Treatment effects of parenteral vitamins in total parenteral nutrition patients

Carob Pulp: A Nutritional and Functional By-Product Worldwide Spread in the Formulation of Different Food Products and Beverages. A Review

Carob (Ceratonia siliqua L.) pod is a characteristic fruit from the Mediterranean regions. It is composed by seeds, the valuable part due to the extraction of locust bean gum, and the pulp, considered a by-product of the fruit processing industry. Carob pulp is a mixture of macro- and micronutrients, such as carbohydrates, vitamins and minerals, and secondary metabolites with functional properties. In the last few years, numerous studies on the chemical and biological characteristics of the pulp have been performed to encourage its commercial use. Its potential applications as a nutraceutical ingredient in many recipes for food and beverage elaborations have been extensively evaluated. Another aspect highlighted in this work is the use of alternative processes or conditions to mitigate furanic production, recognized for its toxicity. Furthermore, carob pulp’s similar sensorial, chemical and biological properties to cocoa, the absence of the stimulating alkaloids theobromine and caffeine, as well as its low-fat content, make it a healthier potential substitute for cocoa. This paper reviews the nutritional and functional values of carob pulp-based products in order to provide information on the proclaimed health-promoting properties of this interesting by-product.

Ascorbic acid dynamics in the seriously ill and injured

BACKGROUND

In addition to the known beneficial effects of ascorbic acid on wound healing and the immune response, it is also a potent extracellular antioxidant. Recent work in septic rats suggests that high-dose ascorbic acid total parenteral nutrition (TPN) supplementation may protect cells from free radical injury and improve survival. In this study, we determined ascorbic acid levels in the immediate post-injury/illness period and evaluated the ability of early short-term high levels of ascorbic acid in TPN to normalize plasma levels.

MATERIALS AND METHODS

Ascorbic acid levels were determined in 12 critically injured patients and 2 patients with severe surgical infections. Each patient received TPN supplemented with increasing doses of ascorbic acid over a 6-day period. Therapeutic responses were determined by plasma and urine measurements using high-pressure liquid chromatography.

RESULTS

The initial mean +/- SEM baseline plasma ascorbic acid concentration was depressed (0.11 +/- 0.03 mg/dl) and unresponsive following 2 days on 300 mg/day supplementation (0.14 +/- 0.03; P = 1.0) and only approached low normal plasma levels following 2 days on 1000 mg/day (0.32 +/- 0.08; P = 0.36). A significant increase was noted following 2 days on 3000 mg/day (1.2 +/- 0.03; P = 0.005).

CONCLUSION

We confirmed extremely low plasma levels of ascorbic acid following trauma and infection. Maximal early repletion of this vitamin requires rapid pool filling early in the post-injury period using supraphysiologic doses for 3 or more days.

Abnormal vitamin levels in patients receiving home total parenteral nutrition

The administration of multivitamins to patients receiving home parenteral nutrition (HPN) was decreased from once daily to three times weekly during the parenteral multivitamin shortage in 1997. Blood vitamin levels were measured to examine whether the decrement in the infused vitamins affected the levels. Six patients with normal renal and liver function, receiving HPN for 6 months to 10 years, were studied 6 months after the institution of 10 mL of multivitamins thrice weekly. Two patients with renal insufficiency who required hemodialysis and HPN were also studied. Multivitamin administration was eliminated in one patient and was reduced to once weekly when elevated pyridoxine levels were found in association with possible neurotoxicity. Five of the six patients with normal renal function had low serum ascorbic acid levels. Serum riboflavin levels were found to be low in one patient, serum pyridoxine was low in one, serum retinoids were low in three, and serum niacin was low in one. There were no clinically obvious untoward effects caused by the vitamin deficiencies. Each of the dialysis patients had elevated serum pyridoxine levels and had some neurologic disturbance (peripheral neuropathy, involuntary movements). The serum pyridoxine levels fell to normal in each after the cessation or decrease of the multivitamin preparation. Ascorbic acid levels were low in one patient and fell into abnormally low levels in the other when the parenteral multivitamins were reduced, but they corrected with the separate administration of intravenous vitamin C. In conclusion, the reduced administration of multivitamins in 1997 resulted in diminished ascorbic acid levels in seven of eight patients receiving total parenteral nutrition. Less often, low levels of retinoids, niacin, pyridoxine, and riboflavin were seen. Patients with chronic renal failure receiving HPN with multivitamins may develop elevated pyridoxine levels, which might result in neurologic sequelae.

