdominal dehiscence reported to occur with a frequency of one per cent even under the best circumstances, is a dreaded complication. Closure of the dehisced abdominal wall under adverse conditions like local infection and wound edge retraction may be difficult. We describe a new technique which is a modification of classical retention sutures for the abdominal wall closure.

Parenchymal transection with ultrasonic scalpel in liver resection.

BACKGROUND: There is no ideal tool for parenchymal transection in liver resection and bleeding is still a major complication. The purpose of this study was to evaluate the usefulness of an ultrasonic scalpel and to describe our clinical experience in open liver resection. METHODS: An ultrasonic scalpel was used in seven consecutive patients undergoing liver resection. During parenchymal transection coagulation shears were used with the power level set at 2 or 3, and the blunt blades were selected. RESULTS: In each case, bleeding from the liver parenchyma was trivial, but haemostasis of large vessels required suture ligation. Postoperatively none of the patients experienced local technical complications such as haematoma, bile leak or infection. DISCUSSION: Although complete haemostasis of large vessels cannot be achieved, the ultrasonic scalpel may be used for parenchymal transection in liver resection to reduce blood loss. Larger series of patients are needed before a definitive statement regarding the efficacy of this method can be made.

Penetration of topical fluconazole into human aqueous humor.

The purpose of this study was to determine the aqueous levels and pharmacokinetics of topical fluconazole 0.2% upon single and multiple drop applications. Forty-nine patients undergoing cataract surgery were given topical fluconazole 0.2%. They either received single drop or a loading dose of 1 drop per 5 min for 20 min. Aqueous samples were obtained during surgery 5, 15, 30, 45 and 60 min after the last drop. The samples were analysed by high-pressure liquid chromatography to determine aqueous concentrations. After single and loading dose applications peak aqueous levels were achieved at 15 min (3.35 +/- 0.64 and 7.13 +/- 0.79 microg ml(-1), respectively). Both had a steady decrease in concentration at 30, 45 and 60 min down to 4.06 +/- 0.37 microg ml(-1)with loading dose and undetectable levels with single dose application. Comparing the concentrations with the minimum inhibitory concentrations (MIC) of yeasts determined by the National Committee for Clinical Laboratory Standards showed that concentrations achieved with single dose applications were higher than MICs of Candida albicans and Candida parapsilosis and concentrations achieved after loading dose applications were higher than MICs of C. parapsilosis, C. albicans and Candida tropicalis. We concluded that topical fluconazole 0.2% penetrates into the aqueous humor in concentrations that satisfy MICs of most of the Candida strains. It can be a good alternative to Amphotericin B for treatment of Candida keratitis.

Risk factors for vitreous loss in cataract surgery.

PURPOSE: To evaluate the risk factors for posterior capsule rupture with or without vitreous loss (PCR +/- VL) in extracapsular cataract extraction (ECCE). METHODS: The charts of 2794 consecutive patients who had ECCE with or without intraocular lens implantation between January 1992 and December 1997 were reviewed retrospectively. Probable risk factors included age, sex, operated eye (right or left), presence of diabetes mellitus, systemic hypertension, history of vitreous loss in the other eye (if operated), type of cataract, axial length of the eye, preoperative visual acuity, glaucoma, presence of pseudoexfoliation, preoperative shallow anterior chamber and experience of surgeon (resident, general ophthalmologist, cataract surgeon). We compared 192 patients who had PCR +/- VL with complete data and 275 randomly selected patients who had no complications, using multiple logistic regression analysis. RESULTS: Two hundred and fifty-four patients (9.09%) had PCR and 197 (7.05%) had PCR + VL. The surgeon's experience (p < 0.0005), glaucoma (p < 0.005), type of cataract (p < 0.005), presence of pseudoexfoliation (p < 0.05) and systemic hypertension (p < 0.05) were significant risk factors. CONCLUSIONS: Patients with risk factors such as glaucoma, pseudoexfoliation, traumatic cataract and systemic hypertension should be operated by experienced surgeons.

