Alcoholism and nutrition: a review of vitamin supplementation and treatment.

PURPOSE OF REVIEW: This is a review of the research on the effectiveness of vitamin supplementation for alcoholism and alcohol-related illnesses. The focus is on research, both clinical and basic on alcohol treatment and nutritional effectiveness of these vital nutrients. RECENT FINDINGS: Most of the research involves basic experiments exploring the impact of vitamin depletion or deficits on physiological systems, especially liver and brain, in rodents. These often include behavioral measures that use cognitive, learning/memory and motivation experiments that model clinical studies. These provide support for hypotheses concerning the impact of such deficiencies in clinical populations. Clinical studies are rare and involve evaluation of the outcome of supplementation usually in the context of a treatment program. Specific vitamins, dosages and treatment programs vary. Deficiencies in retinoids (vitamin A), thiamine (B1) and niacin (B3) are the most frequently investigated. However, there is a greater need for further research on other vitamins, and for more uniform supplementation and treatment procedures. SUMMARY: The literature is primarily basic research on specific vitamins. There are very significant findings with individual vitamin supplementation and combinations that show promise of our understanding of the role of vitamins in the disease of alcoholism and its treatment.

Micronutrients in Liver Disease: Roles, Risk Factors for Deficiency, and Recommendations for Supplementation.

Micronutrients are essential components of the diet and are required to maintain fundamental bodily functions. Liver disease has a profound effect on nutrient intake, metabolism of nutrients, and nutrition status, often resulting in some degree of malnutrition, including micronutrient deficiency. Vitamin and mineral deficiencies can impair metabolic processes at the cellular and biochemical level even before clinical and physical alterations are seen. It is essential that micronutrient status is evaluated as part of a comprehensive nutrition assessment for all patients with chronic or advanced liver disease. Early intervention to correct suspected or confirmed deficiencies may minimize symptoms and improve clinical outcomes and quality of life. In this narrative review, different types of liver disease and associated micronutrient abnormalities are outlined, and methods of micronutrient assessment and supplementation are discussed.

Bariatric surgery and type 2 diabetes.

Type 2 diabetes is primarily managed with lifestyle modifications, self-monitoring of blood glucose, and medication. The goal is to maintain A1C less than 7% in most patients and prevent damage to other organs such as the kidneys and heart. Patients who are obese and cannot achieve normal blood glucose levels despite diet, exercise, and multiple medications may be considered for bariatric surgery. The Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have been shown to improve A1C, reduce weight, and reduce the number of medications patients need for diabetes management. Comorbidities such as hyperlipidemia and hypertension also may improve. This article describes types of bariatric surgery, proper selection of surgical candidates, patient education, and the postoperative patient management necessary for long-term success in improving blood glucose control.

Etiology and Medical Management of Pediatric Intestinal Failure.

Pediatric intestinal failure occurs when gut function is insufficient to meet the growing child's hydration and nutrition needs. After massive bowel resection, the remnant bowel adapts to lost absorptive and digestive capacity through incompletely defined mechanisms newly targeted for pharmacologic augmentation. Management seeks to achieve enteral autonomy and mitigate the development of comorbid disease. Care has improved, most notably related to reductions in blood stream infection and liver disease. The future likely holds expansion of pharmacologic adaptation augmentation, refinement of intestinal tissue engineering techniques, and the development of a learning health network for efficient multicenter study and care improvement.

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.

Severe malnutrition after bariatric surgery and clinic manifestations of infection.

This report describes the post-bariatric-surgery evolution of an obese patient who had low adherence to the diet and micronutrient supplementation. Four years after two bariatric surgeries, the patient was admitted due to transient loss of consciousness, slow thinking, anasarca, severe hypoalbuminemia, in addition to vitamin and mineral deficiencies. She had subcutaneous foot abscess but did not present fever. Received antibiotics, vitamins A, D, B12, thiamine, calcium, and parenteral nutrition. After hospitalization (twenty-eight days), there was a significant body weight reduction probably due to the disappearance of clinical anasarca. Parenteral nutrition was suspended after twenty-five days, and the oral diet was kept fractional. After hospitalization (weekly outpatient care), there was a gradual laboratory data improvement, which was now close to the reference values. Such outcome shows the need for specialized care in preventing and treating nutritional complications after bariatric surgeries as well as clinical manifestations of infection in previously undernourished patients.

