Dietary treatment of rheumatoid cachexia with beta-hydroxy-beta-methylbutyrate, glutamine and arginine: a randomised controlled trial

BACKGROUND & AIMS: Rheumatoid arthritis (RA) is complicated by cytokine-driven alterations in protein and energy metabolism and consequent muscle wasting (cachexia). The aim of this randomised controlled trial was to investigate the efficacy of a mixture of beta-hydroxy-beta-methylbutyrate, glutamine and arginine (HMB/GLN/ARG) as nutritional treatment for rheumatoid cachexia. METHODS: Forty RA patients supplemented their diet with either HMB/GLN/ARG or a nitrogen (7.19 g/day) and calorie (180 kcal/day) balanced mixture of alanine, glutamic acid, glycine, and serine (placebo) for 12 weeks. Body composition and other outcomes were assessed at baseline and follow-up, and analysed by mixed ANOVA. RESULTS: Dietary supplementation with HMB/GLN/ARG was not superior to placebo in the treatment of rheumatoid cachexia (groupxtime interactions P>0.05 for all outcomes). Both amino acid mixtures significantly increased (main effect of time) fat-free mass (727+/-1186 g, P<0.01), total body protein (719+/-1703 g, P=0.02), arms (112+/-183 g, P<0.01) and legs (283+/-534 g, P<0.01) lean mass, and some measures of physical function. No significant adverse event occurred during the study, but patients in the HMB/GLN/ARG group reported fewer gastrointestinal complaints compared to placebo. CONCLUSIONS: Dietary supplementation with HMB/GLN/ARG is better tolerated but not more effective in reversing cachexia in RA patients compared to the mixture of other non-essential amino acids used as placebo. Further controlled studies are necessary to confirm the beneficial anabolic and functional effects of increased nitrogen intake in this population.     

Nutrient intake and nitrogen metabolism in cancer patients during oncological chemotherapy

Aggressive oncological chemotherapy often impairs the nutritional status of tumor patients. To evaluate the pathogenetic mechanisms, food intake in 13 cancer patients was investigated in correlation with nitrogen losses, N balances, muscle wasting, and weight course, during cytostatic therapy. Median daily N and energy intakes were reduced only in patients with weight loss [0.55 g protein, 16.5 kcal/kg ideal body wt (IBW)]. Patients with constant weight had the same intake as control subjects (1.27 g protein, 37.2 kcal IBW). N balances and creatinine height index (CHI) correlated with daily nutrient intake. Fecal N excretions did not correlate with urinary losses; there was no excess of fecal N loss because of cytostatic treatment. The impairment of cancer patients' nutritional status seems to depend primarily on the decrease of spontaneous oral intake as a consequence of the side effects of tumor therapy. Changes in CHI, compared before and after chemotherapy, indicated muscle wasting of weight-losing patients.     

Reducing parenteral energy and protein intake improves metabolic homeostasis after bone marrow transplantation

The purpose of this prospective study was to compare the metabolic effects of reducing parenteral energy and protein intake in bone-marrow-transplant (BMT) patients from 150% (hi-TPN group) to 100% (lo-TPN group) basal energy expenditure. Cytotoxic therapy was given on days 1-5, BMT on day 6, and TPN beginning on days 6 or 7. The lo-TPN group exhibited higher serum albumin (38 +/- 0.4 vs 32 +/- 0.4 g/L, P less than 0.01) but similar nitrogen balance (-83 +/- 8 vs -86 +/- 8 mg.kg-1.d-1, P greater than 0.05). Serum Na+ remained greater than 134 +/- 1 mmol/L in the lo-TPN group but fell to 127 +/- 1 mmol/L in the hi-TPN group (P less than 0.001) despite similar Na+ intakes and balances. Serum K+ remained less than 4.4 +/- 0.2 mmol/L in the lo-TPN group but rose to 5.1 +/- 0.1 mmol/L in the hi-TPN group (P less than 0.01) despite similar K+ intakes and balances. Delivering TPN at lower-than-normal rates after BMT appears to minimize Na+ and K+ disturbances and improve serum albumin concentrations without having any adverse effect on nitrogen balance.     

