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array:24 [ "pii" => "S225488742030117X" "issn" => "22548874" "doi" => "10.1016/j.rceng.2020.07.006" "estado" => "S300" "fechaPublicacion" => "2020-11-01" "aid" => "1902" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2020" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2020;220:511-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0014256520302113" "issn" => "00142565" "doi" => "10.1016/j.rce.2020.07.007" "estado" => "S300" "fechaPublicacion" => "2020-11-01" "aid" => "1902" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2020;220:511-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ARTÍCULO ESPECIAL</span>" "titulo" => "La inflamación, la desnutrición y la infección por SARS-CoV-2: una combinación nefasta" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "511" "paginaFinal" => "517" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Inflammation, malnutrition, and SARS-CoV-2 infection: a disastrous combination" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1612 "Ancho" => 2508 "Tamanyo" => 459123 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Recomendaciones para el abordaje nutricional del paciente COVID-19 hospitalizado.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La exposición ha de ser segura minimizando el riesgo de contagio. Por ello, debemos ser prácticos, realizar una correcta historia clínica y utilizar material desechable. Los cinco puntos fundamentales serán:</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">1. Cribado nutricional, para el que se utilizará el test MNA-SF (por sencillez y porque no se necesita contacto con el paciente; otro test validado, pero en este caso no indicado porque se necesita contacto estrecho con el paciente para el cálculo del IMC, el NRS-2002) y un diámetro de pantorilla inferior a 31 cm. El cribado nutricional se realizará a ser posible en las primeras 48 horas tras el ingreso.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">2. Evaluación nutricional: historia clínica y considerar desnutrición un MNA con puntuación inferior a 12 puntos.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">3. Cálculo de necesidades, según el peso habitual del paciente y el peso ideal en caso de obesidad.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">4. Soporte nutricional: se priorizará la dieta oral, optimizándola siempre que sea posible. Si la ingesta no es adecuada se suplementará con dos SNO de alta densidad calórica y proteica, con proteínas de alta densidad biológica especialmente si hay sarcopenia o es un anciano con multimorbilidad.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Si alcanzar las necesidades diarias está severamente comprometido se procederá a una dieta enteral completa, evitando las sondas siempre que sea posible. Tras el alta hospitalaria se tendrá muy presente la continuidad asistencial, se reforzará la dieta oral manteniendo la suplementación hasta que el paciente alcance el 70% de sus necesidades.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">5. Tener en cuenta las condiciones clínicas más habituales de los pacientes ingresados que pueden condicionar su estado nutricional y el abordaje del mismo.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abreviaturas:</span> Ca2<span class="elsevierStyleSup">+</span>: calcio elemento; EPI: equipo de protección individual; HC: hidratos de carbono; HMB: B-hidroximetilbutirato; K: potasio; MNA-SF: <span class="elsevierStyleItalic">Mini Nutritional Assesment-Short Form</span>; Na: sodio; NE: nutrición enteral; P: fósforo; PCR: Proteína C Reactiva; SNG: sonda nasogástrica; Sat: saturadas; Vit D: vitamina D.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Carretero Gómez, M.C. Mafé Nogueroles, F. Garrachón Vallo, E. Escudero Álvarez, E. Maciá Botejara, J.P. Miramontes González" "autores" => array:7 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Carretero Gómez" ] 1 => array:2 [ "nombre" => "M.C." "apellidos" => "Mafé Nogueroles" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Garrachón Vallo" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Escudero Álvarez" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Maciá Botejara" ] 5 => array:2 [ "nombre" => "J.P." "apellidos" => "Miramontes González" ] 6 => array:1 [ "colaborador" => "en representación del grupo de Diabetes, Obesidad y Nutrición de la Sociedad Española de Medicina Interna (SEMI)" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S225488742030117X" "doi" => "10.1016/j.rceng.2020.07.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S225488742030117X?