Exocrine pancreatic insufficiency following bariatric surgery: unveiling alternative aetiology-case report and short review

Bariatric surgery (BS) is currently the most effective treatment for severe obesity, requiring ongoing multidisciplinary follow-up to ensure proper progress and nutrition post-procedure. Despite its favourable safety profile, it is not exempt from complications, one of which being exocrine pancreatic insufficiency (EPI). The underlying pathophysiological mechanisms of EPI after BS are multifactorial, including poorly synchronized pancreatic enzyme secretion with the passage of nutrients (pancreaticocibal or postcibal asynchrony), insufficient pancreatic stimulation and bacterial overgrowth. We conducted a short literature review of the topic through a case of a patient who underwent BS in our centre and subsequently developed EPI and severe malnutrition. EPI initially was attributed to the surgery, but after a comprehensive evaluation, an unexpected cause was revealed.

Effects of malnutrition on length of stay in patients hospitalized in an acute psychiatric ward

INTRODUCTION

Psychiatric patients are considered at risk for malnutrition due to pharmacological treatments, lifestyle habits and the mental illness by itself. Even though metabolic risk factors have been related to worse outcomes in certain conditions, the evidence regarding the nutritional status and its impact on the length of stay in psychiatric inpatients is scarce. This study aims to characterize the nutritional status in acute psychiatric patients, to correlate it with the length of stay, and to find specific potential indicators of malnutrition.

METHODS

Adult patients admitted to the Hospital Clínic of Barcelona acute psychiatric ward throughout a 1-year period were included in this cross-sectional study. Sociodemographic and clinical variables were registered, including length of stay and the nutritional status measured with the CONUT score.

RESULTS

Malnutrition was observed in 42.5% of patients. Plasmatic transferrin saturation, protein and iron levels were inversely correlated with length of stay, having low iron levels an association with longer hospitalizations. The length of stay was not influenced by diagnosis or treatment. Negative correlations with the nutritional status were found in: BMI, cholesterol, triglycerides, albumin, total proteins, prealbumin, iron, lymphocytes and zinc levels, and transferrin saturation. The multivariate analysis showed a significant association for cholesterol and zinc levels, lymphocyte count, and BMI.

CONCLUSIONS

Our results suggest that nutritional status might influence the course of psychiatric admissions. Cholesterol and zinc levels, lymphocyte count, and BMI might be factors strongly associated with malnutrition. This consideration might allow the identification of profiles in which lifestyle interventions could be implemented.

Effects of free leucine supplementation and resistance training on muscle strength and functional status in older adults: a randomized controlled trial

OBJECTIVE

To assess the effect of free leucine supplementation combined with resistance training versus resistance training only on muscle strength and functional status in older adults.

METHODS

This was a randomized, double-blind, placebo-controlled, parallel study with two intervention groups. Thirty older adults were randomly assigned to receive either 10 g leucine/day (leucine group [LG], n=15) or a placebo (control group [CG], n=15), plus resistance training over a 12-week period. Maximal overcoming isometric leg strength, functional status, nutritional status, body composition, health-related quality of life, depression, and dietary intake were assessed at 4 and 12 weeks. Missing data at 12 weeks were handled using mixed models for repeated measurements for data imputation.

RESULTS

Twenty-four subjects completed the 4-week assessment and eleven completed the 12-week intervention. Clinically significant gains were found in isometric leg strength at both assessment time points. Analysis of the effect size also showed how participants in LG outperformed those in CG for chair stands and the timed up and go test. No significant changes were observed for the rest of the outcomes.

CONCLUSION

Our combined analysis showed moderate changes in isometric leg muscle strength and certain components of functional status. The magnitude of changes found on these outcomes should be qualified as a positive effect of the concomitant intervention.

Cystinosis in adult and adolescent patients: Recommendations for the comprehensive care of cystinosis

INTRODUCTION

Cystinosis is a rare lysosomal systemic disease that mainly affects the kidney and the eye. Patients with cystinosis begin renal replacement therapy during the first decade of life in absence of treatment. Prognosis of cystinosis depends on early diagnosis, and prompt starting and good compliance with cysteamine treatment. Kidney disease progression, extra-renal complications and shorter life expectancy are more pronounced in those patients that do not follow treatment. The objective of this work was to elaborate recommendations for the comprehensive care of cystinosis and the facilitation of patient transition from paediatric to adult treatment, based on clinical experience. The goal is to reduce the impact of the disease, and to improve patient quality of life and prognosis.

METHODS

Bibliographic research and consensus meetings among a multidisciplinary professional team of experts in the clinical practice, with cystinotic patients (T-CiS.bcn group) from 5 hospitals located in Barcelona.

RESULTS

This document gathers specific recommendations for diagnosis, treatment and multidisciplinary follow-up of cystinotic patients in the following areas: nephrology, dialysis,renal transplant, ophthalmology, endocrinology, neurology, laboratory, genetic counselling,nursing and pharmacy.

