Can the Evidence-Based Use of Probiotics (Notably Saccharomyces boulardii CNCM I-745 and Lactobacillus rhamnosus GG) Mitigate the Clinical Effects of Antibiotic-Associated Dysbiosis?

Dysbiosis corresponds to the disruption of a formerly stable, functionally complete microbiota. In the gut, this imbalance can lead to adverse health outcomes in both the short and long terms, with a potential increase in the lifetime risks of various noncommunicable diseases and disorders such as atopy (like asthma), inflammatory bowel disease, neurological disorders, and even behavioural and psychological disorders. Although antibiotics are highly effective in reducing morbidity and mortality in infectious diseases, antibiotic-associated diarrhoea is a common, non-negligible clinical sign of gut dysbiosis (and the only visible one). Re-establishment of a normal (functional) gut microbiota is promoted by completion of the clinically indicated course of antibiotics, the removal of any other perturbing external factors, the passage of time (i.e. recovery through the microbiota's natural resilience), appropriate nutritional support, and-in selected cases-the addition of probiotics. Systematic reviews and meta-analyses of clinical trials have confirmed the strain-specific efficacy of some probiotics (notably the yeast Saccharomyces boulardii CNCM I-745 and the bacterium Lactobacillus rhamnosus GG) in the treatment and/or prevention of antibiotic-associated diarrhoea in children and in adults. Unusually for a probiotic, S. boulardii is a eukaryote and is not therefore directly affected by antibiotics-making it suitable for administration in cases of antibiotic-associated diarrhoea. A robust body of evidence from clinical trials and meta-analyses shows that the timely administration of an adequately dosed probiotic (upon initiation of antibiotic treatment or within 48 h) can help to prevent or resolve the consequences of antibiotic-associated dysbiosis (such as diarrhoea) and promote the resilience of the gut microbiota and a return to the pre-antibiotic state. A focus on the prescription of evidence-based, adequately dosed probiotics should help to limit unjustified and potentially ineffective self-medication.

Global availability of parenteral nutrition: Pre- and post-COVID-19 pandemic surveys

OBJECTIVE

Parenteral nutrition represents a therapeutic option for patients with type 3 intestinal failure. If used exclusively, parenteral nutrition has to be complete to provide all essential nutrients. The aim was to assess the availability of parenteral nutrition in all parts of the world, to better comprehend the global situation, and to prepare an action plan to increase access to parenteral nutrition.

METHODS

An international survey using an electronic questionnaire was conducted in August 2019 and repeated in May 2022. An electronic questionnaire was sent to 52 members or affiliates of the International Clinical Nutrition Section of the American Society for Parenteral and Enteral Nutrition. Questions addressed the availability of parenteral nutrition admixtures and their components, reimbursement, and prescribing pre- and post-COVID-19 pandemic. All participating countries were categorized by their economic status.

RESULTS

Thirty-six country representatives responded, answering all questions. Parenteral nutrition was available in all countries (100%), but in four countries (11.1%) three-chamber bags were the only option, and in six countries a multibottle system was still used. Liver-sparing amino acids were available in 18 (50%), kidney-sparing in eight (22.2%), and electrolyte-free in 11 (30.5%) countries (30.5%). In most countries (n = 28; 79.4%), fat-soluble and water-soluble vitamins were available. Trace elements solutions were unavailable in four (11.1%) countries. Parenteral nutrition was reimbursed in most countries (n = 33; 91.6%). No significant problems due to the coronavirus pandemic were reported.

CONCLUSIONS

Despite the apparent high availability of parenteral nutrition worldwide, there are some factors that may have a substantial effect on the quality of parenteral nutrition admixtures. These shortages create an environment of inequality.

ESPEN practical guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community

RATIONALE

This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSION

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community

RATIONALE

This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings.

METHODS

In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee and a supporting working group with representatives bringing additional global diversity and expertise. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications.

RESULTS

A two-step approach for the malnutrition diagnosis was selected, i.e., first screening to identify "at risk" status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among the GLIM core and supporting working group members. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present. Phenotypic metrics for grading severity as Stage 1 (moderate) and Stage 2 (severe) malnutrition are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

CONCLUSION

A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure further collaboration and endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The diagnostic construct should be re-considered every 3-5 years.

Abstract P1-02-04: Not presented

This abstract was not presented at the symposium.

Abstract B82: Metabolomic analysis reveals association between leucine and lipogenesis for the formation of lipid rafts in the membrane of primary breast tumor samples

Introduction: Upregulation of lipogenesis, via FASN, represents a nearly-universal phenotypic alteration in most malignancies. Experimental studies indicated that leucine deprivation decreased expression of lipogenic gene FASN, saturated fatty acid (SFA) synthesis, and induced apoptosis in breast cancer cells. However, the association between lipogenesis and leucine is not well understood in breast cancer.