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256520302113?idApp=WRCEE" "url" => "/00142565/0000022000000008/v3_202011080645/S0014256520302113/v3_202011080645/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2254887419301286" "issn" => "22548874" "doi" => "10.1016/j.rceng.2019.02.015" "estado" => "S300" "fechaPublicacion" => "2020-11-01" "aid" => "1674" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Rev Clin Esp. 2020;220:518-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Medicine in Images</span>" "titulo" => "Multiple peritoneal splenosis mimicking mesenteric metastases in a woman with breast carcinoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "518" "paginaFinal" => "519" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Esplenosis peritoneal múltiple simulando una metástasis mesentérica en una mujer con carcinoma mamario" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1247 "Ancho" => 1255 "Tamanyo" => 173534 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Y. Gedikli, F. Guven, G. Ongen, H. Ogul" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Gedikli" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Guven" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Ongen" ] 3 => array:2 [ "nombre" => "H." "apellidos" => "Ogul" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256519301419" "doi" => "10.1016/j.rce.2019.02.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256519301419?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419301286?idApp=WRCEE" "url" => "/22548874/0000022000000008/v2_202102250825/S2254887419301286/v2_202102250825/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2254887420300709" "issn" => "22548874" "doi" => "10.1016/j.rceng.2020.05.004" "estado" => "S300" "fechaPublicacion" => "2020-11-01" "aid" => "1856" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2020;220:507-10" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Solving one of the pieces of the puzzle: COVID-19 and type 2 diabetes" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "507" "paginaFinal" => "510" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resolviendo una de las piezas del puzle: COVID-19 y diabetes tipo 2" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Pérez-Martínez, F.J. Carrasco Sánchez, J. Carretero Gómez, R. Gómez-Huelgas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Pérez-Martínez" ] 1 => array:2 [ "nombre" => "F.J." "apellidos" => "Carrasco Sánchez" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Carretero Gómez" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Gómez-Huelgas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256520301351" "doi" => "10.1016/j.rce.2020.05.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256520301351?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887420300709?idApp=WRCEE" "url" => "/22548874/0000022000000008/v2_202102250825/S2254887420300709/v2_202102250825/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special Article</span>" "titulo" => "Inflammation, malnutrition, and SARS-CoV-2 infection: A disastrous combination" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "511" "paginaFinal" => "517" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Carretero Gómez, M.C. Mafé Nogueroles, F. Garrachón Vallo, E Escudero Álvarez, E. Maciá Botejara, J.P. Miramontes González" "autores" => array:7 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Carretero Gómez" "email" => array:1 [ 0 => "juanicarretero@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.C." "apellidos" => "Mafé Nogueroles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Garrachón Vallo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "E" "apellidos" => "Escudero Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Maciá Botejara" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "J.P." "apellidos" => "Miramontes González" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 6 => array:1 [ "colaborador" => "on behalf of the Diabetes Obesity and Nutrition group of the Spanish Society of Internal Medicine (SEMI)" ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Comarcal de Zafra, Badajoz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital de Atención a Pacientes Crónicos y Larga Estancia La Pedrera, Denia, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Unidad de Medicina Perioperatoria, Equipo de Soporte Nutricional, Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de Badajoz, Badajoz, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Río Hortega, Valladolid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La inflamación, la desnutrición y la infección por SARS-CoV-2: una combinación nefasta" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1691 "Ancho" => 2123 "Tamanyo" => 257652 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Relationship between SARS-CoV-2 infection, inflammation, and onset of malnutrition.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The infection of a patient, who may have previous chronic diseases, gives rise to a “cytokine storm” which, due to various mechanisms, triggers the onset of malnutrition.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The World Health Organization declared the epidemic caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the disease it causes, COVID-19, a global public health emergency.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Since the first cases were identified in December 2019 to now, the entity has gone from being considered an infectious disease that is primarily respiratory to being thought of as a systemic disease that can severely compromise a patient's life.