Malnutrición en cirrosis hepática: capacidad diagnóstica de LDUST y otros test de screening nutricional

Introducción: La cirrosis hepática es el último estadio de la hepatopatía crónica, en la que pueden aparecer complicaciones como malnutrición, relacionada en estudios con el aumento de la mortalidad, de la estancia hospitalaria y del riesgo de infecciones e hipertensión portal y sus complicaciones. Dada la elevada prevalencia de malnutrición y su potencial reversibilidad mediante intervención nutricional precoz, es importante disponer de una herramienta de screening para identificar pacientes en riesgo. Este proyecto busca evaluar la aplicación del Liver Disease Undernutrition Screening Tool (LDUST) comparándolo con el Royal Free Hospital-Nutritional Priorizing Tool (RFH-NPT), el Mini Nutritional Assestment-Short Form (MNA-SF) y la valoración nutricional por especialistas en Endocrinología y Nutrición siguiendo el patrón oro consistente en los nuevos criterios Global Leadership Initiative on Malnutrition (GLIM), así como evaluar la correlación de los resultados del LDUST con valores analíticos y resultados clínicos.Objetivos: Traducir al castellano el LDUST y evaluar su utilidad para el cribado de malnutrición en pacientes ambulatorios con cirrosis hepática. Comparar el LDUST con el RFH-NPT y el MNA-SF. Evaluar la prevalencia de malnutrición en los pacientes con cirrosis hepática según los nuevos criterios GLIM y describir sus características sociodemográficas.Material y métodos: Estudio observacional, transversal, no intervencionista, realizado en el servicio de Aparato Digestivo del Hospital Universitario Miguel Servet de Zaragoza. En la primera fase se realizó la traducción del LDUST y una prueba piloto a 10 pacientes ambulatorios con cirrosis hepática para testar su comprensión. En la segunda fase se valoró el estado nutricional del total de 63 pacientes mediante el LDUST, el RFH-NPT, el MNA-SF y la evaluación por un especialista de Endocrinología y Nutrición siguiendo los nuevos criterios GLIM que se consideraron como patrón oro para el diagnóstico de malnutrición.Resultados: Se evaluaron 63 pacientes ambulatorios (61,9% hombres, edad media 63±9.9 años, 58,7% casados, 49,3% estudios básicos) con cirrosis hepática de 7±6,3 años de evolución de media, cuya causa más frecuente fue el consumo de alcohol (53%) seguida de la infección por VHC (23,8%), con estadio Child Pugh A el 60,3%, Child Pugh B el 34,9% y Child Pugh C el 4,8%. El 73% habían presentado descompensación de la enfermedad. El 68,3% tenían factores de riesgo cardiovascular y el 9,5% afirmó consumo de alcohol ocasional. La prevalencia de desnutrición fue de un 40% según los criterios GLIM, siendo en un 15,9% desnutrición moderada y en un 22,2% grave. Los estadios avanzados Child Pugh B/C se relacionaron con mayor prevalencia de malnutrición (56%) (p=0.033). Como medidas de validez diagnóstica de los test, el LDUST presentó una sensibilidad del 83%, especificidad del 62%, valor predictivo positivo del 57% y valor predictivo negativo del 85%; el RFH-NPT una sensibilidad del 67%, especificidad del 82%, valor predictivo positivo del 80% y valor predictivo negativo del 70%; y el MNA-SF una sensibilidad del 87%, especificidad del 97%, valor predictivo positivo del 92% y valor predictivo negativo del 95%. El test con mayor área bajo la curva ROC fue el MNA-SF, seguido del RFH-NPT y por último el LDUST.Conclusiones: El LDUST presenta una especificidad y un valor predictivo positivo más bajos que en estudios anteriores y requiere más estudios para determinar su validez externa. El MNA-SF ha demostrado ser el más útil para evaluar el estado nutricional, presentando el mejor valor de sensibilidad y especificidad, incluso por delante de test específicamente diseñados para pacientes con cirrosis hepática como el LDUST. Según los criterios GLIM, la prevalencia de malnutrición en nuestra cohorte alcanza casi el 40%, siendo severa en un 22%, lo que representa un número muy importante de pacientes. La prevalencia de malnutrición es mayor cuanto más avanzado es el estadio de la enfermedad.<br /

Manejo de la infección por Helicobacter pylori en Atención Primaria y Especializada

