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Azzini E, Furini T, Polito A, Scalfi L, Pinto A, Gasperi V, Savini I. Vitamin Nutritional Status in Patients with Pancreatic Cancer: A Narrative Review. Int J Mol Sci 2024; 25:4773. [PMID: 38732007 PMCID: PMC11084158 DOI: 10.3390/ijms25094773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/09/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Due to the high mortality rate in Western countries, pancreatic cancer is considered one of the big killers, leaving patients and their families with little hope upon diagnosis. Although surgical and drug therapies are critical for cancer patients to improve life expectancy and alleviation of suffering, nutrition plays a key role in improving cancer treatment outcomes. This narrative review, conducted as part of the activities of the Italian Society of Human Nutrition (SINU) working group in oncology, focuses on the prevalence of vitamin malnutrition among pancreatic cancer patients. The results of the literature search show that pancreatic cancer patients are at a heightened risk of water-soluble vitamin deficiencies, particularly of vitamins B1, B3, and B6. Additionally, they also face an increased risk of deficiency of fat-soluble vitamins. Among these vitamins, the potential role of vitamin D in pancreatic cancer has garnered the most attention, with its plasma levels being identified as a significant factor in patient survival. Investigating vitamin nutritional status could provide valuable insights for incorporating nutritional approaches into the prevention and treatment of pancreatic cancer, thereby reducing the exacerbation of symptoms associated with the diagnosis.
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Affiliation(s)
- Elena Azzini
- Council for Agricultural Research and Economics—Research Centre for Food and Nutrition, 00178 Rome, Italy;
| | - Tiziano Furini
- Department of Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (T.F.); (V.G.)
| | - Angela Polito
- Council for Agricultural Research and Economics—Research Centre for Food and Nutrition, 00178 Rome, Italy;
| | - Luca Scalfi
- Department of Public Health, School of Medicine, Federico II University, 80131 Naples, Italy;
| | - Alessandro Pinto
- Experimental Medicine Department, Food Science and Human Nutrition Research Unit, “Sapienza” University, 00185 Rome, Italy;
| | - Valeria Gasperi
- Department of Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (T.F.); (V.G.)
| | - Isabella Savini
- Department of Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (T.F.); (V.G.)
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Uchida N, Ishida M, Yoshioka A, Takahashi T, Furuya D, Ebihara Y, Ito H, Yanagi A, Onishi H, Sato I. Investigation of Whole Blood Thiamine Concentration in Independently Ambulatory Residents of a Provincial Town in Japan: A Cross-Sectional Study. Cureus 2023; 15:e38800. [PMID: 37303326 PMCID: PMC10250136 DOI: 10.7759/cureus.38800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 06/13/2023] Open
Abstract
Background Thiamine deficiency (TD) is an important public health problem in nutrition, occurring in 2-6% of the population in Europe and the US, whereas thiamine levels are reported to be significantly reduced by 36.6-40% in some populations of East Asia. However, there is little information available at present, regarding factors such as age, despite the continued aging of society. Further, studies such as those mentioned above have not yet been undertaken in Japan, the country in which population aging is most advanced. Objective To investigate TD in the Japanese community-dwelling individuals who are independently ambulatory. Methods We undertook an examination of TD in blood samples obtained from 270 citizens in a provincial town, aged 25-97 years, who were able to walk to the venue and provide informed consent for inclusion in this research and of whom 8.9% had a history of cancer. We summarized the demographic characteristics of the subjects. The whole-blood thiamine concentrations were measured using the high-performance liquid chromatography method. A value of 21.3 ng/ml or less was taken as low and a borderline value was set as less than 28 ng/ml. Results The mean (±SD) whole blood thiamine concentration was 47.6 ± 8.7 ng/ml. No TD was observed to exist participating in this study, with no subjects even showing show borderline values. Further, there was no significant difference in thiamine level between those aged 65 or older and those aged less than 65. Conclusions No cases of TD were observed among the subjects in this study, nor was the concentration of thiamine found to be related to age. It is possible that the frequency of TD might be very low in citizens who have a certain level of activity. In the future, it is necessary to expand the prevalence of TD to a wider range of subjects.
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Affiliation(s)
- Nozomu Uchida
- Department of General Medicine, Ogano Town Central Hospital, Ogano, JPN
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Mayumi Ishida
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Akira Yoshioka
- Department of Clinical Oncology, Mitsubishi Kyoto Hospital, Kyoto, JPN
| | - Takao Takahashi
- Department of Supportive Medicine, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Daisuke Furuya
- Department of General Medicine, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Yasuhiro Ebihara
- Department of Laboratory Medicine, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Hiroshi Ito
- Department of General Medicine, Ito Internal Medicine and Pediatric Clinic, Fukuoka, JPN
| | - Akiko Yanagi
- Department of Nursing, Maruyama Memorial General Hospital, Iwatsuki, JPN
| | - Hideki Onishi
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Izumi Sato
- Department of Clinical Epidemiology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, JPN
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Ishida M, Uchida N, Yoshioka A, Sato I, Ito H, Sato R, Mizunuma N, Onishi H. Thiamine Deficiency in a Patient With Schizophrenia: Precautions and Countermeasures for Subclinical Thiamine Deficiency. Cureus 2023; 15:e38454. [PMID: 37273314 PMCID: PMC10234677 DOI: 10.7759/cureus.38454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 06/06/2023] Open
Abstract
Patients with schizophrenia often experience problems associated with ordinary exercises of life due to their mental symptoms. Those experiencing problems related to feeding behavior, in particular, are considered to be susceptible to developing Wernicke encephalopathy due to a deficiency in thiamine, the physiological stores of which are limited; however, there are few reported cases, and most of them were accompanied by the classical triad of signs. We report our experience with asymptomatic thiamine deficiency (TD) in a schizophrenia patient. A 73-year-old female was receiving medication for schizophrenia as an outpatient. No symptoms such as hallucinations or delusions were observed, the patient had a sociable personality and was able to function at a level where she could live alone. Although there were no active complaints about eating by the patient, we investigated the situation due to reports of TD in schizophrenia patients. As results revealed a significant decrease in whole blood thiamine to 19 ng/mL (reference range: 24-66 ng/mL), we administered a large dose of thiamine. No changes were observed in psychosomatic symptoms before and after administration. Patients with schizophrenia experience problems that may lead to TD, such as dietary imbalances and disturbed feeding habits. Therefore, even if patients with schizophrenia do not actively complain about their feeding behavior, it may be necessary to take medical measures such as blood sampling in consideration of the potential for developing TD.
