María Dolores Ballesteros Pomar

Efficacy of enteral nutritional support after hospital discharge in major gastrointestinal surgery patients: a systematic review

INTRODUCTIONnNutritional support for malnourished patients undergoing gastrointestinal surgery reduces the complication rate and shortens the length of stay. The efficacy of nutritional support after hospital discharge was analyzed in this systematic review.nnnMETHODSnThe search strategy (nutrition OR enteral nutrition OR nutritional supplements OR oral nutritional supplements OR sip feed OR sip feeding OR dietary counseling) AND (patient discharge OR discharge OR postdischarge) AND (surgery OR operation OR surgical procedure) was followed in Medline, CENTRAL, and Trip databases. Inclusion criteria comprised: type of study (randomized controlled trial), language (English, Spanish), and subjects (patients undergoing gastrointestinal surgery). The risk of bias was assessed by using the Cochrane methodology.nnnRESULTSnFive studies which were published in six different articles and recruited 446 patients were included. A high risk of bias was detected for most of them. Nutritional support improved energy intake and protein intake when high-protein oral supplements were provided. The intervention was associated with better weight prognosis, but the data about body composition were inconsistent. In most of the trials, nutritional intervention did not enhance functional capacity or quality of life. None of the studies analyzed the effects on complications after discharge.nnnCONCLUSIONnNutritional support provided at discharge may increase dietary intake and improve body weight, but the low quality of studies can weaken the validity of results.

Papel de los prebióticos y los probióticos en la funcionalidad de la microbiota del paciente con nutrición enteral

Set of resident microorganisms in our body that are responsible for the absorption of nutrients and the maintenance of health is named microbiota. The microbiota´s role is protective, trophic and metabolic. Different groups of microbiota intestinal name enterotypes, each one of them are in relation to specific dietary habits. The absence of enteral stimulation affects both epithelial and GALT and the development of the microbiota. This situation modifies the immune system´s interaction, with a less competitive exclusion of more pathogenic bacteria, which can promote infections. These changes are likely reversible when supplementation with enteral nutrition is used. Dietary fibre and probiotics, to be fermented by colonic microbiota produce gases and short-chain fatty acids causing an acid pH in the large intestine which hinders the growth of pathogenic microorganisms. The administration of probiotic with enteral nutrition in critically ill patients was associated with lower rates of infection with no effect on mortality, average stay, or diarrhea. Also proposed as a strategy to reduce infectious complications in elective surgery and to reduce the time of tolerance of enteral feeding in preterm or low birth weight. In acute pancreatitis, it has been suggested a possible role of probiotics to restore intestinal integrity, but more safety studies are needed. There are isolated cases of bacteremia, sepsis or endocarditis usually in immunocompromised patients. Yet the benefits appear to be greater than the risks.Set of resident microorganisms in our body that are responsible for the absorption of nutrients and the maintenance of health is named microbiota. The microbiota´s role is protective, trophic and metabolic. Different groups of microbiota intestinal name enterotypes, each one of them are in relation to specific dietary habits. The absence of enteral stimulation affects both epithelial and GALT and the development of the microbiota. This situation modifies the immune system´s interaction, with a less competitive exclusion of more pathogenic bacteria, which can promote infections. These changes are likely reversible when supplementation with enteral nutrition is used. Dietary fibre and probiotics, to be fermented by colonic microbiota produce gases and short-chain fatty acids causing an acid pH in the large intestine which hinders the growth of pathogenic microorganisms. The administration of probiotic with enteral nutrition in critically ill patients was associated with lower rates of infection with no effect on mortality, average stay, or diarrhea. Also proposed as a strategy to reduce infectious complications in elective surgery and to reduce the time of tolerance of enteral feeding in preterm or low birth weight. In acute pancreatitis, it has been suggested a possible role of probiotics to restore intestinal integrity, but more safety studies are needed. There are isolated cases of bacteremia, sepsis or endocarditis usually in immunocompromised patients. Yet the benefits appear to be greater than the risks.

Repercusiones clínicas y económicas de la desnutrición relacionada con la enfermedad en un servicio quirúrgico

INTRODUCTIONndisease-related malnutrition (DRM) is currently a major challenge in our hospitals, both because of its high prevalence and because of the clinical and economic impact. Our study aims to assess the feasibility and importance of establishing a nutritional screening strategy in our Health Care System.nnnPATIENTS AND METHODSnthis is a prospective study carried out in a Surgery Ward. The nutritional risk was assessed by applying to patients MUST at admission and weekly until discharge. Nutritional evaluation and nutritional intervention were performed if required, as well as coding of diagnoses and nutritional procedures at discharge. Clinical data, length of stay (LOS) and hospital costs were analyzed.nnnRESULTSnMUST detected 15.6% of patients at risk of malnutrition at admission. Patients with malnutrition at admission (MA) had four days longer LOS, higher annual mortality rate and urgent hospital readmissions in 2.4 and 2.0 times, respectively, one year after discharge. Age and urgent hospital admission were the factors associated with a higher annual mortality rate. Nine per cent of patients with an initial MUST < 2 suffered deterioration in their nutritional status during admission (DNS). These patients had longer LOS in seven days with equal comorbidity. Considering only the costs related to LOS in patients who presented MA or DNS, an overcost of 57% and 145%, respectively, was observed.nnnCONCLUSIONnpatients with malnutrition on admission had longer LOS, higher mortality rate and urgent hospital readmissions one year after discharge. Patients who present MA or DNE cause an economic cost overrun. A nutritional screening tool is essential for the management and early detection of DRM.