Severe malnutrition after bariatric surgery and clinic manifestations of infection

SUMMARY This report describes the post-bariatric-surgery evolution of an obese patient who had low adherence to the diet and micronutrient supplementation. Four years after two bariatric surgeries, the patient was admitted due to transient loss of consciousness, slow thinking, anasarca, severe hypoalbuminemia, in addition to vitamin and mineral deficiencies. She had subcutaneous foot abscess but did not present fever. Received antibiotics, vitamins A, D, B12, thiamine, calcium, and parenteral nutrition. After hospitalization (twenty-eight days), there was a significant body weight reduction probably due to the disappearance of clinical anasarca. Parenteral nutrition was suspended after twenty-five days, and the oral diet was kept fractional. After hospitalization (weekly outpatient care), there was a gradual laboratory data improvement, which was now close to the reference values. Such outcome shows the need for specialized care in preventing and treating nutritional complications after bariatric surgeries as well as clinical manifestations of infection in previously undernourished patients.

RESUMO Este relato descreve a evolução pós-cirurgia bariátrica de uma paciente obesa que apresentou baixa adesão à dieta e suplementação de micronutrientes. Quatro anos após duas cirurgias bariátricas, a paciente foi internada por perda transitória de consciência, raciocínio lento, anasarca, hipoalbuminemia grave, além de deficiências vitamínicas e minerais. Apresentava abscesso subcutâneo no pé, mas não apresentava febre. Recebeu antibióticos, vitaminas A, D, B12, tiamina, cálcio e nutrição parenteral. Após a internação (28 dias) houve redução significativa do peso corporal, provavelmente devido ao desaparecimento clínico da anasarca. A nutrição parenteral foi suspensa após 25 dias e a dieta oral foi mantida fracionada. Após a internação (atendimento ambulatorial semanal) houve uma melhora gradativa dos dados laboratoriais, que estavam próximos dos valores de referência. Tal desfecho mostra a necessidade de cuidados especializados na prevenção e tratamento de complicações nutricionais após cirurgias bariátricas, bem como manifestações clínicas de infecção em pacientes previamente desnutridos.

Nutritional and vitamin status in patients with neuroendocrine neoplasms.

Symptoms of gastroenteropancreatic located neuroendocrine neoplasms (GEP-NENs) are often related to food intake and manifest as abdominal pain or diarrhoea which can influence patients nutritional status. Malnutrition is common in cancer patients and influences quality of life, treatment options and survival but is also present in up to 40% of patients with GEP-NENs. As part of malnutrition there are often deficiencies in fat-soluble vitamins, mainly vitamin D. Little knowledge exists on trace elements. Several factors influence the development of malnutrition such as size and localisation of the primary tumour as well as metastases, side effects from treatment but also hormone production of the tumour itself. One of the main influencing factors leading to malnutrition is diarrhoea which leads to dehydration and electrolyte disturbances. Treatment of diarrhoea should be guided by its cause. Screening for malnutrition should be part of routine care in every GEP-NEN patient. Multidisciplinary treatment including dietician support is necessary for all malnourished patients with GEP-NENs.

Chronic Complications of Cholestasis: Evaluation and Management.

Patients with primary biliary cholangitis (PBC) are at risk for various harmful consequences of chronic cholestasis. These include fat-soluble vitamin deficiency, even in the setting of macronutrient sufficiency, as well as metabolic bone disease, including osteoporosis with fractures. Hyperlipidemia is often present and less commonly associated with risk of cardiovascular event; however, the long-term effect of new emerging therapies for PBC remains to be determined. Patients with PBC also have infrequent but notable risk of portal hypertension despite early-stage disease. This review discusses the background, evaluation, and practical management of these complications of chronic cholestasis.

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.

La corrección del déficit de 25-OH-vitamina D mejora el control del hiperparatiroidismo secundario y el estado inflamatorio de pacientes estables en hemodiálisis / Correction of 25-OH-vitamin D deficiency improves control of secondary hyperparathyroidism and reduces the inflammation in stable haemodialysis patients

