Cumplimiento de los objetivos nutricionales durante el uso de Dispositivos de Asistencia Ventricular

Antecedentes: Los dispositivos de asistencia ventricular (VAD, sigla en inglés) se utilizan cada vez más para el manejo de la insuficiencia cardíaca descompensada en unidades de cuidados intensivos. El manejo nutricional es fundamental para la evolución clínica de estos pacientes. Objetivos: El objetivo fue evaluar en cuánto tiempo se puede alcanzar las necesidades nutricionales, utilizando distintas modalidades de apoyo nutricional, en pacientes que requirieron asistencia con VAD por insuficiencia cardíaca aguda en una clínica privada del país. Métodos: En una clínica privada se efectuó un estudio observacional retrospectivo analizando los datos clínicos relacionados al aporte nutricional de 12 pacientes que requirieron asistencia con VAD. Las vías de aporte nutricional evaluadas fueron la nutrición enteral (NE) y/o nutrición parenteral (NP). Se midió el tiempo de implementación del apoyo nutricional y su efecto se estimó por una valoración nutricional subjetiva y por la medición de indicadores de laboratorio. Además, se vigilaron las complicaciones asociadas al aporte nutricional. Resultados: El estudio incluyó a 12 pacientes. Los objetivos nutricionales se alcanzaron por completo en el 91% de los pacientes (n=11) en 3,7 ± 1 días después de iniciado el apoyo nutricional. En ese momento, 5 pacientes recibían NE exclusiva, 4 pacientes NP complementaria a la NE, 1 paciente NE complementaria a la alimentación oral y 1 paciente con vía oral. Al momento de alcanzar los requerimientos nutricionales ningún paciente tenía NP exclusiva. Conclusión: Concluimos que el apoyo nutricional precoz es factible y seguro en pacientes con VAD. Alcanzar los objetivos nutricionales es posible sin efectos adversos graves. Se necesitan estudios futuros para determinar el beneficio a largo plazo del apoyo nutricional agresivo para pacientes en estado crítico que requieren apoyo hemodinámico.

Background: Ventricular assist devices (VAD) are being used more frequently in patients with severe heart failure. Nutritional support is a critical factor for the outcome in these patients. Aim: to evaluate the time required and mode of nutritional support in patients with severe cardiac dysfunction being treated with VAD. Methods: 12 patients with VAD being treated in an intensive care unit were evaluated to determine the time and mode of support required to achieve adequate nutrition. Enteral and / or parenteral modes of nutritional support were used. The outcomes were evaluated by subjective appreciation, weight measurement and serum levels of albumin, pre-albumin and vitamin D. Results: Adequate nutritional support was achieved in 91% of patients a mean of 3 days after beginning of treatment (SD 1 day). At that time 5 patients were receiving only enteral nutrition, 4 patients enteral and parenteral nutrition, 1 patient enteral nutrition in addition to oral nutrition and 1 patients was receiving only oral nutrition. No patient was receiving only parenteral nutrition. Conclusion: early nutritional support is posible and safe in patients with an VAD. Further studies are needed to evaluate long term benefits of this strategy of nutritional support.

Nutritional implications for the patient undergoing extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) for cardiovascular collapse or catastrophic respiratory failure in the critically ill patient imposes a multidisciplinary approach. Nutritional support is one of the issues that must be faced, as this population presents a state of increased metabolic activity, elevated catabolism of protein and rapid accumulating energy deficiency. Provision of adequate nutritional therapy is hard to achieve due to different factors. This article provides a brief overview of the current literature regarding nutritional support during ECMO in adult patients, as no current guidelines address this issue.

La oxigenación por membrana extracorpórea (OMEC) en casos de colapso cardiovascular o falla respiratoria catastrófica en pacientes críticos impone un planteamiento multidisciplinar. El soporte nutricional es uno de los problemas a afrontar, ya que esta población presenta un estado de actividad metabólica aumentada, un elevado catabolismo proteico, y una deficiencia de energía de rápida acumulación. Es difícil conseguir una provisión de terapia nutricional adecuada debido a distintos factores. Este artículo ofrece una breve presentación de la bibliografía actual relativa al soporte nutricional durante la OMEC en pacientes adultos, ya que actualmente no contamos con directrices que aborden este tema.