Fat-soluble vitamin concentration in chronic alcohol-induced pancreatitis. Relationship with steatorrhea

In order to study the fat-soluble vitamin concentration of patients with chronic alcohol-induced pancreatitis (CAIP) we measured vitamins A and E, total lipids, and retinol-binding protein (RBP) in the plasma of 44 patients with CAIP and 83 controls (44 healthy controls; 39 Crohn's disease patients). Mean plasma vitamin E and vitamin E/total lipid ratio were significantly lower in CAIP when compared with either control or Crohn's disease groups. A low vitamin E/total lipid ratio was found in 75% of CAIP patients (91% with steatorrhea) and a ratio less than 1.0 was virtually 100% predictive of steatorrhea. The mean plasma vitamin A level for the CAIP group was significantly lower (overall 16%, 38% with steatorrhea) than in controls. Patients with CAIP show subnormal plasma levels vitamin E more often as compared to vitamin A. Further, the plasma vitamin E/total lipids ratio may be a sensitive and practical means in the detection and follow-up of steatorrhea in these patients.

Low serum folic acid levels in a nursing home population: a clinical experience

Four hundred fifty-five residents of the Wisconsin Veterans Home had fasting serum specimens obtained for folic acid as part of standard practice. Twenty-nine percent were taking folic acid supplements. Six percent (n = 28) were taking phenytoin, a folate antagonist. No resident receiving a folate supplement (400 mcg/day) had a low serum folic acid level. This finding may be important for practitioners selecting a dose of folic acid for nursing home patients. Of the 325 residents not receiving a folate supplement, nine (3%) had low folic acid levels (< 2.5 ng/mL). Two of the nine were receiving phenytoin. Five were characterized by staff as eating well. As low serum levels are preventable with a multivitamin, we believe that supplementation with a multivitamin containing 400 mcg folic acid/day should be considered in nursing home residents.

Vitamin E status of patients receiving long-term parenteral nutrition: is vitamin E supplementation adequate?

Vitamin E status of eight patients receiving total parenteral nutrition (TPN), including 10 IU of all-racemic alpha-tocopheryl acetate daily and Intralipid 20% (500 mL; 12 mg of RRR-alpha- and 92 mg of RRR-gamma-tocopherols) two to three times per week for 69 +/- 45 (mean +/- SD) months was assessed by measuring plasma and adipose tissue tocopherol concentrations. Plasma alpha-tocopherols of TPN patients were similar to controls (17.5 +/- 6.6 mumol/L vs 22.4 +/- 5.1), whereas gamma-tocopherols were significantly reduced (6.0 +/- 3.1 vs 11.2 +/- 3.6, p less than 0.03). The adipose tissue alpha- and gamma-tocopherol/triglycerides (TG) were similar (369 +/- 215 nmol/mmol vs 452 +/- 228, and 125 +/- 102 vs 140 +/- 130, respectively), but cholesterol/TG were increased in the TPN patients (7.8 +/- 2.5 mumol/mmol vs 5.1 +/- 3.5, p less than 0.05), suggesting that adipose tissue was relatively TG-depleted and tocopherol/cholesterol measurements better reflect vitamin E status. The mean alpha-tocopherol/cholesterol ratios were significantly lower in the TPN patients than the controls (55 +/- 36 vs 106 +/- 63, p less than 0.04). Thus, current vitamin E supplementation of TPN patients seems insufficient for maintenance of adequate tissue stores.

Laboratory measurements of nutritional status as correlates of atrophic glossitis

OBJECTIVE

To perform a comprehensive laboratory assessment of nutritional status in two elderly patients selected for the presence of atrophic glossitis, a classic physical sign of malnutrition.

DESIGN

Case report.

SETTING

Inpatient internal medicine ward at the William S. Middleton Memorial Veterans Medical Center, Madison, Wisconsin.

MEASUREMENTS AND MAIN RESULTS

Blood specimens were analyzed by the Nutrition Evaluation Laboratory at the USDA Human Nutrition Research Center on Aging at Tufts University. Both subjects had biochemical evidence of protein-calorie malnutrition and were deficient or marginally deficient in several vitamins and trace minerals.