Introducción: El déficit de 25-OH-vitamina D (25-OH-D) es común en los pacientes en hemodiálisis (HD). Por otra parte, es bien conocida la elevada incidencia de hiperparatiroidismo secundario en este grupo de pacientes, y lo importante que es su adecuado control. La 25-OH-D está implicada en la regulación de la homeostasis del calcio, por lo que tener niveles adecuados puede contribuir en el control del metabolismo óseo-mineral. Objetivos: Evaluar el efecto de la repleción de 25-OH-D en pacientes en HD con déficit vitamínico (niveles<20ng/ml), en el control del hiperparatiroidismo secundario y en el estado de microinflamación. Pacientes y métodos: Estudio observacional, prospectivo en el que se trataron pacientes estables en HD con déficit de 25-OH-D (<20ng/ml), con calcifediol 0,266mcg/15 días vía oral durante 3 meses. Los datos de HD, parámetros bioquímicos y las dosis de fármacos administrados fueron analizados antes y después de la corrección del déficit. Resultados: Un total de 45 pacientes estables en HD con edad media 74,08±12,49 años completaron el tratamiento. Del total, 27 pacientes (60%) alcanzaron niveles de 25-OH-D>20ng/ml (en 23 fueron>30ng/ml, y 4 entre 20-30ng/ml). Las cifras de hormona paratiroidea descendieron en 32 de los 45 pacientes, alcanzando en 23 (51% de tratados) un descenso>30% respecto al valor basal. En cuanto al tratamiento concomitante, se objetivó un descenso significativo de la dosis de activador selectivo del receptor de vitamina D; sin evidenciarse cambios en la dosis de calcimimético ni de quelantes. Respecto al estado de malnutrición-inflamación, destaca un descenso de la proteína C reactiva, aunque no se modificaron otros parámetros de microinflamación como los monocitos activados (CD14+/CD16+ y CD 14++/CD16+). Tampoco se observaron cambios en los niveles de FGF-23. Conclusiones: La corrección del déficit de 25-OH-D en pacientes en HD se asocia a un mejor control del hiperparatiroidismo secundario con menores dosis de análogos de vitamina D y a una mejoría en el estado inflamatorio de estos pacientes. Nuestros resultados apoyan la recomendación de determinar niveles de 25-OH-D y corregir el déficit en pacientes en HD (AU)

Introduction: Patients on haemodialysis (HD) have a high prevalence of 25-OH-vitamin D (25-OH-D)deficiency. Secondary hyperparathyroidismis a common condition in these patients, which is very important to control. 25-OH-D is involved in regulating calcium homeostasis. As such, appropriate levels of this vitamin could help to control bone mineral metabolism. Objective: To evaluate the effect 25-OH-D repletion in HD patients with 25-OH-D deficiency (<20ng/ml) on the control of secondary hyperparathyroidism and microinflammation status. Patients and methods: Prospective observational study in which stable patients on HD with 25-OH-D deficiency (<20ng/ml) were treated with oral calcifediol 0.266mcg/every 2 weeks for three months. Dialysis characteristics, biochemical parameters and drug doses administered were analysed before and after the correction of the deficiency. Results: Forty-five stable HD patients with a mean age of 74.08±12.49 years completed treatment. Twenty-seven patients (60%) achieved 25-OH-D levels above 20ng/ml (23 with levels>30ng/ml and 4 between 20-30ng/ml). Parathyroid hormone levels decreased in 32 of the 45 patients, 23 of which (51%) achieved a>30% decrease from baseline. In terms of concomitant treatment, we observed a significant reduction in the selective vitamin D receptor activator dose, but no changes in calcimimetic or phosphate binders administration. In terms of malnutrition-inflammation status, a decrease in C-reactive protein was noted, although other microinflammation parameters, such as activated monocytes (CD14+/CD16+ and CD 14++/CD16+) were unchanged. No changes were observed in the levels of FGF-23. Conclusions: Correcting 25-OH-D deficiency in HD patients is associated with better secondary hyperparathyroidism control with lower doses of vitamin D analogues, as well as an improvement in inflammatory status. Our results support the recommendation to determine 25-OH-D levels and correct its deficiency in these patients (AU)

Treatment of Vitamin and Mineral Deficiencies After Biliopancreatic Diversion With or Without Duodenal Switch: a Major Challenge.