Effect of lanreotide, a somatostatin analogue, on urea synthesis in normal man

The aim was to investigate the effect of lanreotide (Angiopeptin) on urea synthesis. Lanreotide is a somatostatin analogue used in therapy trials of certain cancers. Cancer patients are often protein catabolic, thus the effect of lanreotide on whole body protein metabolism is of importance. We investigated the effect of lanreotide by measuring urea nitrogen synthesis rate (UNSR) and blood alpha-amino nitrogen levels before, during and after a 30 min iv infusion of 25 g of an electrolyte-free amino acid solution. 6 healthy male subjects were studied following, i) placebo (saline), ii) lanreotide 5 mug/kg, and iii) lanreotide 80 mug/kg. Lanreotide decreased urea nitrogen synthesis rate (mmol/h) during amino acid infusion significantly compared to saline, independent of dose of lanreotide (max +/- SE of urea nitrogen synthesis rate measurements in each study: 117 +/- 8 mmol/h (saline), 85 +/- 10 mmol/h (high dose) and 85 +/- 12 mmol/h (low dose)). This occurred in spite of significantly higher plasma alpha-amino nitrogen following lanreotide (peak +/- SE of alpha-amino nitrogen level in each study: 3.7 +/- 0.1 mmol/l placebo versus 4.8 +/- 0.2 mmol/l low dose and 4.7 +/- 0.4 mmol/l high dose (p < 0.01). We conclude that a single dose of lanreotide decreases whole body urea nitrogen synthesis rate thereby conserving body protein. The results indicate that long term lanreotide therapy may not lead to further protein catabolism in cancer patients.     

Recombinant human growth hormone in patients with acute renal failure.

OBJECTIVE: The objective of this study is to determine the impact of recombinant human growth hormone (rhGH) on metabolic and nutritional parameters in malnourished patients with acute renal failure. DESIGN: The design is an open-labeled pilot trial examining the effects of rhGH administration in a small group of highly catabolic, malnourished patients with acute renal failure. Each patient served as his or her own control. SETTING: An intensive care unit in a tertiary care medical institution. PATIENTS: Five patients with established acute renal failure in a critical care unit. Entry criteria included clinical evidence of malnutrition: a serum albumin level of <3.2 g/dL, a prealbumin level of < or = 20 mg/dL, and an insulin-like growth factor IGF 1 level <200 ng/mL. The study consisted of 3 periods: phase I, 3 day baseline; phase II, 6 day treatment; and phase III, 3 day washout. During the entire study, blood and urine samples were obtained daily to calculate normalized protein catabolic rate, total nitrogen appearance rate (TNA), and nitrogen balance. Additional data were collected to measure metabolic and inflammatory parameters. INTERVENTION: The intervention consisted of administering 100 microg/kg/d of rhGH for 6 days. RESULTS: There were significant changes in TNA, normalized protein catabolic rate, and nitrogen balance during the 3 study phases. TNA decreased from 43.3 +/- 24.4 g/d in phase I, to 25.2 +/- 16.5 g/d during phase II (P <.001). There was a further decrease in TNA to 16.2 +/- 8.3 g/d during phase III (P <.001 v phase I). Nitrogen balance improved from - 31.8 +/- 21.4 g/d during phase I, to - 12.9 +/- 10.3 g/d during phase II (P <.001), and further improved to - 4.1 +/- 4.0 g/d in phase III (P <.001 v phase I). Significant changes were also noted in levels of blood urea nitrogen, phosphorous, serum growth hormone, IGF-1, and serum leptin levels after growth hormone administration. A statistically significant increase in serum albumin was noted in phase III (3.1 g/dL) versus phase I (2.7 +/- 0.7 g/dL). CONCLUSIONS: Administration of rhGH to critically ill patients with acute renal failure resulted in improvements in negative nitrogen balance and a significant decrease in total nitrogen appearance rate. These changes corresponded to increases in serum growth hormone, IGF-1, IGF-1 binding protein 3, and leptin levels after growth hormone administration.     