CONCLUSIONS

A reference document for the comprehensive care of cystinosis represents a support tool for health professionals who take care of these patients. It is based on the following main pillars: (a) a multi-disciplinary approach, (b) appropriate disease monitoring and control of intracellular cystine levels in leukocytes, (c) the importance of adherence to treatment with cysteamine, and (d) the promotion of patient self-care by means of disease education programmes. All these recommendations will lead us, in a second phase, to create a coordinated transition model between paediatric and adult care services which will contemplate the specific needs of cystinosis.

Effects of ezetimibe on cholesterol metabolism in HIV-infected patients with protease inhibitor-associated dyslipidemia: a single-arm intervention trial

Background

The effects of ezetimibe on cholesterol metabolism in HIV-infected patients receiving boosted protease inhibitors have not been thoroughly assessed. The aim of this study was to assess cholesterol homeostasis in patients with PI associated dyslipidemia and its relationship with the response to treatment with the cholesterol-absorption inhibitor ezetimibe.

Methods

Fifteen patients with ritonavir-boosted PI-containig therapy and LDL-cholesterol > 3.36 mmol/L (>130 mg/dL) were assessed at baseline and after an 8-week course of ezetimibe 10 mg/d. Serum non-cholesterol sterols were measured at each visit as markers of cholesterol synthesis and absorption. Total-, LDL-, and HDL-cholesterol triglycerides, apolipoproteins A1 and B, high sensitivity C-reactive protein, CD4 cells and HIV-1 RNA were also measured.

Results

Ezetimibe treatment was well tolerated in all patients and resulted in significant reductions in total cholesterol (-11.4%, p = .002), LDL-cholesterol (-20.4%, p = .003), non-HDL-cholesterol (-13.4%, p = .002) and apolipoprotein B (-9.1%, p = .021).

Treatment with ezetimibe was associated with decreased cholesterol absorption markers (campesterol-to-cholesterol ratio -43.0%, p = .001; sitosterol-to-cholesterol ratio -41.9%, p = .001) and increased synthesis markers (lathosterol-to-cholesterol ratio 53.2%, p = .005). Baseline absorption or synthesis markers were unrelated to the response to treatment. CD4 cell count and plasma HIV-1 RNA remained unchanged.

Conclusions

The level of cholesterol absorption or synthesis does not appear to be a major determinant of the responsiveness to ezetimibe in patients on ritonavir-boosted PI-containing therapy.

Trial registration

EudraCT: 2006-006156-36

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-497) contains supplementary material, which is available to authorized users.

Usefulness of dietary enrichment on energy and protein intake in elderly patients at risk of malnutrition discharged to home

INTRODUCTION

Malnutrition is a cause for concern among many admitted elderly patients, being common at hospital admission and discharge.

OBJECTIVES

The objective of this study was to assess if diet enrichment with small servings of energy and protein dense foods, improves energy and nutrient intake in elderly patients at risk of malnutrition discharged to home.

METHODS

This was a retrospective case series study in elderly patients at risk of malnutrition treated with diet enrichment. There was a data review of dietary and health records of elderly patients discharged to home. Forty-one patients, mean age of 83 ± 5 years, met the inclusion criteria; 13 patients had been lost after 4 weeks of treatment and a total of 24 patients after 12 weeks. Records contained food intake data assessed at baseline, and after 4 and 12 weeks of treatment. Mini Nutritional Assessment, anthropometric measurements, routine biochemical parameters and the Barthel Index were assessed at baseline and after 12 weeks.

RESULTS

Compared to baseline, patients significantly improved their energy and protein intake after 4 weeks of treatment, fulfilling the mean nutritional requirements. The improvement in energy and protein intake was still manifest at week 12. After 12 weeks of dietary enrichment, a significant weight gain was observed (4.1%, p = 0.011), as well. No significant changes were detected in functional status.

CONCLUSIONS

Using small servings of energy and protein dense foods to enrich meals seems a feasible nutritional treatment to increase energy and protein intake and meet nutritional goals among elderly patients discharged to home.

Patterns of food avoidance in chronic fatigue syndrome: is there a case for dietary recommendations?

OBJECTIVES

To assess the dietary habits and food avoidance-behavior in patients with Chronic Fatigue Syndrome (CFS).

METHODS

Cross-sectional pilot study with 28 patients diagnosed with severe CFS. Eating habits were assessed with a food frequency questionnaire and 3-day food records. We analyzed variables related to dietary restrictions induced by symptoms or external information.

RESULTS

The most prevalent restrictions were for dairy products and gluten-containing grains, with 22 and 15 restricting patients, respectively. Patients reported different digestive symptoms, which did not improve with the use of exclusion diets. Thirteen patients had received information against the intake of certain foods through different sources. Six cases of grains restriction and 11 of dairy were compatible with a counseling-induced pattern of exclusion.

