Effects of a Synbiotic Formula on Functional Bowel Disorders and Gut Microbiota Profile during Long-Term Home Enteral Nutrition (LTHEN): A Pilot Study

Long-term enteral nutrition (LTEN) can induce gut microbiota (GM) dysbiosis and gastrointestinal related symptoms, such as constipation or diarrhoea. To date, the treatment of constipation is based on the use of laxatives and prebiotics. Only recently have probiotics and synbiotics been considered, the latter modulating the GM and regulating intestinal functions. This randomized open-label intervention study evaluated the effects of synbiotic treatment on the GM profile, its functional activity and on intestinal functions in long-term home EN (LTHEN) patients. Twenty LTHEN patients were recruited to take enteral formula plus one sachet/day of synbiotic (intervention group, IG) or enteral formula (control group, CG) for four months and evaluated for constipation, stool consistency, and GM and metabolite profiles. In IG patients, statistically significant reduction of constipation and increase of stool consistency were observed after four months (T₁), compared to CG subjects. GM ecology analyses revealed a decrease in the microbial diversity of both IC and CG groups. Biodiversity increased at T₁ for 5/11 IG patients and Methanobrevibacter was identified as the biomarker correlated to the richness increase. Moreover, the increase of short chain fatty acids and the reduction of harmful molecules have been correlated to synbiotic administration. Synbiotics improve constipation symptoms and influences Methanobrevibacter growth in LTHEN patients.

Preoperative oral immunonutrition versus standard preoperative oral diet in well nourished patients undergoing pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy is still associated to high morbility, especially due to pancreatic surgery related and infectious complications: many risk factors have already been advocated. Aim of this study is to evaluate the role of preoperative oral immunonutrition in well nourished patients scheduled for pancreaticoduodenectomy.

METHODS

From February 2014 to June 2015, 54 well nourished patients undergoing pancreaticoduodenectomy were enrolled for 5 days preoperative oral immunonutrition. A series of consecutive patients submitted to the same intervention in the same department, with preoperative standard oral diet, was matched 1:1. For analysis demographic, pathological and surgical variables were considered. Mortality rate, overall postoperative morbility, pancreatic fistula, post pancreatectomy haemorrhage, delayed gastric emptying, infectious complications and length of hospital stay were described for each groups. Chi squared test, Fisher's Exact test and Student's T test were used for comparison. Differences were considered statistically significant at p < 0.05. Statistics was performed using a freeware Microsoft Excel (®) based program and SPSS v 10.00.

RESULTS

No statistical differences in term of mortality (2.1% in each groups) and overall morbility rate (41.6% vs 47.9%) occurred between the groups as well as for pancreatic surgery related complications. Conversely, statistical differences were found for infectious complications (22.9% vs 43.7%, p = 0.034) and length of hospital stay (18.3 ± 6.8 days vs 21.7 ± 8.3, p = 0.035) in immunonutrition group.

CONCLUSION

Preoperative oral immunonutrition is effective for well nourished patients scheduled for pancreaticoduodenectomy; it helps to reduce the risk of postoperative infectious complications and length of hospital stays.

[A serious complication due to liquid silicone injection in the legs for cosmetic purpose]

Liquid injectable silicone has been used to increase volume in determined cutaneous districts, particularly in aesthetical reconstructive surgery. Although considered biologically inert for a long time this substance produced various complications as granulomatous foreign body reaction (siliconomas), secondary limphedema, tissue destruction and lethal embolism. A 35-year-old Caucasian woman came to our department with erithema and edema on the right leg, fever and chills. A thorough examination of the patient's history revealed injection of liquid silicone 7 years before for cosmetic volume increase of both legs. A closer observation revealed a small fistulous element from which came out white-yellow puruloid material. Antibiotic therapy and drainage of the abscess were undertaken. Within few days of treatment erithema and swelling essentially improved and the patient was discharged. After two months she came back to our department due to the same disease on her left leg that we treated with the therapy previously used. We highlight the long time, 7 years, elapsed between liquid silicone injection and onset of cutaneous symptoms.

Lower serum lipid levels are related to respiratory impairment in patients with ALS

BACKGROUND

Recently hyperlipidemia was reported to be related to a significantly better outcome in amyotrophic lateral sclerosis (ALS). To investigate this, we evaluated the status of blood lipids in a large Italian series of patients with ALS, and assessed the effect of hyperlipidemia on patients' survival.

METHODS

The study population included 658 patients with ALS consecutively observed in 2 Italian ALS centers between 2000 and 2006. They were compared to a series of 658 healthy subjects, matched by age and gender.

