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Vegetable lipid emulsions (LE) contain non-declared phytosterols (PS). We aimed to determine PS content depending on the brand and LE batch, and in adult hospitalised patients treated with parenteral nutrition (PN), to establish the association between plasma and administered PS. Part I was the LE study: totals and fractions of PS in three to four non-consecutive batches from six LE were analysed. Part II was the patient study: patients with at least 7 previous days of PN with 0·8 g/kg per d of an olive/soyabean (O/S) LE were randomised (day 0) 1:1 to O/S or 100 % fish oil (FO) at a dose of 0·4 g/kg per d for 7 d (day 7). Plasma PS, its fractions, total cholesterol on days 0 and 7, their clearance and their association with PS administered by LE were studied. In part I, LE study: differences were found in the total PS, their fractions and cholesterol among different LE brands and batches. Exclusive soyabean LE had the highest content of PS (422·36 (sd 130·46) μg/ml). In part II, patient study: nineteen patients were included. In the O/S group, PS levels were maintained (1·11 (sd 6·98) μg/ml) from day 0 to 7, while in the FO group, significant decreases were seen in total PS (−6·21 (sd 4·73) μg/ml) and their fractions, except for campesterol and stigmasterol. Plasma PS on day 7 were significantly associated with PS administered (R2 0·443). PS content in different LE brands had great variability. PS administered during PN resulted in accumulation and could be prevented with the exclusive administration of FO LE.

Objectives The presence of phytosterols in vegetable-based lipid emulsions has been associated with alterations in the results of liver function tests (LFTs). Serum levels of phytosterols are under strict genetic control. T-allele carriers in rs41360247 and C-allele carriers in rs4245791 of ABCG8genes are associated with higher phytosterolemia. The objective of this study was to determine the association between these single-nucleotide polymorphisms (SNPs) and LFT result alterations in an adult hospitalized population treated with parenteral nutrition. Methods This is a substudy of a previous clinical trial (EudraCT 2014-003597-17). It included adult hospitalized patients who had received at least 7 d of parenteral nutrition with 0.8 g/kg/d of an olive/soybean lipid emulsion, randomized 1:1 to receive the same olive/soybean emulsion or 100% fish oil at a dose of 0.4 g/kg/d for 7 d. Plasma phytosterols and their fractions, rs41360247 and rs4245791 of ABCG8 genes, and LFT were determined. Analyses of variance were performed to determine the association between the SNPs and LFT values, as well as total phytosterol values and their fractions. Simple linear regressions were performed to analyze LFT variations and the different interactions of the SNPs studied with phytosterols and their fractions. Interactions of the synergic variable plasma phytosterol and its fractions with SNPs allow us to study the interaction of the SNPs with phytosterols with a regression. Results We included 19 participants. In the multivariate model, total phytosterols, sitosterol, and lanosterol were positively associated with increases in γ-glutamyltransferase. Significant increases with stigmasterol were associated with the T allele of rs41360247, whereas campesterol showed only a tendency to increase that was not significant. Increases in alkaline phosphatase were associated with T-rs41360247 independent of the presence of phytosterols. With stigmasterol, C-allele carriers of rs4245791 showed a tendency to increase, and also for sitosterol and lanosterol, although independent of the SNP analyzed. Increases in alanine aminotransferase were positively associated with total phytosterol and sitostanol, whereas lanosterol and stigmasterol were associated with the presence of the T allele of rs41360247. Conclusions With both SNPs rs41360247 and rs4245791, the alteration in parameters of liver function in adult patients with short-term parenteral nutrition is conditional.

Rationale: To evaluate hypertriglyceridemia (HTG) risk factors in adult hospitalized COVID patients treated with Parenteral Nutrition (PN) Methods: Patients starting PN from 03/16-04/15/2020 were selected Data collected: demographic, nutritional (indication, days of PN, PN composition (g/kg/d by adjusted body weight);COVID treatments and analytical In our COVID protocol, inflammatory state (IS) was considered with at least 2 of the next criteria: PCR>100mg/L, DD>1 000μ/L, LDH>400U/L, ferritin>1 000ng/ml and IL-6>70ng/L HTG was defined as triglycerides (TG)≥3 mmol/L Data expressed as median [IQR] T-student test to compare our results with a previous no-COVID cohort with PN at our center and TG at PN beginning and end Multivariate analysis to study TG at PN beginning and HTG risk factors Results: 54 patients, 72 2% men, 67 6 [13 4] years, 80 [19 3] kg, 29 8 [5 6] kg/m2, 61 1 % had dyslipidaemia PN lasted 5 [5] days 83 3% received PN for enteral intolerance PN composition (g/kg/d): 1 28 [0 05] nitrogen, 0 57 [0 78] lipids, 3 05 [1 53] glucose and 19 8 [7 1] kcal/kg/d No differences between TGC at PN beginning and ending (3,56 [1 01] vs 3 621[1 74], p: 0 89) 80% met IS, 79 6% critical or semicritical, and 50% died 81 5% received tocilizumab, 79 6% propofol and 12 9% tacrolimus TG before PN started were higher than our previous cohort (3 31[1 14] vs 2 24[1 19] mmol/L;p

