Treatment of enterocutaneous fistula with total parenteral nutrition in combination with octreotide: a case report

Octreotide is an analog of the polypeptide hormone somatostatin, which can reduce gastrointestinal, biliary and pancreas secretion, as well as decrease gastrointestinal motility. Octreotide in combination with total parenteral nutrition (TPN) has proven to be effective therapy in patients with high-output enterocutaneous fistula (EF)

Razumijevanje, prevencija i liječenje refeeding-sindroma: uloga tiamina

sindrom (RFS) je ozbiljna i potencijalno fatalna komplikacija koja se javlja u bolesnika s ozbiljnom pothranjenosti različite etiologije nakon ponovnog, nekontroliranog uvođenja prehrane, osobito ugljikohidrata. Nastanak komplikacija RFS-a, koje mogu zahvatiti bilo koji organski sustav ili više njih uslijed ozbiljnog elektrolitskog disbalansa, uvjetovan je brzim metaboličkim promjenama koje nastaju prilikom prelaska organizma iz katabolizma u anabolizam te unutarstaničnom deplecijom fosfora, kalija, magnezija te vitamina i mineralnih tvari. Najčešće komplikacije RFS-a vezane uz nedostatak vitamina odnose se na nedostatak tiamina. Zbog svoje ključne koenzimske uloge u metabolizmu ugljikohidrata i aminokiselina razgranatih lanaca, tiamin je važan čimbenik za održavanje normalne funkcije prije svega cerebralnog metabolizma. Razumijevanje temeljnih biokemijskih procesa tijekom gladovanja te posljedično mehanizama i čimbenika koji utječu na metaboličke promjene tijekom RFS-a važno je radi pravovremenog prepoznavanja bolesnika u riziku i prevencije RFS-a te brojnih kliničkih komplikacija koje nosi bez obzira na modalitet nutritivne potpore

PLACE OF BIOLOGIC THERAPY IN THE TREATMENT OF INFLAMMATORY BOWEL DISEASES AND ASSESSMENT OF ITS EFFICACY

Biološka terapija (infliksimab i adalimumab) u upalnim bolestima crijeva temelji se na IgG1 anti-TNF monoklonalnim antitijelima sa snažnim protuupalnim učincima u podlozi kojih je apoptoza upalnih stanica. Neupitno je, a to proizlazi iz većine dosadašnjih studija i meta-analiza, da se radi o učinkovitoj terapiji u prvom redu za liječenje Crohnove bolesti (CB), ali i ulceroznog kolitisa u različitim kliničkim situacijama. Za sada postoji najviše podataka o učinkovitosti infliksimaba (IFX), ali istraživanja su pokazala kako i drugi anti-TNF lijekovi, prije svega adalimumab i certolizumab imaju slične učinke. Potrebna su daljnja istraživanja kako bi se utvrdila uloga certolizumab pegola u CB i adalimumaba u ulceroznom kolitisu. Važnu ulogu u primjeni biološke terapije ima procjena njene djelotvornosti te odnosa koristi-štetnosti koji se procjenjuju na osnovi redovitih pregleda. U slučaju izostanka odgovora (primarna i sekundarna nereaktivnost) preostaje povećanje doze, skraćenje intervala davanja lijeka te zamjena drugim biološkim lijekom.Biological therapy (infliximab and adalimumab) in inflammatory bowel diseases is based on the IgG1 anti-TNF monoclonal antibodies with potent anti-inflammatory effects whose main mechanism of action is thought to be the induction of inflammatory cell apoptosis. Unquestionably, which arises from the most recent studies and meta-analysis, anti-TNF angents are an effective therapy primarily for the treatment of Crohn’s disease, but also ulcerative colitis, in different clinical situations. Infliximab has the most extensive clinical trial data, but other biological agents, such as adalimumab and certolizumab pegol appear to have similar benefits. In terms of future research, more long-term data are needed for both certolizumab pegol in Crohn’s disease and adalimumab in ulcerative colitis. Important role in the application of biological therapy is assessing its effectiveness and cost-benefit relationships that are estimated by regular follow-up. In the absence of response (primary and secondary) therapeutical options are dose increase, giving the drug in shorter intervals and substitution with other biological drug

