Mariateresa Nardi

Induced hyperammonemia may compromise the ability to generate restful sleep in patients with cirrhosis

In patients with cirrhosis, hyperammonemia and hepatic encephalopathy are common after gastrointestinal bleeding and can be simulated by an amino acid challenge (AAC), or the administration of a mixture of amino acids mimicking the composition of hemoglobin. The aim of this study was to investigate the clinical, psychometric, and wake‐/sleep‐electroencephalogram (EEG) correlates of induced hyperammonemia. Ten patients with cirrhosis and 10 matched healthy volunteers underwent: (1) 8‐day sleep quality/timing monitoring; (2) neuropsychiatric assessment at baseline/after AAC; (3) hourly ammonia/subjective sleepiness assessment for 8 hours after AAC; (4) sleep EEG recordings (nap opportunity: 17:00‐19:00) at baseline/after AAC. Neuropsychiatric performance was scored according to age‐/education‐adjusted Italian norms. Sleep stages were scored visually for 20‐second epochs; power density spectra were calculated for consecutive 20‐second epochs and average spectra determined for consolidated episodes of non‐rapid eye movement (non‐REM) sleep of minimal common length. The AAC resulted in: (i) an increase in ammonia concentrations/subjective sleepiness in both patients and healthy volunteers; (ii) a worsening of neuropsychiatric performance (wake EEG slowing) in two (20%) patients and none of the healthy volunteers; (iii) an increase in the length of non‐REM sleep in healthy volunteers [49.3 (26.6) versus 30.4 (15.6) min; P = 0.08]; (iv) a decrease in the sleep EEG beta power (fast activity) in the healthy volunteers; (v) a decrease in the sleep EEG delta power in patients. Conclusion: AAC led to a significant increase in daytime subjective sleepiness and changes in the EEG architecture of a subsequent sleep episode in patients with cirrhosis, pointing to a reduced ability to produce restorative sleep. (HEPATOLOGY 2012)

Wernicke's Encephalopathy During Parenteral Nutrition

BACKGROUND Thiamine deficiency in humans affects the cardiovascular, muscular, nervous, and gastrointestinal systems. Wernickes encephalopathy is described in alcoholism, in hyperemesis gravidarum, and in prolonged IV feeding without vitamin supplementation. METHODS We report a case of a 66-year-old man undergoing surgery for acute necrotic-hemorrhagic pancreatitis, who presented a Wernickes syndrome during parenteral nutrition (PN). After surgery, he was treated with infusion of industrial 3-compartment bags, without vitamin supplementation. On the seventh postoperative day, nausea and vomiting began, and 5 days later the patient showed diplopia, ataxia, general muscular stiffness, reduction of osteotendinous reflexes, confusional state, and thrombocytopenia. The magnetic resonance scan evidenced pathologic changes in the medial thalamus, in the third and fourth ventricular floor, in the cerebellar vermis, and in the periaqueductal gray substance. RESULTS All neurologic signs and platelet blood count gradually normalized after IV supplementation of thiamine, 100 mg daily. The magnetic resonance scan repeated 40 days after the first one was normal. CONCLUSIONS Our report points out the risk of incorrect procedures in management of industrial 3-compartment bags. Moreover, we suggest that thrombocytopenia may be related to thiamine deficiency.

Impulsivity toward food reward is related to BMI: Evidence from intertemporal choice in obese and normal-weight individuals.

Obesity is a medical condition frequently associated with psychopathological symptoms and neurocognitive and/or personality traits related to impulsivity. Impulsivity during intertemporal choices seems to be typical of obese individuals. However, so far, the specific relationship between different types of reward and neuropsychological and psychopathological profile are yet to be unravelled. Here, we investigated impulsive choice for primary and secondary reward in obese individuals and normal-weight controls with comparable neuropsychological and psychopathological status. Participants performed three intertemporal choice tasks involving food, money, and discount voucher, respectively. Moreover, they completed a battery of neuropsychological tests and psychometric questionnaires assessing psychopathological state, impulsivity, and personality traits. Obese individuals showed increased preference for immediate food reward compared with controls, whereas no group difference emerged concerning money and discount voucher. Moreover, the higher the body mass index (BMI), the steeper the food discounting. These findings emerged in light of comparable neuropsychological and psychopathological profile between groups. Steeper food discounting in obese individuals appears to be related to BMI but not to psychopathological and neuropsychological profile. We suggest using intertemporal choice in the clinical practice as measure of the effectiveness of different types of intervention (e.g., educational, psychological, pharmacological or surgical) aimed at reducing impulsivity toward food and increasing cognitive control during food intake in obese individuals.