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Affiliation(s)
- Mayumi Ishida
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Nozomu Uchida
- Department of General Medicine, Ogano Town Central Hospital, Ogano, JPN
- Department of Supportive Medicine, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Akira Yoshioka
- Department of Clinical Oncology, Mitsubishi Kyoto Hospital, Kyoto, JPN
| | - Izumi Sato
- Department of Clinical Epidemiology, Nagasaki University, Graduate School of Biomedical Sciences, Nagasaki, JPN
| | - Hiroshi Ito
- Department of General Medicine, Ito Internal Medicine and Pediatric Clinic, Fukuoka, JPN
| | - Ryota Sato
- Department of Pharmacy, Maruki Memorial Medical and Social Welfare Center, Moroyama, JPN
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Naoki Mizunuma
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Hideki Onishi
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka, JPN
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Stacpoole PW, McCall CE. The pyruvate dehydrogenase complex: Life's essential, vulnerable and druggable energy homeostat. Mitochondrion 2023; 70:59-102. [PMID: 36863425 DOI: 10.1016/j.mito.2023.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 03/04/2023]
Abstract
Found in all organisms, pyruvate dehydrogenase complexes (PDC) are the keystones of prokaryotic and eukaryotic energy metabolism. In eukaryotic organisms these multi-component megacomplexes provide a crucial mechanistic link between cytoplasmic glycolysis and the mitochondrial tricarboxylic acid (TCA) cycle. As a consequence, PDCs also influence the metabolism of branched chain amino acids, lipids and, ultimately, oxidative phosphorylation (OXPHOS). PDC activity is an essential determinant of the metabolic and bioenergetic flexibility of metazoan organisms in adapting to changes in development, nutrient availability and various stresses that challenge maintenance of homeostasis. This canonical role of the PDC has been extensively probed over the past decades by multidisciplinary investigations into its causal association with diverse physiological and pathological conditions, the latter making the PDC an increasingly viable therapeutic target. Here we review the biology of the remarkable PDC and its emerging importance in the pathobiology and treatment of diverse congenital and acquired disorders of metabolic integration.
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Affiliation(s)
- Peter W Stacpoole
- Department of Medicine (Division of Endocrinology, Metabolism and Diabetes), and Department of Biochemistry and Molecular Biology, University of Florida, College of Medicine, Gainesville, FL, United States.
| | - Charles E McCall
- Department of Internal Medicine and Translational Sciences, and Department of Microbiology and Immunology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
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Can depressed cancer patients with a borderline thiamine concentration develop deficiency within a short time period? Palliat Support Care 2023:1-4. [PMID: 36683386 DOI: 10.1017/s1478951522001808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Despite increasing reports of thiamine deficiency (TD) among cancer patients, there remain some patients with borderline thiamine concentrations (BTC). However, it is unclear whether such patients subsequently develop TD. METHODS Here, we report cases of cancer patients progressing to TD within a short time period after presentation with BTC (24-28 ng/ml). RESULTS CASE 1 A 49-year-old female with lung cancer. During treatment for depression, the patient showed a decreased appetite, and a blood sample revealed BTC (25 ng/ml). Fourteen days later, she reported a continued loss of appetite, and despite the absence of the 3 classical signs of Wernicke encephalopathy (WE), additional testing showed a thiamine level of 23 ng/ml, leading to a diagnosis of TD. CASE 2 A 65-year-old female developed depression during chemotherapy for angiosarcoma. Her blood sample revealed BTC (25 ng/ml). Seven days later, despite the absence of the classical signs of WE, a further testing revealed a thiamine level of 20 ng/ml. CASE 3 A 41-year-old female developed depression during chemotherapy for ovarian cancer. No loss of appetite was observed, but a blood sample revealed BTC (25 ng/ml). Seven days later, despite the absence of the classical signs of WE or decreased appetite, further testing revealed a thiamine level of 19 ng/ml. SIGNIFICANCE OF RESULTS Depressed cancer patients with BTC may develop TD within a short time frame. To prevent TD, health-care professionals should maintain an awareness of its potential and the need for regular testing of thiamine level or prophylactic replacement therapy.
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Syamsu NSW, Bastian Sirait F, Ahmad MR, Gaus S, Husain AAA, Datu MD, Zainuddin AA. Correlation between Oral Thiamine as an Opioid Adjuvant and Cathecol-O-Methyltransferase Enzyme Levels in Cervical Cancer Patients. Open Access Maced J Med Sci 2023. [DOI: 10.3889/oamjms.2023.11012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND: The high prevalence of cancer pain shows that a lot of the patients are undertreatment. Vitamin B is one of the additional alternative substances studied in cancer pain management. Thiamine is believed to modulate pain mechanisms in lowering the Cathecol-O-Methyltransferase (COMT) enzyme level.
AIM: The aim of the study was to assess the correlation between Oral Thiamine as an Opioid Adjuvant and COMT Enzyme Levels in Cervical Cancer Patients
METHODS: This research is a quasi-experimental study with a pre-test and post-test control group design. Patients in this study were 32 cervical cancer patients who experienced cancer pain, divided into two groups (treatment and control groups). The treatment group received morphine plus thiamine 500 mg/8 h/oral, and the control group received morphine alone. Measurement and evaluation of pain scores were carried out after 72 h of thiamine administration and blood collection was carried out again 4 h after the last thiamine administration to check thiamine levels and COMT. Then, data collection and analysis is being evaluated.
RESULTS: From 32 cervical cancer patients studied, there were differences in changes in numeric rating scale (NRS) levels and COMT levels in the thiamine treatment group.
CONCLUSIONS: The administration of thiamine can reduce COMT enzyme levels and clinically reduce NRS in cervical cancer patients. If it confirmed by other findings, thiamine might be considered for its use in the treatment of cancer pain.
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Clinical diagnosis, outcomes and treatment of thiamine deficiency in a tertiary hospital. Clin Nutr 2022; 41:2052-2053. [DOI: 10.1016/j.clnu.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/14/2022] [Indexed: 11/22/2022]
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Queiroz Júnior JRAD, Costa Pereira JPD, Pires LL, Maia CS. The Dichotomous Effect of Thiamine Supplementation on Tumorigenesis: A Systematic Review. Nutr Cancer 2021; 74:1942-1957. [PMID: 34854769 DOI: 10.1080/01635581.2021.2007962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The malignant neoplastic cell is characterized by its diverse metabolic changes. It occurs in order to maintain the high rate of proliferation. The possibility of new pharmacological targets has inserted tumor metabolism as a target for recent research, emphasizing the enzymatic activity of thiamin. This review aims to elucidate the behavior of thiamin against tumor development. This is a systematic review in which studies indexed in Pubmed, Scopus, SciELO and BVS were searched using the descriptors (Thiamin OR Vitamin B1) AND (Cancer OR Malignant neoplasia) AND (Tumor metabolism). Title and abstract were read. Duplicates, literary reviews, books, conference abstracts, editorials, and papers published prior to 2010 were eliminated. 23 records were included in this review. Low doses of thiamin have been shown to be enough to stimulate tumor growth. Another population studies has shown evidence of tumor regression after correction of vitamin B1 deficiency. There is an open path for the development of new research to better assess the influence of thiamin on cancer cells. Once the connections between thiamin and the metabolism of cancer cells are fully established, new opportunities for therapeutic intervention and dietary modification will appear to reduce the progression of the disease in patients with cancer.
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Affiliation(s)
| | | | - Leonardo Lucas Pires
- Department of Medical Sciences, Potiguar University, Natal, Rio Grande do Norte, Brazil
| | - Carina Scanoni Maia
- Department of Histology and Embryology, Federal University of Pernambuco, Recife, Pernambuco, Brazil
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Iimura Y, Andoh S, Kawamata T, Sato A, Yokoyama K, Imai Y, Tojo A, Nojima M, Sugiura M, Kuroda S. Thiamine Deficiency and Neurological Symptoms in Patients with Hematological Cancer Receiving Chemotherapy: A Retrospective Analysis. J Neurosci Rural Pract 2021; 12:726-732. [PMID: 34737507 PMCID: PMC8559079 DOI: 10.1055/s-0041-1735825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objectives
Patients with hematological cancer receiving chemotherapy have a high risk of thiamine deficiency due to accelerated thiamine usage by tumor cells. Mild or severe thiamine deficiency can lead to varying degrees of neurological symptoms. We evaluated the relationship between thiamine deficiency and neurological symptoms, including mild or nonspecific symptoms, and the influence of chemotherapy on thiamine serum levels in patients with hematological cancer receiving chemotherapy.
