Microbiota-Gastric Cancer Interactions and the Potential Influence of Nutritional Therapies

Gastric cancer (GC) is one of the most common causes of cancer deaths, and GC treatments represent a large area of research. Although initially regarded as a sterile organ and unsuitable for microbial communities, the discovery of Helicobacter pylori made us realize that some microbes can colonize the stomach. In recent years, growing interest in gastric bacteria has expanded to the gut microbiota and, more recently, to the oral microbiota. Indeed, the oral-gastric-gut microbiota axis may play a crucial role in maintaining homeostasis, while changes in microbiota composition in GC patients can influence clinical outcomes. On the one hand, the microbiota and its metabolites may significantly influence the progression of GC, while anti-GC treatments such as gastrectomy and chemotherapy may significantly impact the oral-gastric-gut microbiota axis of GC patients. In this context, the role of nutritional therapies, including diet, prebiotics, and probiotics, in treating GC should not be underestimated. Wit this review, we aim to highlight the main role of the gastric, oral, and gut microbiota in GC onset and progression, representing potential future biomarkers for early GC detection and a target for efficient nutritional therapies during the course of GC.

The Role of Gut Microbiota and Leaky Gut in the Pathogenesis of Food Allergy

Food allergy (FA) is a growing public health concern, with an increasing prevalence in Western countries. Increasing evidence suggests that the balance of human gut microbiota and the integrity of our intestinal barrier may play roles in the development of FA. Environmental factors, including industrialization and consumption of highly processed food, can contribute to altering the gut microbiota and the intestinal barrier, increasing the susceptibility to allergic sensitization. Compositional and functional alterations to the gut microbiome have also been associated with FA. In addition, increased permeability of the gut barrier allows the translocation of allergenic molecules, triggering Th2 immune responses. Preclinical and clinical studies have highlighted the potential of probiotics, prebiotics, and postbiotics in the prevention and treatment of FA through enhancing gut barrier function and promoting the restoration of healthy gut microbiota. Finally, fecal microbiota transplantation (FMT) is now being explored as a promising therapeutic strategy to prevent FA in both experimental and clinical studies. In this review article, we aim to explore the complex interplay between intestinal permeability and gut microbiota in the development of FA, as well as depict potential therapeutic strategies.

Leptin-mediated meta-inflammation may provide survival benefit in patients receiving maintenance immunotherapy for extensive-stage small cell lung cancer (ES-SCLC)

BACKGROUND

Only few ES-SCLC patients experience long-term survival benefit by maintenance IT. Adipokines-induced metabolic meta-inflammation has been related to enhanced responsiveness to IT in obese patients; however, their prognostic role in SCLC is currently controversial.

METHODS

Pre-treatment CT scan was used for determining distribution of abdominal adiposity, and blood samples were collected at fasting for measuring glycemia, insulin, ghrelin, leptin and adipokines (TNF-α, IFN-γ, IL-6 and MCP-1). Patients with known history of DM type II or metabolic syndrome with HOMA index > 2.5 were considered insulin resistant (IR).

RESULTS

In ES-SCLC pts receiving maintenance IT, increased leptin concentration and higher leptin/visceral adipose tissue (VAT) ratio were significantly associated with prolonged PFS. By applying a hierarchical clustering algorithm, we identified a cluster of patients characterized by higher leptin values and lower pro-inflammatory cytokines (TNF-α, IFN-γ and IL-6) who experienced longer PFS (13.2 vs 8.05 months; HR: 0.42 [0.18-0.93] p = 0.02) and OS (18.04 vs 12.09 mo; HR: 0.53 [0.25-1.29] p = 0.07).

CONCLUSIONS

Adipokines can play a crucial role to determining effectiveness of anti-cancer immunotherapy. The role of metabolic immune dysfunctions needs further pre-clinical validation and is currently investigated in the larger prospective cohort.

Dynamics of liver stiffness predicts complications in patients with HCV related cirrhosis treated with direct-acting antivirals

BACKGROUND

Direct acting antivirals(DAAs) are effective in reducing inflammatory ant fibrotic markers in patients with chronic hepatitis C virus(HCV) infection and to prevent liver-related complications. Two-dimensional shear wave elastography(2D-SWE) is an effective technique for the assessment of liver fibrosis.

AIM

To evaluate changes in liver stiffness(LS) in HCV cirrhotic patients undergoing DAA therapy and to identify non-invasive parameters that predict the occurrence of liver-related events.

METHODS

We enrolled 229 patients who received DAAs between January 2015 and October 2018. Ultrasound parameters and laboratory data were assessed before treatment and 24(T1) and 48(T2) weeks after end of treatment. Patients were followed up every 6 months to evaluate the development of HCC and other liver related complications. Multiple Cox regression analysis was used to determine parameters associated with the development of complications.

RESULTS

Model for End-stage Liver Disease(MELD) score(HR 1.16; CI 95% 1.01-1.33; p = 0.026) and a change in LS at T2(1-year Delta LS) < 20%(HR 2.98; CI 95% 1.01-8.1; p = 0.03) were independently associated with HCC risk. One-year Delta-LS <20% was independently associated with the development of ascites(HR 5.08; CI 95% 1.03 - 25.14; p = 0.04).

CONCLUSIONS

Dynamic changes of 2D-SWE-measured LS after DAA therapy may be a useful tool to identify patients who are at higher risk of liver related complications.

Polypharmacy and malnutrition in older people: A narrative review

Polypharmacy is the simultaneous use of multiple medicines, usually more than five. Polypharmacy is highly prevalent among older individuals and is associated with several adverse health outcomes, including frailty. The role of polypharmacy in nutritional status seems to be crucial: although a clear association between polypharmacy and malnutrition has been widely reported in older people, the magnitude of the effect of increased number of drugs in combination with their type on the risk for malnutrition remains to be largely explored. Therefore, this review aims to discuss the association between polypharmacy and malnutrition in older people and to provide suggestions for its management. Polypharmacy is prevalent among malnourished frail patients, and the relative contribution of comorbidities and polypharmacy to malnutrition is difficult to be determined. Several mechanisms by which commonly used medications have the potential to affect nutritional status have been identified and described. Deprescribing (i.e., a systematic process of identification and discontinuation of drugs or a reduction of drug regimens) could be an essential step for minimizing the effects of polypharmacy on malnutrition. In this regard, the literature suggests that in older patients taking several medications, the best method to solve this problem is the comprehensive geriatric assessment, based on a holistic approach, including drug review, to find potential unnecessary and inappropriate medications. Nutritional and deprescribing interventions must be tailored to patient needs and to the local context to overcome barriers when applied in different settings.

