[Home parenteral nutrition in Spain 2011 and 2012; a report of the home and ambulatory artificial nutrition group NADYA]

OBJECTIVE

To report the data of the Home Parenteral Nutrition (HPN) registry of the NADYA-SENPE working group for the years 2011 and 2012.

METHODOLOGY

We compiled the data from the on-line registry introduced by reviewers of NADYA group responsible for monitoring of NPD introduced by since January 1, 2011 to december 31, 2012. 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

Year 2010: 184 patients from 29 hospitals , representing a rate of 3.98 patients/million inhabitants/ year 2011, with 186 episodes were recorded NPD . During 2012, 203 patients from 29 hospitals , representing a rate of 4.39 patients/million inhabitants/year 2012 , a total of 211 episodes were recorded NPD .

CONCLUSIONS

We observe an increase in registered patients with respect to previous years.Neoplasia remains as the main pathology since 2003. Although NADYA is consolidated registry and has been indispensable source of information relevant to the understanding of the progress of Home Artificial Nutrition in our country, there is ample room for improvement. Especially that refers to the registration of pediatric patients and the registration of complications.

Home enteral nutrition in Spain; NADYA registry 2011-2012

OBJECTIVE

To describe the results of the home enteral nutrition (HEN) registry of the NADYA-SENPE group in 2011 and 2012.

MATERIAL AND METHODS

We retrieved the data of the patients recorded from January 1st 2011 to December 31st 2012.

RESULTS

There were 3021 patients in the registry during the period from 29 hospitals, which gives 65.39 per million inhabitants. 97.95% were adults, 51.4% male. Mean age was 67.64 ± 19.1, median age was 72 years for adults and 7 months for children. Median duration with HEN was 351 days and for 97.5% was their first event with HEN. Most patients had HEN because of neurological disease (57.8%). Access route was nasogastric tube for 43.5% and gastrostomy for 33.5%. Most patients had limited activity level and, concerning autonomy, 54.8% needed total help. Nutritional formula was supplied from chemist's office to 73.8% of patients and disposables, when necessary, was supplied from hospitals to 53.8% of patients. HEN was finished for 1,031 patients (34.1%) during the period of study, 56.6% due to decease and 22.2% due to recovery of oral intake.

CONCLUSIONS

Data from NADYA-SENPE registry must be explained cautiously because it is a non-compulsory registry. In spite of the change in the methodology of the registry in 2010, tendencies regarding HEN have been maintained, other than oral route.

[The registry of home artificial nutrition and ambulatory of the Spanish Society of Parenteral and Enteral Nutrition; SWOT analysis]

OBJECTIVE

To evidence by means of a SWOT-R analysis performed by an expert consensus the most worrying characteristics of the register on Home-based and Outpatient Artificial Nutrition.

MATERIAL AND METHODS

SWOT-R analysis with expert consensus. We requested the participation of the active members of the NADYA group within the last 5 years with the premise of structuring the SWOT-R based on the characteristics of the NADYA registry from its beginning.

RESULTS

18 experts from hospitals all over Spain have participated. The internal analysis seems to be positive, presenting the registry as having important resources. The external analysis did not show a great number of threats, there are very potent factors, "the voluntariness" of the registry and the "dependence on external financing". The opportunities identified are important. The recommendations are aimed at stabilizing the system by decreasing the threats as one of the main focus of the strategies to develop as well as promoting the items identified as opportunities and strengths.

CONCLUSIONS

The analysis shows that the NADYA register shows a big potentiality for improvement. The proposed recommendations should be structured in order to stay on the track of development and quality improvement that has characterized the NADYA register from the beginning.

Immunoenhanced enteral nutrition formulas in head and neck cancer surgery: a systematic review

INTRODUCTION

Significant malnutrition exists in a high percentage of patients with head and neck cancer. Malnutrition is associated with defects in immune function that may impair the host response to malignancy. Malnutrition and immunosupression make patients highly susceptible to postoperative infections and complications.

OBJECTIVES

Some studies of patients receiving immuno-nutrition in the perioperative period in head and neck cancer have shown beneficial effects on clinical outcome and inmune status. The authors carried out a systematic review of randomised control trials to determine whether perioperative immunonutrition has a role in the treatment of head and neck cancer.

METHODS

14 trials of polymeric nutritional supplementation with immunonutrition were identified. Two studies compared two types of immunonutrition.

RESULTS

A reduction in the length of postoperative hospital stay was seen in some trials, but the reason for this reduction is not clear. Some studides showed statistical differences with less complications in arginine-enhanced group and also showed a significant decrease of fistula complications in patients treated with a high arginine dose enhanced formula, if compared with a medium dose of arginine.

CONCLUSION

[corrected] Those planning future studies face challenges. A suitable powered clinical trial is required before firm recommendations can be made on the use of immunonutrition in head and neck cancer patients postoperatively.

[Clinical management of homocystinuria: case report and review of the literature]

Homocystinuria is a congenital disorder of methyonine metabolism that leads to increased plasmatic, urinary and tissue deposits of methyonine and its main metabolite: homocysteine. Homocysteine deposits are toxic for the skeletal system (osteoporosis), the eyes (lens dislocation), central nervous system (seizures, psychiatric disorders) and also induce vascular damage (stroke and other cardiovascular events). This article reports two patients with homocystinuria in two siblings, followed by a concise review on the therapeutic strategies available for this disorder.

[Hormonal and inflammatory biomarkers in a group of overweight and obese women]

BACKGROUND AND OBJECTIVES

The aim of this study was to describe the hormonal and inflammatory status of a group of overweight/obese women.

PATIENTS AND METHODS

The sample studied was a crosssectional cohort of women > 18 years of age, BMI ≥ 25 < 40 kg/m², prior to starting a weight control program. Data collected were: demographic characteristics, blood pressure, anthropometric parameters, physical activity data, and biochemical, hormonal and inflammatory biomarkers.

RESULTS

The study involved 104 women with a mean age of 48.4 ± 9 years and a BMI of 29.8 ± 3.5 kg/m². Some 48% of the women studied were in menopause. Some 8.9% had hyperinsulinemia. The mean ghrelin value was 38.8 ± 33.6 pg/ml; there was no correlation between ghrelin levels and anthropometric and biochemical variables. CRP, leptin, adiponectin, resistin, IL6, IL10, and PAI1 were 3.0 ± 2.7 mg/dl, 36.3 ± 19.5 ng/ml, 8.3 ± 4.5 mg/ml, 24.3 ± 23.2 ng/ml, 51.6 ± 93.6 pg/ml, 10.0 ± 34.2 pg/ml and 22.3 ± 30.6 ng/ml, respectively. Obese patients had significantly higher mean values of resistin and PAI 1 than those who were overweight. These levels correlated significantly with anthropometric and biochemical variables; however, the correlations were weak. Age, menopause or the regular practice of physical activity had no effect on mean values.

CONCLUSIONS

The group of women studied had altered inflammatory biomarkers in relation to people of normal weight. The study shows the inflammatory status of overweight/ obese individuals, and the values obtained may help to establish standard ranges for these markers.

Impact of two low-calorie meals with and without bread on the sensation of hunger, satiety and amount of food consumed

BACKGROUND

The aim was to compare the differences in feelings of hunger and satiety in a group of overweight/obese women after eating a test meal with or without bread.

PATIENTS AND METHODS

The study included 122 women (BMI≥25<40 kg/m²) who were randomly assigned to consume one of the following test meals: NO BREAD meal (2.40 MJ, 46% carbohydrates, 26% protein, 28% fat; which included rice or pasta) and BREAD meal (2.39 MJ, with equal caloric distribution and the same foods except with bread instead of rice or pasta). A visual analogue scale (VAS) was used, with 5 questions to be answered at different times: 1) just before eating, 2) just after eating and exactly 3) 60 and 4) 90 minutes after eating the test meal. The test was performed at the start and after 16 weeks of following a lifestyle modification program based on a low-calorie diet (with or without bread).

RESULTS

104 women completed the study (48.4±9.0 years) with a baseline BMI of 29.8±3.5 kg/m². At the start of the study there were no significant differences in any of the VAS parameters measured between the groups. After 16 weeks, BREAD group obtained higher scores in question 3 (referring to the sensation of satiety) that were significant at time 3 (7 versus 5; p<0.05) and time 4 (8 versus 4; p<0.01).

