Abnormal FDG Uptake on PET/CT Due to Periosteal Reaction Caused by Hypervitaminosis D in a Pediatric Patient.

A 7-year-old boy presented with diffuse bone pain. FDG PET/CT was performed to find the possible underlying malignant cause of hypercalcemia. The images demonstrated multiple foci of abnormal FDG activity at the sites of periosteal reaction. In addition, calcium deposit was noted in the basal ganglia, stomach, and the colon. History taking revealed that the patient had routinely taken an over-the-counter "supplement" that contains a high dose of vitamin D. One week after calcitonin therapy and stopping the supplement, the patient became symptom free. This case suggests that hypervitaminosis D might cause hypermetabolic periosteal reaction on FDG PET/CT imaging.

Nutritional management in renal transplant recipients: A transplant team opportunity to improve graft survival.

AIMS: The nutritional management of renal transplant recipients (RTR) represents a complex problem either because the recovery of renal function is not complete and for the appearance of "unavoidable" metabolic side effects of immunosuppressive drugs. Nevertheless, it remains a neglected problem, whereas an appropriate dietary intervention could favorably affect graft survival. DATA SYNTHESIS: Renal transplantation is associated with steroids and calcineurin inhibitors administration, liberalization of diet after dialysis restrictions, and patients' better quality of life. These factors predispose, from the first months after surgery, to body weight gain, enhanced post transplant diabetes, hyperlipidemia, metabolic syndrome, with negative consequences on graft outcome. Unfortunately, specific guidelines about this topic and nutritional counseling are scarce; moreover, beyond the low adherence of patients to any dietary plan, there is a dangerous underestimation of the problem by physicians, sometimes with inadequate interventions. A prompt and specific nutritional management of RTR can help prevent or minimize these metabolic alterations, mostly when associated with careful and repeated counseling. CONCLUSIONS: A correct nutritional management, possibly tailored to enhance patients' motivation and adherence, represents the best preventive maneuver to increase patients' life and probably improve graft survival, at no cost and with no side effects.

Considerations for Secondary Prevention of Nutritional Deficiencies in High-Risk Groups in High-Income Countries.

Surveys in high-income countries show that inadequacies and deficiencies can be common for some nutrients, particularly in vulnerable subgroups of the population. Inadequate intakes, high requirements for rapid growth and development, or age- or disease-related impairments in nutrient intake, digestion, absorption, or increased nutrient losses can lead to micronutrient deficiencies. The consequent subclinical conditions are difficult to recognize if not screened for and often go unnoticed. Nutrient deficiencies can be persistent despite primary nutrition interventions that are aimed at improving dietary intakes. Secondary prevention that targets groups at high risk of inadequacy or deficiency, such as in the primary care setting, can be a useful complementary approach to address persistent nutritional gaps. However, this strategy is often underestimated and overlooked as potentially cost-effective means to prevent future health care costs and to improve the health and quality of life of individuals. In this paper, the authors discuss key appraisal criteria to consider when evaluating the benefits and disadvantages of a secondary prevention of nutrient deficiencies through screening.

Can adverse effects of excessive vitamin D supplementation occur without developing hypervitaminosis D?

Vitamin D is a fat-soluble hormone that has endocrine, paracrine and autocrine functions. Consumption of vitamin D-supplemented food & drugs have increased significantly in the last couple of decades due to campaign and awareness programs. Despite such wide use of artificial vitamin D supplements, serum level of 25 hydroxyvitamin D does not always reflect the amount of uptake. In contrast to the safe sunlight exposure, prolonged and disproportionate consumption of vitamin D supplements may lead to vitamin D intoxication, even without developing hypervitaminosis D. One of the reasons why vitamin D supplementation is believed to be safe is, it rarely raises serum vitamin D levels to the toxic range even after repeated intravenous ingestion of extremely high doses of synthetic vitamin D analogs. However, prolonged consumption of vitamin D supplementation may induce hypercalcemia, hypercalciuria and hyperphosphatemia, which are considered to be the initial signs of vitamin D intoxication. It is likely that calcium and phosphorus dysregulation, induced by exogenous vitamin D supplementation, may lead to tissue and organ damages, even without developing hypervitaminosis D. It is needed to be emphasized that, because of tight homeostatic control of calcium and phosphorus, when hypercalcemia and/or hyperphosphatemia is apparent following vitamin D supplementation, the process of tissue and/or organ damage might already have been started.

