INTRODUÇÃO: Indicadores de qualidade em terapia nutricional (IQTN) são importantes ferramentas de avaliação e monitoramento de qualidade da terapia nutricional (TN). No Brasil, além da escassez de recursos humanos e materiais, a aplicação dos IQTNs,disponíveis para prática clínica, tem sido limitada devido ao seu elevado número. O presente estudo procurou identificar os dezIQTNs mais pontuados, dentre aqueles disponíveis no Brasil, através da avaliação da opinião de especialistas em TN. MÉTODOS: Todos os IQTNs disponíveis para aplicação clínica no Brasil (n=36) foram avaliados em duas fases distintas. Na fase 1 (seleção), especialistas em TN (n=26) pontuaramos IQTNs de acordo com quatro atributos (utilidade, simplicidade, objetividade, e baixo custo), utilizando a escala de Likert com 5 pontos. Os IQTNs foram classificadosem ordem da maior para menor pontuação e a confiabilidade da opinião de especialistas para cada indicador foi avaliada poralfa de Cronbach. Na fase 2, os dez IQTNs selecionados com maior pontuaçãoforam submetidos ànova análise dos especialistas, por meio de duas perguntas fechadas. RESULTADOS: Os dez IQTNs selecionadoscom maior pontuação, em ordem do mais para o menos pontuado, foram 1.) Frequência de realização de triagem nutricional em pacientes hospitalizados, 2.) Frequência de diarreia em pacientes em Terapia Nutricional Enteral, 3.) Frequência de saída inadvertida de sonda de nutrição em pacientes em Terapia Nutricional Enteral, 4.) Frequência de obstrução de sonda de nutrição em pacientes em Terapia Nutricional Enteral, 5.) Frequência de jejum digestório por mais de 24 horas em pacientes em Terapia Nutricional Enteral ou Oral, 6.) Frequência de pacientes com disfunção da glicemia em Terapia Nutricional Enteral e Parenteral, 7.) Frequência de medida ou estimativa do gasto energético e necessidades proteicas em pacientes em Terapia Nutricional, 8.) Frequência de infecção por Cateter Venoso Central em pacientes em Terapia Nutricional Parenteral, 9.) Frequência de conformidade de indicação da Terapia Nutricional Enteral, 10.) Frequência de aplicação de Avaliação Subjetiva Global (ASG) em pacientes em Terapia Nutricional. As opiniões dos especialistas entrevistados foram significantemente consistentes. Durante a fase 2, 96% dos especialistas informaram estar satisfeitos com os 10 IQTNs selecionados, e 100% manifestaram que esta seleção refletiu a mesma opinião anteriormente emitida,na primeira fase do estudo. CONCLUSÃO: A avaliação da opinião de especialistas em TN, com o uso de técnicas psicométricas e ferramentas estatísticas, possibilitou a identificação dedezIQTNsmais pontuados,com consistência e representatividade de opiniões entre eles.A redução do número de trinta e seis IQTNs para os dez presentemente identificados pode contribuir para sua aplicação clínica / BACKGROUND: Quality indicators in nutritional therapy (QINT) are central tools to evaluate and monitor the quality of nutritional therapy. In addition to the scarcity of human and material resources, the application of the QINT available for clinical practice in Brazil has been limited also due to its elevated number. This study attempted to identify the ten more scored QINT that suit in the clinical practice, among those available in Brazil, through evaluating experts in Nutritional Therapy (NT). METHODS: All the 36 available QINTs to the clinical application in Brazil were evaluated in two distinct phases. In the phase 1 (selection), 26 experts in NT rated the QINTs following four attributes (utility, simplicity, objectivity and low cost), on a 5- point Likert scale. The top 10 QINTs were identified from the top 10 scores; and the reliability of the experts opinion to each indicator were evaluated by Cronbachs alpha. In phase 2, the top 10 selected QINTs were subjected in a new experts analysis following two closed questions. RESULTS: The top 10 selected QINTs, from the biggest to the least scored order, were: 1) Frequency of carrying out nutrition screening of hospitalized patients, 2) Frequency of diarrhea in patients on Enteral Nutrition (EN), 3) Frequency of involuntary withdrawal of enteral feeding tubes, 4) Frequency of tube feeding occlusion in patients on EN, 5) Frequency of digestive fasting for more than 24 hours in patients on oral nutrition or EN, 6) Frequency of patients with glycemic dysfunction on NT, 7) Frequency of measurement or estimation of energy expenditure and protein needs in patients on NT, 8) Frequency of Central Venous Catheter infection in patients on Parenteral Nutrition, 9) Frequency of indication compliance of NT 10) Frequency of application of Subjective Global Assessment in patients on NT. The opinions of the experts interviewed were significantly consistent. During the phase 2, 96% of the experts were found to be satisfied with the top 10 selected QINTs, and 100% expressed that the selection of the top 10 QINTs interfered the same opinion in the first phase of the study. CONCLUSION: The evaluation of the experts opinion in NT using psychometrics techniques and statistical tools, allowed the identification of the 10 most scored QINTs, with good applicability in NT and representativeness of opinions among them. The reduction of QINT number from 36 to ten, may contribute to their clinical application

