XIII Lección Jesús Culebras. Los farmacéuticos de hospital y el soporte nutricional. De los inicios hasta nuestros días (1976-2018). / XIII Lesson Jesús Culebras. Hospital pharmacists and nutritional support. From the beginning to the present day (1976-2018)

Los farmacéuticos de hospitales fueron, desde los inicios en el decenio de los setenta del siglo pasado, miembros activos en las comisiones de soporte nutricional [nutrición parenteral (NP) y nutrición enteral (NE)] en nuestros hospitales, en el contexto principalmente de la preparación estéril de los componentes de NP. Esta presentación intenta explicar su papel en este recorrido de 42 años. Sin duda, un salto de calidad farmacéutica en la NP fue el paso de la preparación en frascos individuales al “todo en uno”, ya que con ello se disminuían las infecciones por catéter a causa de la menor manipulación. Esto llevó a realizar estudios físico-químicos de la estabilidad de la emulsión lipídica, ya que las partículas ≥ 5 micras producían obstrucción y acumulación lipídica en las arteriolas pulmonares. Esta emulsión del “todo en uno” estudiamos que enmascaraba una posible precipitación de los fosfatos inorgánicos con las sales de calcio, que podía causar unaembolia pulmonar microvascular. Finalmente, investigamos realizar un control microbiológico de nuestras preparaciones diarias. A mediados de los ochenta del siglo pasado se manifestó un incremento de las peticiones de NP. Para disminuir el trabajo del número de preparaciones, algunos hospitales alquilaron servicios de catering externos y otros racionalizaron las indicaciones, apoyándose con el “boom” de la nutrición enteral, con lo que algunas indicaciones de NP pasaron a ser de NE. Ocurren 3 acontecimientos en la década de los noventa del siglo pasado: el primero es que, frente al alud de preparaciones de NP, la industria farmacéutica irrumpe con una preparación de bolsas tricamerales. El segundo son los inicios de estudios de la desnutrición hospitalaria después de comprobar que la malnutrición incrementaba las complicaciones quirúrgicas y médicas. Por último, se publica la Orden de 2 de junio de 1987 para regular la nutrición enteral domiciliaria (NED). (AU)

Hospital pharmacists have been, since the 1970s, active members in nutritional support commissions [parenteral nutrition (PN) and enteral nutrition (EN)] in our hospitals, mainly in the context of sterile preparation of PN components. This presentation is an attempt to explain their role in this 42-year journey. Without any doubt, a quality leap in pharmaceutical quality regarding PN was the step from preparation in individual vials to “all-in-one” admixtures, thereby reducing catheter infections as a result of less handling. This entailed physical-chemical studies of stability of lipid emulsions since particles ≥ 5 microns produce obstruction and lipid accumulation in pulmonary arterioles. We studied the “all-in-one” emulsions that masked a possible precipitation of inorganic phosphates with calcium-phosphate salts, which could cause microvascular pulmonary embolism. Finally, we investigated how to carry out a microbiological control of our daily preparations. In the 1980s there was an increase in PN requests. In order to reduce preparation workload some hospitals rented external catering services whereas others rationalized the indications, supported by the enteral nutrition boom where some indications for PN changed to EN.Three events occurred in the 1990s. First, due to an increase in PN preparations, the pharmaceutical industry designed three-chamber bags. Second, studies on hospital malnutrition were launched after verifying that malnutrition increased surgical and medical complications. Finally, the Order of June 2, 1987 regulated home enteral nutrition (HEN). (AU)

Re-examining chemically defined liquid diets through the lens of the microbiome.

Trends in nutritional science are rapidly shifting as information regarding the value of eating unprocessed foods and its salutary effect on the human microbiome emerge. Unravelling the evolution and ecology by which humans have harboured a microbiome that participates in every facet of health and disease is daunting. Most strikingly, the host habitat has sought out naturally occurring foodstuff that can fulfil its own metabolic needs and also the needs of its microbiota, each of which remain inexorably connected to one another. With the introduction of modern medicine and complexities of critical care, came the assumption that the best way to feed a critically ill patient is by delivering fibre-free chemically defined sterile liquid foods (that is, total enteral nutrition). In this Perspective, we uncover the potential flaws in this assumption and discuss how emerging technology in microbiome sciences might inform the best method of feeding malnourished and critically ill patients.

From ischochymia to gastroparesis: proposed mechanisms and preferred management of dyspepsia over the centuries.

