Influencia de la enfermedad psiquiátrica previa en la evolución de los pacientes sometidos a cirugía bariátrica

IntroductionPresurgical evaluation of patients undergoing bariatric surgery includes, among others, a psychological/psychiatric evaluation. Psychiatric disorders that did not contraindicate surgery may persist and influence on weight loss and postoperative clinical course, hindering the success of the procedure. The aim of our study was to analyze the postoperative evolution of our series of patients with and without psychiatric symptoms before surgery.Patients and methodsRetrospective analysis of 109 patients undergoing bariatric surgery with duodenal switch from 2003 to 2008 (follow up > 6 months). We studied weight changes, immediate and delayed complications of surgery and nutritional deficiencies in post-surgical follow-up in patients with previous psychiatric disorders (group 1, n = 17) compared with patients without psychiatric disorders (group 2, n = 92).ResultsPatients in group 1 showed a greater tendency for weight gain. They regained a 9,4% of the initial excess weight lost between 18 months after surgery and 36 months after surgery, while patients in group 2 regained only 0.2% in the same period (p < 0.05). There was no difference in immediate surgical complications (5/17 vs 25/92 patients). The mean incidence of late surgical complications was 0.71 per patient in group 1 and 0.22 complications per patient in group 2 (p = 0.02). 52.9% of patients in group 1 had at least one late complication compared to 19,6% of patients in group 2 (p = 0.003). The three most common complications in patients with previous psychiatric disorders were chronic diarrhea, vomits and malnutrition. The presence of nutritional deficiencies were common in both groups, mainly soluble vitamins, iron and zinc. During postoperative follow-up, we found 3.1 ± 1.6 nutritional deficiencies per patient in group 1 and 2.5 ± 1.7 in group 2 (p = 0.04). More than three nutritional deficiencies were found in 8 patients in group 1 (52.9%) compared to 23 patients in group 2 (25%) (p = 0.03).ConclusionsThe presence of previous psychiatric disorders may be a predictor of a less positive outcome in morbidly obese patients who undergo bariatric surgery.     

Nutrición basada en la evidencia en la pancreatitis aguda y la enfermedad hepática crónica estable

Acute pancreatitis is a disease that, by definition, generates an increase in metabolism. This metabolic reaction, together with the anorexia produced by the disease, clearly increases morbidity and mortality secondary to malnutrition.Malnutrition affects almost 70% of patients with cirrhosis, with a consequent increase in complications. The present review aims to evaluate the utility of the use of total parenteral nutrition (TPN) and/or enteral nutrition (EN) in patients with acute pancreatitis and in those with stable chronic liver disease.In patients with acute pancreatitis, the administration of enteral nutrition seems to confer advantages over parenteral nutrition in clinical variables (infections, surgical interventions, and mean length of hospital stay) (A-B); nevertheless, further studies stratifying patients according to the severity of pancreatitis and probably its etiology should be designed. Glutamine supplementation can be effective in reducing length of hospital stay and duration of nutritional support (B).In patients with stable chronic liver disease, there are no studies that demonstrate the superiority of EN over PN, or vice versa, in relevant clinical variables (mortality, length of hospital stay, etc.). There is only one study that has demonstrated that EN is superior to oral intake in reducing mortality (B).Improved study designs and the need to perform studies according to the type and severity of liver disease should be a research priority.     

¿Cuál es el papel de la valoración geriátrica integral en Oncogeriatría?

The growing increase in world population and generalised aging have been accompanied by an increase in the prevalence of cancer in the elderly. Aging is associated with certain physiological changes, some of which are enhanced by the neoplasm itself. Along with this, the elderly oncology patient usually has more problems than the rest of the elderly, and has a multitude of deficits. These characteristics require a special handling of the older patient with cancer, by using the main tool used in Geriatrics, the comprehensive geriatric assessment. This article analyses the importance of the comprehensive geriatric assessment in this population group, paying special attention to its ability to predict the toxicity of chemotherapy and the survival of the elderly oncology, as well as its ability to classify these patients into groups that help in the decision making process.     

Impacto de la modalidad de terapia de reemplazo renal en adultos mayores frágiles

IntroductionEnd-stage renal disease prevalence is increasing in older adults. Frailty is highly prevalent in older adults with end-stage renal disease. However, there are no prospective studies comparing the performance of the different modalities of renal replacement therapy (RRT) in frail older adults.ObjectiveTo compare clinically relevant outcomes (hospital admission, falls, hip fractures, and mortality) in prefrail and frail older adults according to the modality of RRT: peritoneal dialysis or haemodialysis.MethodsA prospective observational study in prefrail and frail older adults (according to FRAIL scale) on peritoneal dialysis and haemodialysis was carried out. An evaluation was made using baseline characteristics (age, Charlson, body mass index, time on RRT, compliance with Kt/V dose, haemoglobin, and albumin). The patients were followed-up over 12 months, recording mortality, days and number of hospital admissions, falls, and hip fractures.ResultsA total of 54/65 (83%) older adults on RRT met criteria for prefrailty or frailty, and signed informed consent (27 in each modality). Baseline characteristics were similar, except for serum albumin and time on RRT, both of which were significantly lower in the peritoneal dialysis group. The FRAIL score was similar in both groups. Baseline FRAIL correlated with higher comorbidity, lower albumin levels, and non-compliance of Kt/V dose, while it was independent of age, body mass index, and time on RRT. Days and number of hospital admissions at 12 months were similar in patients on peritoneal dialysis and haemodialysis. Survival on peritoneal dialysis and haemodialysis was similar. There were no differences in falls or hip fractures.ConclusionsPre-frail and frail older adults on peritoneal dialysis and haemodialysis have similar clinical outcomes.     

Aspectos éticos del diagnóstico presintomático de la enfermedad de Alzheimer

Research into the human genome has undoubtedly opened up a new perspective in medicine. The ability to identify the cause of specific diseases, especially neurodegenerative diseases, will definitively change the concepts of disease and treatment, while advances such as antibiotic therapy and anesthesia will be relegated to history. However, the arrival of genome medicine poses major bioethical challenges, many of which remain to be resolved. We review the applicability, results and consequences of predictions based on genetic tests for presymptomatic Alzheimer's disease, as well as the dilemmas and contradictions that are already arising as a result of the commercialization of predictive tests for public use with little or no medical supervision. Given that there is currently no effective treatment of Alzheime?s disease, the greatest challenge and contradiction lies in managing the results of predictive tests. There are no indications for the performance of predictive genetic tests in late or sporadic Alzheimer's disease or for counselling of persons requesting these tests. The PICOGEN program provides a safe, effective, reliable and satisfactory option for persons requesting these tests who meet the inclusion criteria. Currently, caution should be the norm when considering the performance of predictive tests in presymptomatic dementia.