Nutrition Support Therapy.

In most addictions, serious nutritional deficiencies of major proteins, fats, vitamins and minerals exist which prevent their capability to digest carbohydrates efficiently. This review aims to point out some treatment approaches in nutrition management for alcohol addiction, drug addiction, food addiction, Internet addiction and sex addiction, according to existing literatures.

Nutritional Deficiencies and Sarcopenia in Heart Failure: A Therapeutic Opportunity to Reduce Hospitalization and Death.

There is an expanding prevalence pool of heart failure (HF) due to the increasing prevalence of survivors of myocardial infarction, diabetes, hypertension, chronic kidney disease, and obesity. There is increasing interest in the role of nutrition in all forms of HF, given observations concerning micro- and macronutrient deficiencies, loss of lean body mass or sarcopenia, and their relationships with hospitalization and death. This review examines the relationships among loss of lean body mass, macro- and micronutrient intake, and the natural history of HF, particularly in the elderly, in whom the risks for all-cause rehospitalization, infection, falls, and mortality are increased. These risks are potentially modifiable through strategies that improve nutrition in this vulnerable population.

Hypervitaminosis D and Metastatic Calcification in a Colony of Inbred Strain 13 Guinea Pigs, Cavia porcellus.

A commercial diet fed to a colony of inbred strain 13 guinea pigs for approximately 6 weeks was subsequently recalled for excessive levels of vitamin D. Twenty-one of 62 animals exhibited clinical signs, including anorexia, lethargy, and poor body condition. Nine affected and 4 clinically normal animals were euthanized for further evaluation, including serum chemistry, urinalysis, and gross and/or histopathology. Macroscopic findings included white discoloration in multiple organs in 8 animals, and microscopic evaluation confirmed multiorgan mineralization in tissues from 7 animals. Serum 25-hydroxyvitamin D levels were elevated in 10 animals. Serum inorganic phosphorus and alkaline phosphatase levels were increased in all exposed animals; however, total calcium and ionized calcium levels were not significantly higher in exposed animals than in control strain 13 guinea pigs from a different institution. The data support a diagnosis of hypervitaminosis D with metastatic calcification. Following the diet recall, the remaining guinea pigs increased their food intake and regained body condition. Diagnostic testing of 8 animals euthanized approximately 3 months after returning to a normal diet demonstrated that serum parathyroid hormone remained significantly lower, and ionized calcium and ionized magnesium were significantly higher, in recovered animals compared to controls and exposed animals. These results indicate that diagnostic tests other than serum calcium are necessary for a diagnosis of hypervitaminosis D in guinea pigs.

Family and infant characteristics in relation to age at walking in Turkey.

The purpose of this study was to assess the onset of independent ambulation relative to possible relationships with maternal and infant characteristics. In a cross-sectional study, the health files of 1,553 Turkish children aged 12-23 months were selected by the multistage sampling method in the Nomenclature of Territorial Units for Statistics (NUTS) regions coded as low, medium and high malnutrition levels in Turkey. Children were selected from health centers by systematic sampling technique in each region. Kaplan-Meier analysis and estimated mean values were used for data description; log-rank test and the Cox multivariable regression analysis were applied for data analysis. Maternal education level, occupation, region of residence, gestational iron supplementation, child's gender, child's nutritional status, and presence of anemia in the infant during the survey period demonstrated significant relationships with walking unassisted in the univariate analysis. However, multivariable analysis showed that high maternal education, absence of parental consanguinity and appropriate weight-for-age Z score were positively associated with earlier age of walking. These findings showed the importance of improvement in girls' education, prevention of postnatal growth retardation and improvement in diet quality for children's gross motor development. In addition, counseling programs should be given to decrease the rate of parental consanguinity.

Nutrition in alcoholic liver disease.