BACKGROUND: Vitamin and mineral deficiencies are a major concern after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). Evidence-based guidelines how to prevent or how to treat deficiencies in these patients are currently lacking. The aim of the current study is to give an overview of postsurgical deficiencies and how to prevent and treat these deficiencies. METHODS: Retrospective evaluation of a 1-year structured monitoring and treatment schedule for various deficiencies in 34 patients after BPD or BPD/DS. RESULTS: Patients were introduced into the program 12-90 months after surgery. Vitamin B1, B6, B9, and B12 deficiencies could be prevented by mean daily doses of 2.75 mg, 980 µg, 600 µg, and 350 µg, respectively. However, many patients continued to develop deficiencies of vitamin A, D, iron, calcium, and zinc despite major dose adjustments. Current observations suggest that at least total daily doses of 200 mg Fe in premenopausal women and 100 mg in men, 100 mg of Zinc, 3000 mg of calcium, and weekly doses of at least 50,000 IU solubilized vitamin A and vitamin D are needed to prevent the occurrence of major deficiencies. CONCLUSION: Exceptionally high supplementation doses are needed to prevent and treat vitamin and mineral deficiencies in patients after BPD or BPD/DS. Further refinement and simplification of treatment schedules is needed. Focus on improvement of compliance to treatment is recommended.

Fat-soluble Vitamin Deficiencies and Inflammatory Bowel Disease: Systematic Review and Meta-Analysis.

BACKGROUND: Vitamin deficiency is frequently associated with inflammatory bowel disease (IBD). Supplementation of vitamins could thus serve as an adjunctive therapy. The present meta-analysis reviews the deficiencies and alterations in serum fat-soluble vitamins (A, D, E, and K) reported in IBD patients. MATERIALS AND METHODS: PubMed database search was performed to identify all primary studies up to January 2015 that evaluated the serum concentrations of fat-soluble vitamin levels in IBD patients compared with healthy individuals. We estimated pooled mean differences between groups and estimated their relations with some compounding variables (age, disease duration, C-reactive protein, albumin), using a meta-regression analysis. RESULTS: Nineteen case-control studies met selection criteria. In patients with Crohn's disease (CD), vitamin A, D, E, K status was lower than in controls [D=212 µg/L.92; 95% confidence interval (CI), 95.36-330.48 µg/L, P=0.0002; D=6.97 nmol/L, 95% CI, 1.61-12.32 nmol/L, P=0.01; D=4.72 µmol/L, 95% CI, 1.60-7.84 µmol/L, P=0.003; D=1.46 ng/mL, 95% CI, 0.48-2.43 ng/mL, P=0.003, respectively]. Patients with ulcerative colitis had lower levels of vitamin A than controls (D=223.22 µg/L, 95% CI, 44.32-402.12 µg/L, P=0.01). Patients suffering from CD for a longer time had lower levels of vitamins A (95% CI=7.1-67.58 y, P=0.02) and K (95% CI, 0.09-0.71 y, P=0.02). Meta-regression analysis demonstrated statistically significant associations between the levels of inflammatory biomarkers: C-reactive protein (P=0.03, 95% CI, -9.74 to -0.6 mgl/L) and albumin (P=0.0003, 95% CI, 402.76-1361.98 g/dL), and vitamin A status in CD patients. CONCLUSION: Our meta-analysis shows that the levels of fat-soluble vitamins are generally lower in patients with inflammatory bowel diseases and their supplementation is undoubtedly indicated.

[Novel therapies in neurometabolic diseases: the importance of early intervention]. / Terapias novedosas en enfermedades neurometabolicas: importancia de una intervencion precoz.

INTRODUCTION: Individually, neurometabolic diseases are ultra rare, but for some of them there is an effective treatment. DEVELOPMENT: Several recent therapeutic advances are reviewed. Today, the possibilities of treatment for lysosomal diseases have improved. In recent years the use of enzyme replacement therapy has become more widely extended to treat mucopolysaccharidosis type IVA (Morquio A), mucopolysaccharidosis type VII (Sly syndrome), lysosomal acid lipase deficiency and alpha-mannosidosis. It has been proven that very early treatment of mucopolysaccharidoses can change their natural course. Intrathecal enzyme replacement therapy is being tried in some mucopolysaccharidoses with cognitive involvement, in an attempt to halt neurodegeneration. Very positive results have been obtained with genetically modified autotransplants in late-onset infantile metachromatic leukodystrophy and research is being conducted on other pathologies (mucopolysaccharidosis type III, X-linked adrenoleukodystrophy). Novel outcomes are also being achieved in the treatment of some encephalopathies that are sensitive to vitamins or cofactors: triple therapy in pyridoxine dependency, treatment with thiamine for some subacute encephalopathies with involvement of the basal ganglia, treatment with folinic acid for children with cerebral folate deficiency, or treatment with cyclic pyranopterin monophosphate in molybdenum cofactor deficiency type A. CONCLUSIONS: As neuropaediatricians we must update our knowledge, especially in the case of treatable neurometabolic pathologies, since early treatment can change their prognosis significantly.