Materials and Methods
We retrospectively identified 42 patients diagnosed with hematological cancer at our hospital, using electronic medical records collected from March 2019 to March 2020. We evaluated the risk factors associated with neurological symptoms (mild-to-severe cognitive impairment, attention impairment, and mood or emotional disorder), the relationship between the presence of neurological symptoms and thiamine serum levels, and changes in thiamine serum levels after chemotherapy.
Results
Thiamine deficiency was significantly associated with neurological symptoms. The thiamine serum levels in the group with neurological symptoms were significantly lower than those in the group without neurological symptoms. The Wilcoxon rank-sum test showed that thiamine serum levels after chemotherapy were significantly lower than those before administration of chemotherapy.
Conclusion
Thiamine serum levels in patients with hematological cancer may be used as a reference to maintain neurological status during chemotherapy.
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Affiliation(s)
- Yohei Iimura
- Department of Pharmacy, The IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Shohei Andoh
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Toyotaka Kawamata
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Aki Sato
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Kazuaki Yokoyama
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Yoichi Imai
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Arinobu Tojo
- Department of Hematology/Oncology, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Masanori Nojima
- Center for Translational Research, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Munetoshi Sugiura
- Department of Drug Safety and Risk Management, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Hachioji, Japan
| | - Seiichiro Kuroda
- Department of Pharmacy, The IMSUT Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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De Oliveira LC, Wiegert EVM, Santos LAD, Calixto-Lima L. Nutritional status and primary tumour site in incurable cancer. BMJ Support Palliat Care 2021:bmjspcare-2021-003321. [PMID: 34740940 DOI: 10.1136/bmjspcare-2021-003321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/22/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES We aimed (1) to assess the nutritional status (NS) using different methods, according to the primary tumour site and (2) to evaluate the performance of these methods in patients with incurable cancer from a reference centre in Brazil. METHODS Cross-sectional analysis of data from patients admitted to the palliative care unit of a reference cancer centre in Brazil, between July 2016 and March 2020. The primary tumour site was the independent variable and the NS using different methods were the dependent variables. Logistic regressions were performed. RESULTS A total of 2,144 patients were included in the study. The most common primary tumour site was the upper gastrointestinal (GI) tract (18.0%), followed by gynaecological (17.6%) and head and neck (HN) (13.5%). Our results showed that patients with tumours of the upper GI tract followed by HN presented significantly higher risk of worse NS. In contrast, breast tumours, bone and connective tissues and melanoma presented inverse association. The gynaecological cancer was variably associated with nutritional impairment, according to the assessment method. CONCLUSIONS Patients with incurable cancer present high prevalence of NS impairment, depending on the tumour site, shown to be elevated in patients with tumour in the upper GI tract.
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Affiliation(s)
- Livia Costa De Oliveira
- Palliative Care Unit, José Alencar Gomes da Silva National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | | | - Lara Azevedo Dos Santos
- Palliative Care Unit, José Alencar Gomes da Silva National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Larissa Calixto-Lima
- Palliative Care Unit, José Alencar Gomes da Silva National Cancer Institute (INCA), Rio de Janeiro, Brazil
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Onishi H, Sato I, Uchida N, Takahashi T, Furuya D, Ebihara Y, Yoshioka A, Ito H, Ishida M. High proportion of thiamine deficiency in referred cancer patients with delirium: a retrospective descriptive study. Eur J Clin Nutr 2021; 75:1499-1505. [PMID: 33514871 PMCID: PMC8486668 DOI: 10.1038/s41430-021-00859-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 12/23/2020] [Accepted: 01/07/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND/OBJECTIVES Recent studies have revealed thiamine deficiency (TD) as a cause of delirium in cancer patients. However, the extent to which Wernicke encephalopathy is present and in what patients is not well understood. SUBJECTS/METHODS In this retrospective descriptive study, we investigated referred cancer patients who were diagnosed with delirium by a psycho-oncologist to clarify the proportion of TD, the therapeutic effect of thiamine administration, and the factors involved in its onset. RESULTS Among 71 patients diagnosed with delirium by a psycho-oncologist, TD was found in 45% of the patients. Intravenous administration of thiamine led to a recovery in about 60% of these patients. We explored the factors associated with TD using a multivariable regression model with a Markov chain Monte Carlo imputation procedure. We found an association between TD and chemotherapy (adjusted odds ratio, 1.98 [95% confidence interval, 1.04-3.77]); however, there were no significant associations between TD and the other factors we considered. CONCLUSIONS TD is not particularly rare in delirium patients undergoing psychiatric consultation. The delirium was resolved in more than half of these patients by intravenous administration of thiamine. Oncologists should consider TD as a cause of delirium in cancer patients. Further prospective study is needed to clarify the relationship between TD and delirium in cancer patients.
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Affiliation(s)
- Hideki Onishi
- Department of Psycho-oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka City, Saitama, 350-1298, Japan
| | - Izumi Sato
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Nozomu Uchida
- Department of General Medicine, Ogano Town Central Hospital, Ogano, Japan
| | - Takao Takahashi
- Department of Supportive Medicine, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Daisuke Furuya
- Department of General Medicine, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Yasuhiro Ebihara
- Department of Laboratory Medicine, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Akira Yoshioka
- Department of Clinical Oncology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Hiroshi Ito
- Ito Internal Medicine and Pediatric Clinic, Fukuoka, Japan
| | - Mayumi Ishida
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka, Japan.
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12
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Onishi H, Ishida M, Uchida N, Yoshioka A, Sato I. Thiamine deficiency unrelated to alcohol consumption in high-income countries: a literature review. Ann N Y Acad Sci 2021; 1505:5-6. [PMID: 34510472 DOI: 10.1111/nyas.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Hideki Onishi
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Mayumi Ishida
- Department of Psycho-oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Nozomu Uchida
- Department of General Medicine, Ogano Central Hospital, Saitama, Japan
| | - Akira Yoshioka
- Department of Medical Oncology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Izumi Sato
- Department of Clinical Epidemiology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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Abstract
OBJECTIVE B vitamins are essential for the functioning of the nervous system. Vitamin B1 (thiamine) deficiency is associated with neuropsychiatric syndromes such as Wernicke's encephalopathy (WE), which, if untreated, has an estimated mortality of 17-20%. Although the prevalence of thiamine deficiency in the general population is difficult to estimate, it is being increasingly recognized in oncology, especially in the inpatient setting. We describe three cases of thiamine deficiency (TD) in the outpatient psychiatric oncology setting. METHOD Retrospective chart review of three adult patients, who were seen in the psychiatric oncology clinic and found to have TD on laboratory testing, was done. Patient, disease, and thiamine treatment-related information were obtained, and descriptive statistics were used to analyze the data. RESULTS The average age was 59 years, mean body mass index (BMI) was 22.00 ± 4.58 (mean ± SD), and mean thiamine level was 59.10 ± 7.69 that ranged from 45 to 68 nmol/L (normal thiamine level reference: 70-180 nmol/L). None of the patients had brain imaging nor cerebrospinal fluid analysis. Risk factors such as unbalanced nutrition, prior GI surgery, renal disease, and chemotherapy were noted. SIGNIFICANCE OF RESULTS TD can have a multifactorial etiology in oncology. Identification of TD in both inpatient and outpatient setting is important. Our report highlights how early identification of TD in the outpatient setting can help prevent further clinical progression.