Metabolic Disorders and Psoriasis: Exploring the Role of Nutritional Interventions

(1) Background: Psoriasis is a chronic autoimmune disease with a close relationship with metabolic diseases such as obesity, diabetes, and dyslipidemia. The aim of this review was to identify the relationship between psoriasis, metabolic diseases, and dietetic therapies. According to recent findings, there is a strong association between psoriasis and obesity as well as vitamin D and micronutrient deficiencies. (2) Methods: This review was conducted via PubMed, aiming to search for studies involving psoriasis linked with metabolic disorders or with nutritional treatments. (3) Results: Our review shows that a healthy lifestyle can positively influence the course of the disease. The maintaining of a proper body weight together with physical activity and good nutritional choices are associated with an improvement in psoriasis severity. A Mediterranean diet rich in fiber, vitamins, and polyphenols may indeed be a strategy for controlling psoriasis symptoms. The effectiveness of this diet lies not only in its anti-inflammatory power, but also in its ability to favorably influence the intestinal microbiota and counteract dysbiosis, which is a risk factor for many autoimmune diseases. (4) Conclusions: In synergy with standard therapy, the adoption of an appropriate diet can be recommended to improve the clinical expression of psoriasis and reduce the incidence of comorbidities.

Noninvasive Evaluation of Clinically Significant Portal Hypertension in Patients with Liver Cirrhosis: The Role of Contrast-Enhanced Ultrasound Perfusion Imaging and Elastography

BACKGROUND

Hepatic venous pressure gradient (HVPG) is the gold standard for assessing the degree of portal hypertension (PH), but it is not suitable for routine clinical use. The recently developed ultrasonography techniques, dynamic contrast-enhanced ultrasound (D-CEUS) and liver stiffness (LS), have expanded the possibilities for noninvasive evaluation.

AIMS

To investigate the usefulness of D-CEUS and elastographic parameters in assessing the presence and degree of PH.

METHODS

This is a prospective monocentric study. Patients with liver cirrhosis referred for HVPG measurements underwent hepatic Doppler ultrasound, LS measurement, and D-CEUS with a second-generation contrast agent. Pearson's correlation and a receiver operating characteristic (ROC) curve analysis were performed to assess the role of noninvasive findings in predicting clinically significant PH (CSPH) and severe PH (SPH).

RESULTS

46 consecutive patients (31 men; mean age±SD: 57±11 years) were enrolled. A significant positive correlation was noted between LS and HVPG (r = 0.809, p<0.0001) with an area under the ROC curve of 0.923. A cut-off value of 24.2 kPa best predicted CSPH with a positive predictive value of 85%. Among the D-CEUS features, the area under the ROC curves of liver parenchyma peak intensity (PI-LP) was greater than the other indices both for CSPH and SPH (1.000 and 0.981, respectively). A PI-LP under 23.3 arbitrary units indicated the presence of CSPH with a sensitivity and a specificity of 100%.

CONCLUSION

A multimodal ultrasound approach based on D-CEUS and LS might become a reliable predictor of CSPH and SPH and a useful alternative to HVPG.

Short-Chain Fatty-Acid-Producing Bacteria: Key Components of the Human Gut Microbiota

Short-chain fatty acids (SCFAs) play a key role in health and disease, as they regulate gut homeostasis and their deficiency is involved in the pathogenesis of several disorders, including inflammatory bowel diseases, colorectal cancer, and cardiometabolic disorders. SCFAs are metabolites of specific bacterial taxa of the human gut microbiota, and their production is influenced by specific foods or food supplements, mainly prebiotics, by the direct fostering of these taxa. This Review provides an overview of SCFAs' roles and functions, and of SCFA-producing bacteria, from their microbiological characteristics and taxonomy to the biochemical process that lead to the release of SCFAs. Moreover, we will describe the potential therapeutic approaches to boost the levels of SCFAs in the human gut and treat different related diseases.

Special Issue "Gastrointestinal Microbiota and Gut Barrier Impact Human Health and Disease": Editorial

The increasing incidence of non-communicable diseases is a worldwide public health issue, and the role of gut microbiota is becoming evident [...].

Sorghum (Sorghum vulgare): an ancient grain, a novel choice for a healthy gluten-free diet

Celiac disease (CD) is an autoimmune disease related to gluten consumption. To date, the only effective therapy that can reverse symptoms and prevent complications is the gluten-free diet (GFD), which is challenging to maintain and has potential health risks. Identifying foods that can help diversify the GFD and that best match the nutritional needs of people with CD may improve the health and quality of life of celiac patients. This review, conducted through a non-systematic search of the available literature, aims to gather the most recent research on nutritional issues in CD and GFD. Moreover, it highlights how sorghum characteristics could provide health benefits to CD patients that counteract the nutritional problems due to CD and the nutritional consequences of GFD acceptance. Sorghum contains a wide variety of bioactive compounds, such as flavones and tannins, that have shown anti-inflammatory activity in preclinical studies. They can also regulate blood sugar levels and lower cholesterol to reduce the effects of common chronic diseases such as metabolic and cardiovascular diseases. Because it is gluten-free, its use in making foods for celiac patients is increasing, especially in the United States. In conclusion, sorghum is a fascinating grain with nutritional properties and health benefits for supplementing GFD. However, only one study confirms the short-term safety of sorghum inclusion in the GFD, and further long-term studies with a large sample are needed.

COntrolling NUTritional Status (CONUT) as Predictive Score of Hospital Length of Stay (LOS) and Mortality: A Prospective Cohort Study in an Internal Medicine and Gastroenterology Unit in Italy

BACKGROUND

Hospital malnutrition affects nearly 30% of patients in medical wards and correlates with worse outcomes. An early assessment is necessary to stratify the risk of short-term outcomes and mortality. The predictive role of COntrolling NUTritional status (CONUT) score in this context has not yet been elucidated in Western countries. We aimed to test CONUT at admission as a predictive score of hospital outcomes, in an Internal Medicine and Gastroenterology Department of an Italian Tertiary Care University hospital.

METHODS

We prospectively enrolled patients admitted to our center, stratifying them into the four CONUT classes (normal = 0-1; mild = 2-4; moderate = 5-8; severe = 9-12 points) according to serum albumin (g/dL), total lymphocyte count (/mm³), and total cholesterol (mg/dL); the primary outcome measure was length of stay (LOS) and the secondary one was in-hospital mortality.

RESULTS

Out of a total of 203 patients enrolled, 44 (21.7%) patients had a normal status (0-1), 66 (32.5%) had a mild impairment (2-4), 68 (33.5%) had a moderate impairment (5-8), and 25 (12.3%) a severe impairment (9-12). The mean LOS was 8.24 ± 5.75 days; nine patients died. A moderate-severe CONUT correlated with a higher LOS at the univariate [HR 1.86 (95% CI 13.9-3.47); p < 0.0001] and multivariate analysis [HR 1.52 (95% CI 1.10-2.09); p = 0.01]. The CONUT score was also a predictor of mortality, with an AUC of 0.831 (95% CI 0.680-0.982) and with an optimal cut-off at 8.5 points. Nutritional supplementation within 48 h from admission correlated with lower mortality [OR 0.12 (95% CI 0.02-0.56) p = 0.006].

CONCLUSIONS

CONUT is a reliable and simple predictor of LOS and in-hospital mortality in medical wards.