[New lipid lowering agents]. / Nuevos fármacos para el tratamiento de la hipercolesterolemia.

Statins are the preferred treatment for hypercholesterolemia and several studies have demonstrated their long-term safety and efficacy in reducing cardiovascular morbidity and mortality. However, in some cases of severe hypercholesterolemia such as homozygous and heterozygous familial hypercholesterolemia or statin intolerant patients, statins can be less efficient. In recent years, new lipid-lowering agents with novel mechanisms of action have been developed to reduce LDL-cholesterol in patients with severe hypercholesterolemia, associated or not to conventional lipid-lowering therapy. These therapies include microsomal transfer protein inhibitor (Lomitapide), antisense oligonucleotide to Apo B100 (Mipomersen) and monoclonal antibodies against Proprotein convertase subtilisin/kexin type 9 (PCSK9). Different studies have shown the great effectiveness of these new therapies. Short-term studies confirmed their adequate security profile, especially in patients with homozygous familiar hypercholesterolemia or severe hypercholesterolemia. Some of these agents have been also tested in statin-intolerant patients. However, long-term studies are needed to evaluate their safety, effectiveness and impact on cardiovascular risk reduction.

Nuevos fármacos para el tratamiento de la hipercolesterolemia / New lipid lowering agents

Statins are the preferred treatment for hypercholesterolemia and several studies have demonstrated their long-term safety and efficacy in reducing cardiovascular morbidity and mortality. However, in some cases of severe hypercholesterolemia such as homozygous and heterozygous familial hypercholesterolemia or statin intolerant patients, statins can be less efficient. In recent years, new lipid-lowering agents with novel mechanisms of action have been developed to reduce LDL-cholesterol in patients with severe hypercholesterolemia, associated or not to conventional lipid-lowering therapy. These therapies include microsomal transfer protein inhibitor (Lomitapide), antisense oligonucleotide to Apo B100 (Mipomersen) and monoclonal antibodies against Proprotein convertase subtilisin/kexin type 9 (PCSK9). Different studies have shown the great effectiveness of these new therapies. Short-term studies confirmed their adequate security profile, especially in patients with homozygous familiar hypercholesterolemia or severe hypercholesterolemia. Some of these agents have been also tested in statin-intolerant patients. However, long-term studies are needed to evaluate their safety, effectiveness and impact on cardiovascular risk reduction.

[Micronutrient deficiencies one year after sleeve gastrectomy]. / Déficit de micronutrientes a más de un año postoperatorio de gastrectomía en manga.

INTRODUCTION: Obesity is one of the largest problems in public health worldwide today. For patients with severe obesity and associated comorbidities, surgical treatment is recommended. OBJECTIVE: To analyze the frequency of micronutrient deficiencies and food intake at least 12 months after sleeve gastrectomy (SG). MATERIALS AND METHODS: This is a cross sectional study carried out between October and December 2009 with measure of serum levels of vitamin B12, vitamin D, folate, calcium, ferritin, zinc, parathyroid hormone and bone mineral density on patients underwent SG at least 12 months before the study. A food intake questionnaire was also performed. For the statistical analysis, the Pearson or Spearman tests was used. RESULTS: Forty patients were evaluated with a mean age of 40 ± 10 years and mean time post surgery of 26 ± 6 months. Mean plasma level of 25 OH-vitamin D was 20.9 ± 10.5 ng/ml. Forty-three percent had low levels of vitamin D (< 20 ng/ml), and 68% showed low levels of calcium (< 1,1 mmol/L) without secondary hyperparathyroidism. Anemia was present in 28% and iron deficiency occurred in 38% of these patients. Deficit of folic acid and vitamin B12 were observed in 13% of the patients. Average daily food intake was 1,256 kcal, 54% of total calories as carbohydrates, 26% as fat and 21% as protein. CONCLUSION: Iron, calcium and vitamin D are the most prevalent micronutrient deficiencies after SG. Long-term vitamin and mineral supplementation should be considered on every patient. Additional long-term studies are needed to establish specific supplementation recommendations after SG.