PLACE OF BIOLOGIC THERAPY IN THE TREATMENT OF INFLAMMATORY BOWEL DISEASES AND ASSESSMENT OF ITS EFFICACY

Biološka terapija (infliksimab i adalimumab) u upalnim bolestima crijeva temelji se na IgG1 anti-TNF monoklonalnim antitijelima sa snažnim protuupalnim učincima u podlozi kojih je apoptoza upalnih stanica. Neupitno je, a to proizlazi iz većine dosadašnjih studija i meta-analiza, da se radi o učinkovitoj terapiji u prvom redu za liječenje Crohnove bolesti (CB), ali i ulceroznog kolitisa u različitim kliničkim situacijama. Za sada postoji najviše podataka o učinkovitosti infliksimaba (IFX), ali istraživanja su pokazala kako i drugi anti-TNF lijekovi, prije svega adalimumab i certolizumab imaju slične učinke. Potrebna su daljnja istraživanja kako bi se utvrdila uloga certolizumab pegola u CB i adalimumaba u ulceroznom kolitisu. Važnu ulogu u primjeni biološke terapije ima procjena njene djelotvornosti te odnosa koristi-štetnosti koji se procjenjuju na osnovi redovitih pregleda. U slučaju izostanka odgovora (primarna i sekundarna nereaktivnost) preostaje povećanje doze, skraćenje intervala davanja lijeka te zamjena drugim biološkim lijekom.Biological therapy (infliximab and adalimumab) in inflammatory bowel diseases is based on the IgG1 anti-TNF monoclonal antibodies with potent anti-inflammatory effects whose main mechanism of action is thought to be the induction of inflammatory cell apoptosis. Unquestionably, which arises from the most recent studies and meta-analysis, anti-TNF angents are an effective therapy primarily for the treatment of Crohn’s disease, but also ulcerative colitis, in different clinical situations. Infliximab has the most extensive clinical trial data, but other biological agents, such as adalimumab and certolizumab pegol appear to have similar benefits. In terms of future research, more long-term data are needed for both certolizumab pegol in Crohn’s disease and adalimumab in ulcerative colitis. Important role in the application of biological therapy is assessing its effectiveness and cost-benefit relationships that are estimated by regular follow-up. In the absence of response (primary and secondary) therapeutical options are dose increase, giving the drug in shorter intervals and substitution with other biological drug

Visoka učestalost neliječene i nedovoljno liječene deficijencije i insuficijencije vitamina D u bolesnika s upalnim bolestima crijeva