The role of diet in shaping human gut microbiota

Gut microbiota plays a fundamental role within human health, and exerts key functions within the human body. Diet is one of the most powerful modulators of gut microbiota functions and composition. This complex interplay involves also the immune system and the intestinal barrier, highlighting the central role of diet in the pathogenesis and treatment of multiple diseases. In this review article we will paint the landscape of the effects of specific dietary nutrients, and of the detrimental or beneficial outcomes of different dietary patterns, on the composition of human gut microbiota. Moreover, we will discuss the potential application of diet as a therapeutic modulator of gut microbiota, including cutting-edge ways of exploitation, including the use of dietary components as adjuvants to promote microbial engraftment after fecal microbiota transplantation, or personalized nutritional approaches, targeted to the patient microbiome.

Nutritional Interventions during Chemotherapy for Pancreatic Cancer: A Systematic Review of Prospective Studies

BACKGROUND

Pancreatic cancer incidence is growing, but the prognosis for survival is still poor. Patients with pancreatic cancer often suffer from malnutrition and sarcopenia, two clinical conditions that negatively impact oncological clinical outcomes. The aim of this systematic review was to analyze the impact of different nutritional interventions on clinical outcomes in patients with pancreatic cancer during chemotherapy.

METHODS

A systematic review of MedLine, EMBASE, and Web of Science was carried out in December 2022, identifying 5704 articles. Titles and abstracts of all records were screened for eligibility based on inclusion criteria, and nine articles were included.

RESULTS

All nine articles included were prospective studies, but a meta-analysis could not be performed due to heterogenicity in nutritional intervention. This Systematic Review shows an improvement in Quality of Life, nutritional status, body composition, oral intake, and Karnofsky Performance Status, following nutritional interventions.

CONCLUSIONS

This Systematic Review in pancreatic cancer patients during chemotherapies does not allow one to draw firm conclusions. However, nutritional support in pancreatic cancer patients is advisable to ameliorate oncological care. Further well-designed prospective studies are needed to identify nutritional support's real impact and to establish a reliable way to improve nutritional status of pancreatic cancer patients during chemotherapy.

Hospital Services to Improve Nutritional Intake and Reduce Food Waste: A Systematic Review

BACKGROUND AND AIMS

Patients' nutritional intake is a crucial issue in modern hospitals, where the high prevalence of disease-related malnutrition may worsen clinical outcomes. On the other hand, food waste raises concerns in terms of sustainability and environmental burden. We conducted a systematic review to ascertain which hospital services could overcome both issues.

METHODS

A systematic literature search following PRISMA guidelines was conducted across MEDLINE, Web of Science, and Scopus for randomised controlled trials (RCTs) and observational studies comparing the effect of hospital strategies on energy intake, protein intake, and plate/food waste. The quality of included studies was assessed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane Risk of Bias tool from the Cochrane Handbook for Systematic Reviews of Interventions for RCTs.

RESULTS

Nineteen studies were included, assessing as many hospital strategies such as food service systems-including catering and room service-(n = 9), protected mealtimes and volunteer feeding assistance (n = 4), food presentation strategies (n = 3), nutritional counseling and education (n = 2), plant-based proteins meal (n = 1). Given the heterogeneity of the included studies, the results were narratively analysed.

CONCLUSIONS

Although the results should be confirmed by prospective and large sample-size studies, the personalisation of the meal and efficient room service may improve nutritional intake while decreasing food waste. Clinical nutritionist staff-especially dietitians-may increase food intake reducing food waste through active monitoring of the patients' nutritional needs.

Food Emulsifiers and Metabolic Syndrome: The Role of the Gut Microbiota

The use of emulsifiers in processed foods and the rapid epidemic development of metabolic syndrome in Western countries over the past 20 years have generated growing interest. Evidence for the role of emulsifiers in metabolic syndrome through gut microbiota has not been clearly established, thus making it challenging for clinical nutritionists and dietitians to make evidence-based associations between the nature and the quantity of emulsifiers and metabolic disorders. This narrative review summarizes the highest quality clinical evidence currently available about the impact of food emulsifiers on gut microbiota composition and functions and the potential development of metabolic syndrome. The state-of-the-art of the different common emulsifiers is performed, highlighting where they are present in daily foods and their roles. Recent findings of in vitro, in vivo, and human studies assessing the effect of different emulsifiers on gut microbiota have been recently published. There is some progress in understanding how some food emulsifiers could contribute to developing metabolic diseases through gut microbiota alterations while others could have prebiotic effects. However, there are still many unanswered questions regarding daily consumption amounts and the synergic effects between emulsifiers’ intake and responses by the microbial signatures of each individual.

Prognostic impact of sarcopenia in children with cancer: a focus on the psoas muscle area (PMA) imaging in the clinical practice

Skeletal muscle plays a crucial part in the metabolic and inflammatory response. "Sarcopenia", defined as a pathological condition of reduced strength, quantity and quality of skeletal muscle mass, may often develop in the young age as the secondary consequence of a systemic inflammatory illness, like cancer. In children with cancer, sarcopenia is a common finding, playing a negative role in their prognosis. However, its prevalence in clinical practice is underestimated. Moreover, several pre- and post-natal factors may influence skeletal muscle development in childhood, making the issue more complex. Given the frequent use of radiological imaging in clinical practice, prompt analysis of body composition is feasible and able to detect the presence of reduced fat-free mass (FFM) among pediatric patients with cancer. We discuss the recent advances in the study of body composition in children with cancer, dissecting the role of the psoas muscle area (PMA) measure, obtained from computerized tomography (CT) or magnetic resonance images (MRI) as a marker of sarcopenia in this setting. Since age and sex-specific percentile curves for PMA and a PMA z-scores calculator are available online, such a tool may be useful to simply detect and treat sarcopenia and its consequences in childhood cancer.

Preoperative Assessment of Skeletal Muscle Mass and Muscle Quality Using Computed Tomography: Incidence of Sarcopenia in Patients with Intrahepatic Cholangiocarcinoma Selected for Liver Resection

Background: Sarcopenia is considered a predictor of poor postoperative and long-term results following liver resection for intrahepatic cholangiocarcinoma (ICC). The aim of our study was to assess the incidence of sarcopenia in patients resected for ICC and its relation to preoperative clinical factors. Methods: Patients resected for ICC in our unit, with available preoperative CT scans within one month before operation, were enrolled in the study. Skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD) were assessed for each patient. Results: Thirty patients matched all inclusion criteria. Low SMI values were documented in 15 patients (50.0%), and low SMD values were documented in 10 patients (33.3%). SMI was significantly greater in males (p < 0.001). In patients who were underweight, the incidence of low SMI was significantly higher than that of high SMI (p = 0.031). In patients who were overweight/obese, the incidence of high SMI was significantly higher than that of low SMI (p = 0.003) and the incidence of low SMD was significantly higher than that of high SMD (p = 0.038). In the univariate analysis, no preoperative factors (clinical and tumor-related factors), in particular BMI, were found to be independent predictors of low SMI. Conclusions: The incidence of sarcopenia was 50.0% in patients selected for liver resection for ICC and was not related to the preoperative clinical factors. A multidisciplinary evaluation of the nutritional status is fundamental before liver resection in patients.