Background Esophagectomy is a major surgical procedure with a high degree of catabolic and postsurgical inflammatory response that conditions a high morbidity and a significant mortality. Enteral administration of ω-3 fatty acids has been seen to be effective although its use is limited due to tolerance. There are few clinical trials with ω-3 fatty acids parenterally in these patients, so we propose to investigate the effect of combining a lipid emulsion rich in fish oil with the standard enteral nutrition support. Methods Prospective, single-center, randomized, double-blind study in patients diagnosed with esophageal cancer and after esophagectomy treated with a lipid emulsion rich in ω-3 fatty acid emulsion or a mixture of ω-6 long chain triglycerides (LCT) / short chain triglycerides (MCT) 50%. After surgery, these emulsions will be added to the standard nutritional support in continuous infusion until complete 5 days of treatment. Patients will be randomized 1:1:1 in Group A 0,4g/kg/day of lipid emulsion rich in fish oil; Group B 0,8g/kg/day of lipid emulsion rich in fish oil and Group C 0,8g/kg/day of LCT/MCT emulsion. The main objective is to determine whether the administration for 5 days of intravenous lipid emulsions rich in ω-3 fatty acids in patients after esophagectomy is effective in normalizing the interleukin-6 (IL6) compared with LCT/MCT emulsions, and if 0,8 g/kg/day dose is more effective than 0,4g/kg/day. Secondary outcomes include other inflammatory markers as C reactive protein (CRP), tumor necrosis factor alpha (TNF-a) and interleukin-10 (IL-10), and parameters of morbidity, safety, nutrition and mortality. Samples will be collected at the moment of surgery indication and on days 0, 1, 3, 5 and 21 to determine inflammatory, nutritional, hepatic and security parameters. In addition, clinical follow-up throughout the hospital stay and up to one year after surgery. Discussion There are few studies of fatty acids ω-3 administered via parenteral in oesophagectomized patients. This study proposes to investigate the effect of combining fish-oil lipid emulsions administered via parenteral with enteral nutrition support, implying benefits such as: fast incorporation of lipids to the cellular membranes and to the inflammatory cascade, and the use of only one pharmaconutrient.

Introduction: Esophagectomy is a major surgery with a high degree of catabolic and post-surgical inflammatory response accompanied by high morbidity and significant mortality. Post-surgical nutritional support via enteral administration of ω-3 fatty acids has been seen to be effective although its bad tolerance. There are few clinical trials with parenteral ω-3 fatty acids in these patients. We propose to investigate the effect of combining a parenteral fish oil lipid emulsion with the standard enteral nutrition (EN) support. Materials and methods: Prospective, single-center, randomized, double-blind study in esophagectomized patients, and treated after surgery with parenteral lipid emulsions of ω-3 fatty acids or a mixture of ω-6 long-chain triglycerides/short-chain triglycerides 50%. These emulsions will be added to the standard nutritional support in continuous infusion until 5 days of treatment have been completed. Patients will be randomized 1:1:1 in Group A receiving 0.4 g/kg/d of fish-oil lipid emulsion and 0.4 g/kg/d of a lipid emulsion mixture of ω-6 long-chain fatty acids (LCT) plus medium-chain fatty acids (MCT) (total dose of 0.8 g/kg/d of lipid emulsion); Group B receiving 0.8 g/kg/d of fish oil lipid emulsion and Group C receiving 0.8 g/kg/d of LCT/MCT emulsion. The main objective is to determine whether 5 days administration of intravenous ω-3 fatty acid lipid emulsion is effective in normalizing interleukin-6 levels compared with LCT/MCT emulsions, and whether a 0.8 g/kg/d dose is more effective than 0.4 g/kg/d. Secondary outcomes include other inflammatory markers such as C-reactive protein, tumor necrosis factor alpha and interleukin-10, and parameters of morbidity, safety, nutrition and mortality. Samples will be collected at the time when surgery is indicated and on days 0, 1, 3, 5 and 21 to determine inflammatory, nutritional, hepatic and safety parameters. In addition, clinical follow-up will be continued throughout the hospital admision and up to 1 year after surgery. Discussion: Studies of ω-3 fatty acids administered parenterally in esophagectomized patients are scarce. This study proposes to investigate the effect of combining fish-oil lipid emulsions administered parenterally with EN support. Potential benefits include fast incorporation of lipids to the cellular membranes and to the inflammatory cascade, and the use of only 1 pharmaconutrient. Trial Registration: FAR-NP-2017-01 EudraCT number: 2016-004978-17. https://reec.aemps.es/reec/public/detail.html searching the EudraCT number. Version Identifier: Version 2, 08/06/2017.