CONCLUSIONS

The inclusion of bread in a low-calorie meal may result in a greater sensation of satiety after eating. These results contradict the recommendation to exclude bread from a food plan aimed at weight loss.

[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.

Importance of a balanced omega 6/omega 3 ratio for the maintenance of health: nutritional recommendations

The modification of dietary patterns has led to a change in fatty acid consumption, with an increase in the consumption of ω-6 fatty acids and a marked reduction in the consumption of ω-3 fatty acids. This in turn has given rise to an imbalance in the ω-6/ω-3 ratio, which is now very different from the original 1:1 ratio of humans in the past. Given the involvement of ω-6 and ω-3 essential fatty acids in disease processes, the present article examines changes in dietary patterns that have led to the present reduction in the consumption of ω-3 essential fatty acids, and to study the importance of the ω-6/ω-3 balance in maintaining good health. In addition, an assessment is made of the established recommendations for preventing a poor intake of ω-3 essential fatty acids, and the possible options for compensating the lack of these fatty acids in the diet.

[Knowledge of nutrition labelling in general population. Assessment surveys conducted in La Paz University Hospital in Madrid during the 9th "National Nutrition Day 2010"]

INTRODUCTION

Nutrition labelling (NL) provides information on the energy and nutrients in a food and it represents a valuable tool to help consumers make informed decisions about their diet and lifestyle. However, little is known about how consumers perceive the nutrition labelling information.

OBJECTIVES

Evaluate the knowledge of NL of a population survey and examine aspects such as attention, reading, understanding and utility.

MATERIAL AND METHODS

200 volunteers were interviewed about NL on National Nutrition Day (NND) on May 28, 2010 at the La Paz University Hospital in Madrid. The questionnaire was self-administered and this contained 10 closed multiple choice questions.

RESULTS

The surveyed group (66.7% women and 33.3% men) had a mean age of 42.0 ± 15 years and a BMI of 24.1 ± 3.8 kg/m². A percentage of 86.5% had completed secondary and higher education. The concept about NL was knocked by 77.1% of them. This percentage was significantly higher according to the level of their studies (primary 7.1%, secondary 32.1% and higher studies 60.9%; p < 0.0001) and also regarding the age range (42.3% vs. 25% of over that 50, p < 0.05). 73.8% always or almost always readied NL; 67.7% of those who declared that always readied were women and 71% had higher education. 53.8% of people over 50 years were not capable of reading labels due to the small letters. The most interesting information for the consumers was: calories (61%), fats (39%) and cholesterol (25.7%). Nutritional concepts questions had a low percentage of right answers, especially in volunteers with lower level of education and among older age groups.

CONCLUSIONS

Results show that consumers have a low level of nutrition information that would enable a better choice to purchase food. Nutrition education is needed should be necessary to NL had a significant impact on the foods election. Therefore, this fact could contribute to the maintenance of health and disease prevention.

[Efficacy, cost-effectiveness, and effects on quality of life of nutritional supplementation]

This article summarizes the main results and conclusions presented in the Symposium "Nutritional supplementation: evidences and experiences" that took place in the XXIIIrd SENPE Congress (2008). Protein energy malnutrition, that can affect 30-50% of hospitalized patients, increases both time of hospitalization and costs of medical care of this kind of patients. There is a lot of scientific evidences demonstrating that the use of nutritional supplementation improves nutritional status or prevents malnutrition in those patients who do not meet their nutritional needs with a conventional diet or an adapted one with no replacing intake from normal food. This is strengthened by the results that demonstrate the rol of nutritional supplements improving nutritional and functional parameters. Current bibliographic reviews focused on certain clinical frameworks (i.g. geriatrics, oncology), prove that nutritional supplements reduce complications related to pathology and to nutritional status, and also reduce length of hospitalization and mortality. More studies regarding to efficacy of oral nutritional supplements are needed. These studies should be carried out with a period of follow-up longer than the current published studies have. As well as effective, nutritional supplements become a save therapeutic intervention with no important adverse events that, according to bibliography, improve patient's functionality and quality of life. It is worth mentioning that nutritional supplements can be effective on certain kind of patients, for instance, malnourished elderly or elderly in risk of malnourishment, and hospitalized surgical patients. Scientific literature refers that it is necessary to carry out more studies, with an accurate methodology, which assess the effect of nutritional supplements on quality of life and its cost-effectiveness on malnourished patients regarding specific clinical situations. That would allow physicians to make clinical decisions based on evidences and cost analysis.

[Spanish home enteral nutrition (HEN) registry of the year 2008 from the NADYA-SENPE group]

AIM

To present the results of the Spanish home enteral nutrition (HEN) registry of the year 2008 from the NADYA-SENPE group.

MATERIAL AND METHODS

We recorded the HEN registry data from January 1st to December 31st 2008.

RESULTS

The number of patients registered in this period was 6206 (51% male) with up to 6,279 episodes of HEN, from 31 Spanish hospitals. Most of the patients (95%) were older than 14 yr. Mean age was 4.83±3.29 yr in the children group, and 70.75±18.14 yr in the adult group (older than 14 yr). Neurological disorders (39%) and cancer (27%) were the two most prevalent diagnoses. The oral route was the most frequently used (43,4%), followed by nasogastric tube (40,4%), and gastrostomy tube (14,7%). Mean length of treatment was 305,36 days (10 months). The principal reasons for discontinuing treatment were death (43%) and progress to oral diet (40%). Only 33% of the patients had a normal activity level, being limited in different grades in the rest of the patients. Most of the patients required partial (25%) or total help (38%). The enteral formula was provided by the hospital in 65% of the cases and by private pharmacies in 32%. The disposables were provided by the hospital (82,4%) and primary care services (17,2%).

CONCLUSIONS

The number and the age of the patients registered have increased comparing to previous years, with little variations in the rest of analyzed variables. The increase in the length of treatment could reflect misreporting of the weaning process in the registry.

[Assessment of a malnutrition screening tool in cancer patients]

40-80% of cancer patients suffer from diverse degrees of malnutrition, depending on tumor subtype, location and staging and treatment strategy. Malnutrition is associated with increased morbidity and mortality in cancer patients. Both the high prevalence and prognostic significance of malnutrition imply the need for accurate malnutrition screening in cancer patients, which could select those patients at risk of nutritional derangements who would benefit from nutritional therapy. Patient-generated subjective global screening (VSG-GP) remains the reference malnutrition screening method, but its complexity and training requirements prevent wider applicability by oncologists. Thus, easier, more clinic-based malnutrition screening tools are required for cancer patients. In this article we propose a basic screening tool based on three items: weight loss, changes in physical activity and decrease in food intake. Two affirmative responses out of the three questions is considered as a positive response, and would prompt expert nutritional assessment.

RESULTS

Our screening interview showed positive correlation with VSG-GP (ROC 0.85, p<0.001) and allowed for a rapid and accurate identification of patients with cancer-related malnutrition.

[National registry of home enteral nutrition in Spain 2007]

OBJECTIVE

To communicate the results from the registry of Home-Based Enteral Nutrition of the NADYASENPE group in 2007.

MATERIAL AND METHODS

We included every patient in the registry with home enteral nutrition any time from January 1st to December 31st of 2007.

RESULTS

The number of patients with home enteral nutrition in 2007 was 5,107 (52% male) from 28 different hospitals. 95.4% of them were 15 yr or older, with a mean age of 67.96 +/- 18.12, and 4.2 +/- 3.38 among patients aged 14 yr or less. The most common underlying diseases were neurological (37.8%) and neoplastic diseases (29.3%). Enteral nutrition was administered p.o. in most patients (63.5%), followed by nasogastric tube (25.9%), while gastrostomy was only used in 9.2%. The mean time in enteral nutrition support was 9.4 months and the most common reasons for withdrawal were death (58.7%) and switching to oral intake (32%). Activity was limited in 31.4% of patients and 36.01% were house-bound. Most patients needed partial (26.51%) or total (37.68%) care assistance. Enteral formula was provided by hospitals to 69.14% of patients and by pharmacies to 30.17% of them, while disposable material was provided by hospitals to 81.63% and by Primary Care to the remaining patients.

