Nutritional assessment and management in liver transplantation.
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Humans↗
Biomedical subjects
M León Sanz
Publications and source records attributed to M León Sanz.
[Therapeutic alternatives in intestinal failure].
BACKGROUND: Long-term parenteral nutrition is effective in the treatment of intestinal failure. Equally, the results of intestinal transplantation (IT) are promising. The choice of one or other form of treatment depends on the balance between the advantages and disadvantages of each. Based on these premises, we analyzed the outcome of home parenteral nutrition (HPN) for intestinal failure in our patients. METHODS: Intestinal failure was considered when parenteral nutrition was required for more than 5 months. In the 14 patients included in the HPN program since 1993, we reviewed the indication of HPN as well as their suitability for IT. RESULTS: Five of the 14 patients received HPN for causes other than intestinal failure. Of the remaining nine patients, four had severe motility disorder, three had short bowel syndrome, and two had protracted diarrhea of infancy. All these patients would be potential candidates for IT. Five patients were weaned off HPN because of intestinal adaptation between 2.5 and 13 months after starting HPN. One patient died because of lack of venous access. Three patients currently continue on HPN. CONCLUSION: Intestinal rehabilitation constitutes the best option for patients with intestinal failure. HPN offers the best interim treatment while waiting for adaptation. IT should be reserved for those patients with severe complications due to HPN. Nevertheless, it may become a real option for those with indefinite HPN. HPN and IT should be considered as complementary treatments.
Child, Preschool↗
[Should the therapeutic effort in artificial nutrition be limited?].
BASIS: There exists general agreement among the experts in Bioethics in order not to maintain a treatment if it is considered that it is useless. However, there is no unanimity about if serotherapy, enteral nutrition (EN), and parenteral nutrition (PN) are really therapeutic measures or else they are measures that they are part of the concept of palliative care. OBJECTIVE: Know the opinion of users and health workers of National Health System (NHS) in these issues. DESIGN: Cross-sectional descriptive study. AREA: Primary and specialized care. METHODS: A survey was distributed to 219 individuals (84 users of the NHS, 135 health workers), that it included sociodemographic parameters, the opinion on different aspects of ethics and nutritional support, and the measures regarded as palliative care. RESULTS: The majority of the respondents think that the EN (70.8%; 95% IC: 64.2-76.8) and PN (54.8%; 95% IC: 47.9-61.6) are part of the basic care, with differences between the health personnel and the users of the NHS. 50.2% considers that there are no differences between applying or removing nutritional support. 71.3% of the health professionals answer that this decision depends on the medical, 60.5% of the users of the NHS thinks that it depends on the patient himself and/or its family members. All the evaluated measures are regarded as basic care, regardless of the characteristics of the respondent. CONCLUSIONS: Artificial nutrition is understood as a basic care, regardless of the situation and quality of life of the patient. While the health professionals think that the decision to initiate/to retire artificial nutrition depends on the physician, the users of the NHS consider that it depends on the patient/family in case of disability of this.
Adult↗
[Pediatric parenteral nutrition: are standard solutions better than individualized ones?].
OBJECTIVE: Pediatric parenteral nutrition (PN) in Spain has traditionally been prescribed and made up on an individual basis. This practice entails daily indication of the quantity of each of the components of the PN bag as well as precise calculations for its formulation and preparation. The main advantages of individualized prescriptions are their flexibility and precise biochemical control. The aim of this study was to determine whether pediatric PN can be standardized in a tertiary care hospital. PATIENTS AND METHODS: We reviewed the composition of all the pediatric PN bags prepared in our hospital from 1.1.1996 to 31.12.1998. Each individual prescription was compared with a standard PN fulfilling the following criteria: a) Holiday-Segar equation for volume; b) 1 kcal/ml (10 %), and c) macronutrient distribution: 8-15 % amino acids, 55-65 % dextrose; 30-35 % lipids. The results of this comparison were used to estimate the number of bags fulfilling all three criteria and those that fulfilled only the third. We also reviewed the distribution of PN bags prepared according to the protocol used in our center which allows three options: standard PN, individualized prescription, and individualized prescription except electrolytes, supplied in fixed concentrations per liter of PN. RESULTS: Five hundred fifty-four patients received 7,921 PN bags. The mean duration of PN was 14.3 days and the mean number of PN per day was 7.2. Only 4.5 % fulfilled all three criteria but 16.2 % satisfied at least the last criterion. If the three criteria for standardization were applied, only one PN bag/day could be prepared. Analysis of the application of our protocol revealed that of all the PN bags prepared only 27.9 % were partially or totally standardized. However, exclusion of neonates increased this figure to 53.2 %. CONCLUSIONS: If rigid standardization criteria are applied, only a small number of PN bags can be prepared in a tertiary hospital. Combining both standard and tailored PN could reduce pharmacy workload and costs while maintaining flexibility.