The presence of phytosterols in vegetal lipid emulsions has been associated with alterations of liver function tests. Determination of phytosterols content, currently undeclared, would allow the development of strategies to prevent or treat these alterations.3-4 non-consecutive batches of 6 lipid emulsions from different providers (Clinoleic, Intralipid, Lipofundina, Lipoplus, Omegaven and Smoflipid) were analyzed. Differences in total phytosterol assay between providers and batches were statistically studied by a one-way ANOVA and Kruskal-Wallis non-parametric approximation and post hoc Scheffé test (plt; 0.05)Results: The absence of phytosterols was confirmed in Omegaven, emulsion based on fish oil. The highest assay of phytosterols (422.4 ± 130.5 μg/mL) has been related with the highest percentage of soya bean oil in Intralipid. In the remaining emulsions, concentrations were from 120 to 210 μg/mL related to the percentage of soya bean oil. Statistically significant differences of phytosterol content in lipid emulsions were observed among different providers (F = 23.59; p = 0.000) as well as among non-consecutive batches. Clinolenic (F = 23.59; p = 0.000), Intralipid (F = 978.25; p = 0.000), Lipofundina TCL/TCM (F = 5.43; p = 0.045), Lipoplus (F = 123.53; p = 0.000) and Smoflipid (16.78; p = 0.000). Except for Lipofundina TCL/TCM, the differences between batches were marked.Lipid emulsions, registered on Spanish pharmaceutical market, contain variable quantities of phytosterols dependent on commercial brand and batch.Objetivo: La presencia de fitoesteroles en emulsiones lipídicas de origen vegetal se ha relacionado con la aparición de alteraciones de los parámetros de la función hepática. El objetivo es determinar la presencia de fitoesteroles en las emulsiones registradas en el mercado farmacéutico.Método: Se analizaron tres-cuatro lotes no consecutivos de seis marcas distintas de emulsiones lipídicas (Clinoleic®, Intralipid®, Lipofundina®, Lipoplus®, Omegaven® y Smoflipid®) y las diferencias en contenido de fitoesteroles totales entre marcas y entre lotes se estudiaron estadísticamente (ANOVA de un factor, aproximación no paramétrica de Kruskal-Wallis y análisis post hoc Scheffé; plt; 0,05).Resultados: Se encontró ausencia de fitoesteroles en el preparado Omegaven® con aceite de pescado. El contenido más alto de fitoesteroles (422,4 ± 130,5 μg/mL) coincidió con el porcentaje más alto de aceite de soja (Intralipid®). En el resto de las emulsiones se detectaron concentraciones de fitoesteroles entre 120 y 210 μg/mL, relacionadas con el contenido de aceite de soja. Se observaron diferencias estadísticamente significativas entre todas las marcas de emulsiones lipídicas (F = 42,97; p = 0,000) y entre lotes no consecutivos. Clinolenic® (F = 23,59; p = 0,000); Intralipid® (F = 978,25; p = 0,000); Lipofundina® TCL/TCM (F = 5,43; p = 0,045); Lipoplus ® (F = 123,53; p = 0,000),; y Smoflipid® (16,78; p = 0,000). Excepto en el caso de la Lipofundina® TCL/TCM las diferencias entre lotes fueron marcadas.Conclusiones: Las emulsiones lipídicas registradas en el mercado farmacéutico español contienen cantidades variables de fitoesteroles en función e la marca comercial y el lote. La determinación del contenido de fitoesteroles, actualmente no declarados, permitiría desarrollar estrategias para prevenir o tratar la aparición de estas alteraciones.

Phthalates are chemical compounds classified as endocrine disruptors which are present in practically every environment of daily life. In the field of artificial nutrition, they are relevant because they are found as plasticizers in infusion lines made with PVC. They are lipophilic molecules which weakly pair with PVC and, therefore, they are easily extracted by the fatty compounds that are part of both the parenteral and enteral nutrition, as various studies show. As endocrine disruptors, they directly affect the reproductive organs because of their antiandrogenic and estrogenic effects. They promote inflammation and oxidative stress and they are also related to the development of obesity, asthma, neurological and ophthalmic disorders, cholestasis and other gastrointestinal disorders. The legislation establishes the highest recommended exposure level for daily exposure; however, in the medical environment the exposure follows a different pattern, more occasional with very high peaks, for which there are no established thresholds, that is why it is recommended to avoid exposure whenever possible. The industry is working on the development of alternative plasticizers, for which the use experience is still limited. Currently, in the field of artificial nutrition it is recommended to use phthalate-free intravenous and enteral infusion lines.

Objective: this study assessed the incidence of hyperglycemia, hypertriglyceridemia, and liver function test (LFT) alterations among patients older and younger than 65 years receiving parenteral nutrition (PN). A secondary objective was to compare the incidence of any of these three events. Material and methods: inclusion criteria were non-critically ill adult inpatients receiving PN for ≥ 7 days in 15 hospitals in Spain. Exclusion criteria were hyperglycemia, hypertriglyceridemia, LFT alterations, sepsis, shock, pancreatic/hepatobiliary surgery, renal failure, diabetes mellitus (DM) type 1, insulin-treated DM type 2, acute DM complications, or obesity prior to PN. Patients were classified into groups YOUNG (aged 35-64) and OLD (aged 65-95). Results: this study recruited 200 patients. Group YOUNG included 63 (31.5%) patients and OLD, 137 (68.5%). Hyperglycemia appeared in 37 (18.5%) patients, eight (12.7%) in group YOUNG and 29 (21.2%) in group OLD (p = 0.174). Hypertriglyceridemia appeared in only one (0.7%) patient. LFT alterations appeared in 141 (70.5%) patients, 44 (69.8%) in group YOUNG and 97 (70.8%) in group OLD (p = 1.000). The model for hyperglycemia included DM type 2, previous surgical procedure, and use of hyperglycemia-inducing medications. The model for LFT alteration included previous surgical procedure, amount of lipids and amino acids, medications causing LFT alterations and a trend for age group. The model for any event included surgical procedure, DM type 2, and medications causing alterations. Conclusion: patients of ≥ 65 years receiving PN had similar incidences of hyperglycemia, hypertriglyceridemia, and LFT alterations as younger patients. Additionally, older patients had trends toward lower LFT alterations.