RESULTS

The mean levels of total cholesterol, triglycerides, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and the LDL/HDL ratio were similar in patients with ALS and controls. Total cholesterol, HDL, triglyceride, and LDL/HDL ratio levels showed a significant decrease in patients with forced vital capacity <70% compared to those with FVC >or=90%. For each level of ALS-FRS, poorer respiratory function was related to a lower LDL/HDL ratio. Univariate survival analysis did not find any significant effect of LDL/HDL ratio on survival, either when comparing patients with ratios <or=2.99 vs >2.99 or patients in the first quartile of LDL/HDL ratio (<or=1.67) vs those in the fourth quartile (>2.79). No dose-response was found for LDL/HDL ratio subdividing patients into 5 quintiles.

CONCLUSION

Our findings do not support the observation that patients with amyotrophic lateral sclerosis have hyperlipidemia or that hyperlipidemia in this population is related to longer survival. However, some evidence emerged that respiratory impairment, but not a worse clinical status or a lower body mass index, is related to a decrease in blood lipids and LDL/HDL ratio.

Two different techniques in the rehabilitation treatment of low back pain: a randomized controlled trial

AIM

The Back School is a widely accepted and effective method for treating low back pain, whereas no scientific evidence exists about the effects of the Pilates CovaTech method. With this study we wanted to evaluate the efficacy of this new method in patients with low back pain.

METHODS

Fifty-three patients with at least 3 months of nonspecific low back pain were entered into a Pilates therapy or a Back School treatment group, 43 of which completed the study. Small exercise groups of 7 patients each followed a daily kinesitherapy protocol for 10 days. Evaluations were performed at the start of the study and then at 1, 3 and 6 months after the beginning of treatment. We used the Oswestry Low Back Pain Disability Scale (OLBPDQ) to assess disability and the visual analog scale (VAS) to evaluate pain.

RESULTS

Demographic and baseline clinical characteristics were similar for both groups. A significant reduction in pain intensity and disability was observed across the entire sample. The Pilates method group showed better compliance and subjective response to treatment.

CONCLUSIONS

The results obtained with the Pilates method were comparable to those achieved with the Back School method, suggesting its use as an alternative approach to the treatment of non specific low back pain.

Percutaneous radiological gastrostomy: a safe and effective method of nutritional tube placement in advanced ALS

BACKGROUND

Enteral nutrition may be required in amyotrophic lateral sclerosis (ALS), and is usually achieved by percutaneous endoscopic gastrostomy (PEG). As PEG is not indicated in patients with severe respiratory impairment, an alternative is percutaneous radiological gastrostomy (PRG), involving air insufflation into the stomach under fluoroscopic guidance for tube insertion.

OBJECTIVE

To evaluate the safety of PRG and its effect on survival and respiratory function in ALS patients with respiratory failure.

METHODS

25 consecutive ALS patients with severe dysphagia and forced vital capacity (FVC) <50% underwent PRG after October 2000. They were compared with 25 consecutive ALS patients with FVC <50% who underwent PEG before October 2000. Respiratory function was evaluated before and after the procedure.

RESULTS

The two groups were similar for all relevant characteristics. PRG was successful in all cases, PEG in 23/25. One patient in each group died after the procedure. The mean survival time after the procedure was 204 days in the PRG group and 85 days in the PEG group (p<0.004). Respiratory function decreased more in the PEG group than in the PRG group (p<0.02).

CONCLUSIONS

PRG appears to be safer than PEG in ALS patients with moderate or severe respiratory impairment, and is followed by a longer survival.

Percutaneous endoscopic gastrostomy: a long-term follow-up

Percutaneous endoscopic gastrostomy (PEG) is the preferred method of long-term tube feeding, but only a few studies describe a long-term follow-up. The purpose of this study is to analyze the follow-up of PEG enteral feeding patients in the long term, and to report on the complication and survival rates. Between January 1991 and June 1995, we studied 136 patients (49% cancer and 51% non-cancer patients; male = 68%, female = 32%) after PEG insertion. One hundred twenty-eight patients had a long-term follow-up of over 31 d. The mean duration of PEG feeding was 277 +/- 358 d (range 31-1590): 17% of patients returned to oral feeding, 34% continued enteral nutrition, and 49% died. Major complications occurred in 3% of the patients: 1 aspiration pneumonia, 1 subcutaneous abscess. 2 buried bumper syndrome. Minor complications arose in 14% of our cases: 8 tube blockages, 4 tube dislodgements, 6 site infections. For the whole group of 136 patients, survival probabilities after PEG insertion at 1, 6, 12, and 24 mo were 90.5%, 52%, 42%, and 35%, respectively. After 180 d, the difference in survival probabilities between cancer and non-cancer patients became significant (P < 0.02). Median survival probability was 64% for non-cancer and 39% for cancer patients, and this trend did not change over 2 y.

