[Vitamin deficiencies in the adult outpatient setting]. / Carences vitaminiques chez l'adulte en médecine ambulatoire.

Since their discovery more than a century ago to this day, vitamins went from misunderstood molecules with mysterious properties to fundamental components with undoubted clinical implications. Despite the scientific progresses in the understanding of their physiopathological role, vitamins raise to this day multiple interrogations in clinical practice. This article aims at answering questions that are frequently encountered in the outpatient setting regarding vitamin deficiencies: who to screen ? At what moment ? By which test ? How to interpret the results ? How to supplement ? By answering these questions, we hope to provide the general practitioners with a pragmatic tool to guide them in the management of issues related to vitamins.

Depuis leur découverte il y a plus d'un siècle à aujourd'hui, les vitamines sont passées de molécules méconnues et aux propriétés mystérieuses à des composants primordiaux et aux implications cliniques certaines. Malgré les progrès scientifiques dans la compréhension de leur rôle physiopathologique, les vitamines suscitent encore de nombreuses interrogations en pratique clinique. Cet article s'efforce de répondre aux questions fréquem ment rencontrées en médecine ambulatoire portant sur les carences vitaminiques: qui dépister ? À quel moment ? Par quel test ? Comment interpréter les résultats ? Comment supplémenter ? En répondant à ces questions, nous espérons fournir au médecin de premier recours un outil pragmatique pour l'orienter dans la prise en charge des problématiques vitaminiques.

Severe megaloblastic anemia: Vitamin deficiency and other causes.

Megaloblastic anemia causes macrocytic anemia from ineffective red blood cell production and intramedullary hemolysis. The most common causes are folate (vitamin B9) deficiency and cobalamin (vitamin B12) deficiency. Megaloblastic anemia can be diagnosed based on characteristic morphologic and laboratory findings. However, other benign and neoplastic diseases need to be considered, particularly in severe cases. Therapy involves treating the underlying cause-eg, with vitamin supplementation in cases of deficiency, or with discontinuation of a suspected medication.

Nutritional neuropathies.

Neuropathies associated with nutritional deficiencies are routinely encountered by the practicing neurologist. Although these neuropathies assume different patterns, most are length-dependent, sensory axonopathies. Cobalamin deficiency neuropathy is the exception, often presenting with a non-length-dependent sensory neuropathy. Patients with cobalamin and copper deficiency neuropathy characteristically have concomitant myelopathy, whereas vitamin E deficiency is uniquely associated with a spinocerebellar syndrome. In contrast to those nutrients for which deficiencies produce neuropathies, pyridoxine toxicity results in a non-length-dependent sensory neuronopathy. Deficiencies occur in the context of malnutrition, malabsorption, increased nutrient loss (such as with dialysis), autoimmune conditions such as pernicious anemia, and with certain drugs that inhibit nutrient absorption. When promptly identified, therapeutic nutrient supplementation may result in stabilization or improvement of these neuropathies.

Vitamin D supplementation and incident preeclampsia: A systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Maternal vitamin D deficiency has been associated with an increased risk for preeclampsia. Despite this, the current evidence regarding the efficacy of vitamin D supplementation in preventing preeclampsia is controversial. To assess the impact of vitamin D supplementation on the risk of preeclampsia, we performed a systematic review of the literature and a meta-analysis of the available randomized clinical trials (RCTs). METHODS: The primary outcome was preeclampsia. Subgroup analyses were carried out considering the timing of the supplementation, type of intervention and the study design. Meta-regression analysis, including the amount of vitamin D and maternal age, were planned to explore heterogeneity (PROSPERO database registration number: CRD42019119207). RESULTS: Data were pooled from 27 RCTs comprising 59 arms, which included overall 4777 participants, of whom 2487 were in the vitamin D-treated arm and 2290 in the control arm. Vitamin D administration in pregnancy was associated with a reduced risk of preeclampsia (odd ratio [OR] 0.37, 95% confidence interval [CI]: 0.26, 0.52; I2 = 0%). If the vitamin D supplementation was started up to 20 weeks' gestation, the odds was a little lower (OR 0.35, 95% CI: 0.24, 0.50, p < 0.001). The effect was largely independent of the supplementation cessation (until delivery or not), type of intervention (vitamin D alone or in association with calcium), and study design. Increasing dose of vitamin D was associated with reduced incidence of preeclampsia (slope of log OR: -1.1, 95% CI: -1.73, -0.46; p < 0.001). CONCLUSIONS: Results suggest that vitamin D supplementation may be useful in preventing preeclampsia. These data are especially useful for health-care providers who engage in the management of pregnant women at risk for preeclampsia. Our findings are a call for action to definitively address vitamin D supplementation as a possible intervention strategy in preventing preeclampsia in pregnancy.