Methods: In this sense, metabolomics analysis was performed from primary breast cancer and adjacent tissue samples from cohort of 96 breast cancer patients from the Institut Gustave-Roussy and Institute Curie – Paris, University of Debrecen – Hungary, and University of Tartu – Estonia. The Biocrates Life Science® company performed the metabolomics analysis using the Absolute IDQ p180 kit. Statistical analysis was performed by MetaboAnalyst 3.0 software (p <0.05). We performed the combined analysis of genes from public database (GEO) with genes of interest related to metabolic pathways. Differently expressed genes analyses between breast tumor and normal breast tissue were performed by TMev program using TestT student (p< 0.05). We selected only differently expressed genes related with leucine metabolism and lipogenesis for further analyses.

Results: Indeed, in the tumor tissue we observed an increase of lipogenesis, and BCAA (branched chain amino acid) uptake and catabolism. The amino acids valine and isoleucine were used for the synthesis of succinyl and alpha ketoglutarate to meet the increased demand for the TCA (tricarboxylic acid) cycle. Surprisingly, the leucine metabolites indicated that it was used for cholesterol synthesis. Moreover, in tumor tissue samples an increase of SFA synthesis was observed, such as palmitic acid, sphingolipids, and phosphatidylcolines SFA enriched. Together with increased synthesis of cholesterol (via leucine), these data suggest an increase of lipid rafts in the breast tumor cells membrane when compared to normal breast adjacent tissue. To validate these data, we found 12 genes differently expressed genes related to leucine/cholesterol/lipogenesis/lipid rafts from public database.

Conclusion: Our results indicate that lipogenic phenotype is associated with leucine metabolism to promote survival and proliferation, through lipid rafts increase, necessary to receptors (i.e., HER2, EGFR) location and activation within the breast tumor cells membrane.

Citation Format: Jéssica Reis, Ismael Dale, Angela Logullo, Maria Mitzi, Dan Waitzberg, Graziela Ravacci. Metabolomic analysis reveals association between leucine and lipogenesis for the formation of lipid rafts in the membrane of primary breast tumor samples [abstract]. In: Proceedings of the AACR International Conference held in cooperation with the Latin American Cooperative Oncology Group (LACOG) on Translational Cancer Medicine; May 4-6, 2017; São Paulo, Brazil. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(1_Suppl):Abstract nr B82.

Health impact of childhood and adolescent soy consumption

Soyfoods have been intensely researched, primarily because they provide such abundant amounts of isoflavones. Isoflavones are classified as both plant estrogens and selective estrogen receptor modulators. Evidence suggests that these soybean constituents are protective against a number of chronic diseases, but they are not without controversy. In fact, because soyfoods contain such large amounts of isoflavones, concerns have arisen that these foods may cause untoward effects in some individuals. There is particular interest in understanding the effects of isoflavones in young people. Relatively few studies involving children have been conducted, and many of those that have are small in size. While the data are limited, evidence suggests that soy does not exert adverse hormonal effects in children or affect pubertal development. On the other hand, there is intriguing evidence indicating that when soy is consumed during childhood and/or adolescence, risk of developing breast cancer is markedly reduced. Relatively few children are allergic to soy protein, and most of those who initially are outgrow their soy allergy by 10 years of age. The totality of the available evidence indicates that soyfoods can be healthful additions to the diets of children, but more research is required to allow definitive conclusions to be made.

Abstract P6-02-06: Metabolomic profiling of breast cancer and adjacent tissue

Breast cancer (BC) is the most common cause of death among women worldwide. Nowadays, research directed toward the discovery of cancer molecular characteristics has extended into various biological aspects, from early investigations of cancer genomics and proteomics to recent efforts in cancer metabolomics. We consider that breast cancer cells display significantly altered cellular processes, and thus metabolites, compared to normal cells. In this regard, the application of metabolomics towards cancer research can led to the discovery of metabolite cancer biomarkers and the identification of target therapeutics. Methods: Metabolomics signature was extracted from primary BC and adjacent tissue samples from a cohort of 182 breast cancer patients from the Institut Gustave-Roussy and Institute Curie – Paris, University of Debrecen – Hungary, and University of Tartu – Estonia. The Biocrates Life Science® company, performed the metabolomics analysis using the Absolute IDQ p180 kit. Statistical analysis was performed by MetaboAnalyst 3.0 software (p <0.05). Results: We observed 99 differential metabolites between breast tumor and adjacent tissues (p<0,05). In the tumor tissue we observed an increase of glycolysis, glutamine uptake and synthesis, glutamate production, intermediates for redox homeostasis, as well reduction in tricarboxylic acid cycle and β –oxidation impairment. Together, these pathways, favor lipogenesis with a consequent increase in saturated fatty acids and cholesterol synthesis for the formation of membranes and lipid rafts in tumors. The increase in rafts in tumors maintains proliferation signaling via membrane receptors, making them important biomarkers. Conclusion: Metabolomics analysis is useful in identifying differential metabolites between breast cancer and adjacent tissue. In this scenario, cancer cells may be dependent on some metabolites for its development, making them therapeutically valuable biomarkers.