CONCLUSIONS

In 2007, there has been an increase of more than 30% of patients registered with home enteral nutrition comparing with 2006, without any big difference in other data, but a higher proportion of patients with enteral nutrition p.o.

[Postsurgical chylous ascites: case report and literature review]

Chylous ascites derives from chyle leakage into the peritoneal cavity, either due to rupture or obstruction of abdominal lymphatic vessels. The main clinical sign is abdominal distention, while diagnosis requires the presence of triglycerides in ascitic fluid. Neoplasms are the most common cause of chylous ascites, although less common causes, such as abdominal surgery, should also be considered. The mainstay of therapy is hyperproteic diet with fat restriction and middle-chain triglycerides. Parenteral nutrition is reserved for cases in which dietary treatment fails to restore an optimal nutritional status or is contraindicated, whereas surgery is considered for patients that are deemed refractory to conservative therapy. We present a case of chylous ascites secondary to retroperitoneal lymphadenectomy.

[Evaluation of the utility of a Nutrition Education Program with Eating Disorders]

INTRODUCTION

As eating disorders include both psychological and physiological components, appropriate management of these disorders requires input from a number of disciplines working together in a coordinated manner, following an integrated Programme. The Eating Disorders-Nutrition Education Programme has as its purpose achieving healthier habits and modifying eating behaviour. The Programme should take place as one part of Eating Disorders treatment.

OBJECTIVES

To determine the efficacy of a Nutrition Education Programme about nutritional state and eating patterns in a group of patients diagnosed with Eating Disorders who follow the usual check-up protocol in the clinic for nutrition and mental health.

MATERIAL AND METHODS

89 patients were included, including 5% men. They received individual nutritional education with weekly/fortnightly appointments during a period of 4-6 months. Educational counseling was carried out by a dietician. The mean age of the sample was 24 +/- 8 years and the diagnoses were: Anorexia Nervosa Restrictive (ANR) 32.5% Anorexia Nervosa Purgative (ANP) 26.5%, Bulimia Nervosa (BN) 18%, Eating Disorder Not Otherwise Specified (EDNOS) 21% and Binge Eating Disorder (BED) 2%. The average evolution time since the diagnosis was 4.8 +/- 5 years. An anthropometric assessment, assessment of daily oral intake, 24-hour dietary recall, and Eating Attitudes Test (EAT26) questionnaires were completed at the first appointment and again at the end of the programme.

RESULTS

The mean score of the EAT26 questionnaire was 32 +/- 15 initially, and after 4-6 months the score was 23.7 +/- 14 (p < 0.001). This change represents a significant improvement in the patients' symptoms after the Programme. Furthermore there were significant differences in the evaluation of the questionnaire by scales and by diagnosis. After 4-6 months, there was a meaningful reduction in episodes of vomiting per week (from 7.5 +/- 10 to 1 +/- 1.8 p < 0.001) in ANP and BN binge-purging (8 +/- 9.7 vs 2.2 +/- 3.2 p < 0,01). In addition, a favourable trend in the number of binges per week was observed for both diagnoses. The percentage of subjects that ate less than 4 meals per day decreased from 70% to 19% after the Education Programme (p < 0.001). Some 67% of the patients dedicated a specific time for eating and a 54% started to have complete meals. These results that show a very favourable tendency with respect to the normalization of eating patterns. There was improvement in the intake of dairy products, vegetables, fruits, cereals and oil (p < 0.05). At the beginning, 34% consumed at least 3 of the 6 food groups within the recommended range, but at the end 70% did (p < 0.001). After the nutritional education programme, an important increase in energy ingestion and carbonhydrate consumption took place (p < 0.001), as much with ANR as with ANP. With respect to micronutrients, the ingestion of vitamin B2 significantly increased, as well as folic acid and calcium (p < 0.001) in ANP, and magnesium and calcium (p < 0.001) in ANR. In ANR, we found a significant improvement in nutritional status (p < 0.001). Variables including weight, BMI, muscular circumference of the arm and tricipetal fold were at the limit of significance. Regarding ANP and EDNOS, the initial evaluation demonstrated that they were within normal limits, and they were maintained after nutritional education. In BN, progress towards normalization of BMI took place, increasing from 26.4 +/- 6.6 to 25.5 +/- 5.7 (-2.3 kg).

CONCLUSIONS

The Nutritional Education Programme carried out by qualified professionals should be a part of Eating Disorders treatment, along with medical and psychological monitoring and as part of an interdisciplinary, multiprofessional team effort.

Trends in home enteral nutrition in Spain: analysis of the NADYA registry 1992-2007

BACKGROUND

There are few data on trends in home enteral nutrition (HEN) practice in different countries. NADYA is the Spanish home artificial nutrition (HAN) group, and is responsible for the Spanish HAN registry.

METHOD

We performed a 16-year retrospective study (1992-2007) of the Spanish HEN registry by retrieving data from the NADYA database and from publications of the working group. People receiving more than 1000 kcal/d with an enteral formula were included regardless of the access route (oral/tube feeding).

RESULTS

The number of patients registered increased more than 8 times during the study period: the current prevalence is 113 patients/10(6) inhabitants (oral and tube feeding), or 41 patients/10(6) inhabitants (tube feeding). The distribution of the patients was not uniform, and most came from six autonomous communities (Catalonia, Galicia, Castilla-León, Madrid, Andalusia and Extremadura). Gender distribution was nearly 1:1. The number of paediatric patients was very low, representing less than 10% of the total. Mean age in adults was above 65 years in most of the reports. We observed an increase in the age of the patients over the years. The most common underlying diseases were neurological disorders, followed by cancer. We observed an increase in the use of the oral route, from 5.8% in 1992 to 64% in 2007, with a parallel decrease in the use of nasogastric tubes. Gastrostomy tubes were used in 15-20% of the patients. The number of complications was low (less than one complication/patient/year), the most frequent being change of tube, followed by gastrointestinal complications. The principal reasons for discontinuing treatment were death related to the underlying disease (40-50%) and switch to oral diet (30-40%). Most of the patients (75%) were followed by the hospital nutrition unit. Provision of the enteral formula and disposables varied according to the autonomous community. Most of the patients had limited physical activity or were chair- or bed-bound, requiring partial or total help in their daily life.

CONCLUSIONS

The use of HEN has increased dramatically in the last 16 years in Spain. Most of the patients registered were elderly people with neurological disorders and limited physical activity. The oral route was the most frequently used. The number of complications was low. The mortality rate in these patients was highly related to the underlying disease.

[Nutritional risk evaluation and establishment of nutritional support in oncology patients according to the protocol of the Spanish Nutrition and Cancer Group]

INTRODUCTION

Cancer and its oncological treatment cause symptoms which increase the patients risk to suffer from malnutrition. This affects the patients health status negatively by increasing the number of complications, reducing the tolerance to the oncology treatment and a decrease of the patients quality of life. Motivated by this, a group of health professionals from several spanish regions met with the backing of the Sociedad Española de Nutrición Básica y Aplicada (SENBA) to address strategies to improve the quality of nutritional intervention in cancer patients.

METHODS

This multidisciplinary group developed a protocol describing nutritional assessment and intervention in form of algorithms based on literature and personal experience. The patients are classified in a three step process: 1. type of their oncology treatment (curative or palliative); 2. nutritional risk of the antineoplastic therapy (low, medium or high risk) and 3. depending on the Subjective Global Assessment patient-generated (SGA-pg). The patients are classified as: A. patients with adequate nutritional state, B. patients with malnutrition or risk of malnutrition and C. patients suffering from severe malnutrition. During one year, the protocol has been used for 226 randomly chosen female and male patients older than 18 years. They were treated by the Medical and Radiotherapy Oncology outpatient clinic.

RESULTS

More than a half of the patients were suffering from malnutrition (64%) increasing up to 81% for patients undergoing palliative treatment. Most of them were treated curatively (83%) and received oncology treatment with moderate or high nutritional risk (69%). 68% of patients were affected by some feeding difficulty. The mean percentage of weight loss has been 6.64% +/- 0.87 (min 0%, max 33%). Albumin values of 32% of the patients were between 3 and 3.5 g/dl and negatively correlated with feeding difficulties (p = 0.001). The body mass index (BMI) has not found to be a significant parameter for detecting malnutrition (only in 10% of the patients, the value was below 19.9 kg/m2). But a significant linear tendency when compared to feeding problems could be shown, such that in patients with less feeding problems a higher BMI has been found (p = 0.001). More than a half of the patients required nutritional counselling to control symptoms which made food intake difficult. One third of the patients needed oral nutritional supplementation. Following the nutritional intervention the weight of about 60% of the patients could be maintained and of one sixth it could be increased.