Body composition and immunonutritional status in patients treated with pressurized intraperitoneal aerosol chemotherapy (PIPAC) for gastrointestinal peritoneal metastases: a prospective single-center analysis

Objectives

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel drug administration method with promising efficacy for the treatment of peritoneal metastases (PM). This study aimed to evaluate the prognostic value of an immunonutritional assessment on the feasibility, safety, and survival in this setting.

Methods

Data of PM patients undergoing PIPAC between September 2018 and May 2020 were prospectively recorded. A CT scan-derived body composition assessment was performed for each patient.

Results

Fifty-one patients were enrolled, of which 30 (58%) underwent multiple PIPAC cycles, with a pathological response rate of 55%. Prognostic nutritional index (PNI) and neutrophil-to-lymphocytes predicted completion of more than one PIPAC cycle, with a cut off of 36.5 and 4.8 respectively. Muscle attenuation and body fat tissues were associated with pathological response. At multivariate Cox regression analysis, only the presence of a low PNI (HR 2.41, 95% CI 1.08–5.46) was significantly associated with a worse OS.

Conclusions

A pretreatment immunonutritional assessment may provide valuable information for PIPAC patients’ selection and survival, while body composition parameters are able to predict pathological response. Further larger studies are needed to validate the role of these biomarkers in tailoring the treatment and monitoring PM patients undergoing PIPAC.

Vitamin D and colorectal cancer: Chemopreventive perspectives through the gut microbiota and the immune system

Vitamin D and its receptor are involved in health and diseases through multiple mechanisms including the immune system and gut microbiota modulations. Gut microbiota variations have huge implications in intestinal and extra-intestinal disorders such as colorectal cancer (CRC). This review highlights the preventive role of vitamin D in colorectal tumorigenesis through the effects on the immune system and gut microbiota modulation. The different associations between vitamin D, gut microbial homeostasis, immune system, and CRC, are dissected. Vitamin D is supposed to exert several chemopreventive effects on CRC including direct antineoplastic mechanisms, the effects on the immune system, and gut microbiota modulation. Large clinical studies with a randomized design, are required to confirm the role of vitamin D in CRC, confirming its key role in the complex interplay between the gut immune system and microbiota.

Clinical Impact of Nutritional Status and Sarcopenia in Pediatric Patients with Bone and Soft Tissue Sarcomas: A Pilot Retrospective Study (SarcoPed)

Background: We evaluated nutritional and sarcopenia status and their clinical impact in pediatric patients affected by bone and soft tissue sarcomas. Methods: Body mass index (BMI), prognostic nutritional index (PNI), and total psoas muscle area (tPMA) at diagnosis and after 12 months were analyzed. tPMA was measured from single cross-sectional computed tomography (CT) images at L4–L5. Age-specific and sex-specific tPMA Z-scores were retrieved from an online calculator. Results: A total of 21 patients were identified between February 2013 and December 2018. Twelve patients (57.1%) experienced sarcopenia at diagnosis, although not statistically associated with overall survival (OS) (p = 0.09). BMI Z-score, PNI, and tPMA Z-score significantly decreased between diagnosis and after 12 months of treatment (p < 0.05). Univariate analysis showed significant associations between poor OS and the presence of metastasis (p = 0.008), the absence of surgery (p = 0.005), PNI decrease (p = 0.027), and the reduction in tPMA > 25% (p = 0.042) over the 12 months. Conclusions: Sarcopenia affects more than half of the patients at diagnosis. Decreased PNI during 12 months of treatment has significant predictive value for OS. The role of tPMA derived from CT scan among pediatric patients with sarcoma should be investigated in further prospective and larger studies.

OUP accepted manuscript

Background

Early postoperative discharge after colorectal surgery within the enhanced recovery after surgery (ERAS) guidelines has been demonstrated to be safe, although its applicability has not been universal. The primary aim of this study was to identify the predictors of early discharge and readiness for discharge in a study population.

Methods

Early discharge was defined as discharge occurring in 72 h or less after surgery. The characteristics and clinical outcomes of the patients in the early and non-early discharge groups were compared, and variables associated with early discharge were identified. Additionally, independent variables associated with the readiness for discharge within 48 h were evaluated.

Results

Of 965 patients who underwent colorectal surgery between January 2015 and July 2020, 788 were included in this study. No differences in readmission, reoperation, or 30-day mortality were observed between the early and non-early discharge groups. Both early discharge and readiness for discharge had a positive association with adherence to 80 per cent or more of the ERAS items and a negative association with the female sex, duration of surgery, drain positioning, and postoperative complications.

Conclusion

Early discharge after colorectal surgery is safe and feasible, and is not associated with a high risk of readmission or reoperation. Discharge at 48 h can be reliably predicted in a subset of patients. Future studies should collect prospective data on early discharge related to safety, as well as patients’ expectations, possible organizational issues, and effective costs reduction in Italian clinical practice.

Insulin-sensitizing effect and antioxidant action of alpha lipoic acid in oligomenorrheic women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a low-grade inflammatory disease characterized by anovulation and hyperandrogenism, associated with insulin-resistance. The aim of our study was to investigate the effects of a treatment with alpha-lipoic acid on clinical, endocrine and metabolic features of women affected by PCOS.

METHODS

In this pilot cohort study, 60 women (30 hyperinsulinemic and 30 normoinsulinemic patients; age 15-34 years) were enrolled and clinical, hormonal and metabolic parameters were evaluated before and after a six-months treatment with alpha-lipoic acid 800 mg/daily. Investigations were performed during the early follicular phase of the menstrual cycles (spontaneous or progestin-induced cycles): after fasting overnight for 10-12 h, blood samples were collected for hormonal and metabolic assays and oral glucose tolerance test and pelvic ultrasound were performed. Total Antioxidant Capacity was expressed as LAG time.

RESULTS

The treatment was able to increase the number of menstrual cycles during the 6 months considered in all patients and to reduce BMI in the normoinsulinemic population. In hyperinsulinemic patients we observed a statistically significant reduction in AUC-I as well as an increase of total antioxidant capacity.

CONCLUSIONS

The relevant results in restoring menstrual cyclicity in both groups, in addition to the antioxidant effect, confirm that hyperinsulinemia influences only the metabolic response to the treatment, without predict the ovarian function. Even if alpha-lipoic acid mechanisms of action is not clear and further studies are needed to confirm these results, it could be considered a valid therapeutic alternative to traditional drugs, without side effects as reported.

The prognostic value of skeletal muscle index on clinical and survival outcomes after cytoreduction and HIPEC for peritoneal metastases from colorectal cancer: A systematic review and meta-analysis

BACKGROUND

Cytoreductive surgery (CRS) and hypertermic intraperitoneal chemotherapy (HIPEC) represent the most effective strategy to manage peritoneal metastases (PM). This systematic review and meta-analysis aimed to assess the impact of body composition on clinical outcomes in patients with PM.

