Four cases of selenium deficiency in postoperative long-term enteral nutrition

Macrocytic anemia induced by selenium deficiency in the course of anorexia nervosa: A case report

RATIONALE

Anorexia nervosa is characterized by an extreme fear of weight gain. Clinicians often prescribe meal replacement shakes if patients are unable or unwilling to consume typical foods. However, these shakes sometimes lack essential micronutrients, such as selenium, which may lead to health risks. Moreover, selenium deficiency induces macrocytic anemia. Herein, we present a case of a patient with anorexia nervosa with macrocytic anemia due to selenium deficiency, which was alleviated by selenium supplementation.

PATIENT CONCERNS

An 18-year-old female was admitted to our hospital. The patient was diagnosed with anorexia nervosa. Ultimately, she was unable to walk independently because of fatigue and electrolyte disturbances.

CLINICAL FINDINGS

On admission, the height, weight, and body mass index of the patient were 158.5 cm, 27.1 kg, and 10.8, respectively. Our treatment for anorexia nervosa showed relative effectiveness, and the patient's body weight recovered to 29.2 kg by day 60. However, the mean corpuscular volume increased from day 20, suggesting macrocytic anemia.

DIAGNOSES, INTERVENTIONS, AND OUTCOMES

Despite our vitamin B12 and folic acid supplementation interventions, the mean corpuscular volume continued to rise. On day 60, the patient was diagnosed with selenium deficiency, and selenium administration of 100 μg/day was initiated.

OUTCOMES

The macrocytic anemia in the patient was alleviated, and treatment for anorexia nervosa was continued in our hospital.

LESSONS

To the best of our knowledge, this is the first case of macrocytic anemia induced by selenium deficiency with anorexia nervosa comorbidity, underscoring the importance of selenium supplementation in patients with anorexia nervosa, especially in those with macrocytic anemia.

ESPEN micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome.

OBJECTIVE

This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement".

METHODS

The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed.

CONCLUSION

This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.

Acquired disorders with hypopigmentation: A clinical approach to diagnosis and treatment

Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphologic findings, can aid in delineating the causes of acquired hypopigmented disorders. The second article in this 2-part continuing medical education series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.

The effect of pasteurization on trace elements in donor breast milk

OBJECTIVE

Premature infants often receive pasteurized donor human milk when mothers are unable to provide their own milk. This study aims to establish the effect of the pasteurization process on a range of trace elements in donor milk.

STUDY DESIGN

Breast milk was collected from 16 mothers donating to the milk bank at the Royal Brisbane and Women's Hospital. Samples were divided into pre- and post-pasteurization aliquots and were Holder pasteurized. Inductively coupled plasma mass spectrometry was used to analyze the trace elements zinc (Zn), copper (Cu), selenium (Se), manganese (Mn), iodine (I), iron (Fe), molybdenum (Mo) and bromine (Br). Differences in trace elements pre- and post-pasteurization were analyzed.

RESULTS

No significant differences were found between the trace elements tested pre- and post-pasteurization, except for Fe (P<0.05). The median (interquartile range, 25 to 75%; μg l(-1)) of trace elements for pre- and post- pasteurization aliquots were-Zn: 1639 (888-4508), 1743 (878-4143), Cu: 360 (258-571), 367 (253-531), Se: 12.34 (11.73-17.60), 12.62 (11.94-16.64), Mn: (1.48 (1.01-1.75), 1.49 (1.11-1.75), I (153 (94-189), 158 (93-183), Fe (211 (171-277), 194 (153-253), Mo (1.46 (0.37-2.99), 1.42 (0.29-3.73) and Br (1066 (834-1443), 989 (902-1396).

CONCLUSIONS

Pasteurization had minimal effect on several trace elements in donor breast milk but high levels of inter-donor variability of trace elements were observed. The observed decrease in the iron content of pasteurized donor milk is, however, unlikely to be clinically relevant.

