Peripheral endocannabinoids in eating disorders and obesity and its relationship with clinical and anthropometric variables

Introduction

Anandamide (AEA) and 2-Arachidonoylglycerol (2-AG) play a pivotal role in food intake and reward aspects of feeding. Aberrant functioning in the endocannabinoid system has been observed in patients with eating disorders (EDs). This dysfunction may influence the incentive processes stimulating behaviors towards food acquisition or the hedonic evaluation of ingested food.

Objectives

The aims of this study are to compare fasting peripheral levels of AEA and 2-AG in ED patients, obese subjects (OB) and healthy controls (HCs), and to explore their association with clinical and anthropometric variables.

Methods

The sample included a total of 63 adult women. Peripheral blood samples were collected to investigate fasting levels of AEA and 2-AG in 31 ED patients: 22 Anorexia Nervosa (AN) and 9 Binge Eating Disorder (BED), compared to 21 OB and 11 HCs. Several clinical and anthropometric variables were also assessed.

Results

Comparing groups, significant differences in AEA levels were found (p=0.001). Specifically, individuals with AN exhibited lower AEA than OB (p<0.001) and BED (p=0.007), while OB showed higher AEA than HCs (p=0.015). 2-AG was positively correlated with hostility dimension in EDs and negatively associated with impulsive traits in OB. AEA showed a direct association with body dissatisfaction in AN, contrary to OB. Finally, in AN, AEA negatively correlated with the body mass index, while 2-AG was positively associated with the fat mass.

Conclusions

These results suggest an interaction between biological and clinical factors defining a vulnerability pathway that could help fitting personalized therapeutic approaches in each condition.

Disclosure

No significant relationships.

Nutritional deficiencies and bone metabolism after endobarrier in obese type 2 patients with diabetes

Endobarrier® is a minimally invasive, reversible endoscopic treatment for obesity. It provokes malabsorption along 60 cm of the small intestine, which can contribute to the development of vitamin deficiencies and to changes in bone mineral density (BMD). To determine the prevalence of nutrient deficiencies, changes in body composition and BMD during the first year after Endobarrier® placement. Twenty-one patients with type 2 diabetes met inclusion criteria. Levels of vitamins, micro and macronutrients were assessed prior and at 1, 3 and 12 months post-operatively. DEXA was performed before and 12 months after implant. Nineteen patients completed the 12 months follow-up. Vitamin D deficiency was the most prevalent finding before Endobarrier® implant. The percentage of patients with severe deficiency decreased from 19 to 5% at 12 months after supplementation. Microcytic anaemia was initially present in 9.5% of patients and increased to 26.3% at 12 months. Low ferritin and vitamin B12 levels were observed in 14.2 and 4.8% of patients before the implant and worsened to 42 and 10.5%. Low concentrations of magnesium and phosphorus were also common but improved along the study. A significant but not clinically relevant decrease in BMD of 4.14 ± 4.0% at the femoral neck was observed at 12 months without changes in osteocalcin levels. Vitamin deficiencies are common after Endobarrier® implant. It is therefore important to screen patients prior to and at regular intervals after the implant, and to encourage adherence to diet counselling and supplementation.

Apo AIV and Citrulline Plasma Concentrations in Short Bowel Syndrome Patients: The Influence of Short Bowel Anatomy

INTRODUCTION

Parenteral nutrition (PN) dependence in short bowel syndrome (SBS) patients is linked to the functionality of the remnant small bowel (RSB). Patients may wean off PN following a period of intestinal adaptation that restores this functionality. Currently, plasma citrulline is the standard biomarker for monitoring intestinal functionality and adaptation. However, available studies reveal that the relationship the biomarker with the length and function of the RSB is arguable. Thus, having additional biomarkers would improve pointing out PN weaning.

AIM

By measuring concomitant changes in citrulline and the novel biomarker apolipoprotein AIV (Apo AIV), as well as taking into account the anatomy of the RSB, this exploratory study aims to a better understanding of the intestinal adaptation process and characterization of the SBS patients under PN.

METHODS

Thirty four adult SBS patients were selected and assigned to adapted (aSBS) and non-adapted (nSBS) groups after reconstructive surgeries. Remaining jejunum and ileum lengths were recorded. The aSBS patients were either on an oral diet (ORAL group), those with intestinal insufficiency, or on oral and home parenteral nutrition (HPN group), those with chronic intestinal failure. Apo AIV and citrulline were analyzed in plasma samples after overnight fasting. An exploratory ROC analysis using citrulline as gold standard was performed.

RESULTS

Biomarkers, Apo AIV and citrulline showed a significant correlation with RSBL in aSBS patients. In jejuno-ileocolic patients, only Apo AIV correlated with RSBL (rb = 0.54) and with ileum length (rb = 0.84). In patients without ileum neither biomarker showed any correlation with RSBL. ROC analysis indicated the Apo AIV cut-off value to be 4.6 mg /100 mL for differentiating between the aSBS HPN and ORAL groups.

CONCLUSIONS

Therefore, in addition to citrulline, Apo AIV can be set as a biomarker to monitor intestinal adaptation in SBS patients. As short bowel anatomy is shown to influence citrulline and Apo AIV plasma values, both biomarkers complement each other furnishing a new insight to manage PN dependence.