Dyspeptic symptoms are common with most patients suffering functional disorders that remain a therapeutic challenge for medical practitioners. Within the last three decades, gastric infection, altered motility, and hypersensitivity have gained and lost traction in explaining the development of functional dyspepsia. Considering these shifts, the aim of this review was to analyze changing understanding of and approaches to dyspepsia over a longer time period. Monographs, textbooks, and articles published during the last three centuries show that our understanding of normal gastric function has improved dramatically. With increased insight came new ideas about disease mechanisms, diagnostic options, and treatments. Despite shifts over time, the importance of functional abnormalities was recognized early on and explained in the context of societal influences and stressors, anxieties, and biological influences, thus resembling the contemporary biopsychosocial model of illness. Symptoms were often attributed to changes in secretion, motility, and sensation or perception with technological innovation often influencing proposed mechanisms and treatments. Many of the principles or even agents applied more than a century ago are still part of today's approach. This includes acid suppression, antiemetics, analgesics, and even non-pharmacologic therapies, such as gastric decompression or electrical stimulation of the stomach. This historical information does not only help us understand how we arrived at our current state of knowledge and standards of care, it also demonstrates that enthusiastic adoption of various competing explanatory models and the resulting treatments often did not survive the test of time. In view of the benign prognosis of dyspepsia, the data may function as a call for caution to avoid the potential harm of overly aggressive approaches or treatments with a high likelihood of adverse effects.

Aproximación al aporte nutricional de la dieta ordinaria urbana en Vitoria (Álava) en el tránsito del siglo XVIII al XIX a partir de las dietas hospitalarias / Aproximação para a contribuição nutricional da dieta normal urbana em Vitoria (Alava) no trânsito do século XVIII para o século XIX baseado nas dietas hospitalares / Approximation to the nutritional contribution of the ordinary urban diet in Vitoria (Alava) in the transit from the 18th century until 19th century based on the hospital diets

Partiendo de la consideración de que las dietas hospitalarias podrían asimilarse a un prototipo de dieta ordinaria de los menestrales urbanos en el tránsito del Antiguo Régimen a la contemporaneidad, se ha procedido a analizar cinco dietas hospitalarias en la ciudad de Vitoria para determinar si el aporte calórico y de macronutrientes podría suponer un factor de riesgo en la adquisición, curso y convalecencia de enfermedades infecciosas según la propuesta de Livi Bacci. Como conclusión general se ha obtenido que todas las dietas analizadas cubrían los requisitos calóricos mínimos si bien a expensas del consumo de pan, lo que convierte a este alimento en factor clave en la aparición del riesgo inmunológico por desnutrición. De manera secundaria, se ha obtenido un mayor consumo de carne de lo señalado por fuentes bibliográficas y se ha constatado la ausencia de la patata en la dieta ordinaria con anterioridad a 1826 (AU)

Given the fact that hospital diets could be similar to a prototype belonging to urban artisans’ ordinary diet lasting from the Ancient Regime to contemporaneity, five hospital diets have been analysed in the city of Vitoria (Spain) in order to determine if the caloric intake and the macronutrient intake could pose a risk factor in the acquisition, course and convalescence of infectious diseases according to the proposal of Livi Bacci. Conclusion the end result is all diets that were analysed caloric needs at the expense of consumption of bread, which makes this food a key factor in the appearance of an immunological risk caused by malnutrition. As a secondary effect, these has been an increase in the consumption of meat as compared to what bibliographic sources and the lack of potatoes in the ordinary diet prior to 1826 has been proved (AU)

Com base na consideração de que as dietas hospitalares poderia ser comparado a um protótipo da dieta do ordinário dos artesãos urbanos comuns no trânsito do Antigo Regime a contemporaneidade, foi analisar cinco dietas de hospital na cidade de Vitoria (Espanha) para determinar se a ingesta calórica e dos macronutrientes poderia representar um fator de risco na aquisição, curso e convalescença de doenças infecciosas de acordo com a proposta de Livi Bacci. Como uma conclusão geral foi obtido que todas as dietas analisadas cobertas as necessidades calóricas mínimas enquanto a expensas do consumo de pão, o que faz deste alimento um fator determinante no surgimento do risco imunológico de desnutrição. Secundariamente, foi obtido um maior consumo de carne do que foi dito por fontes bibliográficas e foi encontrada a ausência da batata na dieta normal antes de 1826 (AU)

25 años de investigación en nutrición y alimentación en el espacio iberoamericano del conocimiento / 25 years in nutrition and food research in the iberoamerican knowledge área