Neurology of Nutritional Deficiencies.

PURPOSE OF REVIEW: The goal of this chapter is to educate clinicians on the neurologic manifestations of certain nutritional deficiencies in order to promptly identify and appropriately treat these patients. RECENT FINDINGS: Many vitamin and nutritional deficiencies have been described dating back to the early days of neurology and medicine. Some are very rare and thus, there are no randomized controlled studies to assess supplementation or dosage; however, there are reviews of case reports that can assist clinicians in choosing treatments. While endemic vitamin and nutritional deficiencies may be rarely encountered in many countries, vulnerable populations continue to be at risk for developing neurologic complications. These populations include those with diseases causing malabsorption, the elderly, chronic alcohol users, as well as pregnant mothers with hyperemesis gravidarum to name a few. It is important to recognize syndromes associated with these nutritional deficiencies, as prompt identification and treatment may prevent permanent neurologic damage.

Vitamin Excess and Deficiency.

The published literature supports the high prevalence of supplement use in children and adolescents in the United States. Pediatricians today are faced with questions from parents and patients about the benefits, safety, efficacy, and correct dose of vitamins and minerals. In this article, we review 7 vitamins with the most clinical relevance as judged by abundance in food, risks and symptoms of deficiency, and potential for toxicity. Specifically, we focus on possible clinical scenarios that can be indicative of nutritional deficiency. We synthesize and summarize guidelines from nutrition experts, various medical societies, the World Health Organization, and the American Academy of Pediatrics.

Evaluation of Serum Trace Element and Vitamin Levels in Children With Cancer in the First 6 Months After Diagnosis.

Adequate nutrient intake should be provided for the cure of children diagnosed with cancer. The aim of this study was to evaluate serum trace elements and vitamins of children with cancer at diagnosis and during treatment. Children with newly diagnosed cancer who were admitted to our center were evaluated for serum selenium, iron, ferritin, C-reactive protein, vitamin B12, folate, and 25-OH vitamin D levels at presentation, and at the third and sixth months of cancer treatment. Forty-two children (male/female: 15/27) with a median age of 8 years (range, 2 to 17) were included in the study. Mean serum B12, folate, and iron levels were within normal ranges, but selenium and 25-OH vitamin D were low at presentation and during the 6-month period. Serum ferritin levels were high in all 3 measures, but they decreased significantly at the sixth month (P=0.04). There was no relation between micronutrient deficiency and sex, or primary disease, or stage, or place of residence of the patient. In conclusion, serum trace element and vitamin deficiencies are common in children with cancer, and there is a need for further studies with larger patient series.