TITLE: Terapias novedosas en enfermedades neurometabolicas: importancia de una intervencion precoz.Introduccion. Las enfermedades neurometabolicas son individualmente ultrarraras, pero algunas de ellas tienen un tratamiento eficaz. Desarrollo. Se revisan algunas novedades terapeuticas. Las enfermedades lisosomales tienen actualmente mejores posibilidades de tratamiento. En los ultimos años se ha extendido el uso de la terapia enzimatica sustitutiva a la mucopolisacaridosis tipo IVA (Morquio A), a la mucopolisacaridosis tipo VII (enfermedad de Sly), al deficit de lipasa acida lisosomal y a la alfa-manosidosis. Se ha constatado que un tratamiento muy precoz de las mucopolisacaridosis puede cambiar su historia natural. Se esta probando la terapia enzimatica sustitutiva intratecal en algunas mucopolisacaridosis con afectacion cognitiva, en el intento de frenar la neurodegeneracion. Se han obtenido resultados muy positivos con autotrasplante modificado geneticamente en leucodistrofia metacromatica infantil tardia y se esta trabajando en otras patologias (mucopolisacaridosis tipo III, adrenoleucodistrofia ligada a X). Tambien hay novedades en la terapia de algunas encefalopatias sensibles a vitaminas o cofactores: la triple terapia en la dependencia de piridoxina, el tratamiento con tiamina de algunas encefalopatias subagudas con afectacion de ganglios basales, el tratamiento con acido folinico de niños con deficiencia de folato cerebral, o el tratamiento con monofosfato de piranopterina ciclico en los defectos de cofactor de molibdeno de tipo A. Conclusiones. Los neuropediatras debemos actualizar nuestro conocimiento especialmente en aquellas patologias neurometabolicas tratables, dado que una terapia precoz puede cambiar de forma significativa su pronostico.

Fibromialgia y niveles de vitamina D / Fibromyalgia and vitamin D levels

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En los inicios de la psiquiatría franquista. El Congreso Nacional de Neurología y Psiquiatría (Barcelona, 1942) / The beginning of Francoist psychiatry. The National Neurology and Psychiatry Conference (Barcelona, 1942)

Aunque existen algunas aportaciones sobre las características de la psiquiatría franquista, lo cierto es que faltan trabajos que aborden el proceso de reorganización de los profesionales de la medicina mental en el «Nuevo Estado». En este sentido, el Congreso Nacional de Neurología y Psiquiatría, celebrado en Barcelona los días 12, 13 y 14 de enero de 1942, constituye, sin duda, un muy destacado ejemplo de dicho intento de sustitución de ideas y protagonistas en la psiquiatría española. El objeto de este artículo es analizar los principales aspectos organizativos del mencionado Congreso, así como sus contenidos más destacados, con el fin de valorar su importancia estratégica en el marco de los intereses profesionales y científicos, pero también ideológicos y políticos, de los psiquiatras. Las ponencias y comunicaciones versaron sobre neurología y psiquiatría de guerra; avitaminosis y sistema nervioso; y nuevos tratamientos en psiquiatría, en especial las terapias de choque. Asimismo, el congreso tuvo un marcado carácter ideológico y supuso el inicio de una dinámica profesional, con la aparición o el afianzamiento de nuevos líderes que pretendieron sentar las bases de la psiquiatría durante el primer franquismo (AU)

While there has been some research into Francoist psychiatry, much work still needs to be done on the reorganization of the mental health profession within the new state. Held in Barcelona on 12, 13 and 14th January 1942, the National Neurology and Psychiatry Conference undoubtedly played a major role in the attempt to overthrow the dominant ideas in the field of Spanish psychiatry and displace its most influential figures. This article seeks to analyse the Conference's main organizational features and examine its most significant content, with the aim of evaluating its strategic importance in the context of both the psychiatrists' professional and scientific interests and their ideological and political concerns. Conference papers tackled issues such as neurology and psychiatry in wartime, vitamin deficiency and the nervous system, and new psychiatric treatments, including shock therapy. The Conference's marked ideological nature represented the beginning of a new professional dynamic, featuring the emergence or establishment of new leaders intent on laying the foundations of psychiatry during the early years of the Franco regime