Resumen Los ftalatos son unos compuestos químicos clasificados como disruptores endocrinos que están presentes en prácticamente todos los entornos de la vida cotidiana. En el campo de la nutrición artificial son relevantes porque se encuentran como plastificantes en las líneas de infusión elaboradas con PVC. Son moléculas lipófilas que se unen débilmente al PVC y, por lo tanto, se extraen fácilmente por los compuestos lipídicos que forman parte de la nutrición tanto parenteral como enteral, tal y como demuestran diversos estudios. Como disruptores endocrinos, afectan directamente a los órganos reproductivos debido a sus efectos antiandrogénicos y estrogénicos. Favorecen la inflamación y el estrés oxidativo y también se relacionan con el desarrollo de obesidad, asma, alteraciones neurológicas y oftalmológicas, colestasis y otras alteraciones gastrointetinales. La legislación establece unos rangos máximos de exposición que están pensados para la exposición diaria; sin embargo, en el entorno médico la exposición sigue un patrón diferente, más puntual y con picos muy altos, para los cuales no hay márgenes descritos, por lo que se recomienda evitar la exposición siempre que sea posible. La industria trabaja en el desarrollo de plastificantes alternativos para los cuales la experiencia de uso es todavía limitada. Actualmente, en el campo de la nutrición artificial se recomienda utilizar líneas de infusión tanto intravenosa como enteral libres de ftalatos.

Introduction: Malnutrition is common in patients admitted to hospital and is associated with morbidity and mortality. We conducted a study to assess the prevalence of nutritional risk, risk factors associated and its consequences in a third-level hospital. Methods: This is a prospective nutritional screening study of hospitalized patients evaluated within the first 72 hours of admission, by Malnutrition Universal Screening Tool (MUST) and Short Nutritional Assessment Questionnaire (SNAQ) screening tests. The variables recorded included demographic, anthropometric, hospitalization and clinical data. Results: Out of 409 patients, 12.7% and 15.3% were nutritionally at risk according to MUST and SNAQ, respectively, with the highest prevalence in critical care units (33.3%; 25.5%), amongst oncologic patients (17.5%; 28.4%) and those with higher Charlson comorbidity indices (CCI). Length of stay (LOS) was longer in patients at severe malnutrition risk (15.4 vs 9.9 days for MUST; 13.3 vs 9.9 days for SNAQ). Mortality was higher in those with high malnutrition risk (66.7% vs 10.9% for MUST; 50.0% vs 14.2% for SNAQ). Multivariate analysis showed that malnutrition was associated with CCI and mortality. Risk factors associated with LOS were admission as emergencies for both MUST and SNAQ tests. Conclusions: The prevalence of malnutrition is high in patients on admission to a third-level hospital, with a higher prevalence in critical care units, amongst oncologic patients and those with a higher CCI. Malnutrition is associated with longer LOS and higher mortality. The systematic clinical use of screening tools enables to detect patients at risk of malnutrition and take appropriate action. Introducción: la desnutrición es común en los pacientes ingresados en el hospital y se asocia a morbi/mortalidad. El objetivo de este estudio es evaluar la prevalencia de riesgo nutricional, factores de riesgo asociados y sus consecuencias en un hospital de tercer nivel. Métodos: estudio prospectivo de cribado nutricional de pacientes hospitalizados evaluados dentro de las primeras 72 horas de ingreso, mediante las herramientas Malnutrition Universal Screening Tool (MUST) y Short Nutritional Assessment Questionnaire (SNAQ). Las variables registradas incluyen datos demográficos, antropométricos, de hospitalización y clínicos. Resultados: de los 409 pacientes entrevistados, 12,7% y 15,3% presentaban riesgo nutricional según MUST y SNAQ, respectivamente, con una mayor prevalencia en la Unidad de Cuidados Intensivos (UCI) (33,3%; 25,5%), pacientes oncológicos (17,5%; 28,4%) y aquellos con mayor índice de comorbilidad de Charlson (ICC). La estancia hospitalaria fue mayor en pacientes en riesgo de desnutrición severa (15,4 vs. 9,9 días para MUST; 13,3 vs. 9,9 días para SNAQ), así como la mortalidad (66,7% vs. 10,9% para MUST; 50,0% vs. 14,2% para SNAQ). El análisis multivariante mostró una asociación entre desnutrición e ICC y mortalidad. Los factores de riesgo asociados con estancia hospitalaria fueron ingreso por urgencias para ambos tests. Conclusiones: la prevalencia de desnutrición en pacientes al ingreso a un hospital de tercer nivel es alta, siendo mayor en las UCI, entre pacientes oncológicos y con mayor ICC. La desnutrición se asocia con mayor estancia hospitalaria y mayor mortalidad. El uso clínico sistemático de herramientas de detección puede ayudar a identificar pacientes en riesgo de desnutrición y tomar las medidas apropiadas.