Diazoxide attenuates autoimmune encephalomyelitis and modulates lymphocyte proliferation and dendritic cell functionality

Activation of mitochondrial ATP-sensitive potassium (KATP) channels is postulated as an effective mechanism to confer cardio and neuroprotection, especially in situations associated to oxidative stress. Pharmacological activation of these channels inhibits glia-mediated neuroinflammation. In this way, diazoxide, an old-known mitochondrial KATP channel opener, has been proposed as an effective and safe treatment for different neurodegenerative diseases, demonstrating efficacy in different animal models, including the experimental autoimmune encephalomyelitis (EAE), an animal model for Multiple Sclerosis. Although neuroprotection and modulation of glial reactivity could alone explain the positive effects of diazoxide administration in EAE mice, little is known of its effects on the immune system and the autoimmune reaction that triggers the EAE pathology. The aim of the present work was to study the effects of diazoxide in autoimmune key processes related with EAE, such as antigen presentation and lymphocyte activation and proliferation. Results show that, although diazoxide treatment inhibited in vitro and ex-vivo lymphocyte proliferation from whole splenocytes it had no effect in isolated CD4(+) T cells. In any case, treatment had no impact in lymphocyte activation. Diazoxide can also slightly decrease CD83, CD80, CD86 and major histocompatibility complex class II expression in cultured dendritic cells, demonstrating a possible role in modulating antigen presentation. Taken together, our results indicate that diazoxide treatment attenuates autoimmune encephalomyelitis pathology without immunosuppressive effect.

Impact of multidisciplinary cancer care on the postoperative mortality and survival of patients with esophageal and esophagogastric junction cancer

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Background: Modern management of Oesophageal and oesophagogastric junction (OGJ) cancers requires a multidisciplinary approach, which was implemented at our health centre in 2005. This study aimed to assess the impact of this change on clinical outcomes. Methods: A retrospective cohort study was conducted, covering all patients treated for oesophageal and OGJ cancer at the cancer centre established by the Bellvitge University Hospital and Catalonian Institute of Oncology, over two time periods, i.e., 2000-2004 and 2005-2008. Descriptive and multivariate analyses were performed using survival at 1 and 3 years as dependent variables. Results: Between 1 January 2000 and 31 December 2008, 586 patients were included. Number of patients with unknown stage at diagnosis was significantly reduced. Neoadjuvant strategies at the oesophageal location clearly increased in the recent period. A multidisciplinary approach resulted in a significant reduction in surgical mortality (11.8% vs. 2%) in the period 2005-2008. Analysis restricted to patients undergoing surgery with curative intent indicated a significant increase in 1- and 3-year survival in the latter period (68.4% vs. 89.8% and 38.2% vs. 57.1% respectively). Multivariate analysis showed that variables associated with improved survival were: age; tumour stage; radical intent of treatment (surgery and radical combined chemoradiotherapy); and therapeutic strategy. Conclusions: Better selection of patients for therapy together with improved staging resulted in a significant improvement in 1- and 3-year survival in cases undergoing surgery with curative intent. These changes would support the adoption of a multidisciplinary approach to clinical decision-making in cases of oesophageal and OGJ cancer.

[Catheter occlusion and venous thrombosis prevention and incidence in adult home parenteral nutrition (HPN) programme patients]

In adult home parenteral nutrition (HPN) programme patients up to now no evidence-based recommendations exist on the central venous catheter maintenance nor venous thrombosis prevention. The use of heparin flushes could be linked with long term complications, besides, anticoagulants use is controversial.

OBJECTIVES

To be aware of the usual maintenance practice for HPN central venous catheters, catheter occlusion and related venous thrombosis incidence in our country.

METHODS

Retrospective study of active HPN patients older than 18 years registered by the NADYA- SENPE working group until November 2008.

RESULTS

49 patients were registered (16 males and 33 females), with an average age of 52.1 ± 13.9 years, belonging to 6 hospitals. HPN length was 57.4 ± 73.3 months with 5.8 ± 1.8 PN days a week. The most frequent pathologies were actinic enteritis, intestinal motility disorders and mesenteric ischemia (20.4% each), and neoplasm (16.3%). The reason for HPN provision was short bowel syndrome (49.0%), and intestinal obstruction (28.6%). Neoplasm (16.3%), thrombotic diathesis, thromboembolic syndrome and bed rest (6.1% each) were the main venous thrombosis adjuvant factors. Tunnelled catheters were used in 77.6% of patients, with implanted port-catheters in the remainder. Maintenance of the line was done with saline solution flushes (28.6%) and different concentrations of heparin solutions (69.4%). When heparin was used, it was removed before PN infusion in 63.3% of patients. Catheter occlusion and venous thrombotic events rates were 0.061/10³ and 0.115/10³ HPN days respectively. Eleven patients (22.4%) were treated with anticoagulant drugs due to previous episodes of venous thrombosis or pulmonary embolism.

CONCLUSION

[corrected] The incidence of catheter related thrombotic complications incidence is low in this group of patients on HPN. There is a great variety of practices focused on the prevention of both: line occlusion and catheter related venous thrombosis. In conclusion, it would be necessary to standardize practice.

[Home parenteral nutrition registry in Spain for the year 2010: NADYA-SENPE Group]

OBJECTIVES

To report the Group Registry NADYASENPE data about home parenteral nutrition (HPN) in Spain in 2010.

MATERIAL AND METHODS

A descriptive study of the database of the national registry of HPN of NADYA-SENPE (December 10, 2009 to December 10, 2010). For the calculation of prevalence the latest data published by the Institute National Statistics Office (01/01/2009) was used.