Follow-Up Studies↗
[Liver complications associated with short-term parenteral nutrition in children].
OBJECTIVE: Liver dysfunction (LD) with abnormalities in biochemical liver function tests is the most common metabolic complication of parenteral nutrition (PN). The aim of this study was to estimate the prevalence of LD in children receiving short-term PN and to identify risk factors. PATIENTS AND METHODS: Data were gathered retrospectively during a 2-year period. Ninety-four children older than 28 days received PN (mean age 5.4 +/- 5.1 years). PN related LD was defined as when serum levels of one or more of the following liver function tests were increased: ALT > or = 80 IU/L, GGT > or = 120 IU/L and total bilirubin > or = 1.8 mumol/L. Children with previous liver disease were excluded (n = 17), as well as those with incomplete data (n = 16). RESULTS: LD was present in 33 children (54%). The incidence rate was 5.8 cases/100 patient days of PN. It started 9.8 +/- 6.9 days after beginning PN. The nadir appeared during the second week of PN. The following variables did not appear to significantly influence the presence of PN: age, gender, nutritional status, PN caloric load or composition and underlying disease. Length of PN (9.6 +/- 4.4 vs 19.5 +/- 10.5 days; p < 0.001) and presence of sepsis (21% vs 55%, p = 0.014) were the only variables associated with LD. It was not necessary to discontinue PN because of LD in any case. CONCLUSIONS: Early LD is present in more than 50% of our children on PN. In preventing LD we should try to avoid infection and to reduce the time on PN.
Adolescent↗
[Obesity].
Obesity is a chronic metabolic disorder characterized by the presence of a positive energy balance over time that leads to a deposit of fat considered to be excessive with regard to that considered normal. Obesity is more often associated with medical and surgical complications than in people with a normal body weight. Its prevalence is increasing in the Western world and it is one of the main public health problems. In the last years there have been important advances in the understanding of the genetic factors related to obesity. However, there are other factors of an environmental, cultural, hormonal, or psychological origin at the root of this problem. In most cases the diagnosis of obesity is obvious, but before beginning a treatment it is necessary to carry out an individual assessment of the characteristics of the clinical history, physical examination, and laboratory data. Reasonable objectives for weight loss should be established in function of the age, complications, and previous attempts at loosing weight. The treatment measures basically consist of adequating the nutrition to the individual's needs, increasing the physical activity, and changing the life habits. A pharmacological or surgical treatment may be a support measure to these measures.
Chronic Disease↗
[Teaching of clinical nutrition in Spain].
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Curriculum↗
[Home parenteral nutrition: our initial experience].
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Child↗
[Serum osteocalcin and bone turnover in hyperthyroidism].
In hyperthyroidism an increased bone turnover may appear, essentially due to a higher bone resorption. In order to evaluate this complication we have measured the serum levels of Osteocalcin (BGP) in 41 patients, mean age 43 +/- 18 (+/- SD) years. BGP is a protein synthesized by osteoblasts which may be employed as an specific and non-aggressive marker of bone turnover. Serum BGP was significantly increased in these patients with respect to normals (6.2 +/- 4.2 vs 3.7 +/- 1.3 ng/ml). The total group was divided according to BGP values higher and lower than 3.7 ng/ml, emerging two groups with BGP 7.9 +/- 3.8 (n = 30) y 2.2 +/- 1.2 ng/ml (n = 11), respectively. There were not differences between these two groups regarding to thyroid hormones or other data of mineral metabolism. In the total group, only serum BGP and T3 were correlated. Our results suggest the existence of a double effect of hyperthyroidism on bone, as well as a temporal dissociation between thyroid synthesis and bone metabolism.
Adult↗
[Study of bone involvement in hypothyroidism determining the blood levels of osteocalcin].
Several bone abnormalities, characterized by a decreased bone turnover, may develop in patients with hypothyroidism. We have used the measurement of serum Osteocalcin (BGP), a protein synthesized by osteoblasts and proposed as a marker of bone formation, in order to elucidate the bone status in 62 hypothyroid patients, mean age 52 +/- 15 (SD) years. As a group, BGP results in hypothyroidism were not different from normal (3.6 +/- 3.2 vs 3.7 +/- 1.3 ng/ml). However, we were able to differentiate 3 groups: 1) patients with significantly lower BGP values (p less than 0.01) (primary hypothyroidism and total thyroidectomy with body scan); 2) patients with antithyroid drugs had significantly higher BGP levels (p less than 0.05); 3) in the other groups (post-1311, post-surgery, and insufficiently treated hypothyroidism) BGP values were within normal limits. In the total group BGP was significantly correlated with T3T, TSH, alkaline phosphatase and age. Lower serum BGP values in some etiologic groups of hypothyroidism may reflect a greater pathologic effect on the bone in these patients, with a decrease in bone formation.