INTRODUÇÃO: Relatos conflitantes têm dificultado para se estabelecer o potencial benefício da glutamina (GLN) no tratamento de condições inflamatórias agudas. Nós avaliamos o efeito da infusão parenteral de GLN, prévia à pancreatite aguda (PA) experimental, nos mediadores inflamatórios, morbidade e mortalidade. MÉTODOS: Ratos Lewis (n = 131) receberam glutamina parenteral (grupo GG), solução salina (grupo SS ou controle), ou permaneceram sem infusão parenteral (grupo Sham) por 48h. Após este período, foi induzida PA por meio da injecção retrógrada de taurocolato de sódio no ducto pancreático. Sangue, amostras de pulmão, fígado, pâncreas e líquido ascítico foram colhidos a partir de 2, 12 e 24 horas após PA para avaliação das variáveis propostas (citocinas, hsp, histologia, amilase). Sessenta animais permaneceram vivos após PA para a análise da mortalidade em sete dias. RESULTADOS: A análise entre grupos não mostrou diferenças significativas nos níveis de citocinas (p > 0,05). Análise cinética dentro de cada grupo ao longo do tempo mostrou maior INF-y no grupo Sham e SS às 2h do que em 12h e 24h, maior IL-2 e inferior IL-10 no Sham, às 24h do que em 2h e 12h, e menor IL-10 no SS e GG em 24 h do que no tempo de 2h (p <= 0.05). O grupo GG exibiu maior expressão de HSP 90 no pulmão e no fígado do que no grupo Sham nos tempos de 2h e 12h, respectivamente; e maior expressão no fígado de HSP90 e HSP70 no grupo SS no tempo 12 horas (p < 0,01). O grupo Sham apresentou maior expressão de HSP 70 no pulmão e HSP 90 no fígado do que os outros grupos no tempo de 24h. Não ocorreram alterações na taxa de mortalidade. CONCLUSÕES: Em modelo de PA experimental induzida por taurocolato de sódio, o pré-tratamento com GLN parenteral melhorou o perfil dos mediadores inflamatórios, sem afetar a mortalidade / INTRODUCTION: Conflicting reports have hindered establish the potential glutamine (GLN) benefit in treating acute inflammatory conditions. We evaluated the effect of parenteral GLN infusion before experimental acute pancreatitis (AP), as systemic inflammation-reproducing model, on inflammatory mediators and mortality. METHODS: Lewis rats (n=131) received parenteral glutamine (GG group), saline (SS or Control group), or remained without parenteral infusion ( Sham group) for 48h. Thereafter, AP was induced by retrograde injection of sodium taurocholate into pancreatic duct. Blood, lung, liver and pancreas samples were collected from 2, 12 and 24h post-AP to assess serum cytokines levels, tissue HSP expression, histology and amylase. Sixty animals remained alive post-PA for seven-day mortality analysis. RESULTS: Punctual between-groups analysis did not show differences in cytokine levels (p > 0.05). Intragroup analysis over time showed higher INF-y in Sham and SS at 2h than at 12h and 24h, higher IL-2 and lower IL-10 in Sham at 24h than at 2h and 12h, and lower IL-10 in SS and GG at 24h than at 2h timepoint (p <= 0.05). GG group exhibited higher lung and liver HSP90 than Sham at 2h and 12h timepoints, respectively; and higher liver HSP90 and HSP70 than SS at 12h timepoint (p < 0.01). Sham group presented higher lung HSP70 and liver HSP90 than the others at 24h timepoint (p < 0.02). No changes occurred on mortality rate. CONCLUSIONS: In sodium taurocholate-induced PA model, pretreatment with parenteral GLN improved inflammatory mediator\'s profile, without affecting mortality

