Guidelines on artificial nutrition versus hydration in terminal cancer patients

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step I: define the eight key elements necessary to reach a decision: Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e. improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

Decrease in diatom palatability contributes to bloom formation in the Western English Channel

The aim of this paper is to investigate the role of phytoplankton nutritional status in the formation of the spring bloom regularly observed at the station L4 in the Western English Channel. Using a modelling approach, we tested the hypothesis that the increase in light from winter to spring induces a decrease in diatom nutritional status (i.e., an increase in the C:N and C:P ratios), thereby reducing their palatability and allowing them to bloom. To this end, a formulation describing the Stoichiometric Modulation of Predation (SMP) has been implemented in a simplified version of the European Regional Seas Ecosystem Model (ERSEM). The model was coupled with the General Ocean Turbulence Model (GOTM), implemented at the station L4 and run for 10 years (2000-.2009). Simulated carbon to nutrient ratios in diatoms were analysed in relation to microzooplankton biomass, grazing and assimilation efficiency. The model reproduced in situ data evolutions and showed the importance of microzooplankton grazing in controlling the early onset of the bloom. Simulation results supported our hypothesis and provided a conceptual model explaining the formation of the diatom spring bloom in the investigated area. However, additional data describing the microzooplankton grazing impact and the variation of carbon to nutrient ratios inside phytoplanktonic cells are required to further validate the proposed mechanisms.

Modelling the Stoichiometric Regulation of C-Rich Toxins in Marine Dinoflagellates

Toxin production in marine microalgae was previously shown to be tightly coupled with cellular stoichiometry. The highest values of cellular toxin are in fact mainly associated with a high carbon to nutrient cellular ratio. In particular, the cellular accumulation of C-rich toxins (i.e., with C:N > 6.6) can be stimulated by both N and P deficiency. Dinoflagellates are the main producers of C-rich toxins and may represent a serious threat for human health and the marine ecosystem. As such, the development of a numerical model able to predict how toxin production is stimulated by nutrient supply/deficiency is of primary utility for both scientific and management purposes. In this work we have developed a mechanistic model describing the stoichiometric regulation of C-rich toxins in marine dinoflagellates. To this purpose, a new formulation describing toxin production and fate was embedded in the European Regional Seas Ecosystem Model (ERSEM), here simplified to describe a monospecific batch culture. Toxin production was assumed to be composed by two distinct additive terms; the first is a constant fraction of algal production and is assumed to take place at any physiological conditions. The second term is assumed to be dependent on algal biomass and to be stimulated by internal nutrient deficiency. By using these assumptions, the model reproduced the concentrations and temporal evolution of toxins observed in cultures of Ostreopsis cf. ovata, a benthic/epiphytic dinoflagellate producing C-rich toxins named ovatoxins. The analysis of simulations and their comparison with experimental data provided a conceptual model linking toxin production and nutritional status in this species. The model was also qualitatively validated by using independent literature data, and the results indicate that our formulation can be also used to simulate toxin dynamics in other dinoflagellates. Our model represents an important step towards the simulation and prediction of marine algal toxicity.

Moderately elevated plasma homocysteine, MTHFR genotype and risk for stroke, vascular dementia and alzheimer's disease in northern ireland

BACKGROUND AND PURPOSE: Elevated plasma homocysteine level has been associated with increased risk for cardiovascular and cerebrovascular disease. Variation in the levels of this amino acid has been shown to be due to nutritional status and methylenetetrahydrofolate reductase (MTHFR) genotype. METHODS: Under a case-control design we compared fasting levels of homocysteine and MTHFR genotypes in groups of subjects consisting of stroke, vascular dementia (VaD), and Alzheimer disease patients and normal controls from Northern Ireland. RESULTS: A significant increase in plasma homocysteine was observed in all 3 disease groups compared with controls. This remained significant after allowance for confounding factors (age, sex, hypertension, cholesterol, smoking, creatinine, and nutritional measures). MTHFR genotype was not found to influence homocysteine levels, although the T allele was found to increase risk for VaD and perhaps dementia after stroke. CONCLUSIONS: We report that moderately high plasma levels of homocysteine are associated with stroke, VaD, and Alzheimer disease. This is not due to vascular risk factors, nutritional status, or MTHFR genotype

The role of Schizosaccharomyces pombe Cdc2 phosphorylation sites on Cdc25 in mitotic timing

Cell size control and mitotic timing in Schizosaccharomyces pombe is coupled to the environment through several signal transduction pathways that include stress response, checkpoint and nutritional status impinging on Cdc25 tyrosine phosphatase and Wee1 tyrosine kinase. These in turn regulate Cdc2 (Cdk1) activity and through a double feedback loop, further activates Cdc25 on 12 possible phosphorylation sites as well as inhibiting Wee1. Phosphomutants of the T89 Cdc2 phosphorylation site on Cdc25, one with a glutamate substitution (T89E) which is known to phosphomimetically activate proteins and an alanine substitution (T89A), which is known to block phosphorylation, exhibit a small steady-state cell size (semi-wee phenotype), a known hallmark for aberrant mitotic control. To determine whether the T89 phosphorylation site plays an integral role in mitotic timing, the phosphomutants were subjected to nitrogen shifts to analyze their transient response in the context of nutritional control. Results for both up and downshifts were replicated for the T89E phosphomutant, however, for the T89A phosphomutant, only a nutritional downshift has been completed so far. We found that the steady-state cell size of both phosphomutants was significantly smaller than the wild-type and in the context of nutritional control. Furthermore, the constitutively activated T89E phosphomutant exhibits residual mitotic entry, whereas the wild-type undergoes a complete mitotic suppression with mitotic recovery also occurring earlier than the wild-type. In response to downshifts, both phosphomutants exhibited an identical response to the wild-type. Further characterization of the other Cdc2 phosphorylation sites on Cdc25 are required before conclusions can be drawn, however T89 remains a strong candidate for being important in activating Cdc25.

The Role of Micronutrients in Heart Failure

Heart failure is a common condition in the Western world, particularly among elderly persons and with an ever-aging population, the incidence is expected to increase. Diet in the setting of heart failure is important--patients with this condition are advised to consume a low-salt diet and monitor their weight closely. Nutritional status of patients with heart failure also is important--those with poor nutritional status tend to have a poor long-term prognosis. A growing body of evidence suggests an association between heart failure and micronutrient status. Reversible heart failure has been described as a consequence of severe thiamine and selenium deficiency. However, contemporary studies suggest that a more subtle relationship may exist between micronutrients and heart failure. This article reviews the existing literature linking heart failure and micronutrients, examining studies that investigated micronutrient intake, micronutrient status, and the effect of micronutrient supplementation in patients with heart failure, and focusing particularly on vitamin A, vitamin C, vitamin E, thiamine, other B vitamins, vitamin D, selenium, zinc, and copper.

Moderately elevated plasma homocysteine, methylenetetrahydrofolate reductase genotype, and risk for stroke, vascular dementia, and Alzheimer disease in Northern Ireland

Elevated plasma homocysteine level has been associated with increased risk for cardiovascular and cerebrovascular disease. Variation in the levels of this amino acid has been shown to be due to nutritional status and methylenetetrahydrofolate reductase (MTHFR) genotype.

Effect of fruit and vegetable consumption on immune function in older people: A randomized controlled trial

Background: Fruit and vegetable (FV) intake, which is often low in older people, is associated with reduced chronic disease risk. Objective: We determined whether increased FV intake improves measures of immune function. Design: We conducted a randomized controlled trial (The Ageing and Dietary Intervention Trial) in 83 healthy volunteers aged 65-85 y with low FV intakes (=2 portions/d); 82 subjects completed the intervention. Participants were assigned to continue their normal diets or to consume =5 FV portions/d for 16 wk. At 12 wk, tetanus toxoid (0.5 mL intramuscular) and Pneumovax II vaccine (0.5 mL intramuscular; both vaccines from Sanofi Pasteur) were administered. FV intake was monitored by using diet histories, and biomarkers of nutritional status were assessed. The primary endpoint was the antibody response to vaccination. Specific antibodies binding to tetanus toxoid (total IgG) and pneumococcal capsular polysaccharide (total IgG and IgG2) were assessed at baseline and 16 wk. Participants were recruited between October 2006 and June 2008. Results: The change in FV consumption differed significantly between groups [mean change in number of portions (95% CI): in the 2-portion/d group, 0.4 portions/d (0.2, 0.7 portions/d); in the 5-portion/d group, 4.6 portions/d (4.1, 5.0 portions/d); P < 0.001)] and also in micronutrient status. Antibody binding to pneumococcal capsular polysaccharide (total IgG) increased more in the 5-portion/d group than in the 2-portion/d group [geometric mean (95% CI) of the week 16:baseline ratio: 3.1 (2.1, 4.4) and 1.7 (1.3, 2.1), respectively; P = 0.005)]. There was no significant difference in the increases in antibody binding to tetanus toxoid. Conclusion: Increased FV intake improves the Pneumovax II vaccination antibody response in older people, which links an achievable dietary goal with improved immune function. This trial was registered at clinicaltrials.gov as NCT00858728. © 2012 American Society for Nutrition.

The potential role of fruit and vegetables in aspects of psychological well-being: a review of the literature and future directions

The objective of the present paper was to review the literature investigating the potential relationship between fruit and vegetables (FV) and psychological well-being. The rising prevalence of mental ill health is causing considerable societal burden. Inexpensive and effective strategies are therefore required to improve the psychological well-being of the population, and to reduce the negative impact of mental health problems. A growing body of literature suggests that dietary intake may have the potential to influence psychological well-being. For example, studies have suggested that particular dietary constituents, including vitamins and minerals, might be beneficial to psychological health. However, in order to better reflect normal dietary intake, health-based research has increasingly begun to focus on whole foods and dietary patterns, rather than individual nutrients. One food group that has received increasing attention with regard to psychological health is FV. This is probably a result of the strong evidence base, which exists in relation to their protective association with a number of chronic diseases, as well as the fact that they are a rich source of some of the nutrients which have been linked to psychological health. While some promising findings exist with regards to FV intake and psychological well-being, overall, results are inconsistent. Possible reasons for this, such as methodological issues related to study design and the measurement of psychological well-being and FV intake, are discussed within this review. Based on the predominantly observational nature of existing literature, the present paper concludes that future well-designed randomised controlled trials are required to investigate the relationship further.

Biomarkers in nutrition: new frontiers in research and application

Nutritional biomarkers-biochemical, functional, or clinical indices of nutrient intake, status, or functional effects--are needed to support evidence-based clinical guidance and effective health programs and policies related to food, nutrition, and health. Such indices can reveal information about biological or physiological responses to dietary behavior or pathogenic processes, and can be used to monitor responses to therapeutic interventions and to provide information on interindividual differences in response to diet and nutrition. Many nutritional biomarkers are available; yet there has been no formal mechanism to establish consensus regarding the optimal biomarkers for particular nutrients and applications.

European Recommendations for Primary Prevention of Congenital Anomalies: A Joined Effort of EUROCAT and EUROPLAN Projects to Facilitate Inclusion of This Topic in the National Rare Disease Plans

Congenital anomalies (CA) are the paradigm example of rare diseases liable to primary prevention actions due to the multifactorial etiology of many of them, involving a number of environmental factors together with genetic predispositions. Yet despite the preventive potential, lack of attention to an integrated preventive strategy has led to the prevalence of CA remaining relatively stable in recent decades. The 2 European projects, EUROCAT and EUROPLAN, have joined efforts to provide the first science-based and comprehensive set of recommendations for the primary prevention of CA in the European Union. The resulting EUROCAT-EUROPLAN 'Recommendations on Policies to Be Considered for the Primary Prevention of Congenital Anomalies in National Plans and Strategies on Rare Diseases' were issued in 2012 and endorsed by EUCERD (European Union Committee of Experts on Rare Diseases) in 2013. The recommendations exploit interdisciplinary expertise encompassing drugs, diet, lifestyles, maternal health status, and the environment. The recommendations include evidence-based actions aimed at reducing risk factors and at increasing protective factors and behaviors at both individual and population level. Moreover, consideration is given to topics specifically related to CA (e.g. folate status, teratogens) as well as of broad public health impact (e.g. obesity, smoking) which call for specific attention to their relevance in the pre- and periconceptional period. The recommendations, reported entirely in this paper, are a comprehensive tool to implement primary prevention into national policies on rare diseases in Europe.

Height, stunting, and refractive error among rural Chinese schoolchildren: the See Well to Learn Well project.

PURPOSE: To evaluate the hypothesis that changes in nutritional status could be partly responsible for observed increases in myopia prevalence among Chinese children. DESIGN: Cross-sectional cohort study. METHODS: Rural Chinese secondary school children participating in a study of interventions to promote spectacle use were randomly sampled (20% of children with uncorrected vision >6/12 bilaterally, and 100% of remaining children) and underwent cycloplegic refraction with subjective refinement and measurement of height and weight. Stunting was defined according to the World Health Organization standard population. RESULTS: Among 3226 children in the sample, 2905 (90.0%) took part. Among 1477 children undergoing refraction, 1371 (92.8%) had height and weight measurements. These children had a mean age of 14.5 +/- 1.4 years, 59.8% were girls, and mean spherical equivalent refraction was -1.93 +/- 1.82 diopters. Stunting was present in 87 children (6.4%). While height was inversely associated with refractive error (RE) (taller children were more myopic) among boys (r = -0.147, P = .001), this disappeared when adjusting for age, and no such association was observed among girls. Neither girls nor boys with stunting differed significantly in refraction from children without stunting, and neither stunting nor height was associated with RE when adjusting for age, height, and parental education. The power of this study to have detected a 0.75 diopters difference in RE between children with and without stunting was 0.96. CONCLUSION: Results from this cross-sectional study are not consistent with the hypothesis that nutritional status is a determinant of RE in this setting.

Psychological determinants of consumer acceptance of personalised nutrition in 9 European countries

OBJECTIVE: To develop a model of the psychological factors which predict people's intention to adopt personalised nutrition. Potential determinants of adoption included perceived risk and benefit, perceived self-efficacy, internal locus of control and health commitment.

METHODS: A questionnaire, developed from exploratory study data and the existing theoretical literature, and including validated psychological scales was administered to N=9381 participants from 9 European countries (Germany, Greece, Ireland, Poland, Portugal, Spain, the Netherlands, the UK, and Norway).

RESULTS: Structural equation modelling indicated that the greater participants' perceived benefits to be associated with personalised nutrition, the more positive their attitudes were towards personalised nutrition, and the greater their intention to adopt it. Higher levels of nutrition self-efficacy were related to more positive attitudes towards, and a greater expressed intention to adopt, personalised nutrition. Other constructs positively impacting attitudes towards personalised nutrition included more positive perceptions of the efficacy of regulatory control to protect consumers (e.g. in relation to personal data protection), higher self-reported internal health locus of control, and health commitment. Although higher perceived risk had a negative relationship with attitude and an inverse relationship with perceived benefit, its effects on attitude and intention to adopt personalised nutrition was less influential than perceived benefit. The model was stable across the different European countries, suggesting that psychological factors determining adoption of personalised nutrition have generic applicability across different European countries.

CONCLUSION: The results suggest that transparent provision of information about potential benefits, and protection of consumers' personal data is important for adoption, delivery of public health benefits, and commercialisation of personalised nutrition.

Lacertid lizards as bioindicators of agricultural contamination

Apesar do recente aumento no número de estudos, os lagartos persistem como um dos grupos menos estudados em ecotoxicologia e o desconhecimento em relação à sua resposta à contaminação ambiental é enorme. A nível europeu, os lacertídeos têm sido identificados como potenciais espécies modelo para a ecotoxicologia com répteis. O principal objectivo deste projecto era determinar se um lacertídeo abundante pertencente ao género Podarcis, podia ser utilizado como bioindicador de exposição e toxicidade em zonas agrícolas. Para atingir este objectivo, utilizámos uma estratégia integrada com três fases. Numa primeira fase realizou-se um estudo de campo para documentar o tipo de exposição e parâmetros populacionais de populações de lacertídeos que ocorrem em zonas de uso intenso de pesticidas e zonas de agricultura orgânica. A segunda fase consistiu num estudo de mesocosmo em que se expuseram juvenis a um conjunto de pesticidas em condições controladas durante um período de um ano. Finalmente, a terceira fase incluiu um estudo laboratorial sobre os efeitos do clorpirifos, um dos insecticidas mais utilizado a nível global, em lagartixas. No término de cada um dos estudos, analisaram-se diversos biomarcadores e parâmetros de exposição e toxicidade a pesticidas nos diferentes indivíduos. Este conjunto abrangente de parâmetros foi analisado em diferentes níveis de organização biológica, incluindo parâmetros populacionais, bem como comportamentais, fisiológicos, bioquímicos e histológicos. Em geral, detectaram-se poucas diferenças estatísticas significativas entre as populações dos campos expostos a pesticidas e populações referência. Confirmando a dificuldade que existe em isolar os efeitos de diferentes contaminantes sobre as populações de outros factores locais, ciclos sazonais ou eventos estocásticos. As populações de P. bocagei parecem ser capazes de lidar com o nível observado de exposição a pesticidas. No entanto, indivíduos que vivem em locais expostos a pesticidas parecem estar menos adaptados ecologicamente do que aqueles que vivem em locais referência, apresentando um estado de depleção nutricional e sinais de stress metabólico. Os resultados obtidos com os animais da experiência de mesocosmo parecem reforçar estes resultados. Os animais prosperaram relativamente bem em todos os mesocosmos, independentemente do tratamento ou não com pesticidas, apresentando uma ampla gama de comportamentos naturais. A abordagem laboratorial confirmou P. bocagei como um valioso indicador de exposição sub-letal a doses ambientalmente realistas de clorpirifos. De acordo, com o conjunto d resultados obtidos, P. bocagei parece ser um bioindicador adequado de exposição a pesticidas.

Évaluation prospective de l’état nutritionnel et risque de complications post-opératoires de la cystectomie radicale

La cystectomie radicale est le traitement de référence pour les cancers de la vessie infiltrant le muscle. Cette chirurgie entraine un taux élevé de complications et diminue la qualité de vie des patients à court et à long terme. Une revue de la littérature a d’abord été effectuée afin d’identifier les facteurs de l’état nutritionnel associés au risque de complications et de mortalité après la cystectomie radicale. L’hypoalbuminémie a été identifiée comme un prédicteur potentiel de la mortalité post-opératoire. Une étude de cohorte a ensuite été menée afin d’identifier des facteurs de l’état nutritionnel associés au risque de développer des complications après cette chirurgie. Un indice de masse corporelle élevé, une baisse de l’appétit, une perte de poids, une hypo-albuminémie et une hypo-préalbuminémie avant l’opération sont les facteurs qui ont été associés au développement de complications post-opératoires. Des analyses et des études supplémentaires doivent être menées dans l’optique développer des interventions qui pourraient diminuer le risque de complications après la cystectomie radicale.