Inflammatory bowel disease (IBD) patients with vitamin D deficiency show an increased risk of hospital admission, surgery, and loss of response to biologic therapy while high vitamin D levels are identified as a protective factor. Our goal was to investigate the prevalence of untreated and undertreated vitamin D deficiency and factors associated with vitamin D deficiency. In this cross-sectional study, we measured serum vitamin D in a random sample of Caucasian IBD patients. Vitamin D deficiency was defined as <50 nmol/L and insufficiency as 50-75 nmol/L. Supplementation was defined as taking 800-2000 IU vitamin D daily. Untreated patients were defined as not taking supplementation and undertreated group as receiving supplementation but showing vitamin D deficiency or insufficiency despite treatment. Our study included 185 IBD patients, i.e. 126 (68.1%) with Crohn’s disease (CD) and 59 (31.9%) with ulcerative colitis (UC). Overall, 108 (58.4%) patients had vitamin D deficiency and 60 (32.4%) patients vitamin D insufficiency. There were 16 (14.8%) and 11 (18.3%) treated patients in vitamin D deficiency and vitamin D insufficiency group, respectively. The rate of untreated patients was 81.7% (n=49) in vitamin D deficiency group and 85.2% (n=92) in vitamin D insufficiency group. Tumor necrosis factor alpha inhibitors were associated with higher serum vitamin D levels in CD and UC, and ileal involvement, ileal and ileocolonic resection with lower levels. In conclusion, not only is vitamin D deficiency common in IBD patients but the proportion of untreated and undertreated patients is considerably high. We suggest regular monitoring of vitamin D levels in IBD patients regardless of receiving vitamin D supplementation therapy.Bolesnici s upalnim bolestima crijeva (inflammatory bowel disease, IBD) i manjkom vitamina D su pod povećanim rizikom hospitalizacije, operacije i gubitka odgovora na biološku terapiju, dok visoke serumske razine vitamina D predstavljaju zaštitni čimbenik. Cilj ove studije bio je istražiti učestalost neliječenih i nedovoljno liječenih bolesnika s IBD i manjkom vitamina D te čimbenike rizika. U ovoj presječnoj studiji mjerene su serumske razine vitamina D u slučajnom uzorku bolesnika s IBD bijele rase. Deficijencija je definirana kao razine <50 nmol/L, a insuficijencija kao 50-75 nmol/L. Nadoknada vitamina D je definirana kao uzimanje 800-2000 IJ vitamina D na dan. Neliječeni bolesnici su oni bez nadoknade, a nedovoljno liječeni oni s deficijencijom ili insuficijencijom usprkos nadoknadi. Uključeno je ukupno 185 bolesnika s IBD, tj. 126 (68,1%) s Crohnovom bolešću i 59 (31,9%) s ulceroznim kolitisom. Ukupno je 108 (58,4%) bolesnika imalo deficijenciju, a 60 (32,4%) insuficijenciju. Udio liječenih bolesnika s deficijencijom i insuficijencijom vitamina D iznosio je 14,8% (n=16) i 18,3% (n=11). Udio neliječenih s deficijencijom iznosio je 81,7% (n=49), a s insuficijencijom 85,2% (n=92). Terapija inhibitorima faktora tumorske nekroze alfa bila je povezana s višim razinama vitamina D. Niže razine vitamina D su zabilježene kod bolesnika s upalom u području ileuma i resekcijom ileuma ili ileokolona. U zaključku, niske serumske razine vitamina D su česta pojava kod bolesnika s IBD, a dodatno je udio neliječenih i nedovoljno liječenih također visok. Naša preporuka je kontinuirano praćenje razina vitamina D u serumu svih bolesnika s IBD uključujući i one na nadoknadi vitaminom D

Stanje uhranjenosti i kvaliteta prehrane u bolesnika s nealkoholnom bolešću masne jetre

Non-alcoholic fatty liver disease (NAFLD) is becoming a major health burden with increasing prevalence worldwide due to its close association with the epidemic of obesity. Currently there is no standardized pharmacological treatment, and the only proven effective therapeutic strategy is lifestyle modification, therefore it is important to determine the potential dietary targets for the prevention and treatment of NAFLD. We assessed nutritional status in 30 patients diagnosed with NAFLD using anthropometric parameters, hand grip strength, and lifestyle and dietetic parameters (physical activity, NRS2002 form and three-day food diary). The mean body mass index was 29.62±4.61 kg/m2, yielding 86.67% of obese or overweight patients. Physical activity results indicat-ed poorly active subjects. Excessive energy intake was recorded in 27.78% of patients. The mean in-take of macronutrients was as follows: 15.5% of proteins, 42.3% of carbohydrates and 42.2% of fat, with ­deficient micronutrient intake of calcium, magnesium, iron, zinc, and vitamins A, B1 and B2. The ­results showed that the quality of nutrition in study subjects was not accordant to current rec-ommendations and that they consumed a high proportion of fat, especially saturated fatty acids, along with low micronutrient intake. The results obtained might point to the importance of unbalanced diet as a contributing factor in NAFLD development.Nealkoholna bolest masne jetre (NAFLD) postaje velik zdravstveni problem s povećanom učestalosti u svijetu zbog bliske povezanosti s epidemijom pretilosti. Kako zasad ne postoji standardizirano farmakološko liječenje i jedina dokazana učinkovita terapijska strategija je promjena načina života, važno je odrediti potencijalne prehrambne ciljeve za prevenciju i liječenje NAFLD. Procijenili smo nutritivni status 30 bolesnika s dijagnosticiranim NAFLD primjenom antropometrijskih parametara, mjerenjem snage ruke dinamometrom i dijetetskim parametrima (tjelesna aktivnost, upitnik NRS 2002 i tro­dnevni dnevnik prehrane). Srednja vrijednost indeksa tjelesne mase bila je 29,62±4,61 kg/m2 s 86,67% bolesnika koji su bili prekomjerne tjelesne mase ili pretili. Rezultati tjelesne aktivnosti pokazuju da su ispitanici bili slabo aktivni. Prekomjerni energetski unos u odnosu na dnevne potrebe imalo je 27,78% bolesnika. Prosječan dnevni unos makronutrijenata je iznosio: 15,5% proteina, 42,3% ugljikohidrata i 42,2% masti s nedostatnim unosom sljedećih mikronutrijenata: kalcij, magnezij, ­željezo, cink, vitamini A, B1 i B2. Rezultati istraživanja pokazuju da kvaliteta prehrane naših ispitanika nije bila u skladu s aktualnim preporukama i da su konzumirali velike količine masti, pogotovo zasićenih masnih kiselina s niskim unosom ­mikronutrijenata. Dobiveni rezulatati bi mogli ukazati na ulogu nepravilne prehrane kao važnog čimbenika razvoja NAFLD-a