Controversias sobre el rastreo de los niveles séricos de vitamina D y su suplementación / Controversies about serum vitamin D levels screening and its supplementation

Si bien los niveles bajos de vitamina D se han asociado con varios resultados de interés en salud, aún resulta motivo de controversia qué significa un nivel bajo, cual es la utilidad de su suplementación y cuales son sus potenciales efectos adversos. En ese contexto, se realizó en el Servicio de Medicina Familiar y Comunitaria del Hospital Italiano un taller de discusión denominado "Actividad ECCO" (Evidencia Científica en la Clínica Cotidiana) en la que fueron presentados los resulta-dos de estudios identificados que hubieran comparado el uso de vitamina D (con o sin suplementación de calcio) ver-sus placebo, con el objetivo de discutir cuál es la evidencia actual para el rastreo de deficiencia de vitamina D y para, eventualmente, recomendar o no su suplementación. Este artículo resume la evidencia identificada y las conclusiones consensuadas en dicha actividad. (AU)

Although low levels of vitamin D have been associated with several health outcomes, it is controversial what a low level means, the usefulness of its supplementation and its potential adverse effects. In this context, a workshop called "ECCO Activity" (Scientific Evidence in the Daily Clinic) was held in the Family and Community Medicine Division of Hospital Italiano de Buenos Aires, where the results of identified studies that compared the use of vitamin D (with or without calcium supplementation) versus placebo, with the aim of discussing what is the current evidence for screening of vitamin D deficiency and to, eventually, recommend or not its supplementation. This article summarizes the identified evidence and the agreed conclusions in that activity. (AU)

Vitamin Status among Breastfed Infants in Bhaktapur, Nepal.

Vitamin deficiencies are known to be common among infants residing in low- and middle-income countries but relatively few studies have assessed several biochemical parameters simultaneously. The objective of the study was to describe the status of vitamins (A, D, E, B6, B12 and folate) in breastfed infants. We measured the plasma concentrations of trans retinol, 25 hydroxy vitamin D, α-tocopherol, pyridoxal 5'-phosphate, cobalamin, folate, methylmalonic acid, homocysteine, hemoglobin and C-reactive protein from 467 randomly selected infants. One in five (22%) was deficient in at least one vitamin. Mean (SD) plasma folate concentration was 73 (35) nmol/L, and no infant in the sample was folate deficient. Vitamin B6 deficiency and vitamin B12 deficiency was found in 22% and 17% of the infants, respectively. Elevated plasma methylmalonic acid or total homocysteine concentration was found in 82% and 62% of infants, respectively. Fifteen percent of infants were vitamin A deficient and 65% were marginally deficient in vitamin A. Fewer than 5% of infants had low plasma vitamin D concentration or vitamin E concentration (α-tocopherol <9.3 µmol/L). Our results illustrate the importance of continued supplementation campaigns and support the expansion of food fortification and dietary diversification programs that target children and women in Nepal.

[Vitamins and nutritional supplements in older persons: How to diagnose and when to substitute?]. / Vitamine und Nahrungsergänzung bei älteren Menschen : Welche Diagnostik und Substitution ist sinnvoll?

Despite an excellent food supply in Germany, a large percentage of older persons living at home or institutionalized older persons suffer from or are at risk for malnutrition. The purpose of this article is to highlight the association between nutrient deficiencies and age-related diseases and give rational recommendations for substitution. Both malnutrition and low levels of specific nutrients are associated with cognitive and functional impairment, dementia, and depression in older persons. Most prevalent are deficiencies in vitamin B1, vitamin B12, and vitamin D. Serum levels are often misleading and show false negative results in vitamin B1 and B12 deficiencies; therefore, determination of erythrocyte transketolase activity (ETKA) and the thiamine pyrophosphate (TPP) effect for vitamin B1 and of methylmalonic acid and holotranscobalamine for vitamin B12 is recommended. Prophylactic supplementation with vitamins is not supported by prospective trials; however, positive data from observational studies support a Mediterranean diet combined with intake of vitamins, antioxidants, and unsaturated fatty acids. Older persons should be regularly screened for malnutrition and the threshold for determination of vitamin B1, B12, and vitamin D should be low. Vitamin substitution should be reserved for proven deficits. There is now data regarding cognition from prospective trials on effects of a healthy diet combined with other life-style factors like physical and cognitive activity.

Multiple vitamin deficiencies in a patient with a history of chronic alcohol excess and self-neglect in the UK.