A Síndrome do Intestino Curto (SIC) é uma doença complexa que ocorre após extensa ressecção do intestino delgado, levando a uma má absorção de nutrientes e fluidos, uma condição que pode causar diarreia, desnutrição e perda de peso graves com alto risco para o desenvolvimento da osteoporose. Estudos recentes mostram existir ampla interação fisiológica do esqueleto com os diversos sistemas, incluindo o metabolismo energético e o trato digestório. Peptídeos originados não só no tecido adiposo, mas também no intestino como as incretinas [GIP (polipeptídeo trópico insulínico dependente de glicose) e GLP1 (peptídeo 1 tipo glucagon)] modulam a atividade de remodelação óssea. O objetivo principal do atual estudo foi avaliar a relação entre os tecidos adiposos subcutâneo (TAS), visceral (TAV), lipídeos intra-hepáticos (LIH), tecido adiposo da medula óssea (TAMO), bem como do GIP, GLP1, e grelina com a densidade mineral óssea (DMO) em pacientes com SIC. Tratase de um estudo observacional prospectivo composto por dois grupos experimentais pareados por altura, idade e sexo: a) o grupo controle (GC) (n = 18; 9M,9F) e b) o grupo de pacientes com SIC, o qual foi avaliado em 2 ocasiões, com intervalo de um ano entre as análises, sendo denominados SIC0 (n = 14; 7M,7F) e SIC1 (n = 11; 6M,5F). Em comparação com o GC, pacientes com SIC ao longo do estudo apresentaram menor DMO e maior LIH e GIP (p< 0,05). Os valores de TAMO, GLP1 e grelina foram similares entre os grupos. O TAMO teve correlação negativa e significativa com DMO de L3 no GC (r= -0,6; p< 0,05), porém, no grupo SIC esta correlação foi positiva, mas sem significância estatística ao longo do estudo: SIC0 (r= 0,45; p= 0,13) e SIC1 (r= 0,45; p= 0,17). LIH associou-se negativamente com DMO do colo do fêmur (R²= 0,16; p< 0,05) e quadril total (R²= 0,27; p< 0,05). Existe alta prevalência de osteoporose em pacientes com SIC. No entanto, não se observou nem expansão de TAMO e nem relação negativa da DMO com o TAMO. O acesso a calorias parece afetar positivamente a relação entre TAMO e massa óssea. A deposição hepática de lipídeos parece afetar negativamente a massa óssea de pacientes com SIC. / Short bowel syndrome (SBS) is a complex disease that occurs after extensive resection of the small intestine leading to malabsorption of nutrients and fluids, a condition that can cause severe watery diarrhea, dehydration and acute weight loss, developing high risk for the appearance of osteometabolic disease. Studies have shown the progress on the physiological interaction of the skeleton with the various systems, including energetic metabolism and the gastrointestinal tract. Peptides originated not only in adipose tissue but also in the intestine such as incretin [GIP (Glucose-dependent insulinotropic polypeptide) and GLP1 (glucagonlike peptide 1) modulate bone remodeling activity. The main objective of the current study was to evaluate the influence of subcutaneous (SAT), visceral (VAT) adipose tissue, intrahepatic lipids (IHL), bone marrow fat adipose tissue (MAT), as well as the influence of GIP, GLP1, and ghrelin on the bone mineral density (BMD) of SBS patients. It is a prospective observational study composed by two experimental groups matched by height, age and sex: a) the control group (CG) (n = 18; 9M,9F) and b) the SBS group which were evaluated in two occasions with a period between analyzes of one year: named SBS0 (n = 14; 7M,7F) and SBS1 (n = 11; 6M,5F). Compared to CG, SBS patients throughout the study had significantly lower BMD and elevated IHL and GIP (p< 0.05). Values of MAT, GLP1 and ghrelin were similar between groups. MAT was negatively and significantly correlated with L3 BMD in the CG (r = -0.6; p< 0.05) and positively correlated, but not significant with L3 BMD in the SBS group throughout the study: SBS0 (r= 0.45; p= 0.13) and SBS1 (r= 0.45; p= 0.17). IHL was negatively and significantly associated with femoral neck BMD (R²= 0.16; p< 0.05) and total hip BMD (R²= 0.27; p< 0.05). The occurrence of osteoporosis is frequent in SBS patients, but MAT is not increased in these patients and had positive correlation with BMD, although not significant. Access to calories seems to positively affect the relationship between MAT and bone mass. IHL appear to negatively affect bone mass in SBS patients.

No description available.