Passively administered antibody suppresses the induction of measles virus antibodies by vaccinia-measles recombinant viruses

We have used vaccinia-measles recombinant viruses to study vaccination in the presence of pre-existing antibody. When mice were vaccinated with recombinants expressing either the haemagglutinin (H) or fusion (F) measles virus (MV) proteins, the humoral response to the MV protein was suppressed by passively administered polyclonal antibody. However, individual monoclonal antibodies (H or F) did not affect the response. Mice whose anti-MV antibody response to H or F was initially suppressed by passive administration of anti-MV antibody were revaccinated 120 days later and gave a normal humoral response to the MV proteins. The VV-H recombinant induces a strong class I CTL response in Balb/c mice. This was not affected by the presence of levels of anti-MV antibody which inhibited the humoral response.

[Trace nutrients in total enteral nutrition: the basal status and longitudinal course]

INTRODUCTION

Previous studies demonstrated deficiencies of selenium and other micronutrients in patients receiving total enteral nutrition (TEN). The content and bioavailability of trace elements in enteral formulas can be suboptimal.

MATERIAL AND METHODS

Basal blood levels of some trace elements (copper, iron, selenium, zinc) and vitamins (B12, folic acid) were determined in twenty patients at the beginning of TEN. Vitamin E was measured in 7 patients. Primary diagnosis was cancer (no. = 13) and organic brain syndromes (no. = 7). Commercially available polymeric and oligomeric enteral formulas were used, containing respectively, as a percent of RDA in 1500 kcal, 65-39% of copper, 180-135% of iron, 80-100% of zinc. Selenium was not indicated; determinations in our laboratory gave a content of 78-63% of the minimum recommended intake. Blood levels of copper and zinc (no. = 6), selenium (no. = 5), iron, transferrin and ferritin (no. = 13) were measured after two months of TEN (mean intake of 30 +/- 3 kcal/kg/day). Copper, selenium and zinc were measured with atomic absorption; iron with the complessometric method: vitamin B12 and folic acid with RIA; vitamin E with HPLC.

RESULTS

Mean values, expressed as mean +/- SD (range) were: copper: 129 +/- 23 (82-300) micrograms/dl; iron: 37 +/- 18 (16-89) mg/dl; selenium: 53 +/- 20 (22-93) micrograms/dl; zinc: 85 +/- 34 (44-185) micrograms/dl; vitamin B12: 632 +/- 450 (140-1575) pg/ml); vitamin E: 5.4 +/- 1.5 (3.3-7.8) mg/dl; folic acid: 11 +/- 8 (2-20) ng/ml. Values below the lower normal limit were found in 100% (vitamin E), 89% (selenium), 60% (iron), 35% (zinc), 24% (vitamin B12) and 14% (folic acid) of the patients studied. Copper was higher than the upper normal limit in 31% of cases; no data below normal range was found. Mean blood levels of depleted subjects were at the 28%, 43%, 54% and 63% of the mean normal value respectively for iron, selenium, vitamin E and zinc. Blood iron (p < 0.05) and selenium (p < 0.001) were significantly lower in more malnourished patients (weight loss > 20% vs < 20% on usual body weight). After two months of TEN, a reduction of 33% of mean blood selenium was observed in 4 of 5 patients studied. Blood copper and zinc remained stable in 6 subjects with initial normal or higher than normal values. Blood iron increased nonsignificantly, ferritin remained stable, transferrin increased significantly (p < 0.05). No clinical deficiency syndromes were observed.

CONCLUSIONS

A careful monitoring of micronutrients during TEN is recommended. Selenium content of enteral formulas, unless supplemented by the producers, seems to be insufficient to maintain the initial blood level in two months of TEN.