Influencia de los anticuerpos antiperoxidasa tiroidea en los valores de TSH de gestantes y en las complicaciones materno-fetales

INTRODUCTIONnDuring pregnancy, thyroid peroxidase (TPO) antibodies may increase the risk of developing subclinical hypothyroidism (SCH). Both conditions appear to be associated to maternal-fetal complications. The objectives of this study were to analyze if a relationship exists between TSH and TPO levels during pregnancy and the potential effects on gestational and perinatal complications, and to assess whether detectable, but not positive, TPO levels have an impact on development of gestational SCH.nnnMETHODSnA prospective study was conducted at the Leon Health Area (CAULE), where universal screening for gestational thyroid dysfunction is performed between weeks 7-13 of pregnancy. Data on TSH and TPO levels and gestational and perinatal complications were collected for all 2016 deliveries. Positive TPO antibodies were defined as values≥35IU/mL. In a previous study, a TSH level>3.72mU/L was established as the cut-off value for gestational SCH.nnnRESULTSnRecords corresponding to 1,980 deliveries at CAULE, 21 abortions, and 18 deliveries outside the hospital were analyzed. Of the 1,670 pregnant women screened (84.34%), 142 (8.50%) had positive TPO antibodies and their presence was associated to diagnosis of SCH (P<0.01) and to significantly higher mean TSH levels (3.51mU/L vs. 2.46mU/L, P=0.03). There were no significant differences in gestational or neonatal complications. In the group with undetectable TPO antibodies (<10lU/mL), the mean TSH levels was slightly lower than in the group with TPO values ranging from 10-35 IU/mL, but the difference was not significant (P=0.89).nnnCONCLUSIONnPresence of positive TPO antibodies is associated to higher TSH levels and higher risk of gestational SCH, but does not increase the rate of maternal-fetal complications.

Términos, conceptos y definiciones en nutrición clínica artificial. Proyecto ConT-SEEN

BACKGROUNDnImprecision in terms used in the field of clinical nutrition may lead to misinterpretations among professionals.nnnOBJECTIVEnFor this reason, the Spanish Society of Endocrinology and Nutrition (SEEN) promoted this document on the terms and definitions used in clinical artificial nutrition (enteral and parenteral), establishing an agreement between Spanish experts of this specialty.nnnMETHODSnForty-seven specialists in endocrinology and nutrition, members of the Nutrition Area of the SEEN, participated between April and September 2016. After a systematic literature review, 52 concepts were proposed. The coordinators included two additional concepts, and 57were finally selected by the working group: 13 of a general nature, 30 referring to enteral nutrition and 14 to parenteral nutrition. The degree of agreement was subsequently determined using a two-round Delphi process. It was finally ratified by consistency and concordance analysis.nnnRESULTSnFifty-four of the 57 terms had a very consistent agreement and were concordant. Only three showed no concordance, of whom two were very consistent and one inconsistent. In conclusion, there was consensus in the definition of 54 basic terms in the practice of clinical nutrition.

¿Y después del ictus, qué hacemos para nutrirle?

Neurological conditions usually cause altered levels of consciousness or swallowing mechanisms which make artificial nutritional support necessary. International guidelines recommend nutritional screening to detect malnutrition in patients with neurological diseases. nDysphagia is a common problem after a stroke, however, it is a treatable pathology, and swallowing rehabilitation allows for improving patients’ nnutritional status.nAwareness of this problem is required among healthcare professionals both for its diagnosis and for the implementation of nutritional intervention measures. Patients should be tested for dysphagia within the first 24 hours of the stroke onset; this swallowing assessment as well as malnutrition screening should never be delayed by more than 72 hours. The present study addresses diagnostic and therapeutic approaches, the indications of the different nutritional treatments available and the transition to oral feeding in patients who have had a stroke episode.

Organization and management of clinical nutrition in Spain. How do we assess the quality of our activities

INTRODUCTIONnAmong the objectives of the SENPE Management Working Group is the development of knowledge and tools related to the evaluation of health outcomes.nnnOBJECTIVESnTo obtain an approximate profile of clinical nutrition in hospitals in Spain, specifically concerning its organization, endowment, activities and quality indicators.nnnMETHODSnA cross-sectional study conducted in 2013 through a structured survey sent to a random sample of 20% of hospitals from the network of the National Health System of Spain, stratified by the number of hospital beds.nnnRESULTSnThe overall response rate was 67% (83% in hospitals with over 200 beds). In 65% of hospitals, clinical nutrition is run by a coordinated team or unit, with a doctor working full time in only 50% of centers. Other professionals are often not recognized as part of the team or unit. There is a specialized monographic nutrition clinic in 62% of centers and 72% have more than 40 new inpatient consultations per month (27% with more than 80 per month). Among the centers with a clinical nutrition team or unit, there is a greater tendency to monitor quality indicators related to clinical practice.nnnCONCLUSIONSnThere is widespread addition of clinical nutrition teams and units in hospitals in Spain. However, truly multidisciplinary organization is not often found. High workloads are assumed in relation to staffing levels. The existence of well-organized structures may be associated with benefits that directly affect attendance.