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Abstract
OBJECTIVE Cancer patients often want to spend their final days at home, and it is essential that general practitioners have knowledge of and technical skills related to cancer medicine and symptom relief. Recent clinical studies have revealed that Wernicke encephalopathy (WE) is quite common in cancer patients. However, there have been no reports to date on WE in cancer patients undergoing home medical care. METHODS From a series of cancer patient undergoing home medical care, we reported a patient with lung cancer who developed WE. RESULTS An 84-year-old female with lung cancer undergoing home medical care developed an impaired mental state and an attention deficit. Her symptoms fulfilled the diagnostic criteria for delirium. WE was suspected as the patient's food intake had fallen from normal a month previously to somewhere between 50% or just a few mouthfuls. This diagnosis was supported by abnormal serum thiamine and the disappearance of delirium after thiamine administration. SIGNIFICANCE OF THE RESULTS When delirium occurs in cancer patients undergoing home treatment, it is necessary to suspect thiamine deficiency as a potential cause, as appropriate diagnosis and treatment can prevent irreversible brain-related sequelae.
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Association between thiamine decrease and neuropsychiatric symptoms in gastrointestinal and hematological cancer patients receiving chemotherapy. Biomed Pharmacother 2021; 141:111929. [PMID: 34328118 DOI: 10.1016/j.biopha.2021.111929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Clinical evidence of thiamine-related neuropsychiatric symptoms, including the initial stage, is limited because serum thiamine levels tend to be evaluated only for patients who develop severe neuropsychiatric symptoms suspected to be related to severe thiamine deficiency. This study aimed to evaluate the relationship between thiamine decline and neuropsychiatric symptoms, including initial symptoms, and the effect of chemotherapy on serum thiamine levels in gastrointestinal and hematological cancer patients receiving chemotherapy. METHOD We retrospectively identified 87 patients who were diagnosed with gastrointestinal and hematological cancers at our hospital. We evaluated the risk factors associated with neuropsychiatric symptoms, including initial symptoms (neuropsychiatric symptoms), the relationship between the presence of neuropsychiatric symptoms and serum thiamine levels, and changes in serum thiamine levels after chemotherapy. RESULTS Logistic regression analysis identified thiamine decline as a significant factor associated with neuropsychiatric symptoms (p < 0.001, odds ratio = 0.040, 95% confidence interval [CI]: 0.010-0.163). The Mann-Whitney U test showed that patients with neuropsychiatric symptoms had significantly lower serum thiamine levels (19.5 ± 5.4 ng/mL, n = 39) than patients without neuropsychiatric symptoms (31.9 ± 14.2 ng/mL, n = 48) (p = 0.001). In hematological cancer patients, serum thiamine levels gradually declined after chemotherapy, with the lowest levels at 5-8 weeks (23.5 ± 7.6 ng/mL, P = 0.035 vs. 0 weeks, Wilcoxon rank sum test). CONCLUSION Our study showed that a decrease in serum thiamine levels can be a risk factor for neuropsychiatric symptoms, and chemotherapy can lead to a decrease in serum thiamine levels.
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Nakamura ZM, Deal AM, Park EM, Quillen LJ, Chien SA, Stanton KE, McCabe SD, Heiling HM, Wood WA, Shea TC, Rosenstein DL. A randomized double-blind placebo-controlled trial of intravenous thiamine for prevention of delirium following allogeneic hematopoietic stem cell transplantation. J Psychosom Res 2021; 146:110503. [PMID: 33945982 PMCID: PMC8172461 DOI: 10.1016/j.jpsychores.2021.110503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if high dose intravenous (IV) thiamine can prevent delirium during hospitalization following allogeneic HSCT. Secondarily, we evaluated the effects of high dose IV thiamine on thiamine levels and explored risk factors for delirium. METHODS Randomized, double-blind, placebo-controlled trial in patients undergoing allogeneic HSCT at a U.S. academic medical center between October 2017 and March 2020. 64 participants were randomized 1:1 to thiamine 200 mg IV three times daily for 7 days or placebo. We used the Delirium Rating Scale to assess for delirium. Delirium incidence was compared between groups using the chi-square test. Group differences in time to onset and duration of delirium were compared using the Kaplan-Meier method. Fisher's Exact and Wilcoxon Rank Sum tests were used to examine associations between pre-transplantation variables and delirium. RESULTS 61 participants were analyzed. Delirium incidence (25% vs. 21%, Chi-square (df = 1) = 0.12, p = 0.73), time to onset, duration, and severity were not different between study arms. Immediately following the intervention, thiamine levels were higher in the thiamine arm (275 vs. 73 nmol/L, t-test (df = 57) = 13.63, p < 0.0001), but not predictive of delirium. Variables associated with delirium in our sample included disease severity, corticosteroid exposure, infection, and pre-transplantation markers of nutrition. CONCLUSION High dose IV thiamine did not prevent delirium in patients receiving allogeneic HSCT. Given the multiple contributors to delirium in this population, further research regarding the efficacy of multicomponent interventions may be needed. TRIAL REGISTRATION Clinical Trials NCT03263442. FUNDING Rising Tide Foundation for Clinical Cancer Research.
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Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura J Quillen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie A Chien
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kate E Stanton
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean D McCabe
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hillary M Heiling
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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17
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Reversible dementia due to vitamin B12 deficiency in a lung cancer patient: Relevance of preoperative evaluation. Palliat Support Care 2021; 19:377-379. [PMID: 33947505 DOI: 10.1017/s1478951521000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cognitive dysfunction has a negative effect on cancer treatment; however, in a cancer setting, specific treatments can restore cognitive function. Such conditions are known as reversible dementia, with one of these being vitamin B12 (VB12) deficiency. However, there have been no reports of VB12 deficiency identified by preoperative evaluation in cancer patients. METHOD We studied a patient who was referred to the Department of Psycho-oncology on suspicion of cognitive decline prior to lung cancer surgery. Preoperative evaluation revealed VB12 deficiency. RESULTS The patient was an 82-year-old woman diagnosed with lung cancer. She also presented with cognitive decline and, therefore, was referred to the Department of Psycho-oncology for preoperative evaluation. The patient scored 19 points on a Mini-Mental State Examination (MMSE), which is indicative of cognitive decline. As the onset of symptoms occurred several months previously and they were subacute, the possibility of reversible dementia was considered. Extensive examination revealed VB12 deficiency, and VB12 replacement therapy normalized the MMSE score to 25 points before surgery. SIGNIFICANCE OF THE RESULTS When cognitive decline is observed in cancer patients, it is necessary to actively evaluate the serum levels of some B vitamins, including VB12.