RESULTS

There were registered 148 patients from 23 hospitals, 86 women (58.11%) and 9 children (6.08%). The average age of the 139 patients older than 14 years was 53.06 ± 15.41 years. The average duration of HPN was 316.97 days/patient. The most common diagnosis in those younger than 14 years was short bowel traumatic with 5 cases (55.55%) and in those older than 14 years, palliative care cancer with 29 cases (19.59%). The reason for the indication for HPN was short bowel syndrome in 74 cases (47%). The access via most frequently recorded was tunneled catheter in 36 cases (22.78%) followed by implanted port-catheters in 13 cases (8.23%) and other pathways in 3 cases (1.90%). There were 23 catheterrelated infections (82.14%) which represented 0.49 /1,000 days of PN, all of which occurred in cases older than 14 years. During the year 24 episodes of HPN ended, the most frequent cause was the transition to oral nutrition in 12 episodes (50%). It was reported that patients had a normal activity in 70 episodes of HPN (44.30%) with complete autonomy in 88 episodes (55.69%). Some patients 39 (24.68%) were potential candidates for intestinal transplantation.

CONCLUSIONS

The number of registered patients is slightly lower than the previous year, although the number of participating hospitals is the same. The most frequent complication remains catheter-related infection but its incidence has decreased from previous years, presenting the lowest rate since the creation of the record. Differences in participation in the registry observed in the Autonomous Communities causes the development of implementation strategies. There is a gradual increase in day length of HPN over the years, which suggests the chronic treatments of some patients and obliges to study the existence of a possible confounding factor, in case there is an oversight of closing an episode. Therefore, it is necessary to update the registry with warning systems that facilitate periodic review of the patients and optimize the validity of registration.

[Home Parenteral Nutrition (HPN) registry in Spain for the years 2007, 2008 and 2009 (NADYA-SENPE Group)]

OBJECTIVE

To report the data of the Home Parenteral Nutrition (HPN) registry of the NADYA-SENPE working group for the years 2007, 2008 and 2009.

METHODOLOGY

We compiled the data from the on-line registry introduced by the responsible Units for the monitoring of HPN from January 1st 2007 to December 31st 2009. Included fields were: age, sex, diagnosis and reason for HPN, access path, complications, beginning and end dates, complementary oral or enteral nutrition, activity level, autonomy degree, product and fungible material supply, withdrawal reason and intestinal transplant indication.

RESULTS

2007: 133 patients with HPN were registered (61 males and 72 females), belonging to 21 hospitals. Average age for the 119 patients older than 13 years old was 53.7 ± 14.9 years, and 3.6 ± 3.6 y. for the 14 patients under 14 years old. Most frequent pathology was neoplasm (24%), followed by intestinal motility disorders and actinic enteritis (14% both). The reason for HPN provision was short bowel syndrome (43%), malabsorption (27%), and intestinal obstruction (23%). Tunnelled catheters were mostly used (69%), followed by implanted port-catheters (27%). Catheter related infections were the most frequent complications, with a rate of 0.92 episodes/103 HPN days. HPN was provided for more than two years in 50% of the cases. By the end of 2007, 71.4% of the patients remained active; exitus was the most frequent reason to end HPN (57.5%). 26% of the patients were eligible for intestinal transplant. 2008: 143 patients with HPN were registered (62 males and 81 females), belonging to 24 hospitals. Average age for the 133 patients older than 13 years old was 54.7 ± 13.9 years, and 3.7 ± 0.6 y. for the 10 patients under 14 years old. Most frequent pathology was neoplasm (20%), followed by actinic enteritis (14%) and intestinal motility disorders (13% ). The reason for HPN provision was short bowel syndrome (44%), malabsorption (28%), and intestinal obstruction (20%). Tunnelled catheters were mostly used (60%), followed by implanted port-catheters (29%). Catheter related infections were the most frequent complications, with a rate of 0.50 episodes/10³ HPN days. HPN was provided for more than two years in 67% of the cases. By the end of 2008, 71.6% of the patients remained active; exitus was the most frequent reason to end HPN (52.4%). 29% of the patients were eligible for intestinal transplant. 2009: 158 patients with HPN were registered (62 males and 96 females), belonging to 24 hospitals. Average age for the 149 patients older than 13 years old was 55.2 ± 13.0 years. Most frequent pathology was neoplasm (25%), followed by actinic enteritis (12%) and intestinal motility disorders (11%). The reason for HPN provision was short bowel syndrome (42%), malabsorption, and intestinal obstruction (23% both). Tunnelled catheters were mostly used (60%), followed by implanted port-catheters (36%). Catheter related infections were the most frequent complications, with a rate of 0.67 episodes/10³ HPN days. HPN was provided for more than two years in 58% of the cases. By the end of 2009, 79.2% of the patients remained active; full oral nutrition was the most frequent reason to end HPN (48%). 23% of the patients were eligible for intestinal transplant.

CONCLUSIONS

We observe an increase in registered patients with respect to previous years, with a very different prevalence among regions. Neoplasia remains as the main pathology since 2003. We observe a decrease in catheter-related infections in the last two years, being the 2008 rate the smallest since the register's beginning.

[Transversal study on the prevalence of Metabolic Bone Disease (MBD) and Home Parenteral Nutrition (HPN) in Spain: data from NADYA group]

Patients with intestinal failure who receive HPN are at high risk of developing MBD. The origin of this bone alteration is multifactorial and depends greatly on the underlying disease for which the nutritional support is required. Data on the prevalence of this disease in our environment is lacking, so NADYA-SEMPE group has sponsored this transversal study with the aim of knowing the actual MBD prevalence.