Aged↗
[Patients at risk for malnutrition in primary care. Social and health study].
GOALS: The worsening nutritional condition of certain population segments is an ever more frequent situation. Malnutrition also has considerable consequences, both in healthy individuals and in patients, leading to an increase in morbidity/mortality among the general population. The purpose of the present study is to learn the opinion of doctors in primary health care about the frequency of patients at risk of malnutrition attending their clinics; the most common forms of diagnostic technique used, the groups of population and situations that show the greatest risk of malnutrition as well as the therapeutic actions undertaken. MATERIALS AND METHODS: The present study effected 1819 opinion polls of primary health care doctors, distributed in proportion to the provincial distribution of doctors throughout Spain. With a margin of error of +/- 2.3% and a confidence interval of 95.5% (K-2). RESULTS: Of the patients seen in primary health care centres, 11% are at risk of malnutrition and approximately 61% of the total are detected at the medical clinic. The situations with the greatest risk are advanced age (71%), marginalized population (drug abusers, alcoholics) (56%), anorexia (50%), patients with mental disorders (42%), oncological pathologies (41%) and prolonged confinement in bed (39%). The therapeutic attitudes considered most appropriate by primary health care practitioners are a greater attention to diets and the use of nutritional supports in cases of established malnutrition. CONCLUSIONS: The present study reflects a high incidence of malnutrition risk among patients attending primary health care clinics (11%); and highlights the importance, from the point of view of preventive medicine, of improving nutritional education among professionals, as well as the availability of simple therapeutic actions and support measures that might help to avoid larger-scale problems with a large social and financial cost.
Humans↗
[Home parenteral nutrition in patients with advanced cancer: experience of a single centre over ten years].
UNLABELLED: The use of Home Parenteral Nutrition (HPN) in patients with advanced cancer without the possibility of curative treatment continues to be a controversial subject entailing a considerable emotional burden. Nonetheless, this group of patients constitutes the main indication for HPN in many programmes. GOAL: To present the characteristics of a series of patients included on an HPN programme over the last ten years. METHOD: Retrospective study of the case histories of the 11 patients who received HPN over this period. The demographic and clinical details were noted along with their complications and evolution for comparison with those of a control group of patients with benign disease receiving HPN over the same period. For the comparisons, Student's t test and the chi-squared test were used as and when indicated. Results were considered statistically significant if p < 0.05. RESULTS: Eleven patients received HPN, nine of them because of an irresoluble intestinal obstruction and two because of a high flow fistula. The mean age at the start of HPN was 50.8 +/- 12.7 years versus 37.3 +/- 17.2 years for the group with benign disease (p < 0.05). The mean duration of HPN was 71.05 +/- 217 days in the first group, notably less than the second (387.15 +/- 995.85; p < 0.05), with a range between 5 and 760 days. The patients received the infusion through a previously implanted subcutaneous reservoir (n = 9) and on two occasions, electively, through a tunnelled catheter. The infection rate was higher in the group with cancer (0.34 episodes per patient and 1,000 days on HPN) than in the group with benign disease (0.08 episodes; p < 0.05). HPN was suspended in only one of the patients more than 5 days prior to death due to clinical deterioration. Two patients required admission due to a complication associated with the technique. In both cases, a fungal infection of the blood made it necessary to withdraw the catheter. The quality of life, measured by means of an activity scale, was similar at the start of HPN in both groups. None of the patients included on the programme is still alive. CONCLUSIONS: HPN offers patients with advanced cancer and severe intestinal dysfunction the possibility of an at-home treatment with a low complication rate. If we take into account the short mean duration of HPN, inclusion on the programme must be assessed individually and regularly revised.
Adult↗
Current use of parenteral nutrition in a pediatric hospital. Comparison to the practise 8 years ago.