Protein metabolism assessed by 1-13C leucine infusions in patients undergoing bone marrow transplantation

Patients receiving cytoreductive therapy and bone marrow transplantation (BMT) are known to develop marked protein catabolism. To assess the contribution of whole body protein breakdown, amino acid oxidation and incorporation into proteins, plasma leucine kinetics (1-13C-leucine infusion technique) were determined in six patients five times within 14 days before and after cytoreductive therapy (Cyclophosphamide and total body irradiation) and marrow transplantation. Nitrogen balance became negative (-0.20 +/- 0.04 g/Kg/24 hr) after cyclophosphamide (p less than 0.01) and was -0.25 +/- 0.05 g/Kg/24 hr 7 days after BMT in spite of total parenteral nutrition. Plasma leucine concentration increased after BMT by 67% (p less than 0.0015). Leucine plasma appearance was 1.20 +/- 0.15 mumol/kg/min before treatment, it increased slightly and transiently after cyclophosphamide, and increased again from day 5 to day 7 after BMT (p less than 0.01), suggesting increased protein break-down. Leucine oxidation increased from 0.27 +/- 0.07 before therapy to 0.97 +/- 0.16 mumol/kg/min (p less than 0.02) after cyclophosphamide and BMT. Nonoxidative leucine disappearance rate decreased slightly from 0.92 +/- 0.08 to 0.75 +/- 0.16 mumol/kg/min after BMT (ns). Leucine metabolic clearance rate decreased from 11.8 +/- 1.65 before therapy to 6.9 +/- 0.70 ml/kg/min (p less than 0.02) after cytoreductive therapy. After BMT it increased again to 9.9 +/- 1.5 ml/kg/min (p less than 0.02). The results demonstrate that patients undergoing cytoreductive therapy and bone marrow transplantation develop negative nitrogen balance due to increased protein breakdown associated with increased leucine oxidation and increased metabolic clearance rate.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cornstarch ingestion after oral glucose loading: effect on glucose concentrations, hormone response, and symptoms in patients with postprandial hypoglycemic syndrome

In susceptible individuals ingestion of glucose can lead to clinical symptoms of hypoglycemia as well as a reflex rise of counterregulatory hormones. We hypothesized that cornstarch, a slowly absorbed starch, might prevent hypoglycemic-symptom episodes. Eight patients who had characteristic signs, symptoms, and reflex hormonal responses of hypoglycemia at the glucose nadir after ingesting 75 g glucose (OGTT) participated. Patients ingested 75 g glucose followed by 75 g raw cornstarch (OGTT + CS). None of the patients reported symptoms or had signs of hypoglycemia in response to OGTT + CS. The glucose nadir concentration during OGTT + CS (3.8 +/- 0.6 mmol/L) was significantly higher than during OGTT (3.2 +/- 0.6; P less than 0.03). The responses of cortisol (331 +/- 166 nmol) and epinephrine (491 +/- 589 pmol/L) at the glucose nadir during OGTT + CS were significantly lower than the responses of cortisol (524 +/- 193 nmol/L; P less than 0.003) and epinephrine 1834 +/- 1135 pmol/L (P less than 0.0005) during OGTT. A slowly absorbed starch such as cornstarch may be an effective component in dietary management of this disorder.     

Effect of vitamin E supplementation on vitamin K status in adults with normal coagulation status

BACKGROUND: Cases of enhanced anticoagulant effect in response to high-dose vitamin E supplementation have been reported among patients taking oral anticoagulants. Although a vitamin E-vitamin K interaction was proposed to underlie this effect, it has not been systematically investigated in adults with normal baseline coagulation status. OBJECTIVE: The objective was to study the effect of 12 wk of supplementation with 1000 IU RRR-alpha-tocopherol/d on biochemical measures of vitamin K status in men and women not taking oral anticoagulants. DESIGN: Vitamin K status, which was assessed with the use of plasma phylloquinone concentrations, the degree of under-gamma-carboxylation of prothrombin (proteins induced by vitamin K absence-factor II, PIVKA-II), and the percentage of undercarboxylated osteocalcin (ucOC), was determined in 38 men and women with rheumatoid arthritis (study A) and in 32 healthy men (study B) participating in 2 independent, 12-wk randomized clinical trials of vitamin E supplementation (1000 IU/d). RESULTS: Mean (+/- SD) PIVKA-II increased from 1.7 +/- 1.7 to 11.9 +/- 16.1 ng/mL (P < 0.001) in study A and from 1.8 +/- 0.6 to 5.3 +/- 3.9 ng/mL (P < 0.001) in study B in response to 12 wk of vitamin E supplementation. An increase in PIVKA-II is indicative of poor vitamin K status. In contrast, the other measures of vitamin K status (ie, plasma phylloquinone concentration and percentage of ucOC) did not change significantly in response to the supplementation. CONCLUSIONS: High-dose vitamin E supplementation increased PIVKA-II in adults not receiving oral anticoagulant therapy. The clinical significance of these changes warrants further investigation, but high doses of vitamin E may antagonize vitamin K. Whether such an interaction is potentially beneficial or harmful remains to be determined.     

The pulmonological manifestations of rheumatoid arthritis

In their review article the authors overview the primary and secondary pulmonary complications of rheumatoid arthritis with the help of bibliographic data. They emphasize the pulmonological complications of disease modifying antirheumatic drugs used for the pharmaceutical therapy of rheumatoid arthritis, of which they discuss the methotrexate induced pulmonary diseases. Methotrexate participates nearly in all of additive double and triple - O'Dell-scheme - combined disease modifying antirheumatic drugs therapy. Because of that, the early detection of drug-induced pulmonological complications is important. For rheumatologists the treatment of methotrexate resistant rheumatoid arthritis is always getting a higher and higher challenge. Biological therapeutical drugs act as citokine antagonists, by blocking TNF-alpha and, compared to disease modifying antirheumatic drugs, they can more effectively inhibit the progression of the disease. These are the biological response modifyers. Their main representatives are infliximab, adalimumab, and etanercept. At the end, the authors discuss secondary pulmonary complications caused by biological response modifyers, e.g. the biological response modifyers associated pulmonary tuberculosis, bacterial tracheobronchitis, bacterial pneumonia, bronchiectasia, pulmonary oedema, rapid fibrotising alveolitis, and coccidiomycosis. At 3% of patients with rheumatoid arthritis, treated with biological response modifyers, who live in Arizona, California, Nevada, pulmonary and systemic mycosis - coccidiomycosis can appear with a 15% of mortality. As a consequence of frequent earthquakes, the spores getting into the air from the ground infect immunsuppressed patients treated with biological response modifyers. The authors draw attention to the fact that patients who receive biological therapy and travel to the above-mentioned endemic or earthquake-active regions, have a potential high risk, so it is indispensable that they are informed by the doctor. Testing and use of newer and newer groups of biological response modifyers are expected in the near future in the therapy of rheumatoid arthritis. Nowadays - in patients, who are non-reactive for TNF-alpha inhibitor treatment - the use of B-lymphocyte inhibitor rituximab, characteristic in non-Hodgkin lymphoma therapy is possible. The pulmonary complications of rheumatoid arthritis therapy of that citokine are not known yet. Today, antirheumatic therapy results in a significant improvement of patients' life-quality, whilst the more and more modern therapeutical methods cause more complications.     

Elevated plasma homocysteine and low vitamin B-6 status in nonsupplementing older women with rheumatoid arthritis

OBJECTIVE: The purpose of this study was to determine if nonsupplementing older women (aged >or=55 years) with rheumatoid arthritis had higher plasma homocysteine and lower B-vitamin status compared to healthy controls. Elevated plasma homocysteine, a risk factor for cardiovascular disease, may help explain why individuals with rheumatoid arthritis have an increased risk of cardiovascular disease. METHODS: Older, free-living women were classified as rheumatoid arthritis (n=18) or healthy control (n=33). Participants were not using B-vitamin supplements. Fasting blood samples were measured for pyridoxal 5'phosphate (PLP) (the metabolically active coenzyme form of vitamin B-6), folate, red blood cell folate, vitamin B-12, transcobalamin II, homocysteine, C-reactive protein, and lipid concentrations. Participants completed 7-day weighed food records, the Stanford Health Assessment Questionnaire (HAQ), and a visual analog pain scale. RESULTS: PLP concentrations were lower in the rheumatoid arthritis vs healthy control participants (4.93+/-3.85 vs 11.35+/-7.11 ng/mL [20+/-16 vs 46+/-29 nmol/L]; P<0.01) whereas plasma homocysteine was higher in the rheumatoid arthritis group (1.63+/-0.74 vs 1.15+/-0.38 mg/L [12.1+/-5.5 vs 8.5+/-2.8 micromol/L]; P=0.02). Red blood cell folate concentrations were lower in the rheumatoid arthritis vs healthy control participants [414+/-141 vs 525+/-172 ng/mL [938+/-320 vs 1,190+/-390 nmol/L]; P=0.02). No significant differences were found for plasma folate, vitamin B-12, and transcobalamin II. An inverse correlation was found between PLP concentrations and the HAQ disability index (r=-0.37; P<0.01). A positive correlation was found between homocysteine concentrations and the HAQ disability index (r=0.36; P=0.01). Total cholesterol and low-density lipoprotein cholesterol levels were lower in the rheumatoid arthritis group (cholesterol 191+/-43 vs 218+/-33 mg/dL [4.95+/-1.11 vs 5.65+/-0.85 mmol/L]; P=0.02; low-density lipoprotein cholesterol 110+/-36 vs 137+/-29 mg/dL [2.85+/-0.93 vs 3.55+/-0.75 mmol/L]; P<0.01). No significant differences were seen between groups for protein (g/day), fat (g/day), cholesterol (mg/day), folate (microg/day), vitamin B-12 (microg/day), and vitamin B-6 (mg/day) dietary intakes. CONCLUSIONS: Poor vitamin B-6 status and elevated plasma homocysteine concentrations were seen in older women with rheumatoid arthritis compared to healthy controls and may contribute to their increased risk of cardiovascular disease.     