MATERIAL AND METHODS

Retrospective data from 51 patients from 13 hospitals were collected. The questionnaire included demographic data as well as the most clinically relevant for MBD data. Laboratory data (calciuria, PTH, 25 -OH -vitamin D) and the results from the first and last bone densitometry were also registered.

RESULTS

Bone mineral density had only been assessed by densitometry in 21 patients at the moment HPN was started. Bone quality is already altered before HPN in a significant percentage of cases (52%). After a mean follow up of 6 years, this percentage increases up to 81%. Due to retrospective nature of the study and the low number of subjects included it has not been possible to determine the role that HPN plays in MBD etiology. Only 35% of patients have vitamin D levels above the recommended limits and the majority of them is not on specific supplementation.

CONCLUSIONS

HPN is associated with very high risk of MBD, therefore, management protocols that can lead to early detection of the problem as well as guiding for follow up and treatment of these patients are needed.

Is plasma 25(OH) D related to adipokines, inflammatory cytokines and insulin resistance in both a healthy and morbidly obese population?

To analyse in a cohort of healthy subjects and in a group of morbidly obese patients, we studied the association amongst 25(OH) D and plasma concentrations of adipocytokines, inflammatory cytokines and insulin resistance. We also aimed to determine whether vitamin D-deficient patients showed a greater inflammatory profile. In the observational study that the authors conducted, plasma concentrations of 25(OH) D, leptin, resistin, adiponectin and interleukine-18 were determined in 134 healthy men and 127 women. In the population consisting of 44 patients with morbid obesity, plasma concentrations of 25(OH) D, leptin, resistin, adiponectin, interleukine-18, soluble tumor necrosis factor receptors 1 and 2 and C-reactive protein were analysed. In the healthy population, plasma 25(OH) D showed a negative correlation with body mass index, body fat, waist, hip circumference and with leptin. However, no significant associations were found amongst 25(OH) D and plasma concentrations of resistin, adiponectin or interleukine-18. Patients with vitamin D deficiency showed higher body mass index, fat mass percentage and higher leptin concentrations compared with subjects with normal 25(OH) D concentrations. In the morbidly obese subjects, 25(OH) D did not correlate with leptin, resistin, adiponectin, interleukine-18, soluble tumor necrosis factor receptors 1 and 2 or with C-reactive protein. In patients with morbid obesity, no differences were found in adipokines and inflammatory cytokines concentrations regarding 25(OH) D status. No associations were found either between 25(OH) D and plasma glucose and insulin resistance or with lipid profile. Plasma 25(OH) D concentrations are associated with adiposity markers but not with adipocytokines implicated in inflammation. This lack of association does not support a major role of 25(OH) D in the pro-inflammatory environment observed in morbidly obese subjects. In addition, subjects with vitamin D deficiency are not characterized by a greater inflammatory state.

Evaluation of bone disease in morbidly obese women after gastric bypass and risk factors implicated in bone loss

BACKGROUND

In patients undergoing gastric bypass, massive weight loss and impairment of calcium intake and absorption in the duodenum and proximal jejunum may increase the risk of bone mass loss and fractures. However, few data are available regarding the impact of this surgery on the skeleton. The aim of our study was to examine the skeletal changes in a cohort of morbidly obese Caucasian women during the first year after gastric bypass and to analyse the factors implicated in the development of bone loss.

METHODS

Sixty-two morbidly obese white women aged 45.3 +/- 8.9 years were studied. Anthropometric measurements, bone mineral density (BMD) screening using dual-energy X- ray absorptiometry and plasma determinations of calcium, phosphorus, parathyroid hormone (PTH), 25-hydroxyvitamin D [25(OH) D(3)] and insulin-like growth factor-I (IGF-I) were made prior to and 12 months after surgery.

RESULTS

A year after surgery, BMD significantly decreased at the femoral neck (10.2 +/- 5.7%) and at the lumbar spine (3.2 +/- 4.4%). In the follow-up, 16.1% of women had osteopenia at the femoral neck and 19.3% at the lumbar spine, and 1.6% developed osteoporosis at the lumbar spine. Patients with bone disease were significantly older; the percentage of women with menopause was greater in this group and had lower initial and final values of lean mass. However, no differences in body mass index, weight loss, fat mass, calcium, PTH, 25(OH) D(3) or IGF-I values were found between groups. In the logistic regression analysis, lean mass 12 months after surgery and menopause were found to be the main determinants of osteopenia after adjusting for age with odds ratios of 0.82 and 9.13, respectively.

CONCLUSIONS

There is a significant BMD loss at the femoral neck and lumbar spine a year after gastric bypass. Menopausal patients and those with greater lean mass loss are at greater risk and, consequently, should be closely followed up with periodic densitometries.

[Spanish Registry of Home-based Parenteral Nutrition during 2006 (NADYA-SENPE Group)]

OBJECTIVE

To report the data of the Home Parenteral Nutrition (HPN) registry of the NADYA-SENPE working group for the year 2006.

METHODOLOGY

We compiled the data from the on-line registry introduced by the responsible Units for the monitoring of HPN from January 1st to December 31st 2006.

RESULTS

103 patients with HPN were registered (47 males and 56 females), belonging to 19 hospitals. Average age for the 91 patients older than 14 years old was 53.3 +/- 14.9 years old, and that for the 12 patients under 14 years old was 2 +/- 0 years old. Most frequent pathology was neoplasm (29%), followed by intestinal motility disorders (13%). The reason for HPN provision was short bowel syndrome (40%), intestinal obstruction (22%), and malabsorption (21%). Tunneled catheters were mostly used (45%), followed by implanted port-catheters (32%). Catheter related infections were the most frequent complications, with a rate of 0.85 episodes / 10(3) days. HPD was provided for more than two years in 50% of the cases. By the end of 2006, 70.9% of the patients remained active; exitus was the most frequent reason to end HPN (53%). Complementary oral or enteral nutrition was provided to 52% of the patients. 48% of the patients had a normal activity level, and a 55% were autonomous. PN formula was supplied by the hospital in 82% of the cases, while this number was 78% for fungible materials. 27% of the patients were eligible for intestinal transplant.