METHODS

A systematic literature search was performed using Medline, Web of Science and EMBASE databases from inception to the 20^st August 2020. Data were independently extracted by 3 authors. Newcastle-Ottawa Scale was used to assess quality and risk of bias of studies. Pooled analyses were performed using Mantel-Haenszel method to estimate overall effect size with mean differences or odd ratios (ORs) and 95% confidence interval (CI). The primary outcome was postoperative complication (POC) rate, while secondary outcomes were severe POC and postoperative mortality.

RESULTS

A total of 4 studies were included in the systematic review and meta-analysis, including 582 patients. A significant association between low skeletal muscle mass and POC was found (OR 1.45, 95% CI 1.04 to 2.03; p = 0.03), while no differences were found in terms operative time, estimated blood loss, length of hospital stay, and postoperative mortality (p > 0.05).

CONCLUSIONS

Low skeletal muscle mass at diagnosis is a valid prognostic factor for POC development in colorectal and PM patients undergoing CRS. Prospective and larger studies are needed to better investigate the role of CT scan derived body composition and to understand how to implement this tool in clinical practice.

Neoadjuvant treatment: A window of opportunity for nutritional prehabilitation in patients with pancreatic ductal adenocarcinoma

Patients affected by pancreatic ductal adenocarcinoma (PDAC) frequently present with advanced disease at the time of diagnosis, limiting an upfront surgical approach. Neoadjuvant treatment (NAT) has become the standard of care to downstage non-metastatic locally advanced PDAC. However, this treatment increases the risk of a nutritional status decline, which in turn, may impact therapeutic tolerance, postoperative outcomes, or even prevent the possibility of surgery. Literature on prehabilitation programs on surgical PDAC patients show a reduction of postoperative complications, length of hospital stay, and readmission rate, while data on prehabilitation in NAT patients are scarce and randomized controlled trials are still missing. Particularly, appropriate nutritional management represents an important therapeutic strategy to promote tissue healing and to enhance patient recovery after surgical trauma. In this regard, NAT may represent a new interesting window of opportunity to implement a nutritional prehabilitation program, aiming to increase the PDAC patient's capacity to complete the planned therapy and potentially improve clinical and survival outcomes. Given these perspectives, this review attempts to provide an in-depth view of the nutritional derangements during NAT and nutritional prehabilitation program as well as their impact on PDAC patient outcomes.

Prognostic value of skeletal muscle mass during tyrosine kinase inhibitor (TKI) therapy in cancer patients: a systematic review and meta-analysis

Low muscle mass has been associated with worse clinical outcomes in various cancers. This work investigated whether, during tyrosine kinases inhibitors (TKIs) therapy, low muscle mass was associated with treatment toxicity and survival outcomes. A systematic literature search was performed in Pubmed, Web of Science, and Scopus databases from inception to June 2020, based on fixed inclusion and exclusion criteria. Effect sizes were estimated with hazard ratios (HR) and odds ratios (OR) with 95% confidence interval (CI) and heterogeneity was assessed by measuring inconsistency (I²) based on the Chi squared test. A total of 24 retrospective studies were identified, enrolling patients treated with sorafenib (n = 12), sunitinib (n = 6), lenvatinib (n = 3), regorafenib (n = 2), gefitinib (n = 1), imatinib (n = 1), and pazopanib (n = 1). Thirteen studies were deemed eligible for pooled analyses. Meta-analyses found a significant effect of low muscle mass on dose-limiting toxicity (DLT) (OR 2.40, 95% CI 1.26-4.58, p = 0.008, I² = 51%) in patients treated with TKI therapy. A subgroup analysis by treatment showed an association between DLT and low muscle during sorafenib or sunitinib, although not significant. A significant association between low skeletal muscle index and poorer overall survival was observed in HCC patients treated with sorafenib (HR 1.45, 95% CI 1.07-1.96, p = 0.02). For other TKIs, although some results showed an association between low muscle mass and worse outcomes, the number of studies for each TKI therapy was too small to reach conclusions. Skeletal muscle mass could influence the prognosis of some TKI-treated patients. This effect is demonstrated in sorafenib-treated HCC patients but remains almost unexplored in other cancer patients undergoing TKI therapy. Further prospective studies with large sample size and sufficient follow-up are needed to clarify the role of muscle mass in the metabolism of TKI-based cancer treatment, and its association with toxicity and survival.

Gastrointestinal involvement of autism spectrum disorder: focus on gut microbiota

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental disorder typical of early age, characterized by impaired communication, social interaction, and repetitive behaviors. ASD patients frequently suffer from gastrointestinal (GI) symptoms. Neuro-psychological functions, intestinal homeostasis, and functional GI disturbances are modulated by the gut microbiota through the so-called 'microbiota-gut-brain axis'.

AREAS COVERED

Literature regarding GI symptoms among the ASD community as well as the involvement and modulation of the gut microbiota in GI disturbances of ASD patients was searched. Constipation, diarrhea, reflux, abdominal bloating, pain, and discomfort are reported with variable prevalence. ASD is characterized by a reduction of Bacteroidetes/Firmicutes, of the abundance of Bacteroidetes and other imbalances. ASD patients with GI symptoms present microbial changes with plausible relation with deficiency of digestive enzymes, carbohydrate malabsorption, selective eating, bacterial toxins, serotonin metabolism, and inflammation. The strategies to mitigate the GI distress through the gut microbiota modulation comprise antimicrobials, probiotics, prebiotics, fecal microbiota transplantation, and dietary intervention.

EXPERT OPINION

The modulation of the gut microbiota in ASD individuals with GI disturbances seems a promising target for the future medicine. A standardization of the research strategies for large-scale studies together with a focus on poorly explored fields is necessary to strengthen this hypothesis.

NutriCatt Protocol Improves Body Composition and Clinical Outcomes in Elderly Patients Undergoing Colorectal Surgery in ERAS Program: A Retrospective Cohort Study

BACKGROUND

A poor body composition, often found in elderly patients, negatively impacts perioperative outcomes. We evaluated the effect of a perioperative nutritional protocol (NutriCatt) on body composition and clinical outcomes in a cohort of elderly patients undergoing colorectal surgery in a high-volume center adopting the ERAS program.

METHODS

302 out of 332 elderly (>75 years) patients from 2015 to 2020 were identified. Patients were divided according to their adherence, into "NutriCatt + ERAS" (n = 166) or "standard ERAS" patients (n = 136). Anthropometric and bioelectrical impedance analysis data were evaluated for NutriCatt + ERAS patients. Complications, length of hospital stay (LOS), and other postoperative outcomes were compared between both groups. Results: In NutriCatt + ERAS patients, significant improvements of phase angle (pre-admission vs. admission 4.61 ± 0.79 vs. 4.84 ± 0.85; p = 0.001; pre-admission vs. discharge 4.61 ± 0.79 vs. 5.85 ± 0.73; p = 0.0002) and body cell mass (pre-admission vs. admission 22.4 ± 5.6 vs. 23.2 ± 5.7; p = 0.03; pre-admission vs. discharge 22.4 ± 5.6 vs. 23.1 ± 5.8; p = 0.02) were shown. NutriCatt + ERAS patients reported reduced LOS (p = 0.03) and severe complications (p = 0.03) compared to standard ERAS patients. A regression analysis confirmed the protective effect of the NutriCatt protocol on severe complications (OR 0.10, 95% CI 0.01-0.56; p = 0.009).