We report a case of inadequate diet (caused by extreme self-neglect and alcohol excess) which led to chronic severe deficiencies of vitamins A, D and E. At presentation the patient had widespread follicular hyperkeratosis of the skin, keratomalacia of both eyes and a severe cognitive impairment. He responded well to treatment including high dose parenteral vitamins, but lasting impairments in his vision and cognition have caused permanent disability.

The role of vitamin supplementation in the prevention of cardiovascular disease events.

The production, sale, and consumption of multiple vitamins is a multibillion-dollar industry. Most Americans take some form of supplement ostensibly for prevention of cardiovascular disease. It has been claimed that vitamin A retards atherogenesis. Vitamin C is an antioxidant and is thought to possibly decrease free radical-induced endothelial injury, which can lead to atherosclerotic plaque formation. Vitamin E has been extensively studied for its possible effects on platelet function as well as inhibition of foam-cell formation. Low levels of vitamin D have been thought to negatively impact myocardial structure and increase the risk for cardiovascular events. Increased intake of vitamin B6, B12, and folate has been associated with reduction of homocysteine levels; elevated homocysteine blood levels have been associated with the occurrence of stroke, heart attack, and cardiovascular death. The purpose of this study was to review the currently available literature for vitamin supplementation with respect to prevention of cardiovascular disease. Unfortunately, the current evidence suggests no benefit exists with vitamin supplementation in the general US population. Further research is needed to evaluate whether there are specific populations that might benefit from vitamin supplementation.

Fat-soluble vitamin deficiency in children and adolescents with cystic fibrosis.

AIMS: Determine the prevalence of fat-soluble vitamin deficiency in children with cystic fibrosis (CF) aged ≤18 years in New South Wales (NSW), Australia, from 2007 to 2010. METHODS: A retrospective analysis of fat-soluble vitamin levels in children aged ≤18 years who lived in NSW and attended any of the three paediatric CF centres from 2007 to 2010. An audit of demographic and clinical data during the first vitamin level measurement of the study period was performed. RESULTS: Deficiency of one or more fat-soluble vitamins was present in 240/530 children (45%) on their first vitamin level test in the study period. The prevalence of vitamins D and E deficiency fell from 22.11% in 2007 to 15.54% in 2010, and 20.22% to 13.89%, respectively. The prevalence of vitamin A deficiency increased from 11.17% to 13.13%. Low vitamin K was present in 29% in 2007, and prevalence of prolonged prothrombin time increased from 19.21% to 22.62%. Fat-soluble vitamin deficiency is present in 10%-35% of children with pancreatic insufficiency, but only a very small proportion of children who are pancreatic-sufficient. CONCLUSIONS: This is one of few studies of fat-soluble vitamin deficiency in children with CF in Australia. Fat-soluble vitamin testing is essential to identify deficiency in pancreatic-insufficient children who may be non-compliant to supplementation or require a higher supplement dose, and pancreatic-sufficient children who may be progressing to insufficiency. Testing of vitamin K-dependent factors needs consideration. Further studies are needed to monitor rates of vitamin deficiency in the CF community.

[What is a vitamin?]. / Qu'est-ce qu'une vitamine?

In industrialized countries, the major vitamin deficiency syndromes have virtually disappeared. Today they are superseded by marginal deficits, characterized by insufficient vitamins reserves to maintain normal physiologic state. These states strike populations such as infants, pregnant women, alcoholics and the elderly, and may have long-term adverse effects on health. This assumption stems from the analysis of studies that show an increase in the incidence of various diseases such as cancers and cardiovascular, ocular and osteoarticular pathologies in subjects with low vitamin status. Although causal relationships are difficult to establish, a huge scope for public health appears to be open for vitamins, substituting the notion of minimal intake, indispensable to prevent signs of deficiency, to that ensuring optimal health in the medium and long-terms. However, the paradoxical character of the results obtained in several randomized trials should prompt caution in the use of vitamin supplements to prevent chronic diseases.