CONCLUSION

The application of this protocol is useful, easy and could help detecting malnutrition in oncology patients. It provides the possibility to select those patients who can benefit from a specific nutritional intervention. If possible, the application of the protocol should be started immediatly after cancer is diagnosed. Nutritional support proves efficient for most of the patients.

[Self-perception of cancer patients on the relationship existing between their nutritional status, their feeding status, and their illness]

INTRODUCTION

Knowing the opinion of oncologic patients about the importance they give to their feeding, the difficulties they have with feeding, their body image, weight, and ponderal changes, the relationship between their feeding and their illness, the relationship between their physical activity and their mood and health is essential to look for nutritional therapeutic interventions leading to improvement of quality of life and, in general, the feeling of well being. Thus, it is paramount to know the patients' opinion of these issues.

MATERIAL AND METHODS

We passed a questionnaire to 131 patients. The patients were recruited from the Day-Hospital of the Medical Oncology and Radiotherapeutic Oncology Departments, and from the Hospitalization Department of Medical Oncology. In the questionnaire, we asked in a simple manner about the importance the patients give to all these issues. This is a 20-item questionnaire, divided into six parts: 1. Vital statistics; 2) perception about the disease and its relationship with feeding; 3) Perception of the relationship between physical activity and mood with feeding; 4) Nutritional therapies prescribed to the patients and their perception on its effect on the disease progression; 5) Current difficulties with feeding; 6) Demand of nutritional care.

RESULTS

The patients mean age was 57 +/- 13 years. 45% were males, and the remaining females. 81% life in an urban area, and only 14% in a rural area. The educational level was categorized in 5 groups: without education, basic education, elementary school, high school, or college studies. 28% had basic education, and 19% college studies, and only 8% had no education at all. Their occupation was also categorized in five groups: home-keeping, student, unemployed, employed, and retired. 33% were employed, 29% retired, and 34% were home-keepers. Most of the patients (74%) are aware of their illness and perceive it as severe or very much severe. Most of these patients worry about their body image, weight, and ponderal changes, and they relate them with their feeding status. 74% find a relationship between their nutritional status and their physical activity, and 73% relate it with their mood. At least half of the patients perceive their mood as being low. Although 47% manifested having some difficulty for feeding, only 34% had received some information about their diet, 26% had consumed nutritional supplements, and 81% still consumed their diet without any change. The most common difficulties for feeding were decreased appetite (38%), early satiety (32%), and nausea (20%). The nutritional intervention most commonly required by the patients was general and specific nutritional education to alleviate the symptoms associated to oncologic therapies.

CONCLUSIONS

Most of the patients are aware of the severity of their illness and care about their body image, weight, and ponderal changes, which they associate with their nutrition. Most of the patients find a close relationship between their nutritional status, their physical activity and their mood. More than half of the patients manifest having some difficulty feeding, but only one third of the population has received information about their diet some time. It is clearly shown that oncologic patients need different effective nutritional intervention measures contributing to improve their feeling of well being.

[Registry of home-based enteral nutrition in Spain for the year 2006 (NADYA-SENPE Group)]

OBJECTIVE

To communicate the results obtained from the registry of Home-Based Enteral Nutrition (HBEN) of the NADYA-SENPE group for the year 2006.

MATERIAL AND METHODS

Recompilation of the data from the HBEN registry of the NADYA-SENPE group from January 1st to December 31st of 2006.

RESULTS

During the year 2006, 3,921 patients (51% men) from 27 hospital centers were registered. Ninety-seven percent were older than 14 years. The mean age for those < 14 years was 4.9 +/- 3.9 (m +/- SD) and in those > or = 14 years, it was 68.5 +/- 18.2 years. The most common underlying disease was neurological pathology (42%), followed by cancer (28%). Enteral nutrition was administered p.o. in 44% of the patients, through nasogastric tube in 40%, gastrostomy in 14%, and jejunostomy in 1%. The average time of nutritional support was 8.8 months. The most common reasons for ending the therapy were patient's death (54%) and switching to oral feeding (32%). Thirty-one percent of the patients presented a limited activity and 40% were confined to bed/coach. Most of the patients required partial (25%) or total (43%) care assistance. The nutritional formula was provided by the hospital in 62% of the cases and from the reference pharmacy in 27%. The fungible material was provided by the hospital in 80% of the cases and by primary care in the remaining patients.

CONCLUSIONS

Although the number of registered patients is slightly higher than that from the last years, there are no important changes in the patients characteristics, or way of administration and duration of enteral nutrition.

[Nutritional status of adopted Chinese girls in Spain]

INTRODUCTION

Given the increasing number of adoptions from China in countries such as Spain, a study was designed to know and assess the nutritional profile at arrival and its likely implication in global health status, growth, and development of adopted Chinese girls.

PATIENTS AND METHODS

Eighty-five Chinese girls adopted in Spain during the 2002-2003 period and ages ranging 7-33 months of life were studied at the Social Pediatrics Unit of the "Niño Jesús" Hospital, Madrid. Datas regarding institution of origin, nutritional parameters (anthropometrical and biochemical), presence of associated diseases, and developmental retardations (psychomotor/bone age) were gathered.

RESULTS

Waterlow's nutritional index showed a malnourishment rate of 11% based on Chinese reference tables, as compared to 58% based on Spanish tables, of which 82% was acute malnourishment. When comparing the efficacy of both nutritional assessment methods proposed by Waterlow and Gomez, there were no differences in detection of malnourishment in spite of the fact that the latter author gives priority to the weight/age index as a nutritional indicator at ages lower than 2 years. Eighteen percent of the girls were considered at (height/age < p10) of suffering chronic malnourishment, but this was only confirmed in 67% of the group according to Waterlow's criteria. Among assessed plasma parameters, decreased prealbumin, lymphocytes, iron, and transferrin stand out. The predominant pathological findings were thalassemia, dermatitis, psychomotor retardation, and ferropenic anemia.

CONCLUSIONS

These results make us believe in a possible improvement in the conditions at Chinese orphanages. The low age at the time of adoption may justify the low incidence of chronic nutritional deficiencies. As a whole, anthropometrical / nutritional impairments found may be related with the consequences of carelessness and vulnerability of the adoption process. In any case, early diagnosis and implementation of appropriate therapy as soon as possible, as it is being done, is essential to provide appropriate growth and development of these girls.

[Presentation of the new Spanish home artificial nutrition registry]

The registries are databases including information about a treatment or a disease in a definite population. Concerning home artificial nutrition there are registries of patients in different European countries, USA and Japan, collecting data such as the prevalence, indication, follow-up and complications of these treatments. The Spanish group of Home Artificial Nutrition (HAN), NADYA, was established in 1992 with professionals devoted to the practise of artificial nutrition. Since then, one of its wills was the development of the Spanish registry of HAN. This is a voluntary registry accessible through the web page www.nadya-senpe.com. In 2005, this group decided to update the registry according to the Data Protection Law and including other improvements. Thank to the work of all the members of this group we have many data on the practise of HAN in our country. Since 1994, except the years 97-98, the annual registries of patients on home parenteral nutrition and home enteral nutrition have been published periodically, observing an increase in both, the number of patients and collaborating centres, presenting to us the actual practise of HAN in our country.

[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.