Objectives Fish oil (FO)–based lipid emulsions (LEs) have been reported to prevent hepatic dysfunction in patients treated with parenteral nutrition (PN). We studied patients with alterations of γ-glutamyl transferase (GGT) associated with the administration of PN containing olive/soybean (O/S)-based LE. The aim of this study was to determine whether the strategy of reducing the lipid dose by 50%, by changing to an FO-based LE, reduced plasma levels of phytosterols (PS) and GGT more effectively and safely, than the strategy of reducing lipid contribution by 50% while maintaining the same LE composition. Methods A randomized double-blind clinical trial was carried out in patients with normal initial GGT, who after a minimum of 1 wk of daily PN (0.8 g/kg of O/S-based LE) presented with GGT values twice the upper normal value. At the time of randomization 1:1, lipids were reduced to 0.4 g/kg daily. Group A maintained O/S LE and group B changed to FO LE. The primary endpoints were reduction of plasmatic PS and GGT on day 7 after randomization, performed in the study population per protocol by Student's t test and simple linear regression. Secondary outcomes included alkaline phosphatase (AP), alanine transaminase (ALT), and total bilirubin (BIL), and safety variables. Results Nineteen patients were included. On day 7 after randomization, GGT and AP values were higher in the O/S group (n = 10; GGT: median [Med], 4.99; interquartile range [IQR], 4.09; AP: Med, 2.59 μkat/L; IQR 1.74) than in the FO group (n = 9; GGT: Med, 2.26 μkat/L; IQR, 1.07; AP: Med, 1.2 μkat/L; IQR 1.44). Although there were no differences in ALT and BIL values, the ALT decrease was larger and more statistically significant in the FO group than in the O/S group (P = 0.009). Total PS (Med, 21.10 μg/mL; IQR, 5.50) in the O/S group was higher than in the FO group (Med, 13.4 μg/mL; IQR, 10.65; P = 0.002). Significant decreases in PS and their fractions were observed, with the exception of campesterol and stigmasterol. Conclusion Plasma accumulation of PS and high values of GGT, AP, and ALT can be prevented with the exclusive administration of FO-based LE.

Meropenem is a broad-spectrum antibiotic, often used for the empirical treatment of infections in critically ill patients with acute kidney injury. Meropenem has clinically insignificant protein binding and, as a carbapenem antibiotic, shows time-dependent bacterial killing, meaning that the unbound or free antibiotic concentration in blood should be maintained above the minimal inhibitory concentration of the pathogen for at least 40 % of the dosing interval. We developed and validated simple chromatographic methods by ultra-performance liquid chromatography-tandem mass spectrometry to measure plasma, filtrate-dialysate, and urine concentrations of meropenem. Chromatographic separation was achieved using an Acquity(®) UPLC(®) BEH(TM) (2.1 × 100 mm id, 1.7 μm) reverse-phase C(18) column, with a water/acetonitrile linear gradient containing 0.1 % formic acid at a 0.4-mL/min flow rate. Meropenem and its internal standard (ertapenem) were detected by electrospray ionization mass spectrometry in positive ion multiple reaction monitoring mode. The limits of quantification were 0.27, 0.24, and 1.22 mg/L, and linearity was observed between 0.27-150, 0.24-150, and 1.22-2,000 mg/L for plasma, filtrate-dialysate, and urine samples, respectively. Coefficients of variation and relative biases were less than 13.5 and 8.0 % for all biological fluids. Recovery values were greater than 68.3 %. Evaluation of the matrix effect showed ion suppression for meropenem and ertapenem. No carry-over was observed. The validated methods are useful for both therapeutic drug monitoring and pharmacokinetic studies. It could be applied to daily clinical laboratory practice to measure the concentration of meropenem in plasma, filtrate-dialysate, and urine.