CONCLUSIONS

We observe an increase in registered patients with respect to previous years, with a very different prevalence among regions. Neoplasia remains as the main pathology since 2003. We observe a decrease in catheter-related infections with respect to the 2004-2005 period.

[Spanish registry of Home-Based Parenteral Nutrition for the years 2004 and 2005 (NADYA-SENPE Group)]

OBJECTIVE

To report the results of the Home Parenteral Nutrition (HPN) registry of the NADYA-SENPE working group of the years 2004 and 2005.

MATERIAL AND METHODS

We summarized the data of the new on-line HPN registry of the NADYA-SENPE group for the period 2004-2005.

RESULTS

During the year 2004, 70 HPN-patients (23 males and 47 females) were registered from 14 hospitals. Mean age of adults was 53,7 +/- 14,87 years (m +/- SD) and 6 +/- 2,83 years for those younger than 14 years. The most frequent etiologies of the intestinal failure were neoplasia (24%) and mesenteric ischaemia (19%). Tunnelled catheters were used in 75% of the patients. The catheter-related infections were the most frequent complications, with a rate of 0,98 episodes/10(3) days. In 69% of the cases the nutritional support was maintained for more than 2 years. HPN solutions and disposables were supplied by the hospital pharmacy in 81% and 83%, respectively. Up to 54% of the patients had a normal activity level. The most frequent reasons to end HPN treatment were the transition to oral intake (41%), or exitus (28%). During the year 2005, 79 patients (33 males and 46 females) were registered from 14 hospitals. Mean age of adults was 52,39 +/- 14,21 years and 6,5 +/- 5,21 years for those younger than 14 yrs. The most frequent etiologies of the intestinal failure were neoplasia (22%), and mesenteric ischaemia (15%). Tunnelled catheters were used in 63% of the patients. The catheter-related infections were the most frequent complications, with a rate of 1,14 episodes/10(3) days. In 51% of the cases the nutritional support was maintained for more than 2 years. HPN solutions and disposables were supplied by the hospital pharmacy in 76% and 81%, respectively. Up to 50% of the patients had a normal activity level. The most frequent reasons to end HPN treatment were the transition to oral/enteral feeding (41%) and exitus (31%).

CONCLUSIONS

We have observed a mild decrease in the number of HPN patients registered in the period 2004-2005, probably related to the change of the registry. The characteristics of the patients are similar to previous years. We have observed an increase in the septic catheter-related complications in the year 2005.

[The year 2003 National Registry of Home-based Parenteral Nutrition]

OBJECTIVE

To report the results of the Home-based Parenteral Nutrition (HBPN) registry of the NADYA-SENPE working group, for the year 2003.

MATERIAL AND METHODS

Gathering of registry data introduced by all units responsible of HBPN patient care. This an on-line registry available for authorized users of the working group web page (www.nadya-senpe.com). Epidemiological data, diagnosis, access route, complications, hospital admissions, disability degree, and course at December 31st, 2003

RESULTS

Data from 86 patients (62% female and 38% male) from 17 hospitals were gathered. Mean age of adult patients was 50.7 +/- 15.0 years, whereas for patients younger than 14 years was 2.4 +/- 1.5 years (n = 5 patients). Diseases that prone HBPN were neoplasm (21%), followed by mesenteric ischemia (20%), radiation enteritis (16.3%), motility impairments (10.5%), and Crohn's disease (4.6%). Tunneled catheters were used in 66.3% of the cases versus 29.1% of subcutaneous reservoirs. Mean treatment duration has been 8.5 +/- 4.6 months; 67.4% of patients had been on HBPN for a period of time longer than 6 months. Patient follow-up was mostly done from the reference area hospital (88.4%). In no case patient follow-up was done by the primary care team or by specialists other than those prescribing nutritional support. Nutritional support-related complications were seen in 98 occasions. The most frequent complications were infectious ones. They represented 1.60 hospital admissions per patient. The mean number of visits was 7.9 per patient (6.4 for scheduled visits and 1.5 for emergency visits). By the end of the year, we observed that 73.3% of the patients were still on the program, whereas in 23.3% HBPN had been withdrawn. The main reasons for withdrawal were decease (11 patients), and advancing to oral diet (9 patients). As for the disability degree, 13% were confined to a wheelchair or bed, and only 28% had no disability degree or only mild social disability.

CONCLUSIONS

We observed a mild increase in HBPN prevalence rate in Spain (2.15 patients pmp). The main indication was cancer followed by short-bowel syndrome secondary to vascular pathology. Nutritional support-related complications were common, especially those of an infectious origin.

[The year 2002 national register on home-based parenteral nutrition]

AIM

To report on the results of the Registry on Home-based Parenteral Nutrition (HPN) of the NADYA-SENPE working group, corresponding to the year 2002.

MATERIALS AND METHOD

Compilation of the registry data loaded by the Units in charge of HPN patients care. It consists of an on-line registry available to the registered users of the group's web page (www.nadya-senpe.com). Epidemiological, diagnostic, access route, complications, hospital admissions, degree of disability, and course until December 31st of 2002.

