Expert design thinking workshops to analyze users’ perceived applicability of NUTRI-ONCOCARE algorithm to prevent and treat malnutrition in cancer patients under routine clinical practice conditions in Spain: the ALLIANCE study

Cancer nutrition; MalnutritionNutrición oncológica; DesnutriciónNutrició oncològica; DesnutricióPurpose NUTRI-ONCOCARE algorithm has been developed to identify and treat patients with solid tumors who are at risk of malnutrition. The present study is aimed at analyzing users’ opinion about this new tool and at assessing whether it is perceived as useful to achieve the behavioral change required for a successful integration of nutritional assessment into routine cancer care. Methods Design thinking Double Diamond process was applied. A multidisciplinary team composed of ten potential end-users (four oncologists, three endocrinologists, one nutritionist, and two hospital pharmacists) participated in three different workshops aiming to analyze the different tasks included within the NUTRI-ONCOCARE algorithm. Results Users agreed on the need to perform nutritional assessment around cancer diagnosis and through the course of the disease using standardized tools included in hospital nutritional protocols and involving healthcare professionals with nutrition expertise. Nutritional evaluation and intervention should be individual and comprehensive, considering not only nutritional parameters but also patients’ functional status. According to participants’ opinion, the implementation of nutritional screening in routine clinical practice is limited by the lack of time and staff to conduct nutritional assessments, the low level of nutrition expert participation, and the poor support provided by hospital managers, which are often unaware of nutrition’s impact in cancer care. Conclusions Experts recognized the importance of considering nutritional status in cancer patients and identified the opportunity provided by the NUTRI-ONCOCARE algorithm for this purpose, as it meets main requirements for being used routinely in clinical practice.This work was funded by Fresenius Kabi. Medical writing support, provided by Jennifer Redondo at Dynamic S.L.U. (Evidenze Clinical Research), a company of Evidenze Group, was funded by Fresenius

High output stoma: detection and approach

La ostomía de alto débito es una complicación frecuente en pacientes portadores de ileostomías que está poco identificada y que no suele ser adecuadamente abordada desde el punto de vista clínico. No está descrita de manera consensuada, pudiendo variar entre débitos de 2.000 ml en 24h o alrededor de 1.500 ml en durante 3-5 días, según los autores. Suele presentar graves consecuencias para el paciente tanto a corto como a largo plazo y está asociada a reingresos. Se presenta una revisión de la literatura publicada al respecto sobre los factores relacionados con la resección quirúrgica que influyen en una posterior aparición de esta complicación, las causas que intervienen en su desarrollo, la necesidad de establecer un concepto objetivo y claro de alto débito así como las implicaciones negativas presenta. Así mismo se recoge como debe realizarse el manejo de estos pacientes con respecto al tratamiento y abordaje nutricional.High output stoma is a frequent complication in patients with ileostomies that is not well identified and is not often properly addressed by clinicians. It has not been described properly, and can vary between debits of 2.000ml in 24 h to 1.500 ml in 3-5 days, according to different authors. Frequently presents both short-term and long-term negative implications for patients and is associated with readmissions. We present a review of published literature focusing in surgical resection-related factors that influence a later appearance of this complication, causes involved in its development, the need to establish a clear and objective concept of high ouput as well as the negative implications it presents. Also we develop how should we the management of these patients regarding treatment and nutritional approach

Effects of supply with glutamine on antioxidant system and lipid peroxidation in patients with parenteral nutrition

Introducción: En el paciente crítico hay una continua producción de especies reactivas de oxígeno (ERO) que necesitan se neutralizadas para evitar el estrés oxidativo (EO). Entre las defensas antioxidantes endógenas, el sistema glutatión (GSH) es cuantitativamente el más importante, pero en situaciones de estrés severo se encuentra disminuido. Para incrementarlo, la suplementación con glutamina ha demostrado ser efectiva, ejerciendo protección contra el daño oxidativo y reduciendo la morbi-mortalidad. Objetivo: Valorar el efecto de la adición de un dipéptido alanyl-glutamina a la NP sobre la peroxidación lipídica y el metabolismo del glutatión y su relación con la morbilidad de los pacientes críticos. Métodos: Determinación, mediante técnicas espectrofotométricas, de glutatión peroxidasa, glutatión reductasa, glutatión total y malonilaldehído al ingreso y tras siete días de estancia en la Unidad de Cuidados Intensivos (UCI) de 20 pacientes mayores de 18 años con tratamiento nutricional parenteral. Resultados: El grupo de pacientes que recibió nutrición parenteral con adición de glutamina experimentó aumentos signifcativos a la semana de tratamiento nutricional en la concentración del glutatión total (42,35 ± 13 vs 55,29 ± 12 μmol/l; p < 0,05), junto a un incremento de la actividad de la enzima glutatión peroxidasa (470 ± 195 vs 705 ± 214 μmol/l; p < 0,05). En cambio, el grupo con nutrición parenteral convencional no presentó modificaciones significativas en ninguno de los parámetros estudiados (p > 0,05). Sin embargo, tanto la mortalidad como la estancia en UCI no fue diferente para los grupos estudiados, mientras que si se observó una menor gravedad, valorada por e SOFA score, en el grupo de pacientes que recibieron glutamina (SOFA 5 ± 2 vs 8 ± 1,8; p < 0,05). Conclusiones: El aporte de glutamina en pacientes críticos mejora las defensas antioxidantes, lo que repercute en una menor peroxidación lipídica y menor morbilidad durante la estancia en UCI.Introduction: In the critically ill patient, there is a continuous production of reactive oxygen species (ROS) that need to be neutralized to prevent oxidative stress (OS). Quantitatively speaking, the glutathione system (GSH) is the most important anti-oxidant endogenous defense. To increase it, glutamine supplementation has been shown to be effective by protecting against the oxidative damage and reducing the morbimortality. Objective: To assess the effect of adding an alanylglutamine dipeptide to PN on lipid peroxidation lipidica and glutathione metabolism, as well as its relationship with morbidity in critically ill patients. Methods: Determination through spectrophotometry techniques of glutathione peroxidase, glutathione reductase, total glutathione, and maloniladdehyde at admission adn after seven days of hospitalization at the Intensive Care Unit (ICU) in 20 patients older than 18 years on parenteral nutrition therapy. Results: The group of patients receiving parenteral nutrition with glutamine supplementation had significant increases in total glutathione (42.35 ± 13 vs 55.29 ± 12 μmol/l; p < 0.05) and the enzymatic activity of glutathione peroxidasa (470 ± 195 vs 705 ± 214 μmol/l; p < 0.05) within one week of nutritional therapy, whereas the group on conventional parenteral nutrition did not show significant changes of any of the parameters studied (p > 0.05). However, both mortality and ICU stay were not different between the study group, whereas the severity (asessed by the SOFA score) was lower in the group of patients receiving glutamine (SOFA 5 ± 2 vs 8 ± 1.8; p < 0.05). Conclusions: Glutamine intake in critically ill patients improves the antioxidant defenses, which leads to lower lipid peroxidation and lower morbidity during admission at the ICU.Éste estudio ha sido financiado en parte por el FIBAO y el premio Fressenius/SENPE 2006

Protocol for the detection and nutritional management of high-output stomas

Introduction: An issue of recent research interest is excessive stoma output and its relation to electrolyte abnormalities. Some studies have identified this as a precursor of dehydration and renal dysfunction. A prospective study was performed of the complications associated with high-output stomas, to identify their causes, consequences and management.Materials and methods: This study was carried out by a multidisciplinary team of surgeons, gastroenterologists, nutritionists and hospital pharmacists. High-output stoma (HOS) was defined as output ≥1500 ml for two consecutive days. The subjects included in the study population, 43 patients with a new permanent or temporary stoma, were classified according to the time of HOS onset as early HOS (<3 weeks after initial surgery) or late HOS (≥3 weeks after surgery). Circumstances permitting, a specific protocol for response to HOS was applied. Each patient was followed up until the fourth month after surgery.Results: Early HOS was observed in 7 (16 %) of the sample population of 43 hospital patients, and late HOS, in 6 of the 37 (16 %) non-early HOS population. By type of stoma, nearly all HOS cases affected ileostomy, rather than colostomy, patients. The patients with early HOS remained in hospital for 18 days post surgery, significantly longer than those with no HOS (12 days). The protocol was applied to the majority of EHOS patients and achieved 100 % effectiveness. 50 % of readmissions were due to altered electrolyte balance. Hypomagnesaemia was observed in 33 % of the late HOS patients.Conclusion: The protocol developed at our hospital for the detection and management of HOS effectively addresses possible long-term complications arising from poor nutritional status and chronic electrolyte alteration

Estrés oxidativo y su relación con el aporte de antioxidantes nutricionales en el paciente crítico

Tesis Univ. Granada. Departamento de Fisiología. Leída el 11 de julio de 200

Impact of a nutrition consultation on the rate of high output stoma‑related readmission: an ambispective cohort study

We thank the staff of the Pharmacy and Nutrition Department at the Costa del Sol Hospital. The present study is part of a Pharmacy PhD research programme being conducted at the University of Granada.The aims of this study were to assess the impact of a follow-up nutrition consultation for ostomy patients on the rate of high output stoma (HOS)-related readmissions, as well as on the detection of poor nutritional status and their management, and to determine the associated economic impact. A single-centre ambispective cohort study was conducted in which all adult patients undergoing intestinal resection and stoma creation were recruited. Two nutrition consultations were established for early follow-up after hospital discharge and patients were prospectively included. Additionally, a retrospective search was carried out to include a control group. In both groups, a 12-month follow-up was conducted to record readmissions associated with high output stoma. A multivariate logistic regression was performed. Statistical significance level was established at p < 0.05. 170 patients were recruited, 85 patients in each cohort. Demographic data and clinical characteristics were recorded. A significant difference was observed in HOS-related readmissions, with readmission rates of 28.6% vs 10.3% in the retrospective and prospective cohort, respectively. At the first follow-up consultation, 50.5% of patients presented some degree of protein-calorie malnutrition. A statistically significant improvement in nutritional status was observed in the second evaluation. The intervention carried out resulted in a total saving of €24,175. Early follow-up of patients after discharge resulted in a significant reduction in the rate of HOS-related readmissions and allowed to identify a high percentage of patients with malnutrition. The cost analysis showed the process to be a cost-effective improvement

Intragastric balloon: a review concerning alternative balloons compared to the classical ones (Bioenterics)

Since de Tarpon Springs Consensus Conference in 1987, the Bioenterics Intragastric Balloon represents the standard model for obesity treatment with this technique. Nevertheless, over the last 30 years, especially for the last ten years, novel concept of balloons has appeared, as well as new alternative models, which are reviewed in this paperYesDesde la Conferencia de Consenso de Tarpon Spring en 1987, el Balón Intragástrico de Bioenterics se ha impuesto como modelo en el tratamiento de la obesidad con esta técnica. No obstante, a lo largo de los 30 últimos años, y en especial en los 10 últimos, han aparecido nuevos conceptos de balón intragástrico así como modelos alternativos de balón que revisamos en este trabaj

Effects of cyclic parenteral nutrition on parenteral-associated liver dysfunction parameters