- Introducción: La infección por Helicobacter pylori (Hp) es una de las infecciones más prevalentes a nivel mundial. Mayoritariamente su manejo recae en Atención Primaria (AP), a partir de recomendaciones de Conferencias de Consenso sobre la infección por Hp (CCIHP) de gastroenterólogos. En el área III de Zaragoza hemos observado un importante incremento de solicitudes del test del aliento (TA) para su estudio, pero desconocemos si dichas peticiones, y en consecuencia los tratamientos pautados en casos positivos, se adecuan a las recomendaciones de las CCIHP. - Objetivos: Comparar la idoneidad de indicaciones del TA entre AP y consulta de Digestivo (CD) del área III de Zaragoza; analizar la eficacia y adecuación del tratamiento erradicador; valorar el efecto del envío de un documento de recomendaciones sobre el manejo de la infección en AP. - Material y métodos: En la primera fase se analizan y comparan las indicaciones de 250 TA solicitados desde AP y 250 TA desde la CD, y las pautas erradicadoras utilizadas en casos solicitados como control de erradicación. En la segunda fase se valora si se modifica la conducta en AP analizando indicaciones en 250 TA solicitados después del envío del documento con recomendaciones. - Resultados: El 36,4% de solicitudes del TA de AP no tienen indicación adecuada frente al 7,2% de la CD (p<0,001). La eficacia del tratamiento erradicador es significativamente superior en CD (81,4% frente 57,1% en AP, p=0,001), ya que las pautas erradicadoras son significativamente más adecuadas a las recomendaciones de la IV CCIHP en CD (73,6% frente 35% en AP, p<0,0001). Tras el envío del documento con recomendaciones a AP los resultados no han mejorado significativamente la indicación, ya que el 32% de los TA continúan teniendo indicaciones inadecuadas. - Conclusiones: En AP las indicaciones para realizar el TA no son adecuadas según las recomendaciones actuales, lo que conlleva a pautar antibióticos a pacientes que no lo precisan, pudiendo contribuir al aumento de resistencias. Las pautas erradicadoras prescritas por AP presentan una menor eficacia porque no se adecuan a las recomendaciones. El envío de un documento con recomendaciones ha mejorado muy poco la idoneidad en la solicitud del TA

EoE CONNECT, the European Registry of Clinical, Environmental, and Genetic Determinants in Eosinophilic Esophagitis:rationale, design, and study protocol of a large-scale epidemiological study in Europe

BACKGROUND: The growing prevalence of eosinophilic esophagitis (EoE) represents a considerable burden to patients and health care systems. Optimizing cost-effective management and identifying mechanisms for disease onset and progression are required. However, the paucity of large patient cohorts and heterogeneity of practice hinder the defining of optimal management of EoE. METHODS: EoE CONNECT is an ongoing, prospective registry study initiated in 2016 and currently managed by EUREOS, the European Consortium for Eosinophilic Diseases of the Gastrointestinal Tract. Patients are managed and treated by their responsible specialists independently. Data recorded using a web-based system include demographic and clinical variables; patient allergies; environmental, intrapartum, and early life exposures; and family background. Symptoms are structurally assessed at every visit; endoscopic features and histological findings are recorded for each examination. Prospective treatment data are registered sequentially, with new sequences created each time a different treatment (active principle, formulation, or dose) is administered to a patient. EoE CONNECT database is actively monitored to ensure the highest data accuracy and the highest scientific and ethical standards. RESULTS: EoE CONNECT is currently being conducted at 39 centers in Europe and enrolls patients of all ages with EoE. In its aim to increase knowledge, to date EoE CONNECT has provided evidence on the effectiveness of first- and second-line therapies for EoE in clinical practice, the ability of proton pump inhibitors to induce disease remission, and factors associated with improved response. Drug effects to reverse fibrous remodeling and endoscopic features of fibrosis in EoE have also been assessed. CONCLUSION: This prospective registry study will provide important information on the epidemiological and clinical aspects of EoE and evidence as to the real-world and long-term effectiveness and safety of therapy. These data will potentially be a vital benchmark for planning future EoE health care services in Europe

EoE CONNECT, the European Registry of Clinical, Environmental, and Genetic Determinants in Eosinophilic Esophagitis: rationale, design, and study protocol of a large-scale epidemiological study in Europe

Background: The growing prevalence of eosinophilic esophagitis (EoE) represents a considerable burden to patients and health care systems. Optimizing cost-effective management and identifying mechanisms for disease onset and progression are required. However, the paucity of large patient cohorts and heterogeneity of practice hinder the defining of optimal management of EoE. Methods: EoE CONNECT is an ongoing, prospective registry study initiated in 2016 and currently managed by EUREOS, the European Consortium for Eosinophilic Diseases of the Gastrointestinal Tract. Patients are managed and treated by their responsible specialists independently. Data recorded using a web-based system include demographic and clinical variables; patient allergies; environmental, intrapartum, and early life exposures; and family background. Symptoms are structurally assessed at every visit; endoscopic features and histological findings are recorded for each examination. Prospective treatment data are registered sequentially, with new sequences created each time a different treatment (active principle, formulation, or dose) is administered to a patient. EoE CONNECT database is actively monitored to ensure the highest data accuracy and the highest scientific and ethical standards. Results: EoE CONNECT is currently being conducted at 39 centers in Europe and enrolls patients of all ages with EoE. In its aim to increase knowledge, to date EoE CONNECT has provided evidence on the effectiveness of first- and second-line therapies for EoE in clinical practice, the ability of proton pump inhibitors to induce disease remission, and factors associated with improved response. Drug effects to reverse fibrous remodeling and endoscopic features of fibrosis in EoE have also been assessed. Conclusion: This prospective registry study will provide important information on the epidemiological and clinical aspects of EoE and evidence as to the real-world and long-term effectiveness and safety of therapy. These data will potentially be a vital benchmark for planning future EoE health care services in Europe

Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry

BACKGROUND: Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings. OBJECTIVE: To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE. METHODS: Cross‐sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset. RESULTS: Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7‐6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub‐score decreased from a median (IQR) of 2 (1‐2) to 0 (0‐1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively). CONCLUSION: The diagnostic work‐up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay

Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry

Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings. To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE. Cross-sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset. Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7-6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub-score decreased from a median (IQR) of 2 (1-2) to 0 (0-1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively). The diagnostic work-up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay