The 2013 Arvid Wretlind lecture: evolving concepts in parenteral nutrition.

Fifty years after the clinical introduction of total parenteral nutrition (TPN) the Arvid Wretlind lecture is an opportunity to critically analyse the evolution and changes that have marked its development and clinical use. The standard crystalline amino acid solutions, while devoid of side effects, remain incomplete regarding their composition (e.g. glutamine). Lipid emulsions have evolved tremendously and are now included in bi- and tri-compartmental feeding bags enabling a true "total" PN provided daily micronutrients are prescribed. The question of exact individual energy, macro- and micro-nutrient requirements is still unsolved. Many complications attributed to TPN are in fact the consequence of under- or over-feeding: the historical hyperalimentation concept is the main cause, along with the use of fixed weight based predictive equations (incorrect in 70% of the critically ill patients). In the late 80's many complications (hyperglycemia, sepsis, fatty liver, exacerbation of inflammation, mortality) were attributed to TPN leading to its near abandon in favour of enteral nutrition (EN). Enteral feeding, although desirable for many reasons, is difficult causing a worldwide recurrence of malnutrition by insufficient feed delivery. TPN indications have evolved towards its use either alone or in combination with EN: several controversial trials published 2011-13 have investigated TPN timing, an issue which is not yet resolved. The initiation time varies according to the country between admission (Australia and Israel), day 4 (Swiss) and day 7 (Belgium, USA). The most important issue may prove to be and individualized and time dependent prescription of feeding route, energy and substrates.

Adverse effects of high dose carnitine supplementation of total parenteral nutrition on protein and fat oxidation in the critically ill.

The aim of the present study was to investigate the effects of continuous and acute L-carnitine supplementation of total parenteral nutrition (TPN) on protein and fat oxidation in severe catabolism. A critically ill and severely malnourished male patient received TPN (non protein energy = 41 kcal/kg/day, provided equally as fat and glucose) over 38 days, without L-carnitine for 23 days and with carnitine supplements (15 mg/kg/day) for the following 15 days. Subsequently, he was given carnitine-free enteral nutrition for 60 more days. A four-hour infusion of 100 mg L-carnitine was given on day 11 of each TPN period. Indirect calorimetry was carried out after 11 days of either carnitine-free or supplemented TPN and at the initiation of enteral nutrition. Additional measurements were performed 4 hours and 24 hours after the acute infusions of carnitine. The rate of protein oxidation and the respiratory quotient were found to be higher, and the rate of fat oxidation to be lower, with carnitine-supplemented TPN, than with either carnitine-free TPN or enteral nutrition. Acute infusion of carnitine resulted in an increased rate of protein oxidation and a reduced rate of fat oxidation on both TPN-regimens. These unfavourable effects on protein metabolism may be due to an impairment of fat oxidation by excess amounts of carnitine.

Alimentation et hypertension artérielle: au-delà du sel de table [Nutrition and hypertension: more than table salt].

The role of dietary sodium intake in the development, and its impact on the treatment, of hypertension are well recognized. However, many other nutritional compounds have been shown, or are believed, to influence blood pressure. Some compounds, such as caffeine and fructose, may raise arterial blood pressure, whereas others might lower arterial blood pressure, for example garlic, dark chocolate, fibers and potassium. In this article, we review several alimentary compounds and their (hypothesized) mechanisms of action, as well as the available evidence supporting a role of these compounds in the "non pharmacological" treatment and prevention of hypertension.

Changes in arbuscular mycorrhizal fungal phenotypes and genotypes in response to plant species identity and phosphorus concentration.

* Arbuscular mycorrhizal fungi (AMF) are plant symbionts that improve floristic diversity and ecosystem productivity. Many AMF species are generalists with wide host ranges. Arbuscular mycorrhizal fungi individuals are heterokaryotic, and AMF populations are genetically diverse. Populations of AMF harbor two levels of genetic diversity on which selection can act, namely among individuals and within individuals. Whether environmental factors alter genetic diversity within populations is still unknown. * Here, we measured genetic changes and changes in fitness-related traits of genetically distinct AMF individuals from one field, grown with different concentrations of available phosphate or different host species. * We found significant genotype-by-environment interactions for AMF fitness traits in response to these treatments. Host identity had a strong effect on the fitness of different AMF, unearthing a specificity of response within Glomus intraradices. Arbuscular mycorrhizal fungi individuals grown in novel environments consistently showed a reduced presence of polymorphic genetic markers, providing some evidence for host or phosphate-induced genetic change in AMF. * Given that AMF individuals can form extensive hyphal networks colonizing different hosts simultaneously, contrasting habitats or soil properties may lead to evolution in the population. Local selection may alter the structure of AMF populations and maintain genetic diversity, potentially even within the hyphal network of one fungus.

Compliance with the Swiss Society for Nutrition's dietary recommendations in the population of Geneva, Switzerland: a 10-year trend study (1999-2009).

The trends in compliance with the dietary recommendations of the Swiss Society for Nutrition in the Geneva population were assessed for the period from 1999 to 2009 using 10 cross-sectional, population-based surveys (Bus Santé study) with a total of 9,320 participants aged 35 to 75 years (50% women). Dietary intake was assessed using a self-administered, validated, semi-quantitative food frequency questionnaire. Trends were assessed by logistic regression adjusting for age, smoking status, education, and nationality using survey year as the independent variable. After excluding participants with extreme intakes, the percentage of participants with a cholesterol intake of <300 mg/day increased from 40.8% in 1999 to 43.6% in 2009 for men (multivariate-adjusted P for trend=0.04) and from 57.8% to 61.4% in women (multivariate-adjusted P for trend=0.06). Calcium intake >1 g/day decreased from 53.3% to 46% in men and from 47.6% to 40.7% in women (multivariate-adjusted P for trend<0.001). Adequate iron intake decreased from 68.3% to 65.3% in men and from 13.3% to 8.4% in women (multivariate-adjusted P for trend<0.001). Conversely, no significant changes were observed for carbohydrates, protein, total fat (including saturated, monounsaturated, and polyunsaturated fatty acids), fiber, and vitamins D and A. We conclude that the quality of the Swiss diet did not improve between 1999 and 2009 and that intakes deviate substantially from expert recommendations for health promotion and chronic disease risk reduction.

Nutrition préopératoire en chirurgie viscérale: recommandations et réalité [Preoperative nutrition in abdominal surgery: recommendations and reality].

Malnutrition concerns up to 50% at in-hospital admission. Its diagnosis and treatment are fundamental parts of the surgical approach because nutritional status directly influences the clinical outcome. The Nutritional Risk Score (NRS-2002) represents the recommended screening tool by the European Society of Parenteral and Enteral Nutrition (ESPEN). Patients with a score > or = 3 and aged > 70 years old, should receive a nutritional support during 7-14 day before surgery. Depending on patient's clinical conditions, the enteral route of administration should be preferred. Despite strong evidence in favor of nutritional supplementation, much effort must be done to implement these supportive strategies in the everyday clinical practice.

Phosphorus and carbon burial during cretaceous oceanic anoxic events, links with climatic changes

According to Jenkyns (2010), oceanic anoxic events (OAE) record profound changes in the climatic and paleoceanographic state of the planet and represent major disturbances in the global carbon cycle. One of the most studied OAEs on a worldwide scale is the Cenomanian-Turonian OAE 2, which is characterized by a pronounced positive excursion in carbon-isotope records and the important accumulation of organic-rich sediments. The section at Gongzha (Tibet) and the sections at Barranca and Axaxacualco (Mexico) are located in remote parts of the Tethys, and show δ13C records, which are well correlated with those of classical Tethyan sections. Both sections, however, do not exhibit the presence of organic-rich sediments. Phosphorus Mass Accumulation Rates (PMAR) in Tibet show a pattern similar to that observed in the Tethys by Mort et al. (2007), which suggests enhanced Ρ regeneration during the OAE 2 time interval, though there is no evidence for anoxic conditions in Tibet. Ρ appears here to have been mainly driven by detrital influx and sea-level fluctuations. The sections at Barranca and Axaxacualco show that the Mexican carbonate platform persisted during this anoxic event, which allowed the evolution of platform fauna otherwise not present in Tethyan sections. The persistence of this carbonate platform close to the Caribbean Igneous Plateau, which is thought to have released bio-limiting metals, is explained by local uplift which delayed the drowning of the platform and a specific oceanic circulation that permitted the preservation of oligotrophic conditions in the area. The Coniacian-Santonian OAE (OAE3) appears to have been more dependent on local conditions than OAE2. The presence of black shales associated with OAE3 appear to have been restricted to shallow-water settings and epicontinental seas in areas located around the Atlantic Ocean. The sections at Olazagutia (Spain), and Ten Mile - Arbor Park (USA), two potential Global Boundary Stratotype Sections and Points (GSSP) sites, are devoid of organic-rich sediments and lack a δ13C positive excursion around the C-S boundary. The Gabal Ekma section (Sinai, Egypt) exhibits accumulations of organic-rich sediments, in addition to phosphorite bone beds layers, which may have been linked to an epicontinental upwelling zone and/or storm inputs. Our data suggest that OAE 3 is rarely expressed by truly anoxic conditions and seems to have been linked to local conditions rather than global paleoenvironmental change. The evidence for detrital-P being the likely cause of Ρ fluctuations during the OAEs studied here does not negate the idea that anoxia was the principal driver of these fluctuations in the western Tethys. However, an explanation is required as to why the Ρ accumulation signatures are mirrored in both oxic and anoxic sedimentary successions. 'Eustatic/climatic' and 'productivity/anoxic' models may have both operated simultaneously in different parts of the world depending on local conditions, both producing similar trends in Ρ accumulation. - Selon Jenkyns (2010), les événements anoxiques océaniques enregistrent de profonds changements dans le climat et la paléoceanographie de la planète et représente des perturbations majeures du cycle du carbone. L'un des plus étudiés à l'échelle mondiale est l'ΟΑΕ2 du Cénomanien-Turonien, qui est caractérisé par une très forte excursion positive des isotopes du carbone et une importante accumulation de sédiments riche en matière organique. La section de Gongzha (Tibet) et les sections de Barranca et Axaxcualco (Mexique) sont situées aux confins de la Téthys, et enregistrent une courbe isotopique en δ13C parfaitement corrélable avec les sections téthysiennes, mais ne montre pas d'accumulation de black shales. Le taux de phosphore en accumulation de masses (PMAR) au Tibet montre un pattern similaire observé également par Mort et al. (2007) dans la Téthys, suggérant un model de régénération du Ρ durant l'anoxie, cependant aucune conditions anoxiques régnent dans la région du Tibet. Ρ apparaît donc principalement guidé par le détritisme et les fluctuations du niveau marin. Les sections de Barranca et d'Axaxacualco montrent que la plateforme carbonatée mexicaine persiste durant cet événement anoxique, et permet le développement d'une faune de plateforme qui n'est pas présente dans les sections téthysiennes. La persistance de cette plateforme carbonatée si proche du plateau Caribéen, qui est connu pour le relâchement de métaux bio-limitant, peut être expliqué par un soulèvement tectonique local qui inhibe l'ennoiement de la plateforme et une circulation océanique spécifique qui permet la préservation de conditions oligotrophiques dans cette région. L'événement anoxique océanique du Coniacien-Santonien apparaît plus dépendant des conditions locales que pour l'ΟΑΕ2. Les black shales associés à POAE3 sont restreints aux zones situées autour de l'océan Atlantique et plus particulièrement aux eaux peu profondes et épicontinentales. Les sections d'Olazagutia (Espagne), Ten Mile Creek et Arbor Park (USA), qui sont deux potentielles sections GSSP (Sections de stratotype de limite globaux et de points), ne montre pas d'accumulation de black shales et pas de forte excursion positive en δ13C autour de la limite C-S. La section de Gabal Ekma (Sinai, Egypte) montre des accumulations de black shales, en plus des couches de phosphorites et d'accumulation d'os (« bone beds »), vraisemblablement lié à des zones active d'upwelling épicontinentale et/ou d'apport de tempêtes. Nos données suggèrent que l'OAE 3 est rarement exprimé par de vraies conditions anoxiques et semble être plus lié à des conditions plus locales que des changements paléo-environnementaux globaux, comme observés pour le Cénomanien- Turonien. Les arguments pour un modèle lié au phosphore détritique qui serait la cause des fluctuations du phosphore total durant les OAEs, n'écartent pas l'idée que l'anoxie est la principale cause de ces fluctuations dans les sections riches en matière organique de l'Ouest téthysien. Cependant une explication est nécessaire pour comprendre pourquoi la signature de l'accumulation du phosphore est semblable dans les successions sédimentaires déposées dans des conditions oxygénées et anoxiques. Les modèles « Eustatisme/Climat » et « Productivité/anoxie » ont simultanément opéré dans les différentes parties du monde dépendant de conditions locales, et ont produit des tendances similaires en accumulation de phosphore.

Ethical issues in nutrition support of severely disabled elderly persons: a guide for health professionals.

Providing or withholding nutrition in severely disabled elderly persons is a challenging dilemma for families, health professionals, and institutions. Despite limited evidence that nutrition support improves functional status in vulnerable older persons, especially those suffering from dementia, the issue of nutrition support in this population is strongly debated. Nutrition might be considered a basic need that not only sustains life but provides comfort as well by patients and their families. Consequently, the decision to provide or withhold nutrition support during medical care is often complex and involves clinical, legal, and ethical considerations. This article proposes a guide for health professionals to appraise ethical issues related to nutrition support in severely disabled older persons. This guide is based on an 8-step process to identify the components of a situation, analyze conflicting values that result in the ethical dilemma, and eventually reach a consensus for the most relevant plan of care to implement in a specific clinical situation. A vignette is presented to illustrate the use of this guide when analyzing a clinical situation.

Phosphorus burial in the ocean over glacial-interglacial time scales

The role of nutrients, such as phosphorus (P), and their impact on primary productivity and the fluctuations in atmospheric CO2 over glacial-interglacial periods are intensely debated. Suggestions as to the importance of P evolved from an earlier proposal that P actively participated in changing productivity rates and therefore climate change, to most recent ones that changes in the glacial ocean inventory of phosphorus were important but not influential if compared to other macronutrients, such as nitrate. Using new data coming from a selection of ODP sites, we analyzed the distribution of oceanic P sedimentary phases and calculate reactive P burial fluxes, and we show how P burial fluxes changed over the last glacial-interglacial period at these sites. Concentrations of reactive P are generally lower during glacial times, while mass accumulation rates (MAR) of reactive P show higher variability. If we extrapolate for the analyzed sites, we may assume that in general glacial burial fluxes of reactive P are lower than those during interglacial periods by about 8%, because the lack of burial of reactive P on the glacial shelf reduced in size, was apparently not compensated by burial in other regions of the ocean. Using the calculated changes in P burial, we evaluate their possible impact on the phosphate inventory in the world oceans. Using a simple mathematical approach, we find that these changes alone could have increased the phosphate inventory of glacial ocean waters by 17-40% compared to interglacial stages. Variations in the distribution of sedimentary P phases at the investigated sites seem to indicate that at the onset of interglacial stages, shallower sites experienced an increase in reactive P concentrations, which seems to point to P-richer waters at glacial terminations. All these findings would support the Shelf-Nutrient Hypothesis, which assumes that during glacial low stands nutrients are transferred from shallow sites to deep sea with possible feedback on the carbon cycle.