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18
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Aleshin VA, Zhou X, Krishnan S, Karlsson A, Bunik VI. Interplay Between Thiamine and p53/p21 Axes Affects Antiproliferative Action of Cisplatin in Lung Adenocarcinoma Cells by Changing Metabolism of 2-Oxoglutarate/Glutamate. Front Genet 2021; 12:658446. [PMID: 33868388 PMCID: PMC8047112 DOI: 10.3389/fgene.2021.658446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/05/2021] [Indexed: 12/14/2022] Open
Abstract
Thiamine (vitamin B1) is often deficient in oncopatients, particularly those undergoing chemotherapy. However, interaction between the thiamine deficiency and anticancer action of drugs has not been characterized. A major natural thiamine derivative, thiamine diphosphate (ThDP), is a coenzyme of central metabolism, also known to affect transcriptional activity of the master metabolic regulator and genome guardian p53. A direct transcriptional target of p53, p21, regulates cell cycle dynamics and DNA damage response. Our work focuses on dependence of the action of the DNA damaging anticancer drug cisplatin on metabolic regulation through p53/p21 axes and cellular thiamine status in human lung adenocarcinoma cells A549. These cells are used as a model of a hardly curable cancer, known to develop chemoresistance to platinum drugs, such as cisplatin. Compared to wild type (A549WT), a stable line with a 60% knockdown of p21 (A549p21-) is less sensitive to antiproliferative action of cisplatin. In contrast, in the thiamine-deficient medium, cisplatin impairs the viability of A549p21- cells more than that of A549WT cells. Analysis of the associated metabolic changes in the cells indicates that (i) p21 knockdown restricts the production of 2-oxoglutarate via glutamate oxidation, stimulating that within the tricarboxylic acid (TCA) cycle; (ii) cellular cisplatin sensitivity is associated with a 4-fold upregulation of glutamic-oxaloacetic transaminase (GOT2) by cisplatin; (iii) cellular cisplatin resistance is associated with a 2-fold upregulation of p53 by cisplatin. Correlation analysis of the p53 expression and enzymatic activities upon variations in cellular thiamine/ThDP levels indicates that p21 knockdown substitutes positive correlation of the p53 expression with the activity of 2-oxoglutarate dehydrogenase complex (OGDHC) for that with the activity of glutamate dehydrogenase (GDH). The knockdown also changes correlations of the levels of OGDHC, GDH and GOT2 with those of the malate and isocitrate dehydrogenases. Thus, a p53/p21-dependent change in partitioning of the glutamate conversion to 2-oxoglutarate through GOT2 or GDH, linked to NAD(P)-dependent metabolism of 2-oxoglutarate in affiliated pathways, adapts A549 cells to thiamine deficiency or cisplatin treatment. Cellular thiamine deficiency may interfere with antiproliferative action of cisplatin due to their common modulation of the p53/p21-dependent metabolic switch between the glutamate oxidation and transamination.
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Affiliation(s)
- Vasily A. Aleshin
- Faculty of Bioengineering and Bioinformatics, Lomonosov Moscow State University, Moscow, Russia
- Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, Moscow, Russia
| | - Xiaoshan Zhou
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Shuba Krishnan
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Anna Karlsson
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Victoria I. Bunik
- Faculty of Bioengineering and Bioinformatics, Lomonosov Moscow State University, Moscow, Russia
- Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, Moscow, Russia
- Department of Biological Chemistry, Sechenov University, Moscow, Russia
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19
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Yoshioka A, Sato I, Onishi H, Ishida M. Subclinical thiamine deficiency identified by pretreatment evaluation in an esophageal cancer patient. Eur J Clin Nutr 2021; 75:564-566. [PMID: 32895510 PMCID: PMC7943416 DOI: 10.1038/s41430-020-00735-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/18/2020] [Accepted: 08/21/2020] [Indexed: 12/13/2022]
Abstract
Despite the fact that both thiamine deficiency (TD) and Wernicke encephalopathy (WE) have been observed to some degree in cancer patients, such cases of TD and/or WE reported to date have all been diagnosed after the initiation of treatment. We here report a case of TD that presented without the commonly accepted triad of WE symptoms based on a total nutritional evaluation prior to the onset of treatment for cancer. The patient was a 71-year-old man with esophageal cancer who was referred to the oncology outpatient clinic for evaluation to determine the treatment plan. Although he did not present with delirium, cerebellar signs, or ocular symptoms, TD was suspected based on a reduction in appetite lasting 2 months as thiamine stores in the body are depleted in as few as 18 days. Blood findings showed a marked decline in serum thiamine level supported, which the diagnosis of TD. This case revealed the existence of a cancer patient with subclinical TD prior to the onset of treatment for cancer. Due to the fact that TD can occur without the characteristic symptoms as in this case, we believe it is important that total nutritional evaluation of cancer patients always be considered.
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Affiliation(s)
- Akira Yoshioka
- Department of Clinical Oncology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Izumi Sato
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Hideki Onishi
- Departments of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka City, Japan
| | - Mayumi Ishida
- Departments of Psycho-oncology, Saitama Medical University International Medical Center, Hidaka City, Japan.
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20
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Onishi H, Ishida M. Insufficiency of B vitamins with its possible clinical implications. J Clin Biochem Nutr 2021; 68:1. [PMID: 33536702 PMCID: PMC7844661 DOI: 10.3164/jcbn.20-158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Hideki Onishi
- Department of Psycho-oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka City, Saitama 350-1298, Japan
| | - Mayumi Ishida
- Department of Psycho-oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka City, Saitama 350-1298, Japan
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21
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Nakamura ZM, MacKay DP, Davis AM, Brassfield ER, Joyner BL, Rosenstein DL. Reconsidering scarce drug rationing: implications for clinical research. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106739. [PMID: 33246996 DOI: 10.1136/medethics-2020-106739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/15/2020] [Accepted: 10/27/2020] [Indexed: 06/12/2023]
Abstract
Hospital systems commonly face the challenge of determining just ways to allocate scarce drugs during national shortages. There is no standardised approach of how this should be instituted, but principles of distributive justice are commonly used so that patients who are most likely to benefit from the drug receive it. As a result, clinical indications, in which the evidence for the drug is assumed to be established, are often prioritised over research use. In this manuscript, we present a case of a phase II investigational trial of intravenous thiamine for delirium prevention in patients undergoing haematopoietic stem cell transplantation to emphasise several shortcomings in the overarching prioritisation of clinical over research uses of scarce drugs. Specifically, we present the following considerations: (1) clinical use may not have stronger evidence than research use; (2) a strong scientific rationale for research use may outweigh the claim for clinical indications in which there is weak evidence; (3) treatment within the context of a clinical trial may be the standard of care; and (4) research use may not only benefit patients receiving the treatment but also offers the prospect of improving future clinical care. In summary, we argue against allocation schemes that prohibit all research uses of scarce drugs and instead recommend that allocation schemes include a balanced approach that weighs risks and benefits of access to scarce drugs irrespective of the research versus clinical use designation.