L'exposition à la lumière des solutions de nutrition parentérale (NP) génère des peroxydes tels que l'H2O2 et l'ascorbylperoxyde (AscOOH). Cette absence de photo-protection provoque une augmentation des triglycérides (TG) plasmatique chez les enfants prématurés et chez un modèle animal, ayant un stress oxydatif et une stéatose hépatique indépendante de l’exposition au H2O2. Nous pensons que l'AscOOH est l'agent actif conduisant à l'élévation des TG. Le but est d'investiguer le rôle de l'AscOOH sur les métabolismes du glucose et des lipides à l'aide d'un modèle animal néonatal de NP. / The light exposure of parenteral nutritive solutions generates peroxides such as H2O2 and ascorbylperoxide. This absence of photo-protection is associated with higher plasma triacylglycerol concentration (TG) in premature infants and, in animals, with oxidative stress and a H2O2 independent hepatic steatosis. We hypothesized that ascorbylperoxide is the active agent leading to high TG. The aim was to investigate the role of ascorbylperoxide on glucose and lipid metabolism in an animal model of neonatal parenteral nutrition.

Home parenteral nutrition is a treatment enabling the patients with intestinal failure to live their lifes in their home environment. The possibility to commence and practise home parenteral nutrition requires not only a medical and pharmaceutical team, but also paramedical staff, which plays a signifiant part mainly in education of the patient and his close relatives. The study's aim was to characterize the patients involved in the home parenteral nutrition programme (HPN) and catheters used for this purpose and as well to analyze complication rate of the long term catheters related to their use and subsequent care. Into the retrospective quantitative study were included patiens treated with home parenteral nutrition since january 2009 to september 2015 within one nutrition care center. Data collection was realized by research in medical documentation. Altogether 135 patients were included in the study (93 female and 42 male), who have hade 227 catheters inserted in total (114 portcatheters, 73 Broviac catheters and 40 PICC) with 86 187 catheter days. The most frequent basic disease was cancer (36%) and the most prevalent indication to HPN was a short bowel syndrome (50%). Overall complication rate was 2,12/1000 catheter days (1,62 catheter sepsis, identically local infections and thrombotic...

Dissertação de Mestrado em Nutrição Clínica apresentada à Faculdade de Ciências de Nutrição e Alimentação da Universidade do Porto / Resumo da dissertação:A nutrição parentérica (NP) constituiu um grande avanço na área da terapêutica nutricional, ao permitir assegurar um suporte nutricional adequado a doentes com patologias em que até recentemente lhes era impossível fornecer esse suporte. É, no entanto, uma terapêutica relativamente dispendiosa, pelo que se deve ter também em atenção questões associadas ao custo da sua instituição. Paralelamente, as profundas alterações nos processos de gestão nas instituições de saúde Portuguesas, operadas com maior incidência nos últimos anos, têm colocado pressões na diminuição de custos e no aumento da eficácia e eficiência destas instituições. Estes argumentos apontam para a necessidade de se analisar e ponderar, quer do ponto de vista clínico, quer do ponto de vista económico, a escolha do melhor método de preparação e administração de NP. Assim, o presente trabalho tem como principal objectivo a comparação de custos das alternativas em NP, num hospital EPE direccionado para o tratamento do cancro – o Instituto Português de Oncologia do Porto Francisco Gentil EPE, dando importância a outros dois critérios, nomeadamente, qualidade e adequação às necessidades nutricionais de cada doente. Em oposição à actual preparação de NP nas enfermarias com incidência na utilização de bolsas padronizadas, a centralização da preparação de NP numa unidade a ser criada na farmácia hospitalar do IPOPFG EPE teria um impacto muito significativo. A minimização de custos, a obtenção de ganhos de segurança e qualidade no serviço prestado ao doente e finalmente, a personalização dos protocolos de NP contrariamente à sua padronização são as três grandes vantagens concluídas neste estudo. / Dissertation abstract:Parenteral nutrition represents an enormous and relatively recent advance in nutritional therapeutics, allowing for the institution of an adequate nutritional support to patients with certain pathologies. However, this therapy is relatively expensive and this is why it is necessary to pay particular attention on questions concerning the cost of its institution. At the same time, the current and vast changes in Portuguese public health institutions management processes, with higher incidence in the last years, are creating several pressures to reduce costs and increase efficacy and efficiency on those institutions. These arguments point to the need to analyse and reflect both clinically and economically, on the choice for the best method to compound and administrate parenteral nutrition. Therefore, the aim of this work is to compare costs among different alternatives in parenteral nutrition in a EPE Portuguese hospital that deals with patients with cancer - Instituto Português de Oncologia do Porto Francisco Gentil EPE. This comparison also takes in consideration two other crucial criteria, namely, quality and adequacy to specific nutritional needs of a patient. In opposition to the current preparation practice of parenteral nutrition in the wards, the centralization of its preparation in a specialized unit in the hospital pharmacy could have major positive impacts in IPOPFG EPE. The reduction of costs, the benefits in security and quality of services to the patients and the possibility to individualize parenteral nutrition are the three main conclusions of this study.