CONCLUSIONS

The NutriCatt protocol improves clinical outcomes in elderly patients and should be recommended in ERAS colorectal surgery.

Influence of Mediterranean Diet on Human Gut Microbiota

Gut microbiota changes correlate with health status. Literature data on gut microbiota show that all dietary changes can induce the alteration of gut microbiota composition. Mediterranean diet (MD) is associated with a reduction of all-cause mortality and in this review, we analyzed its interactions with human microbiota. In particular, we explored the modulation of the human microbiota, in response to MD adherence, focusing the attention on polyphenols, polyunsaturated fatty acids (PUFA) ω-3 and fiber. Evidences suggest that MD is able to modulate the gut microbiota, increasing its diversity. In fact, a Mediterranean-type dietary pattern is associated with specific gut microbiota characteristics. The available evidence, suggests that gut microbiota of subjects that follow a MD is significantly different from subjects that follow a Western diet model. In fact, the latter show an increased gut permeability, which is responsible for metabolic endotoxemia. For this reason, we can speculate that the gut microbiota of the subjects following a MD is able to prevent the onset of chronic non-communicable degenerative diseases, such as cardiovascular diseases and some types of cancer. However, in order to understand these correlations with dietary patterns, controlled intervention studies on the gut microbiota composition and activity are needed.

Focal nodular hyperplasia: new findings at Doppler ultrasonography

OBJECTIVE

The aim of our study was to explore the features of focal nodular hyperplasia (FNH) at Doppler ultrasonography, analyzing specifically the presence of intratumoral venous flow in patients with an established diagnosis of FNH. Previous studies showed that using a venous Doppler spectrum, intratumoral vessels are often depicted in hepatocellular adenoma (HCA) but less frequently in FNH.

PATIENTS AND METHODS

Forty-five FNHs from thirty-three consecutive patients (26 female, 7 male; mean±SD age: 40±13) underwent color Doppler ultrasonography and spectral analysis according to a standardized protocol. FNH diagnosis was established by the presence of typical behavior at contrast-enhanced ultrasound (CEUS) associated with another imaging technique (contrast-enhanced computed tomography [ceCT] or contrast-enhanced magnetic resonance [ceMR]). A biopsy was performed when imaging was inconclusive. All data concerning Doppler analysis were reviewed by two more operators, blinded to the final diagnosis, and the interobserver agreement for the presence of venous Doppler signal was determined by Cohen's Kappa.

RESULTS

Of the 33 patients, 24 had a single solitary focus, and 9 had multiple foci. Lesion diameter ranged between 1.2 and 8.9 cm (mean ± SD 3.2±1.6 cm). The central feeding artery with the typical arterial spectrum was detected in all 45 lesions, whereas the spoke-wheel sign was observed in 18 cases (40%). A venous Doppler signal was detected in 35 FNHs (77.8%), and in 60% of them, it was identified in the center of the lesion.

CONCLUSIONS

Venous Doppler signal located in the center of the lesion suspected to be a hypervascular benign lesion cannot be considered a typical HCA feature since it has been detected in a high percentage of FNH cases.

Food Additives, Gut Microbiota, and Irritable Bowel Syndrome: A Hidden Track

The interactions between diet, gut microbiota, and irritable bowel syndrome (IBS) have many complex mechanisms that are not fully understood. Food additives are one component of the modern human diet that deserves attention from science and government policies. This review aims at identifying the current knowledge about the impact of food additives on gut microbiota and their potential role in the development of IBS. To date, few data on the effect of food additives on gut microbiota in IBS patients are available. However, exposure to food additives could induce the dysbiosis and dysregulation of gut homeostasis with an alteration of the gut barrier and activation of the immune response. These microbial changes could exacerbate the gut symptoms associated with IBS, such as visceral pain, low-grade inflammation, and changes in bowel habits. Some additives (polyols) are excluded in the low fermentable oligo-, di- and monosaccharide, and polyol (FODMAP), diets for IBS patients. Even if most studies have been performed in animals, and human studies are required, many artificial sweeteners, emulsifiers, and food colorants could represent a potential hidden driver of IBS, through gut microbiota alterations. Consequently, food additives should be preventively avoided in the diet as well as dietary supplements for patients with IBS.

Nutritional Support in Lung Cancer Patients: The State of the Art

Lung cancer (LC) represents the most commonly diagnosed neoplasm worldwide for both sexes and is the leading cause of cancer mortality. Malnutrition is a comorbidity frequently found in neoplastic patients, but it remains often underestimated and thus undertreated. In this review, we aimed to investigate the incidence of malnutrition among LC patients according to different screening and assessment tools, to evaluate the impact of weight loss and body composition on survival, and to analyze the efficacy of different nutritional interventions in this setting. Although malnutrition, weight loss, and body composition changes can affect survival and other clinical outcomes in LC patients, the role of nutritional interventions is not yet strongly proven, and further studies are recommended. Nevertheless, screening, assessing, and eventually treating malnutrition in LC patients are strongly recommended, according to the most recent nutritional intervention guidelines for oncology patients.

Minimal impact of lenvatinib (Lenvima®) on muscle mass in advanced hepatocellular carcinoma and implications for treatment duration. Two cases from the REFLECT study

OBJECTIVE

Two case reports of advanced unresectable hepatocellular carcinoma (HCC) treated with lenvatinib (Lenvima®) are presented; the drug's effect on muscle loss and duration of treatment are discussed.

PATIENTS AND METHODS

Between November 2014 and December 2017, at the Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy, two male patients with advanced HCC enrolled in the lenvatinib arm of the REFLECT trial received the drug over 24 cycles (almost 2 years). We reviewed the clinical charts from baseline, when lenvatinib was started, through 24 months of treatment. The changes in the skeletal mass area (SMA), as assessed by computed tomography (CT) at the third lumbar level (L3), between baseline and month 24 into treatment were recorded.

RESULTS

Case 1: SMA decreased by 2.8 cm2 between baseline and month 24 (134 cm2 vs. 131.2 cm2), with a muscle loss of 2.13%. Case 2: SMA decreased by 13 cm2 between baseline and month 24 (133 cm2 vs. 120 cm2), with a muscle loss of 10.83%.

CONCLUSIONS

The disease remained stable for over 2.5 years in both patients. A minimal loss of muscle mass was noted at 24 months of treatment. The minimum effect on muscle loss may be correlated with the positive clinical response and the drug's low toxicity. Our findings may help to elucidate the effect of lenvatinib on muscle mass and inform the development of the targeted nutritional support for HCC patients.

Effect of vitamin D supplementation on TSH levels in euthyroid subjects with autoimmune thyroiditis

PURPOSE

The impact of vitamin D supplementation on thyroid function is not clear and the relationship between hypovitaminosis D and autoimmune thyroiditis (ATD) incidence and evolution is still a matter of debate. The aim of this study was to retrospectively evaluate the impact of vitamin D supplementation on thyroid function in subjects with and without ATD.