[Relationship between nutritional intervention and quality of life in cancer patients]

Quality of life (QOL) is a concept assessing physical, psychological and social factors which are influencing the patients' well being. Cancer and its therapy induce severe metabolic changes associated with QOL impairment. These alterations contribute to an increased energy wasting and a decreased food intake. Besides, it may lead to tumoral cachexia due to the complex interactions between pro-inflammatory cytokines and the host metabolism. On the other hand, and beyond physical impairments and metabolic effects from cancer, patients often suffer from psychological stress, such as depression. A nutritional intervention should be implemented as soon as cancer is diagnosed. It should be appropriate to the individual needs of the patient, considering the type of oncologic treatment (whether it is curative or palliative), the clinical conditions and the nutritional status. The aim is to reduce or even revert nutritional status impairment, improve the general condition, and subsequently improve quality of life. The primary focus of nutritional intervention accompanying oncologic treatment intended to cure is on the optimization of the balance between energy waste and food intake. Thus trying to achieve further specific purposes such as a decrease of rate of complications and an amelioration of the response and tolerance to the oncologic therapy. The purpose of nutritional support in palliative care is controlling the symptoms related to food intake and delaying the loss of autonomy. And by this means maintaining or improving patients' QOL. It is corraborated by a literature review, that nutritional therapy should form part of the integral oncological support since it contributes considerably to a QOL improvement. Because of the possibility to identify the patients' needs and expectations by assessing their QOL it should be generally included into their nutritional evaluation to be able to tailor the adequate nutritional support.

Trends in adult home parenteral nutrition in Spain. 1992-2003

There are very few data on trends in prevalence in home parenteral nutrition (HPN) in different countries. NADYA is the committee of the Spanish Society for Parenteral and Enteral Nutrition that takes care of the Spanish registry since 1992.

METHOD

A 12-year retrospective study of the activity of the registry was performed. The data were extracted from the NADYA's database as well as from the publications and abstracts reported on a yearly basis since 1992. Data on years 1993 and 1997-9 were not available.

RESULTS

Yearly prevalence has more than doubled to 86 patients since 1992. The number of reporting centres went up to 17 in 2003 (10 centres in 1992) As an average, the number of patients per centre is 5. The prevalence in 2003 was 2.15 patients per million inhabitants. There are trends to increasing age at the time of the first indication (42 years in 1992; 51 in 2003). Ischemic and thrombotic vascular diseases were the most common underlying diagnosis in adults. Tunnelled central venous catheters were chosen in 2/3 of the patients. Only around 17% of the patients received support from home delivery companies (11% in 1992) There were more than 1 complication per patient and year, mostly HPN-related.

CONCLUSIONS

We found a steadily increase in the number of reported patients and reporting centres over time. Prevalence went up to 2.15 patients per million inhabitants in 2003, still far behind the figures from other western countries. The NADYA registry allows a close follow-up of the evolution of HPN in Spain.

[Effects of parenteral glutamine in patients submitted to bone marrow transplantation]

Bone marrow transplantation (BMT) is a therapy used for hematologic malignancies and solid tumors. Associated chemotherapy and radiotherapy to which these patients are submitted induce secondary effects, with a high metabolic stress. Glutamine is considered a conditionally essential amino acid, and has been shown effective in severe catabolic states. The aim of the study was to assess the effect of parenteral nutrition (PN) therapy supplemented with glutamine on duration of nutritional support in a group of patients with BMT. We have also analyzed associated complications, the nutritional status, the clinical course at 6 months, differences as to type of transplantation, and oral ingestion capability. This is a phase IV, randomized, double blind, and parallel clinical trial, done at a single center. The study was performed on 49 patients, 29% male and 71% female patients, with ages between 21-63 years, distributed in 3 diagnostic groups (leukemia, lymphoma, and solid tumors), and admitted to the Hematology Department of our Hospital. Fifty percent of the patients in each group have received PN supplemented with glutamine (0.4 g/kg/day of L-alanine-L-glutamine), and the other 50% have received standard PN.

RESULTS

we have not found significant differences nor at the beginning nor at the end of the study between both groups with regards to studied variables.

CONCLUSIONS

PN is and effective therapy for maintenance of the nutritional status in patients submitted to a therapy with a, highly catabolic effect such as BMT. Although we have not been able to show the efficacy of glutamine supplementation in this study with the used dose, it does have been effective in other reports.

[Conclusions to the first Baxter-Senpe workshop on: ready-to-use (RTU) products for parenteral nutrition]

Conclusions to the workshop on ready-to use (RTU) products for parenteral nutrition. An approximation is done to the definition and advantages in comparison to other parenteral nutrition models. Issues related to management, RTU composition and hospital- and home-based indications are highlighted.

[Bilateral corneal ulceration as a result of caloric-protein malnutrition and vitamin A deficit in a patient with chronic alcoholism, chronic pancreatitis and cholecystostomy]

Since the discovery of vitamins, there has been an increasing interest at relating vitamins with particular diseases. In particular, for vitamin A its singular importance has been determined in multiple vital functions, and its relationship with diseases, both in deficit and in excess, is nowadays completely demonstrated. In developed countries, vitamin deficiency-related diseases have been greatly reduced; however, in some patients with particular features they must be kept in mind. This is the case of a 45 year-old man, with a history of chronic alcoholism, non insulin-dependent diabetes meIlitus and cholecystectomy with a high biliary drainage secondary to emphysematous cholecystitis and perivesicular abscess. He complains of bilateral ocular pain, photophobia, and decreased visual acuity besides a history of pasty, sticky and foul-smelling feces. He is admitted in the Ophthalmology Department and bilateral corneal ulceration is diagnosed. A consultation to the Nutrition Department is made because of cachexia. Severe caloric and mil protein hyponutrition is observed with a BMI of 18.2 and a 23% weight loss for the last 6 months, fat-soluble vitamins (A, D and E) deficit, mild fat malabsorption, and macrocytic and hypochromic anemia. The patient's diet is supplemented with a special hyperproteinic and hypercaloric diet for diabetics, deficient vitamins and pancreatic enzymes to improve absorption are administered, and glycemia is controlled with insulin. Four months later, the patient is assessed and has a BMI of 20, anemia has resolved and from an ophthalmologic viewpoint the course is favorable, the ulcers improve and visual acuity is almost completely recovered. In chronic alcoholic patients with a low dietary intake and clinical complications with nutritional repercussions (pancreatitis that produces malabsorption or cholecystectomy with biliary percutaneous drainage) we should not forget that micronutrients deficits may explain the etiology of other associated diseases, in the present case corneal ulceration.

[Assessment of home parenteral nutrition programme in terminal oncological patients]

BACKGROUND AND GOALS

The assessment of the acceptance of the diets served at the hospital allows the introduction of adjustments to improve the quality of the service provided to hospitalized patients by preventing the complications derived from incorrect nutrition and enhancing their stay in hospital. The goal of the present study was to analyze the acceptance of the menus offered by the Hospital's catering service.

SCOPE OF THE STUDY

Menus provided by the catering service of the "Sant Joan de Reus" University Hospital.

MATERIAL AND METHODS

A total of 160 tray meals consumed were assessed, all chosen at random and corresponding to standard diets and special diets, including puréed food. The assessment was made by two dieticians in the hospital's kitchens. A visual scale was used with the following scores: 0 for a full plate, 1 for residual food amounting to over 75%, 2 from 50% to 75%, 3 more than or equal to 25% and 4 for empty plates.

RESULTS

A total of 68 trays containing a standard diet were analyzed, together with 34 containing special diets and 41 with puréed food. The remains on 36 different courses from the standard diet were analyzed. The mean acceptance score was 3.01 +/- 1.30 in the case of the first courses, 3.24 +/- 1.11 in second courses and 3.53 +/- 0.96 for the desserts. As for special diets, a total of 27 different courses were analyzed. The mean acceptance score was 2.87 +/- 1.38 in the case of the first courses, 3.02 +/- 1.27 in second courses and 3.49 +/- 1.22 for the desserts. The first courses of puréed diets received the worst score of all the dishes served, although the overall mean score was good, 2.76 +/- 1.5.

CONCLUSIONS

In general, a good level of acceptance has been observed for the set meals served in the hospital. Knowing which courses have lower acceptance scores allows changes to be proposed to the hospital menus, with their replacement by others with foreseeably better acceptance.

[National Registry of Home Parenteral Nutrition of the year 2001]

AIM

We analyse the registered data of home parenteral nutrition (HPN) in our country during the year 2001.

METHOD

The data were collected through a previously designed questionnaire. Apart from epidemiological information, the form includes the disease 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, and progress. All data were processed and analysed by the co-ordinating team.