Déficit de micronutrientes a más de un año de postoperatorio en gastrectomía en manga / Micronutrient deficiencies one year after sleeve gastrectomy

Introducción: La obesidad es uno de los principales problemas de salud pública a nivel mundial. Para aquellos pacientes con obesidad severa asociada a comorbilidades, se recomienda el tratamiento quirúrgico. Objetivo: Analizar la frecuencia de déficit de micronutrientes e ingesta alimentaria en pacientes sometidos a gastrectomía en manga (GM) en un tiempo post operatorio del al menos 12 meses. Material y métodos: Se realizó un estudio transversal entre los meses de octubre y diciembre de 2009. Se estudió a pacientes que habían sido sometidos a GM al menos 12 atrás y se les midió niveles séricos de vitamina B 12, vitamina D, folato, calcio, ferritina, zinc, paratohormona y densidad mineral ósea. Además se aplicó un cuestionario de ingesta alimentaria. Se utilizó el test de Pearson o Spearman para el análisis estadístico. Resultados: Se evaluó un total de 40 pacientes con una edad promedio de 40 ± 10 años y un tiempo post operatorio de 26 ± 6 meses. El nivel promedio de vitamina D fue de 20.9 ± 10.5 ng/ml. El 43% presentó nivel bajo de vitamina D (< 20 ng/ml), un 68% presentó nivel disminuido de calcio (< 1,1 mmol/L) sin hiperparatoroidismo secundario. Se encontró anemia en un 28% y déficit de hierro en el 38% de la muestra. El déficit de ácido fólico y vitamina B12 se observó en un 13% de los pacientes. El consumo calórico promedio fue de 1.256 kcal/día, de las cuales un 54% correspondió a hidratos de carbono, un 26% a grasa y un 21% a proteínas. Conclusión: El déficit de hierro, calcio y vitamina D son los más prevalentes luego de la GM. La suplementación de vitaminas y minerales debiera ser considerada en todo paciente. Se requiere mayor estudio a largo plazo para establecer las recomendaciones específicas de suplementación luego de la GM (AU)

Introduction: Obesity is one of the largest problems in public health worldwide today. For patients with severe obesity and associated comorbidities, surgical treatment is recommended. Objective: To analyze the frequency of micronutrient deficiencies and food intake at least 12 months after sleeve gastrectomy (SG). Materials and methods: This is a cross sectional study carried out between October and December 2009 with measure of serum levels of vitamin B12, vitamin D, folate, calcium, ferritin, zinc, parathyroid hormone and bone mineral density on patients underwent SG at least 12 months before the study. A food intake questionnaire was also performed. For the statistical analysis, the Pearson or Spearman tests was used. Results: Forty patients were evaluated with a mean age of 40 ± 10 years and mean time post surgery of 26 ± 6 months. Mean plasma level of 25 OH-vitamin D was 20.9 ± 10.5 ng/ml. Forty-three percent had low levels of vitamin D (< 20 ng/ml), and 68% showed low levels of calcium (< 1,1 mmol/L) without secondary hyperparathyroidism. Anemia was present in 28% and iron deficiency occurred in 38% of these patients. Deficit of folic acid and vitamin B12 were observed in 13% of the patients. Average daily food intake was 1,256 kcal, 54% of total calories as carbohydrates, 26% as fat and 21% as protein. Conclusion: Iron, calcium and vitamin D are the most prevalent micronutrient deficiencies after SG. Long-term vitamin and mineral supplementation should be considered on every patient. Additional long-term studies are needed to establish specific supplementation recommendations after SG (AU)

Más allá del sodio: cambios en la dieta y su efecto en hipertensión / Beyond sodium: diet changes and their effect on hypertension