CONCLUSIONS

There is not a homogeneous pattern of food avoidance. Dietary restrictions should be based on a proven food allergy or intolerance. Dietary counseling should be based on sound nutritional knowledge.

Potential usefulness of an EPA-enriched nutritional supplement on chemotherapy tolerability in cancer patients without overt malnutrition

OBJECTIVES

To assess the effect of an intervention with an Eicosapentaenoic Acid-enriched oral nutritional supplement on chemotherapy tolerability in patients with advanced colorectal cancer.

METHODS

Thirteen patients diagnosed with stage IV colorectal cancer were included. Patients in the experimental group received 2 packs of supplement per day during 12 weeks plus dietary counseling. The control group only received dietary counseling. Patients were assessed for nutritional status, dietary intake, health related quality of life (HRQOL) and chemotherapy compliance.

RESULTS

Only patients in the supplemented group significantly increased their weight after the intervention. They also had better scores in important domains of HRQOL, compared to controls. Although not statistically significant, the supplemented group did not experience interruptions in their chemotherapy treatment compared to the control group, with more interruptions due to toxicity.

CONCLUSIONS

The present study, although limited by sample size, points out towards a positive effect of the intervention on chemotherapy tolerability.

Factors associated with nosocomial diarrhea in patients with enteral tube feeding

OBJECTIVES

Diarrhea is a frequent complication associated to enteral tube feeding (ETF) and it is a frequent cause of reduction or suspension of this type of nutritional support. Our objective was to evaluate the factors associated with nosocomial diarrhea in patients receiving ETF.

RESULTS

The only significant factor associated with the appearance of diarrhea was antibiotic consumption, specially those patients receiving the combination of two or more antibiotics. We did not find any association between factors related to ETF, analytical parameters, nor other medications and diarrhea.

CONCLUSIONS

Our observational data supports the idea that ETF should not be seen as a primary cause of diarrhea, other possible causes should be considered before reducing or discontinuing ETF administration.

Use of Diet, Nutritional Supplements and Exercise in HIV-Infected Patients Receiving Combination Antiretroviral Therapies: A Systematic Review

Background

The use of combination antiretroviral therapy (cART) has improved the prognosis of HIV infection, but it has also been linked to a spectrum of body composition changes and metabolic alterations known as the lipodystrophy syndrome. Nutritional status could influence body composition changes.

Methods

We performed a systematic search of published peer-reviewed data on the effects of diet, nutrition support and exercise on body composition and metabolic complications in patients receiving cART.

Results

Few controlled studies, most of them with small sample size, were found. Oral nutritional support increases protein and energy intake, and results in body weight and fat mass gains. Resistance exercise, with or without an aerobic component, increases lean mass and can improve insulin resistance. Low-fat diets or exercise can result in loss of fat mass, and they should be used with caution in subjects with lipoatrophy.

Conclusions

Nutritional support and exercise result in small but significant body composition changes and can be used as complementary interventions. There is a need for further research on nutritional interventions in HIV-infected patients receiving cART.

Use of diet, nutritional supplements and exercise in HIV-infected patients receiving combination antiretroviral therapies: a systematic review

BACKGROUND

The use of combination antiretroviral therapy (cART) has improved the prognosis of HIV infection, but it has also been linked to a spectrum of body composition changes and metabolic alterations known as the lipodystrophy syndrome. Nutritional status could influence body composition changes.

METHODS

We performed a systematic search of published peer-reviewed data on the effects of diet, nutrition support and exercise on body composition and metabolic complications in patients receiving cART.

RESULTS

Few controlled studies, most of them with small sample size, were found. Oral nutritional support increases protein and energy intake, and results in body weight and fat mass gains. Resistance exercise, with or without an aerobic component, increases lean mass and can improve insulin resistance. Low-fat diets or exercise can result in loss of fat mass, and they should be used with caution in subjects with lipoatrophy.

CONCLUSIONS

Nutritional support and exercise result in small but significant body composition changes and can be used as complementary interventions. There is a need for further research on nutritional interventions in HIV-infected patients receiving cART.

Quality of life, dietary intake and nutritional status assessment in hospital admitted cancer patients

OBJECTIVES

The objectives of this study were to assess the quality of life (QoL), nutritional status, and quantitative food intakes of non-terminal admitted cancer patients receiving oral feeding. As well as to evaluate what kind of relation exists between the quality of life, and the nutritional status and current intake.

SCOPE

Medical Oncology and Radiotherapy Service ward at the Hospital Clinic de Barcelona.

SUBJECTS

Fifty admitted patients in the Service ward.