Probing the bioinorganic chemistry of toxic metals in the mammalian bloodstream to advance human health

The etiology of numerous grievous human diseases, including Alzheimer's and Parkinson's Disease is not well understood. Conversely, the concentration toxic metals and metalloids, such as As, Cd, Hg and Pb in human blood of the average population is well established, yet we know strikingly little about the role that they might play in the etiology of disease processes. Establishing functional connections between the chronic exposure of humans to these and other inorganic pollutants and the etiology of certain human diseases is therefore viewed by many as one of the greatest challenges in the post-genomic era. Conceptually, this task requires us to uncover hitherto unknown biomolecular mechanisms which must explain how small doses of a toxic metal/metalloid compound (low μg per day) - or mixtures thereof - may eventually result in a particular human disease. The biological complexity that is inherently associated with mammals, however, makes the discovery of these mechanisms a truly monumental task. Recent findings suggest that a better understanding of the bioinorganic chemistry of inorganic pollutants in the mammalian bloodstream represents a fruitful strategy to unravel relevant biomolecular mechanisms. The adverse effect(s) that toxic metals/metalloid compounds exert on the transport of essential ultratrace elements to internal organs appear particularly pertinent. A brief overview of the effect that arsenite and Hg(2+) exert on the mammalian metabolism of selenium is presented.

Evaluation of enteral formulas for nutrition, health, and quality of life among stroke patients

Enteral nutritional support has been used via tube feeding for dysphagic stroke patients. We performed long and short term trials to evaluate the effects of commercial enteral nutritional supports on nutrition and health in stroke patients (mRS = 3~5) and quality of life in their caregivers. For a long term study, we recruited chronic (≥ 1 yrs) stroke patients (n = 6) and administered them 6 cans/day (1,200 kcal) of the commercial enteral formula N for 6 months according to IRB-approved protocol. We collected peripheral blood at 0, 2, 4 and 6 months. For a short term study, we recruited acute (≤ 3 months) stroke patients (n = 12) and randomly administered them two different commercial enteral formulas, N or J, for 2 weeks. We collected their blood at 0, 4, 7 and 14 day of the administration. Blood samples were analyzed to quantify 19 health and nutritional biomarkers and an oxidative stress biomarker, malondialdehyde (MDA). In order to evaluate quality of life, we also obtained the sense of competence questionnaire (SCQ) from all caregivers at 'before' and 'after trials'. As results, the enteral formula, N, improved hemoglobin and hematocrit levels in the long term trial and maintained most of biomarkers within normal ranges. The SCQ levels of caregivers were improved in the long term treatment (P < 0.05). In a case of the short term study, both of enteral formulas were helpful to maintain nutritional status of the patients. In addition, MDA levels were decreased in the acute patients following formula consumption (0.05 < P < 0.1). Most of health and nutrition outcomes were not different, even though there is a big difference in price of the two products. Thus, we evaluate the formula N has equal nutritional efficacy compared to the formula J. In addition, long term use of enteral formula N can be useful to health and nutrition of stroke patients, and the quality of life for their caregivers.

Clinical features of selenium deficiency in infants receiving long-term nutritional support

OBJECTIVE

Selenium deficiency is a known complication in patients requiring long-term nutritional support; however, the clinical features of selenium deficiency in infants have not been completely described. We describe the clinical features of selenium deficiency in infants.

METHODS

Six infants with selenium deficiency were studied retrospectively, with a focus on the period of nutritional support, the clinical symptoms, and the chronologic changes in serum selenium concentrations before and after the administration of selenite.

RESULTS

The onset of selenium deficiency in five patients occurred at <6 mo of age; selenium deficiency occurred in one patient 14 mo after birth. One patient received parenteral nutrition for 15 mo after birth; the other five patients primarily received an elemental diet for 2-6 mo. In all patients, growth retardation and alopecia with pseudoalbinism were the characteristic symptoms of selenium deficiency. At the time of diagnosis, the serum selenium level in four patients was <2.0 microg/dL and serum selenium levels in two patients were 3.2 and 3.3 microg/dL, respectively. The resolution of hair symptoms corresponded to the level of serum selenium after 1-2 mo and a rapid improvement in growth occurred in all patients after the administration of selenite.