The effects of acute clostridium difficile diarrhea on fecal nitrogen content in adult hospitalized patients

Clostridium difficile diarrhea (CDD) is a frequent cause of hospital-associated infectious diarrhea and a common reason for nutritional consultation. Limited data are available on fecal nitrogen losses during infectious diarrhea in adults. Eleven patients with acute CDD were studied for stool volume and fecal nitrogen. The mean stool output was 630 +/- 110 g/day and fecal nitrogen 2.5 +/- 0.3 g per 24 hour period (mean +/- SEM). Fecal nitrogen loss was increased from the predicted 12.0 mg/kg BW/day to 38.0 +/- 5.9 mg/kg BW/day. Fecal nitrogen loss in CDD can be an important source of nitrogen loss and should be measured in nitrogen balance studies in such patients.     

药物熏蒸治疗类风湿关节炎临床观察

目的：探讨类风湿关节炎治疗方法。方法：应用药物熏蒸疗法治疗类风湿关节炎,观察治疗前后关节疼痛、肿胀、关节活动障碍、晨僵指数的变化,使用SPSS11．0软件进行统计分析。结果：与治疗前比较,治疗后关节疼痛、压痛、肿胀明显减轻,晨僵和关节功能障碍明显改善（P〈0．01）。结论：应用药物熏蒸疗法治疗类风湿关节炎,能有效控制病情的进展,提高患者的生活质量。     

三联疗法治疗类风湿关节炎的临床疗效和安全性

目的观察探讨三联疗法治疗类风湿关节炎的临床疗效及不良反应,总结其临床治疗经验及临床应用价值。方法选取我院2009年10月至2011年10月108例类风湿关节炎的患者,随机分为观察组与对照组,各有54例,观察组采用三联疗法治疗;对照组采用口服柳氮磺胺吡啶肠溶片与美洛昔康治疗,观察对比两组治疗前后的风湿因子的变化。结果观察组治疗总有效率、治疗期间不良反应发生率与对照组相比有明显差异(P<0.05),具有统计学意义;两组治疗后血中CRP、ESR水平均降低,观察组下降幅度与对照组比较要明显(P<0.05),具有统计学意义。结论三联疗法治疗类风湿关节炎的临床疗效的临床疗效理想,能够显著改善临床症状,且无明显的不良反应,安全性较高,值得在临床推广使用。     

Nutritional and clinical efficacy of ornithine alpha-ketoglutarate in severe burn patients

Ornithine alpha-Ketoglutarate (OKG) displays anabolic and anticatabolic properties in situations of stress. However, studies including both biological and clinical end points are scarce. In this prospective, randomized and double-blind study, 60 patients who had undergone severe burns (20-60% of body surface area) received either ornithine alpha-ketoglutarate (20 g/day) or an isocaloric placebo, for 21 days, starting mean 4 days after injury. In the OKG group, nitrogen balance reached positive values at d5 and stabilized at higher levels vs controls (P< 0.05 or less from day 3 to day 21), resulting in a strongly positive cumulated nitrogen balance at day 21 (mean +/- SEM, OKG group: +127 +/- 13; Control group: -63 +/- 18g nitrogen). As measured at day 21, transthyretin and RBP levels were higher in the OKG group (respectively 259 +/- 9 vs 161 +/- 10, and 45 +/- 1 vs 33 +/- 1 mg/l, P< 0.001). Body weight loss was counteracted at d21 in the OKG group (-2.6% vs -6.3%, P< 0.001). Assessment of the quality of wound healing using objective scoring showed better performances in the OKG group (P< 0.05). The results suggest that improvement in nutritional parameters observed during the treatment of burn-injured patients with ornithine a-ketoglutarate allows better clinical recovery.     