Adherence to a moderate sodium restriction diet in outpatients with cirrhosis and ascites: A real life cross-sectional study

A moderate sodium restriction diet should be indicated in patients with cirrhosis and ascites. Nevertheless, there is a lack of specific investigation on its correct application. To evaluate the adherence of patients with cirrhosis and ascites to a moderately low‐salt diet and the impact on intake of total calories and serum sodium concentration.

Nutritional support for cancer patients: still a neglected right?

Malnutrition is a frequent problem in cancer patients, the prevalence and degree of which primarily depend on tumor stage and site [1]. Its negative consequences are prolonged hospitalization, a greater degree of treatment-related toxicity, reduced response to cancer treatment, lower activity level, impaired quality of life, and a worse overall prognosis [2]. In recent years, there is growing evidence that treatment toxicity and prognosis are particularly associated with lean body mass loss [3], which leads to sarcopenia in the most common cancer types [4–7]. Despite the robust evidence that nutritional status deterioration negatively affects survival and tolerance of anti-cancer treatments, and the availability of international guidelines for nutritional care in cancer patients which have been recently updated [8], we suspect that the attitude towards this issue still varies considerably among oncologists, such that many malnourished patients still do not receive adequate nutritional support [1]. This could be related to insufficient awareness of nutritional problems among health care professionals, a lack of structured collaboration between oncologists and clinical nutrition specialists, and the almost complete lack of evidence supporting the notion that nutritional support improves clinically relevant outcome measures, beyond nutritional parameters, in malnourished or at-risk cancer patients. This last issue is particularly critical, as very few intervention trials are currently available [9, 10], so that the efficacy of nutritional support in different care settings for cancer patients, especially during the early phases of disease, still needs to be properly elucidated. A survey conducted in the UK in 2006, showed that while oncologists accept that nutritional status and intervention are important to outcome in patients receiving active anti-cancer therapy, they fail to identify patients at nutritional risk or to refer those who may benefit from early nutritional interven-

Changes in food habits in cancer patients in Italy: a survey. AIOM - SINPE - FAVO

OBJECTIVES The aim of this study was to investigate the prevalence of cancer patients changing their diet in relation to cancer site, sex, age and geographic distribution. Furthermore, we aimed to explore the rationale behind dietary changes and to identify sources of information in order to plan specific educational training. METHODS Patients ≥18 y of age who accessed the Italian Cancer Patients, Families and Friends Association information points were invited to participate. An ad hoc self-report questionnaire was used. The questionnaire asked patients about changes made to the major food groups. A minimum sample of 100 patients for the most common cancers was planned. We analyzed 1257 questionnaires. We assessed the prevalence of, reasons for, and type of dietary changes. Logistic regression was used to analyze the main determinants of dietary changes. RESULTS Of the 1257 patients, 705 (56.1%) reported changes since receiving the diagnosis of cancer. On the logistic regression analysis, age and tumor site were significantly associated with dietary changes (P <0.001), mainly in patients <50 y of age and in those with upper gastrointestinal cancers. Slightly more than half (50.8%) of patients adopted a healthier diet, with 31.3% doing so to deal with eating-related side effects and 17.9% due to cancer sites. Regardless of the reasons for changing, the most common food items to result in a decrease in consumption were alcohol, red and processed meats, and sugary drinks. Only 15% of patients reported receiving specific nutrition indication. CONCLUSION Italian patients are attentive to the importance of diet during cancer treatment. Personal choices reflect some indications for cancer prevention as there is still a shortage of guidelines for a correct diet during treatment. Nutrition indications are rarely given within the oncologic center.