Tetania neonatal por hipocalcemia secundaria a hipovitaminosis D. Forma extrema de una enfermedad que resurge / Neonatal hypocalcemic tetany due to vitamin D deficiency. Extreme form of a re-emerging disease

Desde el inicio de la era industrial, el raquitismo ha sido una enfermedad endémica. Con el descubrimiento de la vitamina D y el aporte de suplementos, sobre todo en las fórmulas lácteas infantiles, prácticamente había desaparecido, pero durante los últimos años parece haberse convertido de nuevo en un problema de salud pública. La carencia de vitamina D se asocia no sólo a problemas óseos, sino también a un importante incremento del riesgo de enfermedades cardiovasculares, autoinmunes, infecciosas y tumorales. Comunicamos un caso de tetania neonatal por hipocalcemia secundaria a hipovitaminosis D en un neonato de menos de 2 días de vida. La precocidad de la aparición y la gravedad clínica son excepcionales. Además, advierte del problema emergente que constituye el déficit de vitamina D y de la necesidad de instaurar la suplementación con ésta vitamina, siguiendo las últimas recomendaciones de la Asociación Española de Pediatría (AU)

Since industrial revolution, rickets has been an endemic disease. Since the discovery of vitamin D and its supplements, above all in milk formulates, practically it was disappear, but in the last few years it seems to be again a public health problem. Vitamin D deficiency contributes, not only to bone problems, but also to an important increase in the risk of cardiovascular, autoimmune, infectious diseases and cancer. We communicate a case of neonatal hypocalcemic tetany secondary to a vitamin D deficiency that appeared in a neonate before the second day of life. The precocity of its appearance and its clinical severity are exceptional. It also warn of the emergent problem that it suppose the vitamin D deficiency and the necessity of set up the supplementation with this vitamin, following the last recommendations of the Spanish Paediatrics Association (AU)

The influence of deficiencies of essential trace elements and vitamins on the course of Crohn's disease.

In patients with Crohn's Disease (CD), malnutrition is frequently observed and is an important complication, frequently associated with nutritional deficiencies, especially vitamins (both water- and fat-soluble) and essential trace elements. It is often a result of the disease activity, poor oral intake and/or restrictive diets. Nutrition plays an important role in disease management and helps to maintain remission in CD patients. Deficiencies occur in patients with active Crohn's disease, and also in those in remission. Specific supplementation of vitamins and micro- and macronutrients might be helpful or even necessary in this group of patients. This review outlines the most frequent nutritional deficiencies and their complications in relation to the Crohn's Disease Activity Index, and provides an overview of therapeutic perspectives for CD patients in adult patients with inflammatory bowel disease (IBD). Biological therapy, which is being used with increasing frequency, seems not only to mitigate the inflammatory process in the gastrointestinal tract, but also has significant impact on the nutritional status of patients with Crohn's disease.

Vitamins.

• Based on strong research evidence, all infants should receive 400 IU/day of vitamin D beginning in the first few days of age to prevent vitamin D deficiency and rickets. • Based on strong research evidence, children and adolescents age >1 year may require as much as 600IU/day of vitamin D. • Based on strong research evidence, all newborns should receive 1 mg of vitamin K at birth to prevent vitamin K deficiency bleeding. • Based on strong research evidence, preconceptional and pregnant women should be supplemented with folate to decrease the likelihood of neural tube defects.

Invasive pneumonia and septic shock in infants as a presentation of cystic fibrosis with vitamin-deficiency.

Herein we describe three infants with the rare presentation of pneumonia with septic shock as their initial medical encounter leading to the diagnosis of cystic fibrosis (CF). At the time of their presentation all three children had significant nutritional deficiency. We initiated an aggressive treatment regimen including nutritional supplementation which resulted in improvement in their pulmonary status and no further recurrences. This series highlights the possible presentation of CF in infancy as a life-threatening invasive infection of Staphylococcus aureus or Pseudomonas aeruginosa. It also supports neonatal screening and emphasizes the role of early attention to nutritional status and vitamin supplementation.