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Mild symptoms occur in 80% of cases, but 15% of patients experience severe disease and the remaining 5% develop a critical illness with acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome. Up to 20% of patients require a prolonged stay in the intensive care unit (ICU), with the functional sequelae this entails.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">SARS-CoV-2 infection is related to a high risk of developing malnutrition, mainly due to an increase in nutritional requirements and the presence of a severe, generalized inflammatory state. Other symptoms such as cough, dyspnea, diarrhea, and loss of taste or smell contribute to a state of hyporexia that perpetuates the negative nutritional balance. Furthermore, dysphagia worsens—especially after extubation—and makes intake unsafe.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although COVID-19 can affect and cause severe disease in people of all age groups, special attention must be paid to patients who are elderly, who have multimorbidity, or who were previously malnourished, for whom risk of ICU admission is greater.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Mortality due to COVID-19 in elderly patients is dramatic.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Their vulnerability is linked to the biological “wear-and-tear” inherent to age, the greater prevalence of comorbidities, and the fact that up to 50% of elderly patients who need hospitalization present with varying degrees of malnutrition.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We have learned from other viral pandemics, such as MERS-CoV or Influenza A (H1N1), that risk factors for infectious diseases depend on the host, the pathogen, and the environment.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> Various factors associated with severity and a worse prognosis in COVID-19 have been described. They include age, presence of chronic diseases such as type 2 diabetes mellitus (T2DM), hypertension (HT), obesity, and diseases of the immune system.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> If there is anything that connects all of these, it is inflammation, to a greater or lesser degree.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This exaggerated inflammatory response, called a “cytokine storm”, is the main trigger of a severe clinical presentation and death due to COVID-19.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The “cytokine storm” is characterized on the one hand by elevated levels of proinflammatory cytokines, especially interleukins (IL) 6 and 7, and tumor necrosis factor (TNF) alpha, and on the other hand by macrophage activation syndrome; monocyte infiltration in the lung, liver, kidney, or lymph nodes; and severe lymphopenia.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–18</span></a> Elevated cytokine levels are negatively correlated with T lymphocyte levels, especially CD8+, and these in turn are correlated with the severity of the infection. It has been postulated that this severe depletion of cellular immunity could be related to lymphocyte displacement towards the inflamed tissues, but not with a direct infection of T cells by the virus.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">As stated above, the risk factors for infectious diseases also depend on the environment. Society has been moving away from a Mediterranean lifestyle towards more Western ways of living, in which diets rich in saturated fats, carbohydrates, and refined sugars and poor in fiber, antioxidants, and polyunsaturated facts are predominant. These diets are proinflammatory, induce lipotoxicity, and increase oxidative stress, activating the innate immune system through macrophages and neutrophils and inhibiting the adaptive immune system, altering the production and maturation of C.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Lastly, without forgetting the other two actors—the pathogen and the environment—is the host. When speaking of malnutrition, we tend to refer to the condition related to starvation or inadequate intake, which is associated with an elevated morbidity and mortality. Malnutrition conditions disease and disease worsens malnutrition; thus it can correctly be referred to as a malnutrition-disease relationship.</p><p id="par0050" class="elsevierStylePara elsevierViewall">However, in the context discussed herein, another concept must be added to the equation: inflammation. Therefore, it is more appropriate to speak of disease-related malnutrition (DRM). DRM is defined as an alteration of body composition caused by a nutritional deficit (due to decrease in intake or an increase in losses or requirements) as a consequence of an acute or chronic disease which suppresses vital functions and negatively affects clinical progress. DRM increases morbidity and mortality and worsens the prognosis, costs, and quality of life of patients.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In 2010, the European and American nutrition societies, ESPEN and ASPEN, published a consensus document defining DRM and starvation, highlighting the importance of the role of systemic inflammatory response, present to varying degrees in both acute and chronic illnesses, in the development of DRM.