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Affiliation(s)
- Zev M Nakamura
- Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Douglas P MacKay
- Public Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center of Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Arlene M Davis
- Center of Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth R Brassfield
- Philosophy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Benny L Joyner
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Donald L Rosenstein
- Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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22
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Subclinical thiamine deficiency: What is the most appropriate method of diagnosis and treatment? Palliat Support Care 2020; 18:614-616. [PMID: 32985409 DOI: 10.1017/s147895152000098x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The symptoms of thiamine deficiency vary considerably and asymptomatic cases; i.e., subclinical thiamine deficiency (SCTD), are known to exist. However, there is no information available on the treatment of SCTD. METHODS We report a patient who underwent intravenous thiamine replacement therapy for about a month after being diagnosed with SCTD, but who developed SCTD again about three weeks after finishing the treatment. RESULTS The patient was a 64-year-old woman who, after starting treatment for cervical cancer, complained of anxiety and underwent an initial psychiatric examination. The psychiatric diagnosis was an adjustment disorder. Based on the possibility of SCTD complications due to her decreased appetite and weight loss, her serum thiamine concentration was measured and found to be low. Therefore, thiamine was administered intravenously for 29 days. At the end of treatment, thiamine administration was discontinued as there were no apparent neuropsychiatric symptoms or problems with appetite. Twenty-three days later, there were still no problems with appetite or neuropsychiatric symptoms, but a follow-up blood sample revealed that her serum thiamine was again below the normal range. SIGNIFICANCE OF RESULTS Currently, there is no information available regarding the diagnosis and treatment of SCTD in cancer patients. In some cases, such as this case, the deficiency recurs without any symptoms indicative of SCTD; therefore, further examination for diagnosis and treatment is necessary.
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23
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Nakamura ZM, Deal AM, Rosenstein DL, Quillen LJ, Chien SA, Wood WA, Shea TC, Park EM. Design of a randomized placebo controlled trial of high dose intravenous thiamine for the prevention of delirium in allogeneic hematopoietic stem cell transplantation. Contemp Clin Trials 2020; 95:106076. [PMID: 32619524 DOI: 10.1016/j.cct.2020.106076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Delirium is a highly prevalent and preventable neuropsychiatric condition with major health consequences. Thiamine deficiency is a well-established cause of delirium in those with chronic, severe alcoholism, but there remains an underappreciation of its significance in non-alcoholic populations, including patients with cancer. Treatment of suspected thiamine-related mental status changes with high dose intravenous (IV) thiamine has preliminary evidence for improving a variety of cognitive symptoms in oncology inpatient settings but has never been studied for the prevention of delirium in any population. OBJECTIVES The primary objective of this clinical trial is to determine if high dose IV thiamine can prevent delirium in patients receiving allogeneic hematopoietic stem cell transplantation (HSCT) for treatment of cancer. Secondary objectives are to determine if thiamine status is predictive of delirium onset and if high dose IV thiamine can attenuate the deleterious impact of delirium on health-related quality of life (HRQOL), functional status, and long-term neuropsychiatric outcomes. METHODS In this phase II study, we are recruiting 60 patients undergoing allogeneic HSCT, randomizing them to treatment with high dose IV thiamine (n = 30) versus placebo (n = 30), and systematically evaluating all participants for delirium and related comorbidities. We use the Delirium Rating Scale to measure the severity and duration of delirium during hospitalization for HSCT. We obtain thiamine levels weekly during the transplantation hospitalization. We assess HRQOL, functional status, depression, post-traumatic stress symptoms, and cognitive function prior to and at one, three, and six months after transplantation.
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Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura J Quillen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie A Chien
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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24
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Lonsdale D, Marrs C. The potential of lipid soluble thiamine in the treatment of cancer. AIMS BIOPHYSICS 2020. [DOI: 10.3934/biophy.2020002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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25
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Brault C, Marc J, Delette C, Gruson B, Marolleau JP, Maizel J, Zerbib Y. L’effetWarburg, un challenge diagnostique pour le médecin réanimateur. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’effetWarburg (EW) est une complication rare des cancers solides et des hémopathies malignes. Il est lié à une dérégulation du métabolisme glucidique au sein des cellules cancéreuses, entraînant la dégradation du glucose en lactate. Elle s’accompagne d’hypoglycémies asymptomatiques et d’une accumulation de lactate responsable d’une acidose lactique de type B. Dans cet article, nous proposons un algorithme pour aider le clinicien à diagnostiquer l’EW et discutons des thérapeutiques à envisager.
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26
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Thiamine deficiency in a patient with recurrent renal cell carcinoma who developed weight loss with normal appetite and loss of energy soon after nivolumab treatment. Palliat Support Care 2019; 18:241-243. [DOI: 10.1017/s1478951519000658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackgroundNivolumab has become an effective treatment option for cancer in various sites; however, this drug may cause immune-related adverse effects due to its mechanism of action. Furthermore, little has been reported on thiamine deficiency (TD) in patients receiving nivolumab treatment.MethodFrom a series of cancer patients, we reported a patient with recurrent renal cell carcinoma who developed TD after the start of nivolumab treatment.ResultsA 74-year-old man with recurrent renal cell carcinoma was referred to the psycho-oncology department as he had lost about 4 kg and displayed a loss of energy after four cycles of nivolumab treatment. Psychiatric interviews revealed a decrease in energy. Neurological examination did not reveal any impairment in consciousness, ataxia, or ocular symptoms. He did not develop appetite loss. The malabsorption or overconsumption of some nutrients is thought to occur due to the rapid loss of weight; thus, a reduction in vitamin B1, which has a short storage period in the body and is often deficient in cancer patients, was suspected. The diagnosis of TD was supported by the patient's abnormally low serum thiamine level.Significance of resultsIn patients treated with nivolumab, it is necessary to pay careful attention to TD when proceeding with the treatment. It is hoped that future research may reveal the link between nivolumab administration and TD.
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27
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Sinha S, Kataria A, Kolla BP, Thusius N, Loukianova LL. Wernicke Encephalopathy-Clinical Pearls. Mayo Clin Proc 2019; 94:1065-1072. [PMID: 31171116 DOI: 10.1016/j.mayocp.2019.02.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 02/05/2019] [Accepted: 02/21/2019] [Indexed: 12/16/2022]
Abstract
Wernicke encephalopathy (WE) was first described by Carl Wernicke in 1881. WE is caused by thiamine deficiency. Alcoholism is the most common etiologic factor associated with WE in the United States, but it can occur in any patient with a nutritional deficiency state such as hyperemesis gravidarum, intestinal obstruction, and malignancy. WE is a clinical diagnosis. The common findings include mental status changes, ocular dysfunction, and a gait apraxia, present in only 10% of cases. Only a few cases of WE are diagnosed before death. Approximately 80% of patients with untreated WE have development of Korsakoff syndrome, which is characterized by memory impairment associated with confabulation. The initial clinical diagnosis of WE is critical, keeping in mind that the classic triad of symptoms is often absent. Recognition of nutritional deficiency and any portion of the classic triad should prompt treatment. Additionally, hypothermia, hypotension, and coma should raise clinical suspicion for the disease. Primary treatment includes timely administration of thiamine, for which the route and dosage remain controversial. Clinical judgment should be exercised in diagnosis and treatment (dosage, frequency, route of administration and duration) in all cases of WE. Overdiagnosis and overtreatment may be preferred to prevent prolonged or persistent neurocognitive impairments given the excellent safety profile of thiamine. Further prospective research is warranted to better understand the disease biology, risk factors, and treatment recommendations.