Abstract Introduction One of the most common complications of parenteral nutrition (PN) is liver dysfunction (LD). Therapeutic approaches for LD include, among others, administering cyclic parenteral nutrition (cPN), allowing some hours for metabolic rest. The purpose of this study was to evaluate the effectiveness of cPN in treating PN-associated LD. Materials and methods A retrospective observational study was carried out at the Costa del Sol Hospital in Spain between 2013 and 2014. The study involved inpatients ≥18 years old prescribed with cPN due to the development of PN-associated LD. The hepatic biochemical parameters measured at baseline and after completion of cPN included aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), alkaline phosphatase (ALP) and total bilirubin (TB). Quantitative values (age, biochemical parameters) were compared using matched Student’s t-test; the mean change in qualitative variables (sex, indication of PN, hepatic comorbidities, presence of insulin in cPN, infection during cPN, management of LD prior to cPN administrarion) was estimated using Mann-Whitney U test, and bivariate correlation between quantitative variables was determined by Spearman’s coefficient of correlation. Results Thirty-seven patients met inclusion criteria. All hepatic function parameters except ALP improved after the administration of cPN, with statistically significant differences (p < 0.05) in AST GGT and TB. Conclusion cPN improves PN-associated LD by restoring abnormal AST, GGT, and BT levels to normal, and reducing ALT levels close to normal. The results obtained suggest that the administration of cPN is effective in reverting PN-associated LD

Evaluation of a protocol to detect malnutrition and provide nutritional care for cancer patients undergoing chemotherapy.

Patients with cancer frequently experience malnutrition, which is associated with higher rates of morbidity and mortality. Therefore, the implementation of strategies for its early detection and for intervention should improve the evolution of these patients. Our study aim is to design and implement a protocol for outpatients starting chemotherapy, by means of which any malnutrition can be identified and treated at an early stage. Before starting chemotherapy for patients with cancer, a complete assessment was made of their nutritional status, using the Nutriscore screening tool. When nutritional risk was detected, an interventional protocol was applied. Of 234 patients included in the study group, 84 (36%) required an individualised nutritional approach: 27 (32.1%) presented high nutritional risk, 12 had a Nutriscore result ≥ 5 and 45 experienced weight loss during chemotherapy. Among this population, the mean weight loss (with respect to normal weight) on inclusion in the study was - 3.6% ± 8.2. By the end of the chemotherapy, the mean weight gain was 0% ± 7.3 (p

Evaluación de la importancia de la comprensión de las recomendaciones dietéticas y de estilo de vida en los pacientes con ostomía

Objective: the objective of our study was to evaluate the level of understanding of ostomy patients regarding lifestyle, diet, and high output stoma (HOS) management recommendations provided by healthcare professionals. Method: a prospective study to follow up ostomy patients at nutritional consultations was designed. The follow-up process was performed 7-10 days after hospital discharge and again one month later. At the first visit, patients were instructed in the detection and management of HOS. At the second visit, the level of understanding of the training received was assessed using an evaluation questionnaire. A descriptive analysis of the answers to each of the questionnaire’s items was performed. Fisher’s exact test was used to evaluate differences in the level of understanding recorded with the questionnaire. Results: a total of 35 patients were recruited; 71.4 % did not provide correct answers to all the questions. There were no significant differences in the correctness of the answers to the questionnaire according to education level. Conclusions: many patients do not adequately understand the information provided by healthcare professionals and this could have a negative impact on the incidence of clinical complications.Objetivo: el objetivo de nuestro estudio fue evaluar el nivel de comprensión de los pacientes ostomizados con respecto a las recomendaciones sobre estilo de vida, dieta y manejo de la ostomía de alto débito (OAD) proporcionadas por los profesionales de la salud. Método: se diseñó un estudio prospectivo para el seguimiento de pacientes ostomizados en consulta de nutrición. El seguimiento se realizó 7-10 días después del alta hospitalaria y a continuación un mes después. En la primera visita, se instruyó a los pacientes sobre la detección y el tratamiento de OAD. En la segunda visita se evaluó el nivel de comprensión de la formación recibida mediante un cuestionario de evaluación. Se registraron las respuestas dadas a cada uno de los ítems del cuestionario y se realizó un análisis descriptivo. Para evaluar las diferencias en el nivel de comprensión registrado con el cuestionario se utilizó la prueba exacta de Fisher. Resultados: se reclutaron 35 pacientes. El 71,4 % no respondieron correctamente a todas las preguntas. La exactitud de las respuestas al cuestionario no mostró diferencias significativas según el nivel educativo. Conclusiones: un gran número de pacientes no comprende adecuadamen