Introducción: La investigación suele considerarse un indicador del grado de desarrollo. La investigación de un área problemática como la alimentación y nutrición para una determinada región, debería tener un impacto sobre la producción científica en consonancia con la importancia del problema, la capacidad investigadora y los recursos disponibles para generar dicha investigación. Objetivo: Conocer algunos indicadores de la investigación iberoamericana en nutrición y alimentación. Método: Estudio retrospectivo de la producción científica iberoamericana en nutrición y alimentación en los últimos 25 años. Los datos se obtuvieron de la base bibliográfica Science Citation Index Expanded (SCI), Journal Citation Reports Database. Science edition 2011 (Web of Knowledge, Thomson Reuters), y la base de datos del Banco Mundial. Resultados: Se registraron 49.808 artículos, el 3,20% de la producción en Ciencias de la Salud recogida en SCI. La evolución se ajustó al modelo exponencial, N&D (R2 0,962) y FS&T (R2 0,995). La producción media en N&D por población media fue mayor en España con 0,659 artículos/millón. Los mayores índices de productividad y rentabilidad se presentaron en Guatemala 12,963 artículos/1.000 investigadores, y 1,486 artículos/ millón $ respectivamente. La producción media en FS&T de los países por población media fue mayor en Cuba con 21,624 artículos/millón. El índice de productividad fue mayor en Uruguay con 25,999 artículos/mil investigadores. El índice de rentabilidad fue mayor en Guatemala con 0,271 artículos/ millón $. Conclusiones: Existe crecimiento exponencial en las dos categorías estudiadas, N&D y FS&T. La productividad y rentabilidad fue mayor en países con bajo presupuesto en I+D (AU)

Introduction: Research is usually considered a reliable indicator of the degree of development. Research in a problematic area such as food and nutrition for a given region, should have an impact on scientific production in agreement with the importance of the problem, the research capacity and the available resources for generating such a research. Objective: To identify some indicators of Iberoamerican research in nutrition and food. Method: Retrospective study of Iberoamerican scientific production in nutrition and food in the last 25 years. The data were obtained from the bibliographic database Science Citation Index Expanded, Journal Citation Reports Science Edition Database 2011, both included in the Web of Knowledge (Thomson Reuters), and the database of the World Bank. Results: 49,808 papers were registered, the 3.20% of the Health Sciences collection in SCI. The evolution was fitted to an exponential model, N&D (R2 0.962) and FS&T (R2 0.995). The average production in N&D per average population was higher in Spain with 0.659 papers/million. The highest rates of productivity and profitability were f oundin Guatemala with 12.963 papers/1000 researchers and 1.486 papers/million $ respectively. The average production in FS&T of the different countries per average population was higher in Cuba with 21.624 papers/million. The productivity index was higher in Uruguay with 25.999 papers/thousand researchers. The profitability index was higher in Guatemala with 0.271 papers/million $. Conclusion: There is exponential growth in the two categories studied N&D and FS&T. Productivity and profitability was higher in countries with low R&D (Research & Development) budget (AU)

What's next? Nutrition care and science in the 21st century.

The purpose of this review is 2-fold. First, it speculates on future scientific work that will have the greatest effect on clinical practice of nutrition care. Second, it discusses the current and future state of the healthcare system, paying special attention to demographic trends and the future of healthcare reform as it will affect nutrition practice.

Nutrition in critical care.

Critical care has evolved from a prolonged recovery room stay for cardiac surgery patients to a full medical and nursing specialty in the last 5 decades. The ability to feed patients who cannot eat has evolved from impossible to routine clinical practice in the last 4 decades. Nutrition in critically ill patients based on measurement of metabolism has evolved from a research activity to clinical practice in the last 3 decades. The authors have been involved in this evolution and this article discusses past, present, and likely future practices in nutrition in critically ill patients.

Fifty years of Australian pediatric gastroenterology.