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Affiliation(s)
- Shirshendu Sinha
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN.
| | - Archish Kataria
- Division of Gastroenterology, Department of Internal Medicine, University of Texas Health Science Center, San Antonio, TX
| | - Bhanu Prakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Nuria Thusius
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Larissa L Loukianova
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN
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28
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Helali J, Park S, Ziaeian B, Han JK, Lankarani-Fard A. Thiamine and Heart Failure: Challenging Cases of Modern-Day Cardiac Beriberi. Mayo Clin Proc Innov Qual Outcomes 2019; 3:221-225. [PMID: 31193878 PMCID: PMC6543258 DOI: 10.1016/j.mayocpiqo.2019.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/15/2019] [Accepted: 03/05/2019] [Indexed: 12/23/2022] Open
Abstract
Cardiac beriberi, or heart failure due to thiamine deficiency, is considered rare in the developed world. The diagnosis is often only considered in limited populations such as those with chronic alcoholism. Alternatively, the disease can be mislabeled as "alcoholic cardiomyopathy" or "nonischemic cardiomyopathy." The following 2 cases illustrate the need to expand our vigilance to other at-risk populations.
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Affiliation(s)
- Jonathan Helali
- Department of Medicine, Hospitalist Division, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, Hospitalist Division, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Sandy Park
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, CA
- Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Janet K. Han
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, CA
- Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Azadeh Lankarani-Fard
- Department of Medicine, Hospitalist Division, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, Hospitalist Division, David Geffen School of Medicine at University of California, Los Angeles, CA
- Correspondence: Address to Azadeh Lankarani-Fard, MD, Internal Medicine, VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073
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Abstract
AbstractObjectiveThiamine deficiency (TD) is recognized in various kinds of disease with associated loss of appetite including cancer. However, it has not been recognized to date in bereaved partners after spousal loss from cancer.MethodFrom a series of bereaved partners who lost a spouse to cancer, we report on those who developed TD after bereavement.ResultCase 1 was a 57-year-old woman who sought consultation at our “bereavement clinic.” Her husband had been diagnosed with pancreatic cancer one year earlier and had died one month previously. At the first visit, she was observed to suffer depression, anxiety, and decreased appetite. Neurological, blood, and biochemical examinations did not reveal any noteworthy findings. She was diagnosed with uncomplicated bereavement. Detailed examination revealed that her appetite had been markedly decreased for approximately five weeks. The diagnosis of TD was supported by her abnormally low serum thiamine level. Case 2 was a bereaved 73-year-old male who had lost his wife to hypopharyngeal cancer one month previously after a five-year illness. He had shown a lack of energy for the month preceding his wife's death, but because there was no improvement after her death, his family recommended he seek consultation at our “bereavement clinic.” He was suffering from major depressive disorder. Detailed examination revealed that his appetite had been decreased for more than two weeks. Again, the diagnosis of TD was supported by his abnormally low serum thiamine level.Significance of resultsThese reports demonstrate that there is a possibility that bereaved could develop TD after the loss of a loved one. TD should be considered whenever there is a loss of appetite lasting for more than 2 weeks, and medical staff should pay careful attention to the physical condition of the bereaved to prevent complications because of TD.
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Wai JM, Aloezos C, Mowrey WB, Baron SW, Cregin R, Forman HL. Using clinical decision support through the electronic medical record to increase prescribing of high-dose parenteral thiamine in hospitalized patients with alcohol use disorder. J Subst Abuse Treat 2019; 99:117-123. [PMID: 30797383 DOI: 10.1016/j.jsat.2019.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/20/2019] [Accepted: 01/23/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with alcohol use disorder (AUD) are at an increased risk of developing Wernicke's encephalopathy (WE), a devastating and difficult diagnosis caused by thiamine deficiency. Even as AUD is present in up to 25% of hospitalized patients on medical floors, appropriate thiamine supplementation in the hospital setting remains inadequate. These patients are particularly susceptible to thiamine deficiency and subsequent WE due to both their alcohol use and active medical illnesses. The electronic medical record (EMR) has become ubiquitous in health care systems and can be used as a tool to improve the care of hospitalized patients. METHODS As a quality improvement initiative, we implemented a medication order panel in the EMR with autopopulated orders for thiamine dosing to increase the appropriate use of high-dose parenteral thiamine (HPT) for hospitalized patients with AUD. We conducted a retrospective cohort study of all inpatients with AUD who received an Addiction Psychiatry Consult Service consult three months before and after the EMR change. We compared the proportion of patients receiving HPT prior to consultation (primary outcome) and the length of stay (secondary outcome) between the historical control group and the EMR intervention group. RESULTS Patients in the EMR intervention group were significantly more likely to receive HPT than the historical control group (20.2% vs. 2.7%, p < 0.0001). This difference remained statistically significant when adjusted for potential confounders (OR: 9.89, 95% CI: [2.77, 35.34], p = 0.0004). There was a trend towards statistical significance that the intervention group had a higher likelihood of being prescribed any thiamine (76.6% vs. 64.6%, p = 0.06) and had a shorter length of stay (median (IQR): 3.8 (2.4, 7.0) vs. 4.6 (2.9, 7.8) days, p = 0.06). CONCLUSION These results indicate that providing autopopulated thiamine order panels for patients with AUD can be an effective method for specialty services to increase appropriate care practices without additional education or training for providers. Further research should consider the clinical outcomes of increasing HPT for patients with AUD.
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Affiliation(s)
- Jonathan M Wai
- Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 66, Office 3705, New York, NY 10032, USA; Division on Substance Use Disorders, New York State Psychiatric Institute, Unit 66, Office 3705, New York, NY 10032, USA; Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Christopher Aloezos
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA; Department of Psychiatry, NYU School of Medicine, One Park Avenue, New York, NY 10016, USA
| | - Wenzhu B Mowrey
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Sarah W Baron
- Department of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Regina Cregin
- Department of Pharmacy, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
| | - Howard L Forman
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
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Liu X, Cooper DE, Cluntun AA, Warmoes MO, Zhao S, Reid MA, Liu J, Lund PJ, Lopes M, Garcia BA, Wellen KE, Kirsch DG, Locasale JW. Acetate Production from Glucose and Coupling to Mitochondrial Metabolism in Mammals. Cell 2018; 175:502-513.e13. [PMID: 30245009 PMCID: PMC6173642 DOI: 10.1016/j.cell.2018.08.040] [Citation(s) in RCA: 228] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/22/2018] [Accepted: 08/17/2018] [Indexed: 12/17/2022]
Abstract
Acetate is a major nutrient that supports acetyl-coenzyme A (Ac-CoA) metabolism and thus lipogenesis and protein acetylation. However, its source is unclear. Here, we report that pyruvate, the end product of glycolysis and key node in central carbon metabolism, quantitatively generates acetate in mammals. This phenomenon becomes more pronounced in the context of nutritional excess, such as during hyperactive glucose metabolism. Conversion of pyruvate to acetate occurs through two mechanisms: (1) coupling to reactive oxygen species (ROS) and (2) neomorphic enzyme activity from keto acid dehydrogenases that enable function as pyruvate decarboxylases. Further, we demonstrate that de novo acetate production sustains Ac-CoA pools and cell proliferation in limited metabolic environments, such as during mitochondrial dysfunction or ATP citrate lyase (ACLY) deficiency. By virtue of de novo acetate production being coupled to mitochondrial metabolism, there are numerous possible regulatory mechanisms and links to pathophysiology.