RESULTS

Seventeen hospitals participated, and 66 patients were enrolled. Middle age was 5.5 +/- 4.9 years for patients < 14 years old, and 49.2 +/- 15.8 years for those > or = 14 years old. The more prevalent diagnosis were: ischemic bowel (28.9%), neoplasm (22.7%), radiation enteritis (12.1%), motility disorders (4.5%) and Crohn's disease (4.5%). The mean time on HPN was 8.4 +/- 4.5 months. Tunnelled catheter was the preferential route (62.1%), followed by the implantated one (33.3%). The intermittent method (nocturnal) was preferential (81.8%). Patients receive the formula, mainly from hospital pharmacy (75.7%). The complications related to nutrition (1.3/patient) included the infections (0.46 sepsis/patient, and 0.19 catheter contamination/patients), mechanic (0.15/patient), metabolic (0.1/patient) and electrolytic disorders (0.07/patient). The readmission rate, for nutritional problems, was 1.34/patient. At the end of the year, 74.2% of the patients remained in the HPN program, and 25.8% abandoned the treatment (due to death: 52.9%, and to progress to oral feeding (25.3%).

CONCLUSIONS

This review illustrates that the registration of HPN patients in our country is standing (1.65 patients/10(6) habitants), that vascular pathology is the more frequent diagnoses in HPN patients, and the rate of readmission and complications and the behaviour is similar to other series making this as a safe treatment in our place.

[Intestinal transplant in patients with parenteral nutrition at home]

Failure of the intestine, whether due to functional or anatomical reasons, constrains Parenteral Nutrition Therapy in children or adults who, as a result of intestinal resections, alterations in motility, diseases of the microvilli or other reasons, present insufficient intestine to cover their needs in terms of nutrients and fluids. Nonetheless, the maintenance of support with parenteral nutrition at home in subjects with irreversible intestinal failure is not without life-threatening complications: liver disease, recurrent sepsis and loss of central routes recommend the assessment of the indication of intestinal transplant in this group of patients. The incidence of morbidity and mortality after intestinal transplant is greater than in other transplants (kidney, liver), but the long-term survival is around 50-60%. In Spain, 7 transplants (6 children and 1 adult) have been performed so far: 3 of intestine alone, 3 of liver plus intestine and 1 mutivisceral transplant. In 4 cases, the indication for transplant was due to terminal liver disease, with the remainder being due to the loss of venous access, intractable diarrhoea and intra-abdominal desmoid tumour, respectively. Except for one girl who presented severe rejection of the graft, the rest achieved digestive autonomy. One boy has presented lymphocyte neoplasia (PTLD) after 2 years and another died after the transplant as a result of a routine liver biopsy (with functioning grafts). Of the 38 patients assessed for transplant, 18 were considered as candidates and of these, three youthful candidates for hepato-intestinal transplant (with short intestine syndrome) have died while on the waiting list and a fourth in the operating theatre prior to an attempted multivisceral transplant. Intestinal transplants must not be considered as the last desperate therapeutic option in patients with permanent intestinal failure. The type of graft, clinical expertise and the use of new inducers (Sirulimos) all contribute to the results of this therapy, in which survivors remain free from parenteral support and can take up once more their day-to-day activities, can improve over time.

[Complications of enteral nutrition at home. Results of a multicentre trial]

AIM

In spite of the increasing number of home enteral nutrition (HEN) patients, only few articles had reported the frequency of complications related to this treatment. Our multicentric study analyzes the HEN complications in relation to access device and time of treatment.

METHOD

92 HEN patients from 8 hospitals were randomly selected. Patients were distributed in relation to the time of treatment and access device (nasogastric tube and percutaneous or surgical gastrostomies). After an educational program, they were filled in an initial questionnaire and repeated it the days 15 and 30. They received a mean of 1650 Kcal of enteral solution. A total of 2760 HEN prospective days were analyzed.

RESULTS

In prospective study 42% of patients had some complication (112 episodes). The most frequent were gastrointestinal (55%) and mechanical (29%); 0.16 complications of patient-year were registered. The most common complications were: extraction (15%), constipation (13%), vomiting (12%) and diarrhoea (10%). The gastrostomy group had more gastrointestinal complications. In retrospective evaluation, percutaneous gastrostomy group had the lowest ratio of complications and nasogastric tube group required more tube replacements (4 vs 2) and had 1.96 episodes/patient (percutaneous group 1.85 and surgical gastrostomy 3.1 episodes/patient).

CONCLUSION

HEN is safe with low incidence of complications. An adequate educational program is very important and we expect, in the future, to establish an proper National Home Care System.

[Parenteral nutrition at home: NADYA register for the year 2000]

AIM

We analyze the registered data of home parenteral nutrition (HPN) in our country during the year 2000.

METHOD

The data were collected through a previously designed questionnaire. Apart from epidemiological information, the form includes the disease 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, and progress. All data were processed and analysed by the co-ordinating team.

RESULTS

Fourteen hospitals participated, and 67 patients were enrolled. Middle age was 5 +/- 4 years for patients < 14 years old, and 48 +/- 15 years for those > or = 14 years old. The more prevalent diagnosis were: ischemic bowel (28.4%), neoplasm (16.4%), radiation enteritis (13.4%), motility disorders (7.5%), Crohn's disease (2.9%), and other. The mean time on HPN was 7.5 +/- 4.4 months. Tunelized catheter was the preferential route (77.6%), followed by the implantated one (20.9%). The intermittent method (nocturnal) was preferential (91.0%). Patients receive the formula from hospital pharmacy more frequently than from Nutriservice (71.5% versus 19.4%). The complications related to nutrition (0.32/100 days of HPN) included the infections (0.12 catheter sepsis/100 d of HPN), metabolic (0.06/100 d of HPN), mechanic (0.03/100 d of HPN) and electrolitic disorders (0.03/100 d of HPN). The readmission rate, for nutritional problems, was 0.3 hospitalizations/100 d of HPN. At the end of the year, 61.2% of the patients remained in the HPN program, 37.3% abandoned the treatment (due to death (40%), to progress to oral feeding (48%), and to progress to enteral nutrition (4%); and 1.5% of the patients were not follow up.

CONCLUSIONS

This review illustrates that there is an increment in the registration of HPN patients in our country (1997: 0.7 patients/10(6) habitants, 2000: 1.9 patients/10(6) habitants), that vascular pathology is the more frequent diagnoses in HPN patients, and the rate of readmission and complications and the behaviour is similar to other series making this as a safe treatment in our place.

[Enteral nutrition at home: National register for the year 2000]

GOAL

Once again, the NADYA-SENPE Working Group analysed the registered data of Home Enteral Nutrition (HEN) in our country, during the year 2000.

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 analysed by the co-ordinating team.

RESULTS

Twenty two hospital participated and 2,986 patients, aged 65.1 +/- 19.7 years, were enrolled. Of these patients, 41.2% were diagnosed with neurological diseases and 33.3% with cancer. The mean time on HEN was 6.3 +/- 4.4 months. Oral nutrition was the preferential route (50.8%), followed by nasoenteral tube (30.5%), and in 17.4% ostomy tubes were placed. Polymeric was the formula composition mainly used (83.2%). Patients were followed (70.1%) by the hospital reference Nutritional Support Unit. The complications related to nutrition included the gastrointestinal (0.25 complications/patient), the mechanical one (0.19 complications/patient), and the metabolic (0.007 complications/patient). Feeding tube need to be replaced 0.3 times/patient/year. The readmission rate, for nutritional problems, was observed in 0.03 patients. At the end of the year, 54.9% of the patients were in the HEN program, and in 30.3% HEN was finish due to different reasons. In 21.9% of the patients no, o light, discapacity degree was found.

CONCLUSIONS

Related to previous years, there is an increment in the number of enrolled patients. 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 were feed with ostomy tube. Finally, due to the few readmission rate and complications, HEN is a safe treatment in our country.