[Percutaneous endoscopic gastrostomy]

Surgical gastrostomies were first performed in the middle of the 19th century and modified during the following years, but the most important technical improvement was percutaneous endoscopic placement (PEG), in 1980 by Ponsky and Gauderer. This technique doesn't require anesthesia and it in possible also in patients with contraindications to surgical gastrostomy. The simple procedure involves a shorter hospitalization, lower risks and reduced costs. Many authors already reported the good results of this new technique, that can be performed on a day-hospital regimen as well. The main indications are head and neck cancers, neurologic diseases involving food intake capacity, cancer cachexia, obstruction of the GI tract when there is enough space for an endoscopic procedure. Every disease that can compromise food intake for a period longer than 60 days can find an indication in placing a percutaneous gastrostomy. The advantage for the patient is a much better psychological tolerance compared with a naso-gastric tube. Also the incidence of mechanical complications of a PEG is much lower. In our experience from October '90 to July '92 we followed 34 patients with PEG, 22 males and 12 females, with mean age of 69 years (range 41-88). We used 9-French tube placed using the pull-method technique. All patients received antibiotic therapy for 5 days. About 12 hours after PEG placement all patients began using the gastrostomy, initially with the administration of electrolyte solutions and later with enteral polymeric formulas. The constant increase led all patients to a 1500 non protein calories daily intake in 3-4 days.(ABSTRACT TRUNCATED AT 250 WORDS)

[Enteral nutrition in the elderly]

Elderly is particularly at risk of malnutrition: he is not able to feed himself adequately, it is then important to attain correct intakes using also artificial enteral nutritional techniques (nasogastric tube, gastrostomy, etc.). These techniques may lead to complications (ab ingestis pneumonia, metabolic complications, alvus disorders): the use of artificially nutrition in the elderly must be carefully evaluated. 257 patients (M = 180, F = 77) aged 65 or more, mainly affected by neoplastic diseases (n 195) and by neurological and vascular diseases (n 62). The feeding route were evaluated in this study: 74% by nasogastric tube, 13% by gastrostomy, 11% by jejunostomy. In a group of 55 patients similar concerning clinical and nutritional conditions we evaluated at the beginning of enteral feeding and four months later, caloric/protein intake, body weight and plasmatic albumin. In patients fed by nasogastric tube a mean intake of 1300 +/- 365 Kcal n.p./die, with a protein rate of 58.5 +/- 16.9 g/die was attained; by gastrostomy 1450 +/- 324 Kcal n.p./die and 65.5 +/- 16 g/die; by jejunostomy 1219 +/- 398 Kcal n.p./die and 53.3 +/- 21 g/die. The compliance to enteral nutrition was well in 37% of patients night administration was performed. Clinical complications: nausea and vomiting were observed in 9 patients with nasogastric tube, in 1 patient with gastrostomy and in 3 patients with jejunostomy; diarrhea has been noticed in 6 patients with nasogastric tube and in 1 patient with jejunostomy. Mechanical complications; nasogastric tube (n 189): 35 displacements, 7 breakages, 4 obstructions; pharyngostomy (n 6): 2 displacements and 1 obstruction; gastrostomy (n 33): 3 displacements; jejunostomy (n 29): 2 misplacements.(ABSTRACT TRUNCATED AT 250 WORDS)

Benfluorex and blood glucose control in non insulin-dependent diabetic patients

Benfluorex has been reported to decrease blood glucose in different dismetabolic conditions, particularly in noninsulin-dependent diabetic (NIDD) patients, but the mechanism of this effect is poorly known. We evaluate fasting glucose production (3H-glucose infusion) and B-cell secretion (phi 1, phi 2 and glucose utilization SI) (minimal model technique) in 7 mild, diet treated, NIDDM patients after 6-week administration of benfluorex (450 mg/day) and placebo, in random sequence and double blind design. Body weight, HbA1c, plasma glucose profile, fasting plasma insulin, lactate, pyruvate, beta-OH-butyrate, total cholesterol, HDL-cholesterol and triglycerides were also measured at the end of each treatment. Mean values of body weight (71 +/- 4 vs 69 +/- 4 kg, p less than 0.01), HbA1c (8.3 +/- 0.2 vs 7.7 +/- 0.2%, p less than 0.01), fasting plasma glucose (137.0 +/- 6.5 vs 121.4 +/- 5.6 mg/dl, p less than 0.01), lactate (1.82 +/- 0.13 vs 1.22 +/- 0.11 mmol/l, p less than 0.0025) pyruvate (0.164 +/- 0.011 vs 0.095 +/- 0.010 mmol/l, p less than 0.0005), and beta-OH-butyrate (0.91 +/- 0.06 vs 0.66 +/- 0.04 mmol/l, p less than 0.005) were significantly lower after benfluorex than after placebo. phi 1, phi 2 and SI values were not significantly different in the two treatments. Fasting glucose production was significantly lower after benfluorex than after placebo: 2.46 +/- 1.57 vs 1.84 +/- 0.85 mg/kg.min, p less than 0.02. These results demonstrate that 6-week treatment with benfluorex produces a significant blood glucose lowering effect in mild NIDDM patients, mainly by decreasing glucose production.