Lipid emulsions (LE) are a component of parenteral nutrition (PN) and its fatty acid (FA) profile determines various physiological responses.To assess the adequacy of a clinical not restricted protocol in the choice of LE by studying complementary biochemical and hematological parameters (BHP) at the beginning of the PN.A 4-year retrospective observational study of LE administered to patients with PN. Demographic, clinical, nutritional and analytical variables at the beginning of the PN were collected. Univariate and multivariate analyses were performed to study the correlation between the initial clinical and biochemical parameters and the LE profile used.Four hundred and sixty patients (29.5%) out of 1,558 had BHP at the beginning of PN and used mainly the LE combinations soybean (SO) + medium-chain triglycerides (MCT) + olive (OO) + fish (FO) (37.4%) and SO + MCT + OO (35.6%). Statistically significant differences on the LE pattern were observed between patients with and those without initial BHP (44.8% vs39.5% received FO, respectively). Conditions regularly associated with elevated C-reactive protein (CRP) were associated with increased use of FO LE: SO+OO+FO (OR: 4.52 [95% CI: 1.43-13.91]) and SO+MCT+OO+FO (OR: 3.34 [95% CI: 2.10-5.33]). In those complex conditions related with the critical patient MCT were used: hepatic failure (SO+MCT OR: 2.42 [95% CI: 1.03-5.68]) and renal failure (SO+MCT+FO OR: 3.34 [95% CI: 1.12-9.99]).The use of BHP at the beginning of PN treatment allows complementing the clinical and metabolic criteria in LE selection.INTRODUCCIÓN: el patrón de ácidos grasos (AG) de las emulsiones lipídicas (EL) utilizadas en nutrición parenteral (NP) condiciona diferentes respuestas fisiológicas. OBJETIVOS: estudiar si los criterios clínicos de prescripción de EL en NP establecidos en nuestro protocolo abierto y basados en recomendaciones se correlacionan con marcadores bioquímicos y hematológicos iniciales. MÉTODOS: estudio observacional retrospectivo de cuatro años. Se recogieron variables demográficas, clínicas, nutricionales y analíticas al inicio de la NP. Se realizó un análisis uni y multivariante para estudiar la asociación entre los valores iniciales de los parámetros bioquímicos y hematológicos (PBHE) y el tipo de emulsión lipídica empleada. RESULTADOS: de los 1.558 pacientes, 460 pacientes (29,5%) tenían PBHE al inicio de la NP y utilizaron mayoritariamente las combinaciones soja (AS) + triglicéridos de cadena media (MCT) + oliva (AO) + pescado (AP) (37,4%) y AS+MCT+AO (35,6%). Se encontraron diferencias estadísticamente signifiativas en el patrón EL utilizado entre los pacientes con y sin PBHE: patrón de AG con AP 44,8% vs.39,5%, respectivamente. Las situaciones clínicas con proteína C-reactiva (PCR) elevada se asociaron con mayor uso de EL con AP: AS+AO+AP (OR: 4,52 [IC 95%: 1,43-13,91] y AS+MCT+AO+AP (OR: 3,34 [IC 95%: 2,10-5,33]). En situaciones clínicas complejas asociadas con paciente crítico se utilizó EL con MCT: afectación hepática (AS+MCT OR: 2,42 [IC 95%: 1,03-5,68]) y afectación renal (AS+MCT+AP OR: 3,34 [IC 95%: 1,12-9,99]). CONCLUSIONES: la inclusión protocolizada de PBHE al inicio de la NP permite complementar criterios clínicos y metabólicos en la elección de la EL.

Malnutrition is common in patients admitted to hospital and is associated with morbidity and mortality. We conducted a study to assess the prevalence of nutritional risk, risk factors associated and its consequences in a third-level hospital.This is a prospective nutritional screening study of hospitalized patients evaluated within the first 72 hours of admission, by Malnutrition Universal Screening Tool (MUST) and Short Nutritional Assessment Questionnaire (SNAQ) screening tests. The variables recorded included demographic, anthropometric, hospitalization and clinical data.Out of 409 patients, 12.7% and 15.3% were nutritionally at risk according to MUST and SNAQ, respectively, with the highest prevalence in critical care units (33.3%; 25.5%), amongst oncologic patients (17.5%; 28.4%) and those with higher Charlson comorbidity indices (CCI). Length of stay (LOS) was longer in patients at severe malnutrition risk (15.4 vs 9.9 days for MUST; 13.3 vs 9.9 days for SNAQ). Mortality was higher in those with high malnutrition risk (66.7% vs 10.9% for MUST; 50.0% vs 14.2% for SNAQ). Multivariate analysis showed that malnutrition was associated with CCI and mortality. Risk factors associated with LOS were admission as emergencies for both MUST and SNAQ tests.The prevalence of malnutrition is high in patients on admission to a third-level hospital, with a higher prevalence in critical care units, amongst oncologic patients and those with a higher CCI. Malnutrition is associated with longer LOS and higher mortality. The systematic clinical use of screening tools enables to detect patients at risk of malnutrition and take appropriate action.

n-3 Fatty acids have clinical benefits. The primary aim of the present study was the assessment of infection in patients who underwent major high-risk elective gastrointestinal surgery receiving postoperatively fish oil (FO)-supplemented parenteral nutrition (PN), compared with those receiving a standard olive oil (OO) emulsion. The secondary aims were the assessment of anti-inflammatory response and evaluation of tolerance and safety of these emulsions. A prospective, randomised, double-blind study was performed in patients requiring at least 5 d of PN. An isoenergetic and isoproteic formula was administered: group A received OO alone, while group B received OO that was partially replaced with FO (16·6 %, w/w). End points were outcome measures (mortality, sepsis, infection, hospitalisation days and PN duration), inflammatory response (C-reactive protein (CRP), prealbumin and leucocytes) and safety (TAG and glucose metabolism, and liver and kidney function). Statistical analysis was done using Student's t test and Fisher's exact test (P v. 78·6 %, P = 0·007). CRP, prealbumin and leucocytes were not significantly different between the groups. There were no differences in safety parameters. We conclude that high-risk surgical patients receiving FO-supplemented PN for 5 d present a lower incidence of infection. Emulsions were safe and well tolerated.