Regenerative capacities of normal and cirrhotic livers following 70% hepatectomy in rats and the effect of alpha-tocopherol on cirrhotic regeneration.

BACKGROUND: The regeneration of normal and cirrhotic liver has been very well demonstrated after partial hepatectomy; although the tissue regenerated by cirrhotic liver is also cirrhotic. The structural differences of the regenerated tissues between normal and cirrhotic livers may also indicate different regeneration capacities. The objective of this study was to compare the regeneration capacities of normal and cirrhotic livers by bromodeoxyuridine (BrdU) incorporation and proliferating cell nuclear antigen (PCNA) labeling indices in replicating nuclei and mitotic figures in cells in partially hepatectomized normal and cirrhotic rats and to study the effect of alpha-tocopherol on cirrhotic liver regeneration. METHODS: Five groups of adult Wistar rats comprised normal livers, cirrhotic livers, regenerated normal livers, regenerated cirrhotic livers, and alpha-tocopherol-treated regenerated cirrhotic livers. Cirrhosis was induced by intragastric administration of carbon tetrachloride and phenobarbital in the drinking water of the rats. Liver regeneration capacities in normal and cirrhotic rats and following partial hepatectomy in normal and cirrhotic rats and cirrhotic rats that were administered alpha-tocopherol were evaluated through BrdU incorporation, PCNA labeling, and mitotic indices. RESULTS: BrdU and PCNA labeling and mitotic indices were zero for normal rats and 4.3 +/- 3.5, 6.5 +/- 5, and 2.5 +/- 1.5 for cirrhotic rats, respectively. The values after partial hepatectomy in normal and cirrhotic rats were 46.2 +/- 8.7 and 27.8 +/- 7.5 for BrdU labeling, 83.7 +/- 6.5 and 51.3 +/- 6.8 for PCNA labeling, and 31.8 +/- 4.2 and 18.6 +/- 3.4 for mitotic index, respectively. For the fifth group comprising cirrhotic rats that were administered alpha-tocopherol and had undergone partial hepatectomy, BrdU incorporation, PCNA labeling, and mitotic indices were 37.5 +/- 6.3, 76.5 +/- 6.2, and 27.2 +/- 4.2, respectively. When the cirrhotic liver regeneration group was compared with the normal liver regeneration group, rates of liver regeneration in the cirrhotic group were significantly depressed (P < 0.01). Although the BrdU incorporation and PCNA labeling indices of the alpha-tocopherol-administered cirrhotic liver regeneration group indicated significantly lower rates of liver regeneration when compared with the normal liver regeneration group (P < 0.05), the liver regeneration rates of the alpha-tocopherol-administered cirrhotic group were also significantly higher than those of the cirrhotic liver regeneration group that was not administered alpha-tocopherol (P < 0.01). CONCLUSIONS: Cirrhotic livers revealed a significantly depressed capacity for regeneration following partial hepatectomy. alpha-Tocopherol administration seemed to improve the rates of regeneration in cirrhotic rats with respect to the BrdU incorporation, PCNA labeling, and mitotic indices.

Reliability of intraocular pressure measurements after myopic excimer photorefractive keratectomy.

OBJECTIVE: To determine the reliability of intraocular pressure (IOP) measurements by Goldmann applanation tonometry and pneumotonometry in eyes treated with excimer myopic photorefractive keratectomy (PRK). DESIGN: A prospective case series. PARTICIPANTS: Forty consecutive eyes treated with PRK were evaluated. INTERVENTION AND MAIN OUTCOME MEASURES: Central and peripheral corneal Goldmann tonometry and pneumotonometry measurements were done before surgery, at 1 week, and at 1 and 3 months after surgery. RESULTS: The IOP by Goldmann tonometry from the central cornea was significantly lower than the peripheral IOP; however, there was no difference between IOP measured from central and peripheral corneas by pneumotonometry, which, in turn, correlated with peripheral Goldmann measurements. There was a trend, but not a statistically significant correlation, between the spherical equivalent of the treatment and the amount of decrease in central Goldmann IOP. CONCLUSIONS: Pneumotonometry measures the IOP reliably after PRK from all parts of the cornea, whereas central Goldmann tonometry underestimates the IOP by 2.40+/-1.23 mmHg.