(EN) Home parenteral nutrition (DPV) has become a routine part of patients care whose oral intake is reduced or completely eliminated. An integral part of the application of DPV is also the permanent or temporary need for functioning vascular access. Catheter complications negatively affect the quality of life, morbidity and in case of catheter sepsis the patient mortality. In addition it also brings increased costs for therapy and the need for patients re-hospitalization. The main objective of our study is to analyze catheter-related complications and to determine whether use of catheter plugs like TauroLock and TauroLock Hep and Tegaderm CHG antimicrobial dressing affect the incidence of catheter complications with DPV, and whether the incidence of complications is affected by a person who treated the catheter. The secondary objective is to characterize patients with served DPV and types of catheter used for this purpose.The method chosen is a retrospective observational cohort study. The study contains 52 patients with 72 catheters (39 Broviac, 18 PICC and 15 ports). The monitored number of catheter- days in total was 33,875. We conclude that the use TauroLock Hep is effective in the prevention of catheter complications and significantly reduces the overall incidence of all complications (p =...

Objective: The objective of this thesis was to facilitate clinical trials of the optimal lipid based approach (e.g.: omega-3 containing lipid emulsions or minimization of conventional lipid) for the prevention of Intestinal Failure Associated Liver Disease (IFALD). This was achieved through 3 related projects. Project 1: The first project examined the risk of advanced IFALD associated with exposure to conventional intravenous lipid in a logistic regression model. The study demonstrated that each day of conventional lipid (> 2.5 g/kg/day) was associated with a significant increase in the risk of advanced IFALD [Odds Ratio: 1.04 95% CI: 1.003 – 1.06]. Project 2: The second project surveyed experts in Intestinal Failure regarding their beliefs of the efficacy of lipid minimization and lipid emulsions containing omega-3 fatty acids relative to conventional emulsions. The goal of the project was to develop prior distributions of the treatment response for these therapies that can be used in Bayesian analyses of clinical trials. Our results demonstrated consistent expert opinion that the novel lipid based approaches are superior to conventional therapy. Estimates of the treatment effect were similar for the two approaches (median elicited treatment response, relative to conventional lipid, was a relative risk of 0.53 for omega-3 lipid and 0.45 for lipid minimization). Project 3: The final project was a pilot randomized controlled trial of an omega-3 emulsion. The study demonstrated that the randomized design is a feasible strategy for evaluating lipid based approaches for the prevention of IFALD. A Bayesian preliminary assessment of the results of the trial, suggests a high likelihood that the trial will demonstrate a difference between the conventional and omega-3 emulsion evaluated in the trial. However, since the analysis was blinded, the direction of the difference is not known. Conclusion: This thesis will contribute to the design and analysis of high quality and feasible randomized trials that will allow investigators to address the optimal lipid based approach to the management of IFALD.

L'exposition à la lumière des solutions de nutrition parentérale (NP) génère des peroxydes tels que l'H2O2 et l'ascorbylperoxyde (AscOOH). Cette absence de photo-protection provoque une augmentation des triglycérides (TG) plasmatique chez les enfants prématurés et chez un modèle animal, ayant un stress oxydatif et une stéatose hépatique indépendante de l’exposition au H2O2. Nous pensons que l'AscOOH est l'agent actif conduisant à l'élévation des TG. Le but est d'investiguer le rôle de l'AscOOH sur les métabolismes du glucose et des lipides à l'aide d'un modèle animal néonatal de NP. / The light exposure of parenteral nutritive solutions generates peroxides such as H2O2 and ascorbylperoxide. This absence of photo-protection is associated with higher plasma triacylglycerol concentration (TG) in premature infants and, in animals, with oxidative stress and a H2O2 independent hepatic steatosis. We hypothesized that ascorbylperoxide is the active agent leading to high TG. The aim was to investigate the role of ascorbylperoxide on glucose and lipid metabolism in an animal model of neonatal parenteral nutrition.