Citation Format: Santos JR, Brentanni MM, Tortelli T, Dale I, Waitzberg A, Waitzberg D, Ravacci G. Metabolomic profiling of breast cancer and adjacent tissue [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-02-06.

Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee

BACKGROUND & AIMS

Multiple definitions for malnutrition syndromes are found in the literature resulting in confusion. Recent evidence suggests that varying degrees of acute or chronic inflammation are key contributing factors in the pathophysiology of malnutrition that is associated with disease or injury.

METHODS

An International Guideline Committee was constituted to develop a consensus approach to defining malnutrition syndromes for adults in the clinical setting. Consensus was achieved through a series of meetings held at the A.S.P.E.N. and ESPEN Congresses.

RESULTS

It was agreed that an etiology-based approach that incorporates a current understanding of inflammatory response would be most appropriate. The Committee proposes the following nomenclature for nutrition diagnosis in adults in the clinical practice setting. "Starvation-related malnutrition", when there is chronic starvation without inflammation, "chronic disease-related malnutrition", when inflammation is chronic and of mild to moderate degree, and "acute disease or injury-related malnutrition", when inflammation is acute and of severe degree.

CONCLUSIONS

This commentary is intended to present a simple etiology-based construct for the diagnosis of adult malnutrition in the clinical setting. Development of associated laboratory, functional, food intake, and body weight criteria and their application to routine clinical practice will require validation.

[Total regression of advanced gastric lymphoma after drug therapy]

Primary gastric lymphoma is a relatively rare entity that may have several different methods of treatment, including surgery, chemotherapy and radiotherapy. We describe a case of advanced primary gastric lymphoma treated with chemotherapy. A 51-year-old male patient underwent total gastrectomy after two cycles of chemotherapy. The histologic examination of the gross specimen revealed total regression of the lymphoma. Literature review of this condition and a discussion about the diagnosis and treatment are presented.

Phase II trial of etoposide (V), adriamycin (A), and cisplatinum (P) in patients with metastatic gastric cancer

The efficacy and toxicity of a combination of etoposide (100 mg/m2 i.v. on days 1 to 3), Adriamycin (20 mg/m2 i.v. on days 1 and 8) and cisplatinum (40 mg/m2 i.v. on days 2 and 8) repeated every 4 weeks as an outpatient regimen were assessed in 29 consecutive patients with metastatic gastric cancer with measurable disease. Five of these patients were refractory to 5-Fluorouracil, Adriamycin, and Mitomycin C. Three of these previously treated patients responded to the etoposide. Adriamycin, cisplatinum (VAP) therapy. An overall objective response rate of 72.5% was achieved, including 14% that were complete responses. The median duration of response was 6.0 months; median overall survival was 7.2 months, overall one-year survival was 34.4%. Hematologic toxicity was intense, particularly among patients with lower performance status. Three patients died as a consequence of nadir sepsis episodes.

The influence of nutritional status on skin anergy in experimental cancer

Malignant tumours as well as severe malnutrition can interfere with carcass weight, serum albumin and delayed hypersensitivity tests. In order to identify the separate effects of these two phenomena, Wistar rats were submitted to various nutritional manipulations prior to Walker-256 carcinosarcoma inoculation (TU). Six groups of well-nourished rats with positive response to the Keyhole Limpet Haemocyanin (KLH) test were studied. Three TU-bearing groups were established, [1] protein-deprived before and after TU (group DDT), [2] protein deprived before TU and later brought back to normal chow (group DNT), and [3] those receiving a complete diet throughout the experiment (group NNT). Identical control groups without TU, sham-injected, were called DDC, DNC and NNC. Tumour size and body weight were measured daily. KLH tests were done sequentially and serum albumin was determined at sacrifice. Results indicated that cancer produced marked changes in immune response. Malnutrition was responsible for anergy and weight loss, and further aberrations tended to occur when both conditions were present. Feeding was able to restore body weight and KLH response in tumour-bearing as well as in control rats, but subsequent deterioration occurred in cancer bearing rats after the first week of tumour development. It is concluded that cancer potentiates the effects of malnutrition, on body weight and immune response, but temporary recovery could be demonstrated after adequate refeeding.