METHODS

One hundred and ninety-eight euthyroid subjects, with diagnosis of "hypovitaminosis D" (<30 ng/mL) who had been taking supplementation therapy with cholecalciferol for different time periods, were included. They were divided in two groups according to the previous diagnosis of ATD: "ATD-neg" group including subjects without ATD [n = 103 (52%)]; "ATD-pos" group including subjects with a confirmed diagnosis of ATD [n = 95 (48%)]. For both groups, we considered TSH and 25 hydroxyvitamin D (25OHD) levels before (T0) and after (T1) cholecalciferol supplementation. We also considered the treatment duration and the monthly dose of cholecalciferol expressed as IU/month.

RESULTS

In hypovitaminosis D subjects with ATD, TSH levels significantly decreased after therapy with cholecalciferol 100.000 IU/month [mean ± SD, TSH at T0: 2.67 ± 1.21 vs. TSH at T1: 2.28 ± 0.86, p = 0.028]. No significant TSH variation was observed in ATD-neg group, irrespective of treatment dose and duration. As expected, 25OHD levels significantly improved with all monthly doses and especially in the group receiving 100.000 IU/month.

CONCLUSIONS

Cholecalciferol supplementation improved thyroid function in euthyroid ATD-pos subjects affected with severe hypovitaminosis D. In particular, a significant reduction in TSH levels was observed in subjects with very low baseline 25OHD levels, after taking high monthly doses of cholecalciferol.

Anticoagulant therapy in the treatment of splanchnic vein thrombosis associated to acute pancreatitis: a 3-year single-centre experience

Splanchnic vein thrombosis (SVT) is a possible complication of acute pancreatitis (AP). There are no precise guidelines on the use of anticoagulant therapy (AT) in these patients. The aim of the study was to determine the safety and the efficacy of AT in AP-associated SVT. Two hundred twenty-one patients were retrospectively and consecutively enrolled from the Pancreatic Outpatient Clinic of the "A. Gemelli" hospital. Patients had a diagnosis of AP and a diagnostic imaging to evaluate whether they had or not SVT. Twenty-seven out of 221 AP patients had SVT (12.21%) and AT therapy was administered to 16 patients (59.3%), for 5.2 ± 2.2 months. A therapeutic dose of low molecular weight heparin was administered (100 UI/kg b.i.d.) at the diagnosis, with fondaparinux 7.5 mg/day, or vitamin K antagonist, or the novel direct oral anti-coagulants, upon discharge. The presence of SVT resulted significantly associated to male sex (p = 0.002). The recanalization rates were 11/16 (68.7%) in patients who received AT, and 3/11 (27.3%) in patients who did not receive it. There was a significant difference between the recanalization rates with and without AT (p = 0.03, OR 5.87). No SVT recurrence was registered during follow-up. No treated patient developed haemorrhagic complications after AT. No deaths were recorded, either in the group undergoing AT or in the one that was not. In conclusion, AT in AP-associated SVT appears to be safe and effective; yet prospective clinical trials are needed to confirm our results.

The Facts about Food after Cancer Diagnosis: A Systematic Review of Prospective Cohort Studies

Nutritional guidelines suggest specific energy and protein requirements for patients with cancer. However, cancer patients, often malnourished, use self-made or web-based diets to ameliorate the prognosis of their disease. This review aimed to investigate the associations between post-diagnostic diet and prognostic outcomes in cancer patients. A systematic literature search was performed in Pubmed and Web of Science databases from inception to 30 October 2019, based on fixed inclusion and exclusion criteria. The risk of bias was assessed. A total of 29 prospective studies was identified. Breast (n = 11), colorectal (n = 9), prostate (n = 8) cancers are the most studied. Low- fat diet, healthy quality diet, regular consumption of fiber such as vegetables and high-quality protein intake are beneficial while Western diet (WD) and high consumption of saturated fats could be associated with a higher risk of mortality. Bladder (n = 1), gynecological (n = 1), lung, stomach, and pancreatic cancers still remain almost unexplored. This systematic review suggested that detrimental dietary patterns such as WD should be avoided but none of the food categories (meat, dairy products) should be eliminated in cancer patients' diet. Further large prospective studies are needed to assess the role of post-diagnostic diet in patients with cancer.

Impact of malnutrition on survival and infections among pediatric patients with cancer: a retrospective study

OBJECTIVE

Recognizing and managing malnutrition among hospitalized children affected by cancer is a rising need. Awareness and consideration of malnutrition among clinicians are still largely insufficient. This can principally be explained by the lack of consciousness and the shortage of easy and objective tools to identify malnutrition status. The aim of this study is to explore the impact of malnutrition on survival and infections among a population of pediatric patients with cancer.

PATIENTS AND METHODS

All children aged between 3 and 18 years, newly diagnosed with a malignancy between August 2013 and April 2018, were included in our study. We assessed nutritional risk at diagnosis (with STRONGkids), then we evaluated anthropometric measurements (BMI Z-scores and weight loss), data about survival and number of hospitalization for febrile neutropenia (FN) in the first year after diagnosis. Cut-off values for malnourishment were chosen as BMI Z-score ≤-2.0.

RESULTS

One hundred twenty-six pediatric cancer patients were included in the study. At diagnosis 36 pediatric cancer patients (28.6%) were at high risk of malnutrition (STRONGkids 4 or 5), whereas 6 (4.7%) others were malnourished (BMI Z-score≤-2.0). The risk of mortality and the rate of infections (≥3 hospitalizations for FN episodes) were significantly increased by malnutrition and rapid weight loss in the initial phase of treatment (3-6 months after diagnosis). Multivariate analysis confirmed the independent effect of weight loss≥ 5% at 3 months on both survival and infections, and the independent impact of a high risk of malnutrition at diagnosis on infections.

CONCLUSIONS

A personalized evaluation of nutritional risk at diagnosis and a close monitoring of nutritional status during the initial phase of treatment are crucial for ensuring a timely and personalized nutritional intervention, which may potentially improve tolerance to chemotherapy and survival, and prevent prolonged hospitalization for infections in childhood cancer patients.

Effects of nutritional interventions on nutritional status in patients with gastric cancer: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND & AIMS

Nutritional interventions may improve quality of life, morbidity and mortality in gastric cancer (GC) patients. A growing number of randomized controlled trials (RCTs) evaluated different nutritional strategies - oral nutritional supplements (ONS), enteral nutrition (EN), enteral immunonutrition (EIN), parenteral nutrition (PN) and nutritional counselling - in GC patients. This systematic review and meta-analysis aims to assess the effects of these nutritional interventions on nutritional status of GC patients undergoing gastrectomy and/or chemotherapy.

METHODS

A systematic literature search was performed in Pubmed, Web of Science and Scopus databases from inception to March 2020, based on fixed inclusion and exclusion criteria. Effect sizes were estimated with mean difference (MD) or standard mean difference (SMD) with 95% confidence interval (CI) and heterogeneity was assessed by measuring inconsistency (I²) based on chi-squared test. Pooled analyses and quality assessment were performed with Review Manager 5.3.