CONCLUSION

The early clinical symptoms of selenium deficiency in infants include growth retardation and alopecia with pseudoalbinism, which are reversible if the patients are treated with adequate amounts of selenite. Clinicians who manage infants receiving long-term nutritional support, including an elemental diet, should be aware of the symptoms associated with selenium deficiency.

Association of low plasma selenium concentrations with poor muscle strength in older community-dwelling adults: the InCHIANTI Study

BACKGROUND

Although selenium plays an important role in muscle function, the relation between circulating selenium and muscle strength in elderly adults has not been characterized.

OBJECTIVE

The objective was to examine the hypothesis that low plasma selenium is associated with poor muscle strength in older adults.

DESIGN

We measured plasma selenium and hip, grip, and knee strength in a cross-sectional study of 891 men and women aged >or=65 y from the Invecchiare in Chianti (InCHIANTI) Study, a population-based cohort study in Tuscany (Italy). Poor muscle strength was defined as the lowest quartile of hip flexion, grip, and knee extension strength.

RESULTS

Overall, mean (+/-SD) plasma selenium was 0.95 +/- 0.15 mumol/L. After adjustment for age, sex, education, total energy intake, body mass index, and chronic disease, participants in the lowest versus the highest quartile of plasma selenium were at higher risk of poor hip strength [odds ratio (OR): 1.69; 95% CI: 1.02, 2.83; P = 0.04, P for linear trend = 0.04], knee strength (OR: 1.94; 95% CI: 1.18, 3.19; P = 0.009, P for linear trend = 0.01), and grip strength (OR: 1.94; 95% CI: 1.19, 3.16; P = 0.008, P for linear trend = 0.08).

CONCLUSIONS

Low plasma selenium is independently associated with poor skeletal muscle strength in community-dwelling older adults in Tuscany.

Skeletal muscle disorders associated with selenium deficiency in humans

Skeletal muscle disorders manifested by muscle pain, fatigue, proximal weakness, and serum creatine kinase (CK) elevation have been reported in patients with selenium deficiency. The object of this report was to review the conditions in which selenium deficiency is associated with human skeletal muscle disorders and to evaluate the importance of mitochondrial alterations in these disorders. A systematic literature review using the Medline database and Cochrane Library provided 38 relevant articles. The main conditions associated with selenium deficiency fell into three categories: (1) insufficient selenium intake in low soil-selenium areas; (2) parenteral or enteral nutrition, or malabsorption; and (3) chronic conditions associated with oxidative stress, such as chronic alcohol abuse and human immunodeficiency virus (HIV) infection. In low soil-selenium areas, reversibility of muscle symptoms was similar after selenium supplementation and placebo administration, suggesting a role for other factors in the development of disease. In parenteral or enteral nutrition, or malabsorption, muscle symptoms improved after selenium supplementation in 18 of 19 patients (median delay: 4 weeks). The reason that only a minority of selenium-deficient patients present with skeletal muscle disorders is unclear and is possibly related to cofactors, such as viral infections and drugs. Prospective studies of selenium-deficient myopathies would be useful in critically ill patients, alcohol abusers, and HIV-infected patients.

Peripartum cardiomyopathy: a selenium disconnection and an autoimmune connection

BACKGROUND

Increased incidence and prevalence of peripartum cardiomyopathy (PPCM) have been documented in the Hospital Albert Schweitzer (HAS) District of Haiti. Although the basis for this increased incidence of PPCM remains unclear, there is growing evidence for an underlying autoimmune process. One potential risk factor for increased autoreactivity is a micronutrient deficiency. In Africa, low plasma selenium (Se) level has been reported as a possible risk factor for PPCM. This report details results of initial studies to test the hypothesis that plasma levels of Se and/or other micronutrients may be related to PPCM risk in this population.

METHODS

Under the direction of the Institutional Review Board (HAS Ethics Committee) and with informed consent, levels of Se and other micronutrients were measured in plasma samples obtained from PPCM mothers and parity-matched control mothers from the HAS District of Haiti.