When the Gastroenterological Society of Australia (GESA) began 50 years ago there were very few pediatric gastroenterologists in the world. The 'Mother' of Paediatric Gastroenterology was Australian Charlotte ('Charlo') Anderson who established one of the world's first pediatric gastroenterology units in Melbourne in the early 1960s. Her earlier work in Birmingham had identified gluten as the component of wheat responsible for celiac disease and helped separate maldigestion (cystic fibrosis) and mucosal malabsorption. The first comprehensive textbook of Paediatric Gastroenterology was edited by Charlotte Anderson and Valerie Burke in 1975. Rudge Townley succeeded Charlotte Anderson in Melbourne and went on to further develop small bowel biopsy techniques making it a safe, simple, and quick procedure that led to much greater understanding of small bowel disease and ultimately the discovery of Rotavirus by Ruth Bishop et al. and subsequently to Rotavirus immunization. Australian Paediatric Gastroenterology subsequently developed rapidly with units being established in all mainland capital cities by the end of the 1970s. The Australian Society of Paediatric Gastroenterology Hepatology and Nutrition (AuSPGHAN) was established in the 1980s. Australians have contributed significantly in many areas of gastroenterology in infants, children, and adolescents including celiac disease, cystic fibrosis, liver disease, transplantation, gastrointestinal infection, allergy, indigenous health, inflammatory bowel disease, gastrointestinal motility, and the development of novel tests of gastrointestinal function and basic science. There have also been major contributions to nutrition in cystic fibrosis, end-stage liver disease, and intestinal failure. The future of Australian Paediatric Gastroenterology is in good hands.

The role of basic nutritional research in pediatric liver disease: An historical perspective.

The advent of liver transplantation for end-stage liver disease (ESLD) in children has necessitated a major rethink in the preoperative preparation and management from simple palliative care to active directed intervention. This is particularly evident in the approach to the nutritional care of these patients with the historical understanding of the nutritional pertubations in ESLD being described from a single pediatric liver transplant center. ESLD in children is a hypermetabolic process adversely affecting nutritional status, metabolic, and non-metabolic body compartments. There is a complex dynamic process affecting metabolic activity within the metabolically active body cell mass, as well as lipid oxidation during fasting and at rest, with other factors operating in conjunction with daily activities. We have proposed that immediately ingested nutrients are a more important source of energy in patients with ESLD than in healthy children, among whom energy may be stored in various body compartments.

Teams, strategies and networks: developments in nutritional support; a personal perspective.

Chris Pennington was an archetypal team player, strategist and networker. Clinical nutritional support has progressed remarkably since the 1970s and it has been a privilege to work in this field over this period during which teamwork, strategy development and networking have been crucial. British experience has been characterised by groups of individuals of differing professions and specialties coming together to enable progress to be made. This approach was initially in the form of nutrition support teams orientated to patient-centred ward-based care, then as hospital strategic committees and the concept of the 'patient journey'. Indeed, the formation of the British Association for Parenteral and Enteral Nutrition (now known as BAPEN) in 1992 required the statesmanlike burying of jealousies as societies came together into a multiprofessional association. With the understanding that disease-related malnutrition was highly prevalent it became apparent that it must be managed on a broad and organised clinical front. In the Organisation of Food and Nutritional Support in Hospitals a group of professionals developed for BAPEN concepts of hospital-wide organisation to tackle malnutrition that were based on previous reports, both national and international, and were made easily accessible from the BAPEN website, especially the 'Malnutrition Universal Screening Tool' and the National Institute for Health and Clinical Excellence nutrition guidelines. The coming together of six national clinical societies to develop evidence-based consensus guidelines for intravenous saline therapy (also on the BAPEN website) has shown that BAPEN can catalyse opinion well beyond its own nutritional constituency. In England Chris Pennington's Scottish lead is being followed by developing a patient-centred strategic framework for a managed home parenteral nutrition and intestinal failure national network. In research, education or clinical practice the engines of progress have been teams, strategies and networks.

[Origin, functions and expectations of the specialty in nutritional support]. / Origen, funciones y expectativas de las especialidad en endonutrición.

Considerations are presented on the causes and frequency at the beginning or worsening of malnutrition in hospitalized patients. Most of the children had a more accelerated metabolism, and we examined how this malnutrition modifies their metabolic and functional responses and increases morbidity and mortality. During the 20th century the study and treatment with total parenteral nutrition (TPN) began. This allows the patient's nourishment to be maintained through the administration of nutrients directly into the circulatory system because of the inability of the patient to receive food by the digestive route. The benefits, as well as the risks and complications of the procedure, have been documented for the last 30 years. On the other hand, the technology has allowed the modification of the physicochemical characteristics of the nutrients. This is an alternative for some of the digestive processes to favor its absorption in the intestine in those patients who cannot receive natural nourishment. This procedure is known as specialized enteral nutrition (SEN). These two groups of procedures (TPN and SEN) are the cornerstones of a new specialty. The meanings of this specialty are several, including nutritional support and metabolic support. The adoption of the term "endonutrition" is proposed.