RESULTS

A total of 25 RCTs were identified, including ONS (n = 7), EN (n = 6), PN (n = 4), EIN (n = 5) and nutrition counselling (n = 3) interventions. Ten RCTs with 1838 patients were deemed eligible for pooled analyses. Body weight loss was found lower in ONS group versus control group (MD 0.77; 95% CI -0.02-1.56; p = 0.05). PN and EIN studies did not assess body weight, while all nutrition counselling studies did not show significant differences (p > 0.05). Twenty-three out of 25 studies evaluated serum protein levels - albumin (ALB) and/or prealbumin (PA) and/or transferrin (TF). ALB levels did not significantly differ (p > 0.05) in 4 ONS studies. Significant improvements of PA levels from baseline to postoperative day (POD) ≥ 7 were shown in EN compared with PN groups (MD 19.90; 95% CI 10.09-29.70; p < 0.0001). Compared with EN, EIN interventions showed no significant improvements of ALB, PA and TF levels (p > 0.05) from baseline to POD ≥ 7. Amino-acid enriched PN showed no significant improvements of ALB, PA and TF levels (p > 0.05) while the effect of omega-3 enriched PN was debated. Only three studies out of 25 evaluated total fat mass and skeletal muscle mass and no significant differences (p > 0.05) were found between ONS versus control groups.

CONCLUSIONS

Whereas our meta-analysis showed promising results from ONS and EN interventions the optimal delivery of GC nutritional support and nutritional status assessment are still unclear. Moreover, the majority of studies did not consider muscle mass and strength as nutritional parameters. This review highlights the crucial need to close this research gap, with high-quality, large RCTs, adopting effective nutritional assessment tools to evaluate the appropriateness of nutrition strategies.

Early oral vs parenteral nutrition in acute pancreatitis: a retrospective analysis of clinical outcomes and hospital costs from a tertiary care referral center

Nutritional support is a crucial issue in Acute Pancreatitis (AP) management. Recommendations on nutrition in AP are still not completely translated in the clinical practice. We aimed to compare and evaluate the effects of parenteral nutrition (PN) vs oral/enteral nutrition (EN) on several clinical and economic outcomes in AP. This is a retrospective monocentric study conducted in a tertiary care center for pancreatic diseases. The primary outcomes were length of hospital stay (LOS) and associated costs. The secondary outcomes were the use and cost of antibiotics and fluid therapy, and the complication's rates. One hundred seventy-one patients were included from January 2015 to January 2018. Patients were 69 (40.4%) in PN group and 102 (59.6%) in EN group. There was a significant reduction in LOS in EN vs PN group in both mild AP (p < 0.0001), and moderate-severe AP (p < 0.005). There was a significant reduction in the total hospitalization costs in EN group vs PN group in both mild AP (p < 0.0001), and moderate-severe AP (p < 0.005). There was a significant reduction in the total costs of antibiotics and pain therapy in EN vs PN group (p < 0.0001 and p = 0.05, respectively). Finally, a significant reduction in the infected peri-pancreatic fluid collections rate (p = 0.04) was observed in EN vs PN group. The use of EN in AP is associated with substantial clinical and economic benefits. Thus, the application of the standard of care in nutrition and following AP guidelines is the best way to cure patients and improve healthcare system costs.

Skeletal muscle mass as a prognostic indicator of outcomes in ovarian cancer: a systematic review and meta-analysis

BACKGROUND

Muscle mass plays a key role in predicting clinical outcomes in cancer. This systematic review and meta-analysis aimed to evaluate whether computed tomography (CT) scan indexes of muscle mass quantity and quality could be used as prognostic factors in ovarian cancer.

METHODS

Three electronic bibliographic databases (MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials) were used to conduct a systematic literature search from inception to January 2020. The primary outcome was overall survival. Pooled analyses of hazard ratios (HRs) and 95% confidence intervals (CIs) were performed with Review Manager 5.3. Heterogeneity was assessed by measuring inconsistency (I² based on the χ² test). Secondary outcomes included progression free survival, disease free survival, postoperative complications, and chemotoxicity. Study quality and quality of evidence were assessed.

RESULTS

A total of 15 studies were included in the systematic review, of which six studies (1226 patients) were included in the meta-analysis. Summary unadjusted HRs (HR 1.11, 95% CI 0.84 to 1.46, p=0.47) and adjusted HRs (HR 1.10, 95% CI 0.84 to 1.43, p=0.49) did not show a significant association between low skeletal muscle index and overall survival (p>0.05) in ovarian cancer. Instead, although the quality of evidence was low, pooled data of three studies, comprising 679 patients, showed a significant association between low skeletal muscle radiodensity and poor overall survival (HR 1.63, 95% CI 1.28 to 2.07, p<0.0001). Moreover, the heterogeneity between studies precluded the possibility of performing a meta-analysis and reaching conclusions for progression free survival, disease free survival, surgical complications, and chemotoxicity.

CONCLUSIONS

This work suggested that the measurement of skeletal muscle radiodensity by routine CT scan at diagnosis, with standardization of diagnostic criteria, could be a reliable tool to select at risk patients and to individualize effective nutritional strategies. However, prospective homogeneous studies with a larger number of patients are required to confirm these results.

Switching From Immediate-Release to Fractionated Dual-Release Hydrocortisone May Improve Metabolic Control and QoL in Selected Primary Adrenal Insufficiency Patients

OBJECTIVE

The use of once-daily dual-release HC (DR-HC) in primary adrenal insufficiency (PAI) is often associated with benefits in metabolic parameters when compared to immediate-release HC (IR-HC). In this study, we evaluated the effects on clinical, biochemical and metabolic parameters of switching from IR-HC to lower-dose DR-HC given both in once and fractionated daily doses.

METHODS

Twenty autoimmune-PAI subjects were included. Patients on 30 mg/day divided in three doses IR-HC regimen (group A) were switched to DR-HC 25 mg/day given in two daily doses (20 mg in the morning and 5 mg at 2.00 p.m.); patients on 25 mg/day divided in two doses IR-HC regimen (group B) were switched to DR-HC 20 mg once daily. Biochemical and metabolic parameters, BMI and quality of life (QoL) were evaluated at the baseline and six months after the switch.

RESULTS

Our small non-randomized study with short follow up showed significant benefits in both group A and group B without any apparent side-effects. After the switch to DR-HC, a significant decrease in adrenocorticotropic hormone (ACTH), HbA1c, total cholesterol, triglycerides, LDL, cholesterol, BMI as well as a significant improvement in QoL, were observed in both groups. At 6 months, ACTH levels were lower in group A while HbA1C and total cholesterol were lower in group B.

CONCLUSION

The DR-HC is a valid and effective therapeutic strategy to improve the metabolic control and the QoL in PAI. The reduction of ACTH levels with DR-HC regimens reflects a better biochemical control of PAI, obtained by using a lower dose and more physiological HC formulation. Both once-daily and fractionated daily doses of DR-HC showed advantages compared with IR-HC formulation.