[Fiber and enteral nutrition]

Dietary fibre is a mixture of various substances and is essential for maintaining appropriate intestinal functionality and it is currently considered to be a necessary part of a healthy diet. Current recommendations for fibre consumption by adults range from 20 to 35 g/day. Enteral nutrition is an emerging therapeutic variation in both hospital and domestic settings. To a great extent, this development has been made possible thanks to the design of new formulas that adapt better and better to the clinicla conditions or our patients. The type of fibre used in these preparations varies greatly. Some have only one source of fibre while others use differnet combinations. There are currently 32 formulas available on the Spanish market, without counting the modules or specific preparations of individual types of fibre. Despite the enormous advances in the knowledge of the beneficial effects of fibre, the fact of the matter is that enteral nutrition that we routinely prescribe in normal clinical practice does not contain fibre. The are several explanations for this, perhaps the most plausible is that these formulas may lead to problems in their administration and tolerance. It is necessary to choose the correct calibre of catheter and define the best infusion method and timing. Another difficulty may be the gastrointestinal tolerance of the formulas containing fibre. No large-scale problems of intolerance have however been described in healthy volunteers nor in patients with acute or chronic pathologies, although it is of fundamental importance to monitor the rhythm of depositions in all patients with enteral nutrition (EN) and ensure proper intake of liquids, which would also be useful to prevent occlusion of the catheter. The theoretical benefits of EN with fibre with a view to maintaining or improving normal intestinal structure and function are very varied. Nonetheless, it has noit yet been possible to prove many of these effects in controlled clinical trials. At the present time, there are sufficient reasons of a physiological nature for using EN with fibre in many patients, particularly in those predisposed to constipation or suffering from diarrhoea, in those requiring long-term EN and in some intestinal pathologies. In the near future, fibre can be expected to form part of EN as standard component and we should define its optimal composition for different pathologies. In the meantime, we need to continue working intensely in this highly promising area of knowledge.

[Nutritional evaluation in patients with total gastrectomy]

Gastric cancer continues to be the second cause of cancer-related mortality in the world. Surgery is the only potentially curative therapy, although the adverse effects of surgery are considerable and include digestive symptoms, loss of appetite and malnutrition. Our study included 45 patients subjected to gastrectomy who were under treatment at our unit during 2000. The data given here refer to their first visit following surgery. The most frequent complications were diarrhoea (31%), pain (29%) and early dumping (24%). Other complications found were late dumping, nausea/vomiting and dysphagia. Anorexia appeared in 49% and 29% presented a negative attitude towards food. These complications give rise to insufficient food intake, leading to malnutrition, mainly marasmic in nature. Only 7% of the patients were normonourished, with 86% presenting slight or moderate malnutrition and 7% severe malnutrition. The mean Body Mass Index (BMI) of these patients was 20 +/- 3 kg/m2. The most frequent analytical alterations were anaemia with ferropenia and b12 deficit, and a reduction in the levels of zinc and retinol transporting protein. Many patients had impaired quality of life; 43% did not leave home and only 13% were able to work. Three groups were established depending on the time that had passed since the gastrectomy was performed before the first nutritional assessment (less than 3 months, from three months to a year, and over one year), without significant differences being found in any of the parameters studied. In this article we include recommendations for the nutritional handling and treatment of patients following gastrectomy.

[Changes in carbohydrate metabolism in the HIV/AIDS patient]

Over the last few years, there has been a considerable reduction in the mortality and morbidity associated with HIV patients, due to the use of protease inhibitors which have led to a true revolution in the treatment of this infection. A new problem has arisen with the increased life expectancy: the onset of a plurimetabolic syndrome characterized by hypertriglyceridaemia, hypercholesterolaemia and hyperglycaemia; in addition to anomalies in composition and distribution of body fat (central obesity and loss of peripheral fat) due to the associated lipodystrophy. As a result of the metabolic alterations, there is an increase in the risk of cardiovascular disease. Hyperglycaemia is the result of insulin resistance and is detected in between 13.6% and 46% of patients, possibly leading to type 2 diabetes (diagnosed in between 2.4% and 7% of the patients). These alterations have been documented as potentially related with the use of protease inhibitors and other drugs used in the handling of HIV patients. The appropriate treatment of altered metabolism of carbohydrate requires: 1) a customized dietary approach depending on individual BMI and lipid alterations; 2) a physical exercise programme; 3) the use of insulin sensitization drugs: metformin and thiazolidinediones and, where the therapeutic goals are not achieved or there is a contraindication for oral hypoglycaemic drugs; 4) insulin therapy with regimens similar to other diabetic patients.

[Home enteral nutrition. Annual report 1999. NADYA-SENPE Group]

GOAL

During 1999, as in previous years, the NADYA-SENPE Group has maintained an annual register of patients with Artificial Nutrition at Home in order to keep up to date our available knowledge of this therapy. The present paper analyzes the results of the sixth National Register of patients under treatment with Enteral Nutrition at Home corresponding to 1999, produced with the co-operation of twenty-three centres in the Spanish national health network.

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 that led to the prescription of nutrition, nutritional treatment, access path, complications and admissions to hospital, follow-up of the treatment, patients' quality of life and progress. All of the data are processed by the co-ordinating team. The Nutrition Unit at La Paz Teaching Hospital in Madrid has acted as the group co-ordinator.

RESULTS

During 1999, a total of 2,262 patients at the twenty-three collaborating centres followed treatment with Home Enteral Nutrition (NED in its Spanish acronym). The mean age was 63.6 (19.67 years (males: 57.6%; females: 42.3%). The mean time with nutritional treatment is 5.89 (4.25 months. The neurological alterations (37.5%) and neoplasias (36.8%) were the most frequent indications for NED. Most patients used oral administration (50.7%), the use of artificial routes is less frequent, with 5NG being used on 27.9% and PEG on 12.7%. The polymeric formulas are the ones most commonly used (87.7%). The number of complications recorded amounted to 1,403 episodes, representing 0.62 complications per patient per year, of which 40.8% were gastro-intestinal (0.26 complications per patient per year) and 18.7% were mechanical complications, with only 9 recorded cases of bronchoaspiration. It was necessary to admit patients to hospital on 836 occasions (0.38 admissions per patient), albeit generally for causes not associated with nutrition (86.1%). At year-end, 51.4% of patients continued to receive nutritional support.

CONCLUSIONS

Enteral nutrition at home is a safe technique whose use is growing in Spain. It requires the existence of appropriately equipped nutrition teams as well as the collaboration of the Primary Health Care services and the suitable training of patients and relatives. It is essential to progress more deeply into the development and application of clinical routes that provide a clear and concise methodology covering all nutrition-related aspects. In itself, nutrition is a therapeutic alternative regardless of whether access is obtained through a natural or an artificial route. It is necessary for the persons responsible for health-care administration to realize that the appropriate nutrition of patients leads to an improvement in their general health, a shorter course for their illness and, therefore, a reduction in costs.

[Artificial nutrition in the home. Annual information 1996.Group NADYA-SENPE]

Using a simplified questionnaire from the NADYA group, data referring to age, sex, diagnosis, access route, duration, form of administration, complications, and quality of life have been gathered from 1,400 patients (57% male, 43% female) who receive home enteral nutrition, and from 38 patients (20% male and 18% female) who receive home parenteral nutrition. All of these patients come from the 1996 national registry. The most common indication for home enteral nutrition are neoplasias (39%) followed by neurological alterations (33%). The most common access route is oral (48%), followed by a nasogastric tube in 34%, PEG in 10% and surgical ostomies in 7%. The average treatment duration is 6 months. There is an index of 0.74 complications/patient-year (gastrointestinal 0.28 and mechanical alterations 0.19). At the end of the year 58% of the patients continued to use at home enteral nutrition, with a death rate of 17%. The majority of the treated patients presented a severe social disability (28%) or was bed-ridden (22%). The most common indications for home parenteral nutrition are: neoplasia (42%), Crohn_s disease (10%), and mesenteric ischemia (10%). AIDS (8%), radical enteritis (5%), and motility disorders (5%) are less common. In 42% of the cases tunneled catheters are used, and port-a-cath are used in 53%. The average treatment duration is 6.9 months. 1.06 hospitalizations/patient-year have been registered in relation to the nutritional treatment (mainly catheter sepsis). A mortality of 29% is registered, and there is recovery of the oral route in 7.9% of the cases. 50% of the patients present a severe social disability.

Effect of four enteral foods on the small bowel of undernourished rats after midgut resection

OBJECTIVE

To describe the effects of new enteral foods on the adaptation of the gut mucosa after massive intestinal resection in rats.

DESIGN

Laboratory experiment.

SETTING

Teaching hospital, Spain.