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In 2019, <span class="elsevierStyleItalic">The Global Leadership Initiative on Malnutrition</span> (GLIM) released a consensus document for the diagnosis of DRM. It was based on phenotypic criteria (involuntary weight loss, low body mass index, or loss of muscle mass) to which, as a novelty, an etiological criterion was added, among which disease-associated inflammation was again included.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The role of inflammation in both the pathophysiology of DRM and in a severe clinical presentation in COVID-19 appears obvious. The aggression, in our case SARS-CoV-2 infection, gives rise to an inflammatory response. This response is initially beneficial if well controlled, but in severe cases leads to the aforementioned “cytokine storm”, with severe metabolic consequences. With the increase in energy output, muscle amino acids are released that are used for gluconeogenesis and protein synthesis, which are highly necessary for the immune response and tissue repair.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In parallel, hormonal changes contribute to modifying the metabolic response. Hyperinsulinemia increases the production of ketone bodies and their use as a substrate in the brain. Eventually, this situation of hyperinsulinemia and insulin resistance worsens hyperglycemia, a factor known to increase morbidity and mortality,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> along with secondary hypertriglyceridemia, lipolysis, and fatty acid oxidation.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The heart can lose up to 30% of its usual weight due to a decrease in myofibroblasts, necrosis, or inflammatory infiltrates. In the lungs, the number of alveolar macrophages and levels of pulmonary surfactant decrease, making the individual more prone to attack. Modifications occur in the synthesis and secretion of growth hormone, insulin, glucagon, and gonadotropins.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The detrimental consequences the onset of DRM has on the clinical course of COVID-19 seem obvious. On the one hand, they are due to the onset of a defective, insufficient immune response. On the other, they are due to the onset of sarcopenia secondary to physical deconditioning that produces loss of muscle mass and functional capacity, perpetuating the cycle and slowing the patient’s recovery.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Identifying malnutrition risk and beginning appropriate, early nutritional support from the moment of first contact with a patient are fundamental pillars for improving the prognosis of COVID-19 patients.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28,29</span></a> But how can we do this? We must adapt the universal algorithm for nutritional management to these clinical and epidemiological conditions.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The need for rigorous personal protection due to the high risk of transmission limits contact with the patient; the use of instrumentation for the evaluation of the patient’s nutritional state, dysphagia, or sarcopenia; and treatment. It is recommended to limit the time and frequency of contact and to avoid using reusable materials and procedures which could generate aerosols. Nevertheless, there is one tool within our reach that is easy to use and low-cost: the medical record, which our treatment plan should be based on and which allows us to determine a patient's needs, even with limited resources.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Adequate nutritional support must form part of the comprehensive treatment plan during the entire disease process. This nutritional plan must be re-evaluated and changed according to the calculation of a patient’s needs (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), the presence of dysphagia (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), and sarcopenia (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). An appropriate nutritional state reduces complications, the length of the ICU and hospital stay, and sequelae.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The COVID-19 pandemic will leave us with a large number of recuperated patients with the same prior chronic conditions in addition to the sequelae of the infection. All will be susceptible to worsening if we do not focus on optimizing the patient's nutritional state during his or her hospitalization and upon discharge (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0100" class="elsevierStylePara elsevierViewall">Therefore, it is recommendable to take into account the role of chronic metabolic pathologies and the eating pattern in the susceptibility to and recovery from SARS-CoV-2 infection.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Lastly, we cannot forget the third piece of the puzzle, physical exercise, always adapted to the patient’s functional condition.