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Affiliation(s)
- Xiaojing Liu
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Duke University, Durham, NC 27710, USA
| | - Daniel E Cooper
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - Ahmad A Cluntun
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Duke University, Durham, NC 27710, USA
| | - Marc O Warmoes
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Duke University, Durham, NC 27710, USA
| | - Steven Zhao
- Department of Cancer Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael A Reid
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Duke University, Durham, NC 27710, USA
| | - Juan Liu
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Duke University, Durham, NC 27710, USA
| | - Peder J Lund
- Department of Biochemistry and Biophysics, Penn Epigenetics Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Mariana Lopes
- Department of Biochemistry and Biophysics, Penn Epigenetics Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Benjamin A Garcia
- Department of Biochemistry and Biophysics, Penn Epigenetics Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kathryn E Wellen
- Department of Cancer Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David G Kirsch
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Duke University, Durham, NC 27710, USA; Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - Jason W Locasale
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Duke University, Durham, NC 27710, USA.
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Subclinical thiamine deficiency identified by preoperative evaluation in an ovarian cancer patient: Diagnosis and the need for preoperative thiamine measurement. Palliat Support Care 2018; 17:609-610. [DOI: 10.1017/s1478951518000615] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveAlthough thiamine deficiency (TD) and Wernicke encephalopathy (WE) are not rare in cancer patients, the cases reported to date developed TD and/or WE after treatment had started.MethodFrom a series of cancer patients, we report a patient diagnosed with TD without the typical clinical symptoms of WE at the preoperative psychiatric examination.ResultA 43-year-old woman with ovarian cancer was referred by her oncologist to the psycho-oncology outpatient clinic for preoperative psychiatric evaluation. Her tumor had been growing rapidly before the referral. Although she did not develop delirium, cerebellar signs, or eye symptoms, we suspected she might have developed TD because of her 2-month loss of appetite as the storage capacity of thiamine in the body is approximately 18 days. The diagnosis of TD was supported by abnormally low serum thiamine levels.Significance of resultsCancer therapists need to be aware that thiamine deficiency may occur even before the start of cancer treatment. In cases with a loss of appetite of more than 2 weeks’ duration, in particular, thiamine deficiency should be considered if the tumor is rapidly increasing, regardless of the presence or absence of delirium.
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Abstract
OBJECTIVE Wernicke encephalopathy (WE) is a neuropsychiatric disorder caused by thiamine deficiency. It is recognized in various stages of the cancer trajectory but has not previously been recognized during nivolumab treatment. METHOD From a series of WE patients with cancer, we report a lung cancer patient who developed WE during treatment with nivolumab. RESULT A 78-year-old woman with lung cancer was referred to our psycho-oncology clinic because of depressed mood. Psychiatric examination revealed disorientation to time, date, and place, which had not been recognized 1 month previously. Her symptoms fulfilled the diagnostic criteria for delirium. No laboratory findings or drugs explaining her delirium were identified. WE was suspected as she experienced a loss of appetite lasting 4 weeks. This diagnosis was supported by abnormal serum thiamine and the disappearance of delirium after intravenous thiamine administration. SIGNIFICANCE OF RESULTS We found WE in an advanced lung cancer patient receiving treatment with nivolumab. Further study revealed the association between nivolumab and thiamine deficiency. Oncologists should consider thiamine deficiency when a patient experiences a loss of appetite of more than 2 weeks regardless of the presence or absence of delirium.
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Nakamura ZM, Tatreau JR, Rosenstein DL, Park EM. Clinical Characteristics and Outcomes Associated With High-Dose Intravenous Thiamine Administration in Patients With Encephalopathy. PSYCHOSOMATICS 2018; 59:379-387. [PMID: 29482863 DOI: 10.1016/j.psym.2018.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 01/09/2018] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Wernicke encephalopathy is a common neuropsychiatric syndrome due to thiamine deficiency. There is no consensus regarding thiamine dosing when Wernicke encephalopathy is suspected. A longstanding dosing strategy for Wernicke encephalopathy is 100mg daily, yet updated clinical guidelines suggest using high-dose intravenous (HDIV) thiamine. OBJECTIVE To describe thiamine prescribing practices at a large, public academic hospital and investigate clinical characteristics and outcomes associated with HDIV thiamine in patients with encephalopathy who received IV thiamine. METHODS Electronic medical records of hospitalized patients who received thiamine between 4/4/2014 and 11/1/2015 were reviewed. Chi-square tests, Wilcoxon Rank Sum tests, and logistic regression were used to compare clinical variables in patients with encephalopathy who received HDIV thiamine (≥ 200mg twice daily) vs lower doses of IV thiamine. RESULTS Among the total of 5236 thiamine orders, 29% (n = 1531) were IV; 10% (n = 150) of IV orders met HDIV criteria. In patients with encephalopathy who received IV thiamine (n = 432), HDIV thiamine was administered to 20% (n = 86) and only 2.1% (n = 9) received dosing consistent with Royal College of Physicians guidelines. In bivariable analyses, HDIV thiamine was associated with surgical services (p = 0.001), psychiatric consultation (p < 0.001), and decreased mortality (p = 0.004). In multivariable models, the association between HDIV thiamine and decreased in-hospital mortality did not meet statistical significance (p = 0.061). CONCLUSIONS In a large, public academic hospital, guideline-concordant thiamine supplementation is rare and HDIV thiamine is infrequently prescribed to patients with encephalopathy. Further studies are needed to confirm the possible benefits of HDIV thiamine for patients with suspected thiamine-deficient encephalopathy.
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Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC.
| | - Jason R Tatreau
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC
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Abstract
AbstractObjectiveThiamine is an essential coenzyme for oxidative metabolisms; however, it is not synthesized in the human body, and the average thiamine storage capacity is approximately 18 days. Therefore, thiamine deficiency (TD) can occur in any condition of unbalanced nutrition. If TD is left untreated, it causes the neuropsychiatric disorder Wernicke encephalopathy (WE). Although WE is a medical emergency, it is sometimes overlooked because most patients with WE do not exhibit all of the typical symptoms, including delirium, ataxia, and ophthalmoplegia. If all of the typical clinical symptoms of WE are absent, diagnosis of TD or WE becomes more difficult.MethodFrom a series of cancer patients, we reported three patients who developed TD without the typical clinical symptoms of WE.ResultA 69-year-old woman with pancreatic body cancer receiving chemotherapy with paclitaxel and gemcitabine for six months. Her performance status (PS) was 1. A detailed interview revealed that she had appetite loss for six months. Another 69-year-old woman with ovarian cancer received nedaplatin; her PS was 0. A detailed interview revealed that she had appetite loss for three months. A 67-year-old woman with colon cancer receiving ramucirumab in combination with second-line fluorouracil with folinic acid and irinotecan. Her PS was 1. A detailed interview revealed that she had appetite loss for three weeks. None exhibited typical clinical signs of WE, but they developed appetite loss for six months, three months, and three weeks, respectively. The diagnosis of TD was supported by abnormally low serum thiamine levels.Significance of the resultsThis report emphasizes the possibility of TD in cancer patients even when patients do not develop typical clinical signs of WE. The presence of appetite loss for more than two weeks may aid in diagnosing TD. Patients receiving chemotherapy may be at greater risk for developing TD.
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