[The role of the intestine in the pathogenesis and treatment of multiple organ failure]

Infection and sepsis remain major causes of death in medical and surgical services, despite the availability of potent antibiotics, aggressive surgery and close monitoring of patients in intensive-care units. Actually the terminology to define this type of events in multiple organ failure: we considered the role of intestine in its pathogenesis and its management.

[Influence of coffee on plasma lipids]

The influence of coffee on plasma lipids has been largely investigated during the last twenty years, but still many doubts remain about this subject. For this reason the influence of the assumption of coffee on plasma lipids, in healthy people, during six weeks has been studied. The coffee was prepared with an Italian coffee-machine (moka). No relationship was found between coffee assumption and increase of hematic cholesterol.

[Role of diet in the treatment of constipation. Review of the literature]

Constipation represents a common social phenomenon today, correlated with the habits of diet and life. Many studies have shown the lack of alimentary fiber as a cause of constipation. In analyzing the different types, the characteristics, the physical and metabolical action of fiber, it has been shown that it is necessary to introduce fiber into the everyday diet to be able to prevent or cure constipation. In addition, it has been seen that there has been a reduction in the consumption of fiber in many nations and some reasons have been investigated.

Electromyographic observations in patients with foot pain syndromes

Abductor hallucis muscle EMGs were performed in control subjects and in patients with chronic foot pain (9 affected by the disease of the metatarsophalangeal joint of the big toe, 6 affected by chronic foot strain) to investigate pathophysiological mechanisms of muscle pain syndromes. Unlike control subjects, patients showed an abnormal involuntary activity when standing. All patients presented a decrease of abnormal EMG activity when postural changes were induced either by variations in body weight distribution on the feet, or by changes of position in the weight-bearing foot achieved by arch supports or by boards of variable thickness applied under the forefeet or the heels. Anaesthesia of the metatarsophalangeal joint of the hallux (injection into the joint cavity of 2-3 ml 0.50% bupivacaine) reduced the abnormal EMG activity only in patients with hallux valgus, whereas it did not affect muscular activity in the other patients. Present results support the idea of the role of abnormal muscular activity in causing and maintaining chronic pain and suggest that alterations of postural mechanisms and of afferent input, in particular that arising from joint receptors, are involved in the genesis of this abnormal muscular activity.

Relationships between characteristics of electrical stimulation, muscle pain and blink responses in man

The present research was undertaken in 11 healthy volunteers with the aim of investigating the relationship between blink response, a feature of the startle reaction, and muscular pain evoked by muscle electrical stimulation (train of stimuli). At a repetition rate of 0.1 Hz, a close relationship was found between the threshold for muscle pain and that for the blink response, without apparent habituation. At the same rate and with stimulation intensity maintained at pain threshold, the subject could voluntarily inhibit the blink response, but not pain. Under the same conditions both pain and blink response were inhibited during a mental task. By increasing the current intensity pain became more intense and the blink response tended to increase in amplitude and to decrease in latency. Similar effects were achieved by increasing the repetition rate with the current intensity maintained at pain threshold. Habituation of the blink response, but not of pain, was found at repetition rates of 1 Hz or more. Present results indicate that nociceptive inputs from muscle have a facilitatory effect on central mechanisms subserving the blink response. It is suggested that the comparative analysis of pain sensation and the blink response may be a useful tool for pain research in man.

[Reactivation of the allogenous component of experimental skin inflammation after exposure to ultraviolet rays]

The effects of U.V. radiation induced cutaneous erythema on an experimental inflammation focus in another part of the body have been studied. The skin inflammation caused by carbon dioxide snow was used as a model. The onset of erythema is followed by reactivation of the diminishing inflammation process. It is therefore deduced that such effects are transmitted humorally and that reactivation is caused by histamine circulation. Histamine is released locally from the U.V. induced erythema and, entering into the circulation, increased the permeability of the microvessels in the inflamed area. This sends inactive chemical mediators to the interstitial sector where the appropriate conditions for their activation exist.

[Reactivation of the algogenic component in experimental inflammation induced by histamine administration]

The action of i.v. histamine on human skin inflammation experimentally induced with carbon dioxide snow in man is described. Histamine was injected when the skin reaction was on the wane to determine its possible reactivation of inflammation. Complete recrudescence of erythralgia was noted (reappearance of pain and of erythralgic halo, with a fresh spread of secondary hyperalgesia). It is felt that histamine was responsible. Its arrival to the reaction site through microvessels in a state of increased permeability during the remission of inflammation may be assumed to promote the passage of chemical mediators in the preactive stage from the vascular to the interstitial sector, and thus to pave the way for their activation.