SUBJECTS

91 male Wistar rats, 69 of which were studied (5 were excluded and 17 died).

INTERVENTIONS

Previously undernourished rats were subjected to either massive bowel resection (n = 30) or laparotomy (n = 26) and fed four enteral hypocaloric diets for 7 days: Alitraq (n = 7 in each group), Impact (n = 8 and 7), Enrich (n = 8 and 6), and Elemental (n = 7 and 6). The remainder were not operated on and fed chow (n = 7) or a diet containing no protein (n = 6). Two diets were high in protein (Alitraq and Impact) and two contained normal amounts (Enrich and Elemental).

MAIN OUTCOME MEASURES

Bowel mucosal thickness and proliferation; disaccharidase activity; intestinal weight and length; body weight; and plasma somatostatin, IGF-1, and peptide YY concentrations.

RESULTS

Enriched diets provided a higher body and intestinal weight, and increased length of jejunal and ileal villous size. Peptide concentrations were modified by resection but not by the diet given. Concentrations of somatostatin and insulin-like growth factor were reduced in all groups with the exception of somatostatin in the two diets high in protein in the sham-operated rats.

CONCLUSIONS

Enriched diets all improve the intestinal adaptive response to massive bowel resection in rats, offering advantages over diets with normal amounts of protein.

[Evaluation of the cost of home enteral nutrition in relation to different access routes]

When home enteral nutrition is needed, there is still, despite the undisputed increase in the quality of life that can be achieved with a Percutaneous Endoscopic Gastrostomy (PEG), a reservation in its use because this technique and its maintenance is considered to be very costly. We aim to assess the true cost of home enteral nutrition using the oral route, a nasogastric tube, and PEG.

PATIENTS AND METHODS

The data of 65 patients who required home enteral nutrition during 1996, were analyzed retrospectively. The access route was a nasogastric tube in 20 cases, 18 patients had PEG, and 27 candidates used an oral route. The average age was 56 years. 50% were men and 50% were women. The most common diagnoses that led to the indication were oropharyngeal-maxillofacial neoplasms and neurological disorders. In all cases the material and formula used was assessed, as were the associated complications and the cost of the at home enteral nutrition.

RESULTS

The average duration of the treatment was 175 +/- 128 days, and this was similar in all three groups. The average formula/day cost was slightly higher in the patients using the oral access route. The average total day cost and the average material/day cost was slightly higher in patients with a PEG. Patients with a PEG presented fewer complications than those with a nasogastric tube. The cost derived from possible complications must be higher in the nasogastric tube group, especially considering the repeated tube changes due to obstruction or loss.

CONCLUSIONS

The cost of home enteral nutrition is slightly lower if one uses a nasogastric tube. The greater incidence of complications that were mild but required a tube change, in this case a nasogastric tube, suggests higher indirect costs. The oral route is associated with the need for special formulae that are more expensive.

[Analysis of the results of treatment of obesity in the hospital outpatient department]

The results obtained in the treatment of obesity in the out patient department of the Nutrition Unit of "La Paz" hospital during the first 6 years of experience were analyzed. To this end, different aspects of the treatment of obesity were studied in a successive manner. The first approach prospectively compared the results obtained with individual or group health care education (HCE); with no statistically significant differences being found. Before analyzing the results obtained with the different treatments, one notes a high rate of abandonment (65%). One sees that the global weight lost is statistically significant (7%). The amount of weight los differs depending on the degree of obesity (measured by the Body Mass Index): grade I and II obesities lost the same percentage of weight (7%), grade III lost 8% and grade IV is the grade that loses the most, 12%. Keeping in mind the treatment modality used, the results are as follows: both the diet alone and the diet in association with health care education in a group, achieve a weight loss of 7%, modified fasting yields 6%, adding drugs to the diet achieves a loss of 11% and the most effective is bariatric surgery with a loss of 18%.

[Artificial nutrition in the home. 1995 yearly report. NADYA-SENPE Group (Natiional Registry of Patient-Spanish Society for Parnteral and Enterlal Nutrition]

By means of a simplified questionnaire, the NADYA group has gathered and analyzed data with regard to the age, sex, diagnosis, access route, duration, form of administration, complications, and quality of life, in 812 patients (62% male; 37% female) with At Home Enteral Nutrition (AHEN), and 19 patients (42% male; 57% female) with At Home Parenteral Nutrition (AHPN) corresponding the National Registry of 1995. The most frequent indication of AHEN was a neoplasm (41%), followed by neurological alterations (33%). The most common access route is the NGT (37%) followed by oral administration in 37%, PEG in 13% and surgical ostomics in 8%. The mean treatment time is 8 months. The index of complications/patient-year is 0.50 (gasterointestinal 0.17, and mechanical alterations 0.9). At the end of the study, 63% of the patients continued to receive AHEN, showing a mortality rate of 70%. The majority of the patients undergoing treatment presented a sever social disability (20%) or were bed ridden (18%). The most common indications for the AHPN are: radical enteritis (26%), Crohn's disease (21%), and mesenteric ischemia (16%). AIDS, motility alterations, and neoplasic diseases are scantly represented (10%). Tunneled catheters are used in 58% of the cases, and Port-a-Cath in 31%). The mean duration for the treatment was 7.9 months. An index of 0.47 hospitalization/patient-year was seen in relation to the nutritional treatment (mainly due to catheter septicemia). A mortality of 16% is noted, and 21% show a recovery of the oral route. 42% of the patients did not present an assessable social disability.

[Evaluation of the quality of life in artificial nutrition]

If we define quality of life as being the social, physiological, mental intellectual, and general well being of people, we realize that there is no known health care system that is able to guarantee that well being in all its possible aspects. When we as clinicians assess the positive effects of a treatment applied to a patient, we are not only assessing the offered quality of life, but also the quantity of life, so what we are really assessing is the usefulness. We could say, therefore, that while the quality of life is subjective, not exact, and cannot be quantified, the usefulness on the other hand, can and should be measured and quantified, even though, as this is a subjective assessment, it is somewhat difficult to quantify. The object of our publication is to find an appropriate method for assessing this parameter in the area that concerns us: artificial nutrition. Artificial nutrition is indicated when the patient cannot does not want to, or does not know how to eat in the natural manner. Therefore, in principle it could seem inhuman and even unethical to deny a vital support measure that is practically without any risks in a patient who cannot feed him-or herself. However, in a situation of limited resources, if the treatment were inappropriate we should consider that possibility. Under these circumstances we could consider that even a concept as essential as nutrition (in this case artificial) would lose its inalienable character. In order to assess usefulness, one must include parameters that can be quantified in percentages and whose results can be set out in units of time (years, months, or days). We use the concept of the individual usefulness, whose unit of time is the QALY (Quality Adjusted Life Years). In 1996 we made a personal modification of Rosser's Index, which was specific for evaluating the quality of life obtained by means of artificial nutrition. This consisted of substituting the assessment parameters of intensity of pain, by other that are specific in function of the limitation of the ingestion capacity presented by the patient who was subjected to AN. The third factor that corresponds to the concept of usefulness would be the index of beneficial applicability percentage of patients who benefit from the support. The combination of these three factors, applicability, life expectancy, and quality of life, would yield the usefulness of the procedure. In order to assess usefulness in all its aspects, one must also define intention, as this can be applied with three goals: essential or curative, complementary or adjuvant, and maintenance or merely palliative. We can say that the economical limitations and the cost of the therapeutic resources leads to rationing by the administration. In the face of this action, we would recommend a rational and reasonable restriction of the available resources, which lead to the so-called rationalization, a term that is more correct ethically and esthetically, than rationing. As a final conclusion we could state that ethics and economics help us to use the resources appropriately, without any contradictions, as the economy attempts to give the society the greatest possible degree of well being based on the available resources, and that is an ethical objective, The quantification of the benefits obtained by applying a treatment using measureable units, involves socio-economic concepts such as usefulness, cost/benefit, quality of life, etc. should not elicit rejection as though we were dealing with a merchandising of our ethical values. We clinicians are capable of assessing this together, both with regard to the obtained costs and benefits, and with regard to the final results, both intra- and extra-hospital, and using the appropriate tools, we can reach conclusions that can guide us objectively in making decisions, with the aim of optimizing our therapeutic actions.