Objective There is currently a controversy regarding interactions between levofloxacin and warfarin. The aim of this study was to determine the clinical relevance of this interaction in our setting. Setting A university hospital in Barcelona, Spain. Methods We carried out a retrospective evaluation of all patients hospitalized in our hospital during the period 2000–2005, selecting all those concomitantly treated with levofloxacin and warfarin for the study. The following data were compiled: demographic information, concomitant medication, comorbid conditions, and relevant analytical parameters, particularly the international normalized ratio (INR), including values taken before, during, and after concomitant administration of the two study drugs. Patients for whom INR values during concomitant administration were not available were excluded. Differences in INR before and during the potential interaction, and before and after the interaction were analyzed with the Wilcoxon t test using SPSS (V12.0). In addition, patients were stratified according to presence or not of toxic habits (smoking/alcohol consumption) to investigate the possible impact of these factors on the interaction under study. Results Among the 30 patients identified, 9 were excluded because INR data during concomitant administration of warfarin and levofloxacin were not available. Statistical analysis demonstrated significant increase in INR (P = 0.001) following addition of levofloxacin to warfarin therapy. Conclusions. The results of this study reaffirm the hypothesis that concomitant administration of levofloxacin and warfarin leads to INR increase; hence close monitoring of INR is advisable when patients are prescribed this combination of drugs.

Summary Background & aims Intravenous fat emulsions are associated with liver disease and there is some evidence that the administration of intravenous fish oil (FO) may be useful in reversing it. The aim of our study was to assess whether there are differences in the changes of liver function tests (LFTs) in hospitalized adult patients with parenteral nutrition (PN) with FO and vegetal lipids vs patients without FO. The secondary aim was to study the relationship between impaired LFT and FO. Methods This was a 4-year, propensity score-matched analysis including patients aged ≥18 years treated with PN for ≥10 days. The exclusion criteria were previous liver disease, biliary disorders or pancreatic cancer, and altered initial LFT values. Patients were classified into 2 groups: FO cohort (patients who received FO – in addition to vegetal oil – after the first week of PN) and the vegetal oil cohort (patients who received only vegetal oil). A propensity score matched cohort design was developed. Univariate analyses were used to study the changes in LFTs. To evaluate whether LFT alterations vary with FO administration, four stepwise multiple linear regression models were conducted. Results 52 patients were included, 52% men, median 66 (55–75) years and 69 kg (61.7–78.8), with 18.5 (14–31.8) days of PN treatment. Maximum FO supplementation was 23%. During the first week with PN (none of the groups receiving FO), gammaglutamyl transferase (GGT), alkaline phosphatase (AP) and total bilirubin (BIL) increased significantly. Comparing LFT values at seven days of PN with at the end of PN treatment, the univariate analysis showed a better response for the FO group. The group without FO showed a significant increase for GGT and AP. In multivariate models, the percentage of FO administered was associated with a decrease in GGT, B = −0.33 [CI 95% = −0.54/−0.12], in AP, B = −0.12 [CI 95% = −0.20/−0.03] and ALT, B = −0.12 [CI 95% = −0.21/−0.024]. Conclusions Lipid composition plays a significant role in LFT alteration associated with PN, and FO intravenous lipid emulsions (ILEs) minimize disturbance of LFTs in hospitalized adult patients.

Background Hepatic dysfunction is a complication associated with parenteral nutrition (PN). Our primary objective was to study the relationship between doses of intravenous fish oil (FO) emulsion in PN and the variation in the main liver function tests (LFTs) in hospitalized PN-treated adults. As a secondary objective, we studied the safety of FO administration. Methods We conducted a retrospective study in adult patients receiving FO supplementation in PN. Demographic, nutritional and safety variables were collected. Variation of LFTs was defined as the difference between values just before the first administration of FO and values at the end of PN. A multiple linear regression was performed to study the association between PN-lipids (FO or vegetable) and the variation of each LFT; the following variables were used to adjust the effect of lipids: sepsis, length of stay in the intensive care unit and lipids dose. Student t-test was used to study safety variables. Data were analyzed using SPSS 19.0. Results Patients (53, median age 68 years (24-90); 62 % men) with the principal diagnosis of digestive neoplasm (42 %) received PN for a median of 19 (7-75) days. In the multivariate analysis, the amount of FO was related to a decrease in gamma-glutamyl transferase (GGT) (B = −2.23;CI95 % = −4.41/-0.05), a decrease in alkaline phosphatase (AP) (B = −1.23;CI95 % = −2.07/-0.37), and a decrease in alanine aminotransferase (ALT) (B = −0.82; CI95 % = −1.19/-0.44). No differences were found in safety variables. Conclusions GGT, AP and ALT improved with FO PN-supplementation. Moreover, the improvement was greater when the doses of FO were higher. FO administration in PN is safe.