UNLABELLED: Parenteral nutrition (PN) has become a mainstay in the treatment of critically ill children, and in the management of extremely premature newborns. We analyse the changes in the profile of pediatric PN in our institution during the last decade. METHOD: The clinical record of all patients under 16 who received PN in 1994 and 2002 were reviewed. Epidemiological data as well as composition of the solutions were recorded. Student t test and Chi-square were used for comparisons as appropriate. p value < 0.05 was considered as statistically significant. RESULTS: 194 patients received PN in 1994 (123 neonates and 71 children); 186 in 2002 (112 neonates and 74 children). The percentage of inpatients who received PN was 10.7% in 1994 vs 3.7% in 2002 in neonates; 1% in 1994 vs 1.3% in 2002, in infants and children. Gastrointestinal surgery in infants and children and extreme prematurity in newborns were the most frequent indication. All neonates received tailored PN solutions while it was standardised in almost 60% of children. Internal jugular vein in children and peripherally inserted central venous catheters in neonates were the most usual vascular access. Length of PN was 10 +/- 8.7 days in 1994 vs 9.2 +/- 8.2 in 2002 in neonates; 15.2 +/- 14.8 days in 1994 vs 11.0 +/- 14.9 in 2002 in infants and children. 21% of the children presented at least one complication due to PN. CONCLUSIONS: There have been very few changes in the use as well as in the profile of the PN practise during the last decade. Gastrointestinal surgery and prematurity were the most frequent indications.
Catheters, Indwelling↗
[Should hydration and artificial nutrition be accepted as a palliative care?].
BACKGROUND: Ethical considerations are becoming more and more common in clinical practice. There is no unanimous agreement on which measures should be deemed as basic care, specially regarding hydration and artificial nutrition. AIM: To know the opinion of lay people and health professionals, stratified according to their university degree, about which palliative measures, including hydration and artificial nutrition, should be judged as palliative care. METHODS: A descriptive transversal study has been designed to know the opinion of 256 subjects: 91 users of the National Health System (NHS), 80 nurses, 47 pharmacists and 38 physicians. A questionnaire examined which of the following measures should be considered as palliative care: hygiene, analgesia, pressure ulcer care, position change, sedation, oxygen administration, urinary catheter, hydration, enteral and parenteral nutrition. RESULTS: More than 50% of the participants think that all the proposed measures can be considered as a palliative care, except parenteral nutrition. There is unanimous agreement to accept analgesia, pressure ulcer care, position change and enteraL nutrition as basic care, but there is disagreement in relation to hygiene (p = 0.000), sedation (p = 0.005), oxygen administration (p = 0.007), urinary catheter (p = 0.011) and parenteral nutrition (p = 0.000). There were not differences of opinion after adjusting for age, sex, religious beliefs, and length of professional experience among the individuals that answered the questionnaire. CONCLUSION: There is no agreement on which measures should be considered as palliative care. Opinions differ regarding hygiene, sedation, oxygen administration, urinary catheterisation and parenteral nutrition. In comparison to enteral nutrition, many responders believe that parenteral nutrition is a therapeutic option. The opinions shown in this questionnaire were independent from the demographic characteristics of the subjects that answered it.
Adult↗
[Hypocaloric peripheral parenteral nutrition].
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Energy Intake↗
[Home parenteral nutrition in the management of patients with chronic idiopathic intestinal pseudo-obstruction].
Home parenteral nutrition is indicated in all those patients who are unable to cover all their needs orally or enterally during prolonged periods of time, and who do not require any other general care other than the parenteral nutrition. Our objective is to prove the use of home parenteral nutrition as a nutritional support in patients with severe forms of chronic idiopathic intestinal pseudo-obstruction. In our unit, three patients with this disease, have received home parenteral nutrition between 1993 and the present date. One patient received it during four months, with the catheter being removed due to a fungemia. At present she is being maintained with oral and enteral nutrition. The other two patients continue in the program: one since October 93 and the other since July 94. The hydroelectric alterations caused during the episodes of sub-occlusion make more frequent changes in the composition of the parenteral nutrition necessary, compared to other types of patients. The low incidence of complications and the degree of acceptance by the patient makes this technique an ideal method for the long term nutritional support.
Adult↗
[Stability of vitamins in parenteral nutrition: a comparison of multi-layer and uni-layer bags].
The goal of this study was to compare vitamin A, E, C, B12, B2 and folic acid concentrations in parenteral nutrition solutions in multilayer and single layer EVA bags. Two different bag trade marks were used: Bexen and Miramed. We measured vitamin concentrations at 24 hours, the fifth and seventh day after refrigerated storage and the eighth day after 24 hours at room temperature. Trace-element and temperature influence were studied. Vitamins A, E, B12, B2 and folic acid had a similar behaviour with multi-layer and one-layer bags. No differences were observed between solutions with and without trace-elements. The concentrations remained within acceptable ranges. We observed a clear decrease of vitamin C, that can be avoided with the use of multilayer bags. These bags can be useful in home parenteral nutrition or when vitamins cannot be added immediately before its administration. An important loss of vitamin A was also detected in parenteral nutrition solutions without lipids, both in multilayer and single layer bags, despite photoprotection and refrigeration.
Ascorbic Acid↗
[Parenteral nutrition and gastric emptying].
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Gastric Emptying↗