RESULTS

Data from 74 patients were gathered (56.8% women and 43.2% men), from 18 hospital centers. Mean age of adult patients was 49.4 +/- 15.5 years and 2.3-1.1 years for patients younger than 14 years (n=3 patients). Diseases that prompted the use of HPN were mesenteric ischemia (29.7%), followed by neoplasms (16.2%), radiation enteritis (12.2%), motility impairments (8.1%), and Crohn's disease (5.4%). Tunneled catheters were used in 52.7% of cases, as compared to 36.5% of subcutaneous reservoirs. Mean treatment duration was 8.7 +/- 4.4 months; 68.9% of patients remained on HPN for a duration longer than 6 months, and in 41.9% longer than one year. Patients' follow-up was mainly done from the reference hospital (87.8%), and the remaining patients (12.5%) by the home care team. In no case patients were followed by the primary care team or other specialists than the ones that prescribed nutritional support. In 94 cases there were complications related to nutritional therapy. The more frequent complications presented were infectious. These complications represented 1.84 admissions per patient. The mean number of visits was 12.9 per patient (10.2 routinary visits and 2.7 emergency visits). At the end of the year, we observed that 74.3% patients stayed in the program, whereas in the remaining 23.6% HPN had been discontinued. The main causes for discontinuation were death (52.9%), and switch to oral diet (23.5%) or enteral nutrition (11.8%). With regards to disability degree, 16.1% were confined to a wheelchair or bed, and 17.6% had no disability at all or only a mild social disability.

CONCLUSIONS

We observed a sustained HPN prevalence rate in Spain (1.8 patient pmp). The main cause for its use was short bowel syndrome secondary to vascular disease, followed by cancer. Complications associated to nutritional therapy were common, especially of infectious origin.

[Home Enteral Nutrition: National Registry 2001]

GOAL

The NADYA-SENPE Working Group analyzed the registered data of patients on Home Enteral Nutrition (HEN) in our country, during year 2001.

MATERIAL AND METHODS

The data were collected through a closed questionnaire included on our web site (www.nadya-senpe.com). Apart from epidemiological information, the form includes the indication to prescribe this treatment, the specific nutritional treatment used and its duration, access path, complications and readmission rate in hospital, follow-up of the treatment, patient's quality of life and progress. All data were processed and analyzed by the coordinating team.

RESULTS

Twenty two hospitals participated and 3,458 patients, aged 5.6 +/- 4.0 y for those younger than 14 y, and 67.1 +/- 19.5 y for those older than 14 y, were enrolled. Of these patients, 43.4% were diagnosed with neurological diseases and 33.5% with cancer. The mean time on HEN was 6.5 +/- 4.5 months. Oral nutrition was the preferential route (54.5%), followed by nasoenteral tube (32.3%), and in 13.3% ostomy tubes were placed. Polymeric was the formula composition mainly used (85.9%). Patients were followed (71.1%) by the hospital reference Nutritional Support Unit. The complications related to nutrition included mainly the gastrointestinal (0.16 complications/patient), and the mechanical one (0.15 complications/patient). At the end for the year, 48.3% of the patients were in the HEN program, and in 33.3% HEN was finish due to different reasons. In 22.9% of the patients no, o light, discapacity degree was found.

CONCLUSIONS

Neurological diseases and cancer were the more frequent diagnoses in HEN patients. Oral access was the higher feeding route due, probably, to the high prevalence of cancer patients. In spite of the elevated prevalence of neurological diseases, a few number of patients, as previous years, were feed with ostomy tube. Due to the few complications observed, HEN is a safe treatment in our country.

Plasma urea-cycle-related amino acids, ammonium levels, and urinary orotic acid excretion in short-bowel patients managed with an oral diet

BACKGROUND AND AIMS

The small intestine contains several enzymes involved in arginine synthesis and converts glutamine to citrulline, the major compound for endogenous arginine synthesis. This study was conducted to assess the plasma status of urea-cycle intermediates and orotic urinary excretion in short-bowel patients.

METHODS

Thirteen stable short-bowel syndrome patients (7 men; 60.2+/-15.2 years) were studied. Patients were divided into moderately resected (Group A; n=6) and severely resected (Group B; n=7) according to their remnant bowel length (Group A: 61-150 cm; Group B: < or =60 cm). All subjects were consuming an oral diet plus dietetic supplements. Plasma urea-cycle amino acids, ammonium and urinary orotic acid were determined.

RESULTS

Plasma glutamine levels were significantly higher in both patient groups than in the control group (P<0.001). Regarding citrulline, Group B levels were significantly lower vs. controls (P<0.001). Comparisons between patient groups showed higher arginine in Group A (P<0.05) and non-statistically lower citrulline in Group B. Blood ammonium and orotic urinary excretion were normal.

CONCLUSIONS

Although plasma citrulline and glutamine alterations were found, patients showed no hyperammonemia or orotic aciduria, which suggests a certain degree of adaptation in arginine and related amino acid metabolism, when an adequate dietary supply of arginine is provided.

Do corticosteroids add any benefit to standard GVHD prophylaxis in allogeneic BMT?