The liver plays an important role in the metabolism, synthesis, storage, and absorption of nutrients. Patients with cirrhosis are prone to nutritional deficiencies and malnutrition, with a higher prevalence among patients with decompensated disease. Mechanisms of nutritional deficiencies in patients with liver disease are not completely understood and probably multifactorial. Malnutrition among patients with cirrhosis or alcoholic liver disease correlates with poor quality of life, increased risk of infections, frequent hospitalizations, complications, mortality, poor graft and patient survival after liver transplantation, and economic burden. Physicians, including gastroenterologists and hepatologists, should be conversant with assessment and management of malnutrition and nutritional supplementation.

Nutritional considerations in patients with cystic fibrosis.

Nutritional status is strongly associated with pulmonary function and survival in cystic fibrosis patients. Attainment of a normal growth pattern in childhood and maintenance of adequate nutritional status in adulthood represent major goals of multidisciplinary cystic fibrosis centers. International guidelines on energy intake requirements, pancreatic enzyme-replacement therapy and fat-soluble vitamin supplementation are of utmost importance in daily practice. The present review summarizes the most up-to-date information on early nutritional management in newly diagnosed patients and evaluates the benefits of aggressive nutritional support, assessment of nutritional status, recommendations for nutrition-related management in pancreatic-insufficient patients and the possible therapeutic impact of fat intake modulation upon inflammatory status.

Strategies for optimizing nutrition and weight reduction in physical therapy practice: the evidence.

Poor nutrition and obesity can directly lead to pathological conditions managed by physical therapists or negatively influence recovery from movement dysfunction. The physical therapist/client relationship provides an opportunity for screening for poor nutrition as well as recommending and supporting better nutrition practices by the clients under their care. As such, it is important for the physical therapy professional to understand optimal nutrition for healthy living and serve as a consultant for better nutrition for their clients. To achieve this end, this article addresses strategies for identifying nutritional trends for the specific groups of clients, screening for nutritional problems, assessing clients' readiness to change eating habits, providing useful information and resources concerning optimal nutrition, and recognizing the need for referral to nutrition professionals.

Nutrient dyshomeostasis in congestive heart failure.

The clinical syndrome congestive heart failure (CHF) has its origins rooted in a salt-avid state mediated largely by effector hormones of the renin-angiotensin-aldosterone system. In recent years, this cardiorenal perspective of CHF has taken on a broader perspective. One which focuses on a progressive systemic illness, whose major features include the presence of oxidative stress in diverse tissues and elevated circulating levels of proinflammatory cytokines coupled with a wasting of soft tissues and bone. Experimental studies, which simulate chronic renin-angiotensin-aldosterone system activation, and translational studies in patients with salt avidity having decompensated biventricular failure with hepatic and splanchnic congestion have forged a broader understanding of this illness and the important contribution of a dyshomeostasis of Ca2+, Mg2+, Zn2+, Se2+, and vitamins D, B12, and B1. Herein, we review biomarkers indicative of the nutrient imbalance found in CHF and raise the question of a need for a polynutrient supplement in the overall management of CHF.

Dry beriberi mimicking the Guillain-Barre syndrome.

A 44-year-old man is described with severe flaccid quadriparesis that evolved over 3 weeks. He had regularly binged on alcohol-up to 20 cans of beer per day with occasional consumption of spirits-for more than 15 years but had balanced this with regular food intake. However, for a week prior to the current episode he had not eaten anything of significance. Nerve conduction studies revealed a background peripheral, mainly sensory, neuropathy with a superimposed acute motor axonopathy. CSF was normal. He improved with high dose vitamin replacement and physiotherapy but remains dependent on a Zimmer frame for mobility and a splint for wrist drop.

Lack of meal intake compensation following nutritional supplements in hospitalised elderly women.

Undernutrition contributes to poor clinical outcomes in hospitalised elderly patients but the potential impact of oral nutritional supplements may be reduced by suppressing subsequent food intake. We investigated this possibility in elderly female patients recovering mainly from hip fracture by studying the effect of oral supplements on subsequent food intake during an ad libitum buffet luncheon meal. We tested the effect in seven women by giving the supplement 90 min before the meal and compared energy and macronutrient intake with a control water pre-load condition. A similar study was carried out in another seven women with the supplement or water drink given 30 min beforehand. Both self-rated appetite and energy intake were low in these women. The nutritional supplement did not alter ratings of hunger, fullness or prospective consumption or subsequent energy and macronutrient consumption whether given 90 or 30 min before the meal. There were significant independent correlations between the lack of adequate compensation of energy intake at meals and chronic undernutrition (as assessed by skinfold thickness) and energy intake during the control meal. We conclude that elderly women during the recovery phase after major fractures have low appetites and energy intakes and markedly impaired adjustment of energy intake following liquid oral nutritional supplements. The reasons for this are unknown but are related to anorexia and undernutrition. The consumption of liquid oral supplements given up to 30 min before a meal does not suppress subsequent energy intake from meals.