Recurrent primary sclerosing cholangitis after orthotopic liver transplantation: is chronic rejection part of the disease process?

BACKGROUND: The possibility of primary sclerosing cholangitis (PSC) recurrence after liver transplantation has been debated. The aim of this study is to examine whether recurrent PSC and chronic rejection (CR) are different expressions of the same disease process. METHODS: One hundred consecutive patients receiving 118 grafts for the diagnosis of PSC were reviewed and placed into three groups: group A, recurrent disease, as evidenced by cholangiographic and pathologic findings with radiographic arterial flow to the liver (n=18; 15.7%); group B, those who developed CR (n=15; 13.0%); and group C, all others (n=82; 71.3%). Cholangiograms and histopathologic specimens were examined in a blinded fashion. RESULTS: Demographic factors were similar, except for age, with a significantly younger age and more episodes of rejection in groups A and B (P<0.03). Group A had a higher incidence of cytomegalovirus hepatitis (P=0.008). Five-year graft survivals for A, B, and C were 64.6%, 33.3%, and 76.1%, respectively (P=0.0001), 5-year patient survivals were 76.2%, 66.7%, and 89.1%, respectively (P=0.0001), and repeat transplantation rates were 27.8%, 46.7%, and 8.5%, respectively (P=0.005). Radiographically, 90% of cholangiograms in patients with recurrent disease showed at least multiple intrahepatic strictures. Histopathologically, patients with recurrent disease and CR shared many features. CONCLUSIONS: We have described a high incidence of recurrent PSC and CR in patients who received transplants for PSC. Histopathologic analysis suggests that CR and recurrent PSC could represent a spectrum of indistinguishable disease. However, the distinct difference in clinical outcome, as evidenced by an increased repeat transplantation rate and lower graft and patient survival in the CR group, clearly suggests that they are two distinct entities that require very different treatment strategies.

Does intraoperative hepatic artery flow predict arterial complications after liver transplantation?

BACKGROUND: Little is known about the value of intraoperative hepatic artery (HA) flow measurement on the development of HA complications in orthotopic liver transplantation (OLT). We undertook this study to see whether assessing HA flow at the OLT helps predict posttransplant HA complications (HA thrombosis or stenosis). METHODS: Four hundred and eleven consecutive OLT in 367 adult patients who received grafts between November 1992 and August 1995 were reviewed. Of these, 259 grafts in 255 patients with at least 1 year of follow-up and with complete data were studied. HA flow, portal vein flow, percentage of cardiac index going to HA (HA/CI), HA flow per 100 g of liver tissue, mean arterial pressure, central venous pressure, and CI were analyzed. Preservation injury was assessed by posttransplant alanine aminotransferase and aspartate aminotransferase levels. RESULTS: Thirty-four patients with 35 grafts developed HA thrombosis or stenosis during a median follow-up time of 29 months. HA complications occurring within the first 100 days of OLT were classified as early complications. HA flow at the time of surgery and percentage of CI going to the liver were found to be significant variables in early HA complications. Hepatic hemodynamics were not different in the late HA complication group compared to the control. Systemic hemodynamics and posttransplant alanine amino-transferase and aspartate aminotransferase levels were similar in all three groups. Logistic regression analysis showed that patients with HA flows less than 400 ml/min were more than 5 times as likely to develop HA complications (risk ratio 5.1). CONCLUSIONS: HA flow measurement should be obtained at the time of OLT and may help to predict early but not late posttransplant HA complications. Patients with HA flows less than 400 ml/min or HA/CI values of less than 7% may carry a higher risk for HA stenosis or thrombosis and may need close surveillance to detect such problems.