In a retrospective study, we compared 15 patients who received cyclosporine (CsA), methotrexate (MTX) and prednisone (PDN) and 15 patients who received CsA-MTX for GVHD prophylaxis after allogeneic BMT (HLA-identical sibling (n = 22), related one HLA mismatch (n = 1), unrelated matched donors (n = 6), unrelated one HLA mismatch (n = 1)). The primary objectives of this study were to compare the incidence of GVHD and post-transplantation complications. Secondary objectives were to compare relapse rate, transplant-related mortality and overall survival. The incidence of acute GVHD grade III-IV was similar between the two groups (P = 0.66), as was the incidence of chronic GVHD (P = 0.67). Incidence of arterial hypertension was significantly higher in patients who received prophylactic PDN, (P = 0.03) and more insulin treatment was required in this group (P = 0.003). We observed no differences in the incidence of infections or upper digestive tract bleeding. Musculoskeletal complications appeared earlier in the group which received PDN. With a median follow-up of 4.4 years, patients in the CsA-MTX group had better overall survival, 46.7% vs 13.3% (P = 0.026). Relapse was a more frequent cause of death in the CsA-MTX group, whereas procedure-related mortality was more frequent in the CsA-MTX-PDN group (P = 0.013). These results suggest that prophylactic prednisone when combined with cyclosporine and methotrexate adds no benefit in acute or chronic GVHD prevention and may increase the morbidity of allogeneic transplantation. Corticosteroids may be reserved for GVHD treatment.

Serum albumin as indicator of clinical evolution in patients on parenteral nutrition. Multivariate study

BACKGROUND AND AIMS

The aim of this study is to establish whether serum albumin concentration at the beginning of parenteral nutrition is related to morbidity and mortality.

METHODS

In this cohort study spanning four years, a number of patients were classified into twelve groups, depending on their clinical status at the beginning of parenteral nutrition. Their serum albumin concentration and other clinical parameters were then measured and twelve multiple logistic regression models were thus generated in order to model the relationship between initial albumin concentration and risk of morbidity/mortality.

RESULTS

1953 (84%) of the 2321 patients studied were hypoalbuminemic. In six models, this condition was associated with a significant increase in the risk of nosocomial infection. However, no model could be associated to significant risk of renal failure, and only patients with previous hepatopathy were at risk for hepatic failure. In seven models, there was a significant increase in mortality.

CONCLUSIONS

Serum albumin concentration at the beginning of parenteral nutrition is related to mortality and morbidity associated with nosocomial infection in some groups of the study.

Serum leptin concentrations in patients with short-bowel syndrome

BACKGROUND

Short-bowel syndrome is a state of severe malabsorption resulting from absence or removal of the small bowel for several causes. A number of short-bowel patients develop hyperphagia. Leptin, a protein secreted from adipose tissue, signals the amount of energy stores to the brain.

OBJECTIVE

To study body composition and leptin regulation in short-bowel patients and to determine whether or not leptin concentrations are linked with hyperphagia.

DESIGN

We studied 25 short-bowel patients (remnant bowel less than 150 cm) and 31 controls and 10 oral nutrition. Fifteen patients received total parenteral nutrition and 10 oral nutrition. Anthropometric measurements, body composition (by bioelectrical impedance), and cholesterol, triacylglycerol and leptin concentrations were studied in all subjects.

RESULTS

There were no differences between short-bowel patients and controls in anthropometric variables, body composition, or leptin concentrations. Leptin concentrations were higher in short-bowel women than men (9.21+/-8.54 vs. 3.22+/-1.86 ng/ml, P=0.01). Leptin concentrations correlated positively with age (r=0.4, P=0.045), body mass index (r=0.52, P=0.007), fat mass (r=0.67, P=0.001) and body fat (r=0.68, P=0.0001); there were no correlations with other body composition parameters. We found no correlations between parenteral or oral nutrition and body composition parameters, or between leptin concentrations and the presence of hyperphagia. Logistic regression analysis showed that body fat correctly identified leptin concentrations in 60% of patients.

CONCLUSIONS

Body composition, leptin concentrations and leptin regulation in patients with short-bowel syndrome are similar to those of controls. Leptin concentrations do not correlate with hyperphagia in short bowel-patients.

[Home enteral nutrition]

Enteral nutrition in the home is applied to stabilized patients who do not require hospitalization or to chronically ill patients who can stay in their homes. However, ensuring the correct administration of this treatment requires a coordinated, expert multidisciplinary team. This article reviews the conditions for use of enteral nutrition in the home, the means of access, the nutritional formulas, the administrative technique, and the complications enteral nutrition in the home may present. Furthermore, the composition and characteristics of the multidisciplinary team which will be in charge of carrying out this treatment is discussed.

Evaluation of immune markers in asymptomatic AIDS patients receiving fish oil supplementation

The effects of oral fish oil (FO) supplementation (8 g/day, capsules) on nutritional status and selected immune markers (CD4/CD8 ratio, IL-1beta, erythrocyte MDA release, dehydroepiandrosterone sulfate [DHEA-S]) were studied in a homogeneous group of asymptomatic HIV-infected patients during 6 weeks. All subjects were classified clinically as A2 according to the CDC revised criteria (mean CD4 count 290 +/-123 cells/mm(3)) and were receiving zidovudine retroviral treatment. The calculated mean energy intake was 3437 +/- 372 Kcal/d, composed of 14% protein, 38% lipids and 48% carbohydrates, and was not modified during the study. The anthropometric parameters, and hematological and plasma biochemistry data showed non-significant changes after FO supplementation. Mean malonyldialdehyde (MDA) release before treatment was: unstimulated 71.5 +/- 37 and stimulated 350.9 +/- 79.8 nmol/g Hb. After FO supplementation (T(6)) MDA release showed unstimulated values of 96.1 +/- 62, and a significant increase after stimulation of 614.1 106.4 nmol/g Hb, which was, however, within the normal range. In the patient's samples, IL-1beta levels in the unstimulated blood culture showed a statistical increase with respect to the normal range before (T(0)) and after (T(6)) FO supplementation with a slight decrease after (mean 49.8 vs 40.9 pg/ml). The stimulated IL-1beta levels after treatment showed a statistically significant decrease that was maintained within the normal range (T(0): 797.7 vs T(6): 535.6 pg/ml). Taken collectively, these results suggest a tendency toward improvement in immune function.