RESULTS

Mean plasma Se level in 18 PPCM patients was 110 ng/ml (range 67-145) compared to mean plasma Se level in 34 control mothers of 121 ng/ml (range 98-172) (P=0.1748). These levels are substantially greater than those reported for pediatric patients with Keshan cardiomyopathy, which can be prevented by Se prophylaxis. No deficiency or significant difference was found in any other micronutrient tested (Vitamin A (retinol), Vitamin B(12), Vitamin C, Vitamin E, and B-Carotene) for these PPCM and control mothers.

CONCLUSION

Although there are several possible mechanisms by which Se could play a role in the pathobiology of PPCM, there is no evidence that Se deficiency is a cause of PPCM or a risk factor for the development of PPCM in this district of Haiti. The results of this investigation indicate that future studies of PPCM in this population should focus on other potential etiologic and risk factors.

Dietary intake after pancreatectomy

BACKGROUND

Nutritional intake after pancreatectomy may be impaired. The extent of the problem and the effect on intake of specific nutrients is unknown.

METHODS

A 1-week weighed dietary food intake (using digital scales and a food diary) was studied in 15 patients, a median of 4 (range 1-30) months after pancreatectomy. Results were expressed as a percentage of estimated average requirement (EAR), reference nutrient intake (RNI) or lower RNI (LRNI) values.

RESULTS

The median energy intake was 1914 (range 1154-2804) kcal/day, representing a median of 88 (56-154) per cent of EAR. Fat intake was low (72 (60-123) g/day); protein intake was adequate (139 (99-219) per cent of RNI). Deficiencies were observed in the intake of vitamin D (17 (6-56) per cent of LRNI) and, in some patients, selenium (107 (19-203) per cent of LRNI).

CONCLUSION

Nutritional intake in the months after pancreatectomy could be improved by increasing fat intake (with enzyme supplements as appropriate). This 7-day study also suggests that these patients may require vitamin D and possibly selenium supplementation.

Grains or veins: is enteral nutrition really better than parenteral nutrition? A look at the evidence

BACKGROUND

Enteral nutrition is said to be better than parenteral nutrition for providing nutrition support to humans.

PURPOSE

To assess the literature documenting the assertions that enteral nutrition is superior to parenteral nutrition with respect to cost, safety, physiology, intestinal structure and function, bacterial translocation, and outcome.

DATA IDENTIFICATION

Sources included MEDLINE search, personal files, and references from human comparative studies of enteral vs parenteral nutrition.

STUDY SELECTION

The goal was to include all human studies directly addressing questions of comparative efficacy of enteral and parenteral nutrition. Emphasis was given to prospective randomized controlled studies where available. Retrospective comparisons were not included.

DATA EXTRACTION

An attempt was made to briefly summarize methodology and findings of relevant studies. No general attempt was made to assess quality of individual studies.

RESULTS OF DATA SYNTHESIS

Enteral nutrition appears to be less expensive than parenteral nutrition, but new economic analyses are needed given the newer aggressive access techniques for enteral nutrition. Enteral nutrition is associated with meaningful morbidity and mortality. The little comparative data existent suggest no differences in safety. Comparative studies of physiology and metabolism as well as comparative and noncomparative studies of intestinal function and structure do not support putative advantages of enteral nutrition. There is no evidence that enteral nutrition prevents bacterial translocation in humans. Enteral nutrition probably reduces septic morbidity compared with parenteral nutrition in abdominal trauma. Otherwise, there is no evidence that enteral nutrition consistently improves patient outcome compared with parenteral nutrition.

CONCLUSIONS

With the exception of decreased cost and probable reduced septic morbidity in acute abdominal trauma, the available literature does not support the thesis that enteral nutrition is better than parenteral nutrition in humans.

Micronutrients in adult nutritional support: requirements and benefits

The prevention of micronutrient deficiency alone is no longer an adequate objective in micronutrient provision. New research indicates that many micronutrients are involved in other aspects of cell metabolism, especially in preventing cell damage caused by free radicals produced as part of oxidative metabolism. Clinical trials of micronutrient supplements are now becoming available, so that biochemical changes can be related to physiological, immunological, and clinical endpoints.