Hepatitis and cholestasis in infancy: clinical and nutritional aspects.

A major complication of cholestasis is fat malabsorption related to decreased intestinal bile acids, which leads to malnutrition and fat-soluble vitamin deficiency. The impaired excretion of bile acids leads to a low intraluminal micellar concentration that causes long-chain triglyceride lipolysis and absorption to be ineffective. Medium-chain triglycerides (MCTs) are more readily absorbed when there are low concentrations of bile acids and therefore are a good source of fat calories; MCTs can be administered as MCT-containing formulas. In those children who are unable to take sufficient calories by mouth, it is important to start nocturnal enteral feeding to improve nutritional status. In infants with cholestasis, the absorption of fat-soluble vitamins (A, D, E and K) that require bile acids is also impaired, and supplementation is mandatory. Vitamin K deficiency may be responsible for hypoprothrombinaemia, which may lead to bleeding diathesis, Vitamin K (phytomenadione) should therefore be promptly administered intravenously, at a dose of 1 mg. Chronic vitamin E (alpha-tocopherol) deficiency is associated with a progressive neuromuscular syndrome that can cause cerebellar ataxia, areflexia and peripheral neuropathy. Supplements are given orally in doses of 3-5 times the normal requirement if cholestasis is incomplete. In complete cholestasis, supplements must be given intramuscularly at monthly intervals. In infants who fail to thrive, dietary supplements of carbohydrate polymers and MCTs are required.

Micronutrients and fetal growth.

Fetal undernutrition affects large numbers of infants in developing countries, with adverse consequences for their immediate survival and lifelong health. It manifests as intrauterine growth retardation (IUGR), defined as birth weight <10th percentile, which probably underestimates the number failing to achieve full growth potential. Birth weight is a crude measure of the dynamic process of fetal growth and does not capture effects of fetal undernutrition on body composition and the development of specific tissues. The link between maternal nutrition and fetal nutrition is indirect. The fetus is nourished by a complex supply line that includes the mother's diet and absorption, endocrine status and metabolism, cardiovascular adaptations to pregnancy and placental function. Micronutrients are essential for growth, and maternal micronutrient deficiency, frequently multiple in developing countries, may be an important cause of IUGR. Supplementation of undernourished mothers with micronutrients has several benefits but there is little hard evidence of improved fetal growth. However, this has been inadequately tested. Most trials have only used single micronutrients and many were inconclusive because of methodological problems. Several food-based studies (some uncontrolled) suggest benefits from improving maternal dietary quality with micronutrient-dense foods. One trial of a multivitamin supplement (HIV-positive mothers, Tanzania) showed increased birth weight and fewer fetal deaths. Well-conducted randomized controlled trials of adequate sample size and including measures of effectiveness are needed in populations at high risk of micronutrient deficiency and IUGR and should include food-based interventions and better measurements of fetal growth, maternal metabolism, and long-term outcomes in the offspring.

[Nutritional recovery. An unresolved challenge]. / Recuperación nutricional. Un desafío pendiente.

Factors that modulate catch up growth influence the quantity and quality of the recovered tissue. Insulin and IGF-1 respond to dietary changes in carbohydrates and proteins; evidence shows that IGF-1 and leptin may be good indicators of nutritional recovery. The optimal diet to promote catch up growth is still controversial. There is consensus on the need to adjust the energy-protein intake to the growth velocity observed, without encouraging excessive eating, to avoid obesity. Zinc supplementation and physical activity appear as relevant factors to promote the synthesis of lean mass. In some models of early malnutrition, a better catch up growth during childhood, is associated with a higher frequency of chronic diseases and mortality in adulthood. In this context, we will review some factors that seem relevant to the modulation of catch up growth, which should be taken into account when reviewing the therapeutic guidelines to treat malnourished children.