[A practical nursing guide for the planning and evaluation of the care of the patient with domiciliary parenteral nutrition. The planning of patient care with DPN]

We present a proposal for the planning of nursing care for the patient with home parenteral nutrition (HPN). In this proposal the problems, goals, and actions to be taken by the nurse are defined. In this working guide, it is explained what the diverse aspects are that the nurse taking care of a patient with HPN needs to know, as well as the care to be given and the evaluation of the same, in order to insure that the patient with HPN is given a good preparation in his self-care, giving the patient an acceptable degree of independence and quality of life, as well as a lower risk of complications.

[Changes in the biochemical parameters during parenteral nutrition. The experience in Hospital de Bellvitge]

The purpose of this study is to evaluate the modifications in biochemical parameters before and after the initiation of nutritional therapy, and to observe whether there is a relationship between the patient's development (exitus or improvement) and the presence of sepsis. The study was performed on 578 adults treated in our hospital from January 1988 to October 1989. The parameters analyzed were the following: glucose, triglycerides, total proteins, albumin, cholesterol, alkaline phosphatase, GOT, GPT, bilirubin, GGT, urea, urates, creatinine and electrolytes. The average initial values of each parameter were compared against those obtained after interrupting the PN by means of the Student t test. The results showed that within the parameters indicating the hepatic function, GGT and alkaline phosphatase were those that showed the most significant differences after ceasing the PN. Furthermore, the parameters indicating hepatic function and the electrolytes showed greater variations, regardless of the clinical evolution of the patient (improvement or exitus). The remainder of the parameters showed significant variations based on the clinical evolution.

Growth hormone response to thyrotropin-releasing hormone in acromegalic patients: reproducibility and dose-response study

The aim of the study was to analyze 14 consecutive patients with active acromegaly who had not undergone any therapy, the dose response of growth hormone (GH) to thyrotropin-releasing hormone (TRH), the existence of reproducibility of such response as well as to rule out the possibility of spontaneous fluctuations of GH which would mimic this response. On several nonconsecutive days, we investigated the GH response to saline serum, 100, 200 (twice) and 400 micrograms of TRH administration. We also studied both basal serum prolactin, serum prolactin after TRH administration and thyrotropin values. Our results show an absence of GH response after saline serum infusion, whereas after TRH doses, 36.3 42.8 and 45.4% positive responses were obtained, respectively. All GH responders were concordant to the different doses administered. The mean of GH concentrations of the different doses at different times did not reach significant differences. The response to the administration of the same dose brought about a significative increase, although it was not identical. It demonstrated a progressive increase of the area under the response curve, as did the means of increments after each TRH administration, albeit without reaching statistical significance. Between the GH-responding and GH-nonresponding groups there were no differences in either basal serum prolactin or serum prolactin and thyroid-stimulating hormone levels after TRH stimulation. The present study clearly shows that TRH elicits serum GH release from GH-secreting pituitary tumors. The response was reproducible in qualitative terms rather than quantitative, and no dose-response relationship was found between the TRH concentrations and the amounts of GH secreted.

[Thyroid dysfunction induced by amiodarone in Catalonia. Prevalence and characteristics]

The purpose of this study was to review the epidemiological aspects and the characteristics of the thyroid disfunction produced by amiodarone in Catalonia, an area with type I endemic goiter. For this purpose, three groups of patients have been studied: 1) 102 patients with prolonged amiodarone treatment, out of whom 6 (5.9%) presented hyperthyroidism, and 2 (1.9%) hypothyroidism. 2) 909 patients with hyperthyroidism of any origin out of which 42 (4.6%) were produced by amiodarone. 3) 203 patients presenting primary hypothyroidism of any origin out of which 11 (3.8%) were induced by amiodarone. Out of the 48 patients with amiodarone induced hyperthyroidism, 16 presented multinodular goiter, 2 toxic thyroid goiter and 7 Graves Basedow disease. Thyroid uptake of 131I was studied in 10 cases being normal or increased in six of them, all with a underlaying thyroid pathology. Out of the 13 patients with amiodarone induced hypothyroidism, 3 presented diffuse goiter; thyroid uptake of 131I was studied in 5 patients, being normal or increased in 4 cases, 2 of which with thyroid pathology. Amiodarone administration very often produces thyroid disfunction, specially hyperthyroidism. These patients with hyperfunctional thyroids usually present underlying thyroid pathologies in which thyroid uptake of 131I are frequently not suppressed as well as in those patients in whide amiodarone induced hypothyroidism.

Transient hypothyroidism after iodine-131 treatment of Graves' disease

One hundred twenty six patients with Graves' disease, 26 with toxic multinodular goiter, and 18 with toxic adenoma were treated with 131I (3-15 mCi), and followed at monthly intervals for six months. Transient hypothyroidism occurred at two months in 22 patients with Graves' disease. In this state TSH levels became elevated in seven patients, but were normal or suppressed in seven. In 17 patients T4 and T3 levels returned to normal without T4 replacement. Five patients developed recurrent thyrotoxicosis, and required repeated doses of 131I. The possibility of transient hypothyroidism in the early months after 131I therapy in Graves' disease should be borne in mind.