INTERVENTIONS

There was a follow-up of the dietary intake during 3 working days through direct observation, as well as an assessment of anthropometrical and biochemical parameters, a record of symptomatology related data, and a QoL assessment through the EORTC QLQ-C30 questionnaire.

RESULTS

Our data show that 32.6% of the patients did not reach 25 kcal/kg/day, and 23.3% did not even fulfill 1 g protein/kg/day. Concerning QoL, mean score for global health status and overall QoL for all patients was 46.2. Compared to the general population, there were important deficits among cancer patients regarding physical, role and social functioning. The most pronounced differences in the symptom scales were for fatigue, and in single items for appetite loss and constipation. A low protein intake was associated to a poorer perception on physical functioning (p = 0.01), and fatigue was close to significance (p = 0.058). No significant differences were found regarding caloric intake and QoL.

CONCLUSIONS

A significant percentage of patients who received exclusive oral feeding did not cover a minimum acceptable quantity of their protein-energy requirements. Our results point-out that poor food intakes can affect QoL by themselves.

[Home enteral nutrition. Case load of the Clinical Hospital of Barcelona]

The use of Enteral Nutrition at Home (ENH) in the Hospital Clínico de Barcelona has grown greatly over the last decade, with a certain trend towards stabilization being observed in the last two years, but still growing at a rate of 9.2% per annum. A transverse analysis of the active patients on our ENH register at a given moment has revealed a total of 315 patients receiving treatment. The retrospective analysis of our series during 1998 gave a figure of 643 new cases. The most frequent indication for ENH was neoplasia (44%), followed by neurological pathology (28%). The administration route most frequently used was oral (66% of cases). In the oral route, oncological diagnoses were dominant (52%), whereas administration by means of a naso-gastric tube was mainly due to neurological disorders (72%). The use of PEG (12.5% of administrations via tube) was distributed between oncological and neurological patients, with a slight predominance of the first. Of those patients completing ENH in the same year, duration was in most cases (67%) less than one month. The decrease of the patient due to the underlying disorder was the main cause of termination, followed by the need for short-term nutritional support following discharge from hospital.

Transient hypothyroidism after iodine-131 therapy for Grave's disease

We studied 355 patients with Grave's disease to characterize transient hypothyroidism and its prognostic value following 131I therapy.

METHODS

The patients received therapeutic 131I treatment as follows: 333 received a dose < 10 mCi (6.6 +/- 1.9 mCi) and 22 received a dose > 10 mCi (12.8 +/- 2.9 mCi). Diagnosis of transient hypothyroidism was based on low T4, regardless of TSH within the first year after 131I followed by recovery of T4 and normal TSH.

RESULTS

After administration of < 10 mCi 131I, 40 patients developed transient hypothyroidism during the first year; transient hypothyroidism was symptomatic in 15. There was no transient hypothyroidism after high doses (> 10 mCi) of 131I. Iodine-131 uptake > 70% at 2 hr before treatment was a risk factor for developing transient hypothyroidism (Odds ratio 2.8, 95% confidence interval 0.9-9.4). At diagnosis of transient hypothyroidism, basal TSH levels were high (51%), normal (35%) or low (14%); therefore, the transient hypothyroidism was not centralized. If hypothyroidism developed during the first 6 mo after basal TSH > 45 mU/liter ruled out transient hypothyroidism.

CONCLUSION

The development of transient hypothyroidism and its hormonal pattern did not influence long-term thyroid function. Since no prognostic factors reliably predicted transient hypothyroidism before 131I or at the time of diagnosis, if hypothyroidism appears within the first months after 131I, the reevaluation of thyroid function later is warranted to avoid unnecessary chronic replacement therapy.

[Basal cortisol and ACTH in the immediate postoperative period in ACTH-producing hypophyseal adenomas]

BACKGROUND

Evaluate the usefulness of basal cortisol and ACTH during the immediate postoperative period following hypophyseal surgery, as early indicators of remission in patients with Cushing's disease.

METHODS

Nine patients with Cushing's disease and on whom selective transphenoidal adenomectomy was performed were included in the study. Basal cortisol and ACTH levels were compared the first week after surgery, with definitive results being obtained after a month's time during which basal cortisol levels below 165 nmol/l indicated patients cured of Cushing's disease.

RESULTS

Cortisol levels determined post-op, in five patients in remission, were found to be lower than those in patients who were not cured (63 +/- 55.8 versus 606 +/- 267 nmol/l, p < 0.01). However, ACTH levels were not lower. All the patients in remission had initial cortisol levels lower than 182 nmol/l, whereas the uncured patients had levels higher than 404 nmol/l. There was a correlation between cortisol measured in the first week and the definitive value (r = 0.81, p < 0.01).

CONCLUSION

Cortisol in the immediate postoperative period following hypophyseal surgery is a good indicator of definitive adrenocorticotropic function and permits the identification of those patients in remission.