Resumen: La hipertensión arterial (HTA) es un importante factor de riesgo cardiovascular y su prevalencia aumenta con la edad, dado el aumento de la expectativa de vida de nuestra población esta condición constituye una prioridad a nivel de salud pública. Tanto para el tratamiento como para la prevención de la HTA son importantes las medidas no farmacológicas como cambios en el estilo de vida y especialmente la alimentación. Además de la restricción de sodio, existen otras medias dietéticas que han demostrado estar asociadas con un mejor control de la HTA en diversos ensayos clínicos, tales como la reducción del peso corporal, la dieta rica en frutas y verduras, el mayor consumo de potasio y magnesio, la vitamina D, los ácidos grasos ome-ga-3, los flavonoides y la disminución de la ingesta de sacarosa, fructosa, cafeína y alcohol. Dado la gran prevalencia de HTA en nuestro país del orden de un 26,9 por ciento, es importante dar a conocer medidas dietéticas que nos permitirán un mejor control de la presión en pacientes hipertensos y un retraso de la aparición de esta enfermedad en sujetos sanos, además de su incorporación en campañas de educación nutricional poblacional por parte de las autoridades sanitarias.

Hypertension is an important cardiovascular risk factor and its prevalence increases with age. Given the rising life expectancy in Chile, the prevention of hypertension is a priority for public health policies. Non pharmacological therapies, such as life style and diet changes are especially important. In addition to sodium restriction, several clinical studies have shown that other dietary interventions, such as an increased fruit and vegetable content of diet, higher intake of potassium and magnesium, vitamin D, omega-3 fatty acids, flavonoids, decreased intake of sucrose, fructose, caffeine and alcohol, lead to better control of hypertension. Given de high prevalence of hypertension in Chile (26.9 per cent overall) better information about the benefits of diet changes might be very important in order to help prevent and delay the appearance of hypertension. Appropriate public educational policies should be implemented by the sanitary authorities.

Linear IgA bullous dermatosis: report of five cases in Chile.

BACKGROUND: Linear IgA bullous dermatosis (LABD) is an acquired autoimmune sub-epidermal vesiculobullous disease characterized by continuous linear IgA deposit on the basement membrane zone, as visualized on direct immunofluorescence microscopy. LABD can affect both adults and children. The disease is very uncommon, with a still unknown incidence in the South American population. MATERIALS AND METHODS: All confirmed cases of LABD by histological and immunofluorescence in our hospital were studied. RESULTS: The confirmed cases were three females and two males, aged from 8 to 87 years. Precipitant events associated with LABD were drug consumption (non-steroid inflammatory agents in two cases) and ulcerative colitis (one case). Most of our patients were treated with dapsone, resulting in remission. DISCUSSION: Our series confirms the heterogeneous clinical features of this uncommon disease in concordance with a larger series of patients reported in the literature.

Periorbital syringoma treated with radiofrequency and carbon dioxide (CO2) laser in 5 patients.

Syringomas are common benign eccrine ductal adnexial tumors, commonly found in periorbital area. Periorbital syringomas are aesthetically disturbing difficult to treat. Many treatment modalities are described in the literature, including topical and surgical methods, with potential problems such as postinflammatory hyper- and hypopigmentation, low efficacy, or scar formation. We present 5 patients with syringoma treated with the combination of radiofrequency ablation and carbon dioxide (CO2) lasers. Using low-energy parameters on the CO2 laser, and low energy on the radiofrequency, we could complement both treatments maximizing the destruction of the tumors and minimizing the adverse effects in only two sessions. This is a relatively easy, safe, and less painful treatment, with good cosmetic results on periorbital syringomas.

Set-point theory and obesity.

Obesity is a consequence of the complex interplay between genetics and environment. Several studies have shown that body weight is maintained at a stable range, known as the "set-point," despite the variability in energy intake and expenditure. Additionally, it has been shown that the body is more efficient protecting against weight loss during caloric deprivation compared to conditions of weight gain with overfeeding, suggesting an adaptive role of protection during periods of low food intake. Emerging evidence on bariatric surgery outcomes, particularly gastric bypass, suggests a novel role of these surgical procedures in establishing a new set-point by alterations in body weight regulatory physiology, therefore resulting in sustainable weight loss results. Continuing research is necessary to elucidate the biological mechanisms responsible for this change, which may offer new options for the global burden of obesity.