Objective Lipids in parenteral nutrition (PN) have been linked to liver damage. The aim of this study is to 1) determine whether the incidence of alterations in liver function tests (LFTs) changes over time among hospitalized adult patients receiving PN; 2) evaluate whether the alteration in LFTs varies with the pattern of lipid administration; and 3) study the relationship between LFT alterations and fish oil (FO) emulsions. Methods Patients treated with PN over 4 y were included. Demographic, clinical, nutritional, and analytical variables were collected. LFTs (γ-glutamyl transferase [GGT], alkaline phosphatase [AP], alanine aminotransferase [ALT], and total bilirubin [BIL]) were collected during PN treatment. Differences in LFTs were studied with t tests for paired samples. To match the type of lipid with each of the LFTs studied, four multivariate statistical models were performed. Significance was reported with the 95% confidence interval (CI) at p Results We studied 1555 patients. LFT alterations at baseline were high and increased during PN treatment except ALT. GGT and AP showed significant increases from baseline values. In the multivariate study, daily dose of FO (g·kg−1·d−1) was associated with a significant decrease in GGT (B = −11.189; 95% CI, −19.799 to −2.578) and in AP (B = −5.250; 95% CI, −10.263 to −0.237). Daily dose of vegetal oil (g/kg) had a tendency for a significant increase in GGT (B = 0.441; 95% CI, −0.107 to 1.039) and AP (B = 0.312; 95% CI, −0.023 to 0.648). Conclusions GGT and AP increased throughout the clinical course of PN administration. These alterations had a multifactorial component. The administration of FO was associated with a significant decrease in the levels of GGT and AP.

Esophageal cancer represents a high-risk group of patients. This study determines the association of artificial nutrition with morbidity, mortality, and survival and studies clinical situations that determine the choice between enteral (EN) and parenteral support (PN). This retrospective single-center study compared 2 periods: 1) treatment centered in surgical process with discretionary demand of support, and 2) elective therapeutic and nutritional interventions were systematized. Risks factors that determined use of PN and survival were included in 4 multivariate regression models: 2 logistic, 1 multinomial, and a survival Cox analysis. Significance determined with 95% confidence interval (CI) of 95%; inclusion criteria was P0.1. During an 11-yr period, 175 patients were studied. Artificial nutrition consisted of 45 jejunostomy EN, 28 PN, and 102 both. Risk factors that conditioned PN were first period (OR: 2.41; 95% CI: 1.13-5.14), stay in intensive care unit (ICU)3 days (OR: 1.70; 95% CI: 0.93-3.71), and surgical reintervention (OR: 3.83; 95% CI: 0.94-16.95). Risk factors associated with mortality were first period (OR: 22.7; 95% CI: 2.31-172.05), respiratory infection (OR: 11.23; 95% CI: 2.33-55.5) and coloplasty surgery (OR: 13.16; 95% CI: 2.11-83.33). Longer survival was associated with second period (OR: 2.36; 95% CI: 1.38-4.05) and lower neoplasm staging (OR: 1.43; 95% CI: 1.21-1.69). A multidisciplinary management that includes nutritional support of esophagectomized patients is 1 of the factors that improves survival. Protocol implies greater use of EN; PN remains an important nutritional therapy.

Introduccion: el patron de acidos grasos (AG) de las emulsiones lipidicas (EL) utilizadas en nutricion parenteral (NP) condiciona diferentes respuestas fisiologicas. Objetivos: estudiar si los criterios clinicos de prescripcion de EL en NP establecidos en nuestro protocolo abierto y basados en recomendaciones se correlacionan con marcadores bioquimicos y hematologicos iniciales. Metodos: estudio observacional retrospectivo de cuatro anos. Se recogieron variables demograficas, clinicas, nutricionales y analiticas al inicio de la NP. Se realizo un analisis uni y multivariante para estudiar la asociacion entre los valores iniciales de los parametros bioquimicos y hematologicos (PBHE) y el tipo de emulsion lipidica empleada. Resultados: de los 1.558 pacientes, 460 pacientes (29,5%) tenian PBHE al inicio de la NP y utilizaron mayoritariamente las combinaciones soja (AS) + trigliceridos de cadena media (MCT) + oliva (AO) + pescado (AP) (37,4%) y AS+MCT+AO (35,6%). Se encontraron diferencias estadisticamente signifiativas en el patron EL utilizado entre los pacientes con y sin PBHE: patron de AG con AP 44,8% vs.39,5%, respectivamente. Las situaciones clinicas con proteina C-reactiva (PCR) elevada se asociaron con mayor uso de EL con AP: AS+AO+AP (OR: 4,52 [IC 95%: 1,43-13,91] y AS+MCT+AO+AP (OR: 3,34 [IC 95%: 2,10-5,33]). En situaciones clinicas complejas asociadas con paciente critico se utilizo EL con MCT: afectacion hepatica (AS+MCT OR: 2,42 [IC 95%: 1,03-5,68]) y afectacion renal (AS+MCT+AP OR: 3,34 [IC 95%: 1,12-9,99]). Conclusiones: la inclusion protocolizada de PBHE al inicio de la NP permite complementar criterios clinicos y metabolicos en la eleccion de la EL.