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they received no external funding for the creation of this manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The content and recommendations of this document have been created based on the opinions of its authors with no interference from the sponsoring institution, the Spanish Society of Internal Medicine (SEMI). Said entity did not participate in any of the phases of design, decision-making, or creation of the material.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1471345" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1340009" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1471344" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1340010" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 6 => array:2 [ "identificador" => "xack515550" "titulo" => "Acknowledgments" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-24" "fechaAceptado" => "2020-07-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1340009" "palabras" => array:4 [ 0 => "Disease related malnutrition" 1 => "Inflammation" 2 => "Cytokine storm" 3 => "SARS-CoV-2" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1340010" "palabras" => array:4 [ 0 => "Desnutrición relacionada con la enfermedad" 1 => "Inflamación" 2 => "Tormenta de citoquinas" 3 => "SARS-CoV-2" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">SARS-CoV-2 infection is associated with a high risk of malnutrition, mainly due to increased nutritional requirements and the presence of a severe and universal inflammatory state. Associated symptoms contribute to hyporexia, which perpetuates the negative nutritional balance. Furthermore, dysphagia, especially post-intubation, worsens, and makes intake unsafe. This risk is greater in elderly and multimorbid patients. Inflammation to varying degrees is the common link between COVID-19 and the onset of malnutrition, and it is more correct to refer to disease-related malnutrition (DRM). DRM worsens the poor prognosis of SARS-CoV-2 infection, especially in the most severe cases. Therefore, it is necessary to identify and treat people at risk early, avoiding overexposure and direct contact with the patient. We cannot forget the role that a healthy diet plays in both prevention and recovery after discharge.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">La infección por SARS-CoV-2 se relaciona con un riesgo alto de malnutrición, principalmente por el aumento de los requerimientos nutricionales y la presencia de un estado inflamatorio severo y universal. Los síntomas asociados contribuyen a la hiporexia, que perpetua el balance nutricional negativo. Además, la disfagia, especialmente posintubación, empeora y hace poco segura la ingesta. Este riesgo es mayor en pacientes ancianos y multimórbidos. La inflamación en distinto grado es el nexo común entre la COVID-19 y la aparición de desnutrición, siendo más correcto hablar de desnutrición relacionada con la enfermedad (DRE). La DRE empeora el mal pronóstico de la infección por SARS-CoV-2, sobre todo, en los casos más severos. Por ello es necesario identificar y tratar precozmente a las personas en riesgo evitando la sobreexposición y el contacto directo con el paciente. No podemos olvidarnos del papel que juega la dieta saludable tanto en la prevención como en la recuperación tras el alta.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Carretero Gómez J, Mafé Nogueroles MC, Garrachón Vallo F, Escudero Álvarez E, Maciá Botejara E, Miramontes González JP. La inflamación, la desnutrición y la infección por SARS-CoV-2: una combinación nefasta. Rev Clin Esp. 2020;220:511–517.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1691 "Ancho" => 2123 "Tamanyo" => 257652 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Relationship between SARS-CoV-2 infection, inflammation, and onset of malnutrition.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The infection of a patient, who may have previous chronic diseases, gives rise to a “cytokine storm” which, due to various mechanisms, triggers the onset of malnutrition.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1605 "Ancho" => 2500 "Tamanyo" => 430342 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the nutritional approach to hospitalized COVID-19 patients.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Exposure must be safe, minimizing the risk of contagion. Therefore, we must be practical, take a proper medical history, and use disposable materials. The five fundamental points are:</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">1. Nutritional screening, for which the MNA-SF test (due to its simplicity and because patient contact is not necessary. Another test that is validated but not recommended because it entails close contact with the patient for calculating the BMI is the NRS-2002) and a calf diameter (cutoff point of 31<span class="elsevierStyleHsp" style=""></span>cm) will be used. If possible, the nutritional screening will be performed in the first 48<span class="elsevierStyleHsp" style=""></span>hours following admission.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">2. Nutritional evaluation: medical history and a determination of malnutrition with an MNA-SF test score of less than 12 points.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">3. Calculation of needs according to the patient’s habitual weight and ideal weight in the case of obesity.