CROATIAN GUIDELINES FOR NUTRITION IN THE ELDERLY, PART II – CLINICAL NUTRITION

Malnutricija i sarkopenija često se javljaju u osoba starije dobi koje su hospitalizirane ili su smještene u institucijama. Takav loš nutritivni status povećava pobol i smrtnost te negativno utječe na svakodnevne aktivnosti, funkcije i kvalitetu života. Uporaba enteralne i parenteralne prehrane opravdana je kod pothranjenih bolesnika starije dobi, i u bolnici i kod kuće. Bolesnici starije dobi dijele indikacije s bolesnicima ostalih dobnih skupina, iako se veće značenje kod ovih bolesnika daje kvaliteti života. U ovim Smjernicama predstavljamo indikacije i posebna razmatranja pri primjeni enteralne i parenteralne prehrane u osoba starije dobi te smjernice za kliničku prehranu kod tri česta patološka zbivanja u gerijatriji: dekubitalnih ulkusa, disfagije i demencije.Malnutrition and sarcopenia are frequent in the hospitalized and institutionalized elderly. They have negative consequences on morbidity, mortality, function and quality of life. Enteral and parenteral nutrition are valid options in the malnourished elderly, both in the hospital and at home. Elderly patients share most indications and complications with adult patients, even though more focus needs to be put on function and quality of life than on mortality. In these guidelines we discuss the indications and special considerations of enteral and parenteral nutrition in geriatric patients as well as guidelines for clinical nutrition in three common pathologies in the elderly: decubital ulcers, dysphagia and dementia

Smjernice za rano prepoznavanje, dijagnostiku i terapiju neurogene orofaringealne disfagije [Guidelines for early detection, diagnostics and therapy of neurogenic oropharyngeal dysphagia]

Guidelines for the early detection, diagnostics and therapy of neurogenic oropharyngeal dysphagia have been made as a result of collaboration of clinicians of different backgrounds who are dealing with patients with neurogenic oropharyngeal dysphagia (NOD). These guidelines have been written by the representatives of the Croatian Society of Clinical Nutrition, Croatian Medical Association, Croatian Neurological Society, Croatian Medical Association, Croatian Society of Gastroenterology and Croatian Society of Nutritionists and Dietitians. The aim of these guidelines is to raise the awareness about NOD that is encountered in acute and chronic neurological diseases, especially in patients with stroke, extrapyramidal diseases, neuromuscular and demyelinisation diseases and dementia. We provide a detailed description of diagnostics of dysphagia, and we recommend the establishment of a multidisciplinary team for dysphagia involving neurologists, internists, speech therapists, dietitians, pharmacists and nurses with special competences for the management of NOD. An educated team member conducts diagnostics and rehabilitation in accordance with the validated tools, classifications and categorizations shown in these guidelines to allow a systematic and consistent treatment. The guidelines also provide detailed algorithms for introducing nutritional support – from the application of modified texture foods, proper hydration to artificial nutrition (enteral and parenteral nutrition)