CONCLUSIONS

Much work needs to be done to determine the sensitivity and positive predictive value of the classic physical signs of malnutrition as predictors of low biochemical levels and adverse clinical outcomes. The presence of atrophic glossitis should prompt the clinician to consider a basic nutritional assessment.

Effect of vitamin A in enteral formulae for burned guinea-pigs

A burned guinea-pig model (30 per cent body surface area) was used to study the effects of dietary vitamin A. Sixty-five female guinea-pigs were infused enterally via gastrostomy feeding tubes with identical formulate (175 kcal/kg/day, 20 per cent of calories as protein) containing varying amounts of vitamin A. Groups I, II, III and IV received formulae containing 0, 10,000 iu (approximately equivalent to the guinea-pigs' RDA), 50,000 iu (5 x RDA) and 250,000 iu (25 x RDA) of vitamin A per litre, respectively. After 14 days of tube feeding, the animals were killed. Group I animals had evidence of vitamin A deficiency including low haemoglobin levels, lower red blood cell counts and lower caecal mucosal weight. Findings of hypervitaminosis A were observed only in animals given the highest dose of vitamin A (25 x RDA). These were elevated serum alkaline phosphatase and complement C3 levels and enlarged adrenal glands. Group IV also showed defective cell-mediated immunity as reflected by reduced delayed cutaneous response to dinitrofluorobenzene. In a second experiment groups I, II, III and IV were given formulas containing 0, 1 x RDA, 5 x RDA, and 10 x RDA of vitamin A respectively for 14 days. Through postburn days 12 to 14 they were injected subcutaneously with 3 x 10(8) of Staphylococcus aureus once daily. On postburn day 15 the animals were killed and the numbers of viable bacteria at each injection site were counted. No significant differences were observed in viable bacterial numbers between the groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma and red blood cell vitamin E status of patients on total parenteral nutrition

Plasma and red blood cell (RBC) tocopherol isomer (alpha, beta, delta, and gamma) concentrations were measured prior to, and following total parenteral nutrition (TPN), with Intralipid. Before feeding, nine of 13 patients had plasma total tocopherol levels less than 0.6 mg/dl (normal range 0.63-1.24 mg/dl) and 10 of 13 had total RBC tocopherol levels less than 0.2 mg/dl (normal range (0.20-0.39 mg/dl). Following 7 days TPN plasma vitamin E status increased significantly (p less than 0.001). However, this was due mostly to increases in the circulating level of beta + gamma-tocopherols. RBC vitamin E status was also significantly increased (p less than 0.001) following TPN, however, this was again due to incorporation of non-alpha-tocopherols. In a second study a alpha-tocopherol supplement, Vitlipid N, (9.1 mg alpha-tocopherol/day) was included in the feed. In these patients, large increases in plasma concentrations of non-alpha-tocopherol isomers were accompanied by an apparent improvement in alpha-tocopherol status (0.64 vs 0.44 mg/dl after 7 days). However, RBC alpha-tocopherol concentration did not change appreciably in these patients following either 7 or 14 days feeding. It is concluded that RBC vitamin E status is markedly influenced by the available plasma tocopherol pool and that provision of a small supplement of alpha-tocopherol is not sufficient to compete with the high concentration of non-alpha-isomers present in Intralipid. TPN utilizing fat emulsions containing high levels of non-alpha-tocopherol isomers (even when accompanied by alpha-tocopherol supplements) does not improve alpha-tocopherol status.

Clinical aspects of vitamin and trace element metabolism

An adequate provision of all micronutrients, vitamins and essential trace elements is necessary for maintenance of normal tissue function. In patients requiring nutritional support, these factors are essential for optimal utilization of the major nutrients and play a role in all aspects of intermediary metabolism. In this chapter, some of the main features of the micronutrients have been described, together with suggestions regarding their provision enterally or parenterally. For most of these nutrients, diagnostic methods are not available to permit accurate assessment of status and hence the level of provision necessary for optimal results. However, there is now sufficient understanding of nutritional requirements such that few patients should now develop clinical or biochemical signs of under- or overprovision of micronutrients.