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">4. Nutritional support: oral intake will be prioritized, optimizing it when possible. If intake is not adequate, it will be supplemented with two oral nutrition supplements that are high in calorie and protein density, especially if there is sarcopenia or if the patient is elderly with multimorbidity.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">If reaching daily needs is severely endangered, total enteral nutrition will be used, avoiding tubes so long as it is possible. Continuity of care will be taken closely into account after discharge from the hospital. Oral intake will be reinforced by maintaining supplementation until the patient reaches 70% of his or her needs.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">5. Take into account the most common clinical conditions of hospitalized patients, which may affect their nutritional state and the approach to it.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations:</span> Ca2<span class="elsevierStyleSup">+</span>: elemental calcium; PPE: personal protective equipment; CH: carbohydrates; HMB: β-hydroxy β-methylbutyrate; K: potassium; MNA-SF: <span class="elsevierStyleItalic">Mini Nutritional Assessment-Short Form</span>; Na: sodium; EN: enteral nutrition; P: phosphorus; PCR: Polymerase chain reaction; NGT: nasogastric tube; Sat: saturated; Vit D: vitamin D.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1780 "Ancho" => 2501 "Tamanyo" => 237821 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the approach to dysphagia in hospitalized and post-ICU COVID-19 patients.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">In the approach to dysphagia, it is necessary to distinguish between diagnosis and treatment. The diagnosis will be made based on the clinical record and on the EAT-10 screening tool. The screening will be carried out at first contact with the patient, although given that direct contact is not recommended in these cases, using the MECV-V test in select patients can be considered. Treatment will be individualized and safe in order to avoid the generation of aerosols and to promote patient autonomy.</p> <p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Proper oral hygiene must not be forgotten. We recommend prioritizing an oral diet adapted in composition and texture. In the event supplements are needed, they will be provided through specific supplements with adapted textures. If intake is not sufficient, the use of feeding tubes can be proposed, with a postpyloric approach in these cases. Parenteral nutrition will be reserved for severe cases or those in which it is impossible to use a gastric tube.</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations:</span> EAT-10: <span class="elsevierStyleItalic">Eating Assessment Tool</span>; MECV: Volume-Viscosity Clinical Exploration Method; NP: parenteral nutrition; O<span class="elsevierStyleInf">2</span>: oxygen; ONS: oral nutritional supplementation; NGT: nasogastric tube; ICU: intensive care unit.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1449 "Ancho" => 2500 "Tamanyo" => 316930 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the approach to sarcopenia in hospitalized and post-ICU COVID-19 patients.</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The diagnosis of sarcopenia will be based on the medical record. First, the common symptoms: fatigue and prolonged repose due to asthenia, hypoxia, or sedation which, along with systemic inflammatory symptoms, hypercatabolism, and significant weight loss, entail physical deconditioning.</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">In order to diagnose sarcopenia—and following the maxim of avoiding contact with the patient and/or use of non-disposable material as much as possible—the MNA-SF score and calf diameter (cutoff point of 31<span class="elsevierStyleHsp" style=""></span>cm, which correlates well with lean mass and muscle strength) will be prioritized, as indicated in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Bioimpedance is not available in the majority of internal medicine departments. If it is available, it can be used, given that it is a simple technique that uses a portable, easy-to-clean device. Avoid techniques that entail a high risk of transmission, such as a DEXA scan, for example.</p> <p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Treatment is based on two pillars: oral diet and early mobilization of the patient. First, the oral diet has to be adapted and have a high content of high biological value protein and energy density. If nutritional supplements are needed, those enriched with high biological value protein, HMB, and leucine will be prioritized, as they regulate protein turnover. Second, early mobilization of the patient: it will be active or passive, if incapacity is severe, and adapted to each patient’s functional condition.</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations:</span> HMB: β-hydroxy β-methylbutyrate; MNA-SF: <span class="elsevierStyleItalic">Mini Nutritional Assessment-Short Form</span>; Prot: protein; ICU: intensive care unit; Vit. 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