GUIDELINES FOR EARLY DETECTION, DIAGNOSTICS AND THERAPY OF NEUROGENIC OROPHARYNGEAL DYSPHAGIA

Smjernice za rano prepoznavanje, dijagnostiku i terapiju neurogene orofaringealne disfagije nastale su suradnjom kliničara različitih disciplina koji se bave brojnim aspektima skrbi o bolesnicima s neurogenom orofaringealnom disfagijom (NOD). U izradi smjernica sudjelovali su predstavnici Hrvatskog društva za kliničku prehranu Hrvatskoga liječničkog zbora (HLZ-a), Hrvatskoga neurološkog društva HLZ-a, Hrvatskoga gastroenterološkog društva i Hrvatskog društva nutricionista i dijetetičara. Smjernice imaju cilj povećati svijest o NOD-u koji se javlja kod akutnih i kroničnih neuroloških bolesti, posebice kod moždanog udara, ekstrapiramidnih bolesti, neuromuskularnih i demijelinizacijskih bolesti te demencija. Nadalje, smjernice donose detaljan opis dijagnostike disfagije te preporučuju osnivanje multidisciplinarnog tima za disfagiju u kojem sudjeluju neurolozi, internisti, logopedi, dijetetičari, farmaceuti i medicinske sestre s posebnim kompetencijama na području NOD-a. Educirani član tima provodi dijagnostiku i rehabilitaciju u skladu s provjerenim alatima, klasifikacijama i kategorizacijama prikazanim u ovim smjernicama kako bi se omogućilo sustavno i izjednačeno postupanje. Smjernice donose i detaljne algoritme uvođenja nutritivne potpore – od primjene hrane promijenjene teksture, pravilne hidracije do artificijalne prehrane (enteralne i parenteralne).Guidelines for the early detection, diagnostics and therapy of neurogenic oropharyngeal dysphagia have been made as a result of collaboration of clinicians of different backgrounds who are dealing with patients with neurogenic oropharyngeal dysphagia (NOD). These guidelines have been written by the representatives of the Croatian Society of Clinical Nutrition, Croatian Medical Association, Croatian Neurological Society, Croatian Medical Association, Croatian Society of Gastroenterology and Croatian Society of Nutritionists and Dietitians. The aim of these guidelines is to raise the awareness about NOD that is encountered in acute and chronic neurological diseases, especially in patients with stroke, extrapyramidal diseases, neuromuscular and demyelinisation diseases and dementia. We provide a detailed description of diagnostics of dysphagia, and we recommend the establishment of a multidisciplinary team for dysphagia involving neurologists, internists, speech therapists, dietitians, pharmacists and nurses with special competences for the management of NOD. An educated team member conducts diagnostics and rehabilitation in accordance with the validated tools, classifications and categorizations shown in these guidelines to allow a systematic and consistent treatment. The guidelines also provide detailed algorithms for introducing nutritional support – from the application of modified texture foods, proper hydration to artificial nutrition (enteral and parenteral nutrition)

Smjernice za prevenciju, prepoznavanje i liječenje nedostatka vitamina D u odraslih [Guidelines for the prevention, detection and therapy of vitamin D deficiency in adults]

It is estimated that over one billion of people around the globe have low serum values of vitamin D, therefore, we can consider vitamin D deficiency as a pandemic and public health problem. Geographic position of Croatia, especially the continental part of the country, is a risk factor for the development of deficiency of vitamin D in the population. The aim of these guidelines is to provide the clinicians with easy and comprehensive tool for prevention, detection and therapy of vitamin D deficienney in healthy population and various groups of patients. They were made as a result of collaboration of clinicians of different backgrounds who are dealing with patients at risk of vitamin D deficiency. These guidelines are evi- dence-based, according to GRADE-system (Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendation. The main conclusions address the recommended serum vitamin D values in the population which should be between 75 and 125 nmol/L and defining recommended preven- tive and therapeutic dosages of vitamin D in order to reach the adequate levels of serum vitamin D