Clonidine reduces diarrhea and sodium loss in patients with proximal jejunostomy: a controlled study

BACKGROUND: Patients with short bowel syndrome have significant fluid losses. This represents a significant management problem, especially in patients with minimal residual intestine. We determined whether clonidine, an alpha2-adrenergic agonist, is effective in decreasing fecal water and sodium (Na) losses in patients with proximal jejunostomy. Eight parenteral nutrition (PN)-dependent subjects (3 men, 5 women), aged 49.9+/-10.2 years, with a residual small bowel length of 71.8+/-152.0 cm that ended in a jejunostomy, were studied. METHODS: Subjects were admitted to the North-western General Clinical Research Center (GCRC) for a 2-day equilibrium period while receiving a self-selected 100 g fat diet with protein 1.5 g/kg/d and 30 kcal/kg/d and 1 L/d of oral rehydration solution. A D-xylose test was performed after an overnight fast. On days 3-5, all stool and urine were collected for volume, weight, fat, nitrogen, energy, sodium, magnesium, potassium, and calcium. Meals were provided in duplicate and the equivalent portions consumed by each patient were analyzed for fluid volume, fat, nitrogen, energy, sodium, magnesium, calcium, and potassium in order to calculate nutrient balances. At the conclusion of the stool and urine collections (day 6), a clonidine (0.3 mg) patch was applied to the shoulder. Subjects were restudied after 1 week. RESULTS: Daily fecal volume and weight were 4.514+/-1.769 L/d and 4394+/-1727 g/d, respectively, at baseline. Five subjects were net "secretors" in that excreted fecal volume exceeded oral intake. Fecal volume decreased by 427+/-562 mL/d (8.9%, p=.07). Fecal weight decreased by 438+/-527 g/d (9.4%, p=.05). Urine volume correspondingly increased by 747+/-1934 mL (18.9%, p=not significant [NS]). The increase in urine output was weakly and negatively correlated with the decrease in fecal volume and weight (r=-0.37 and -0.41, respectively, p=NS). Oral fluid intake decreased slightly from 3.328+/-1.246 L/d baseline to 3.203+/-1.119 L/d with clonidine therapy (-3.8%, p=NS). Fecal Na loss was significantly decreased from baseline (887+/-996 mg/d, 11.2+/-12.3%; p=.036). This was not related to decreased oral Na intake, which actually increased from baseline (3.799+/-2.271 g/d) to 3.933+/-1.314 g/d after clonidine therapy (p=NS). No patient developed hypotension. CONCLUSIONS: Our results show the transdermal administration of clonidine is associated with a modest but clinically significant decrease in fecal output in patients with short bowel syndrome and high-output proximal jejunostomy that require chronic parenteral fluid infusion. This is accompanied by decreased fecal Na loss.     

Comparison of omega-3 fatty acids and sulfasalazine in ulcerative colitis

Fish oil omega-3 fatty acids exert antiinflammatory effects on patients with ulcerative colitis. However, a comparative study in patients with mild to moderate ulcerative colitis receiving only sulfasalazine or omega-3 fatty acids has not been performed. We sought to detect changes in the inflammatory disease activity with the use of either fish oil omega-3 fatty acids or sulfasalazine in patients with ulcerative colitis. Ten patients (five male, five female; mean age = 48 +/- 12 y) with mild to moderate active ulcerative colitis were investigated in a randomized cross-over design. They received either sulfasalazine (2 g/d) or omega-3 fatty acids (5.4 g/d) for 2 m.o. Disease activity was assessed by clinical and laboratory indicators, sigmoidoscopy, histology, and whole-body protein turnover (with 15N-glycine). Treatment with omega-3 fatty acids resulted in greater disease activity as detected by a significant increase in platelet count, erythrocyte sedimentation rate, C-reactive protein, and total fecal nitrogen excretion. No major changes in protein synthesis and breakdown were observed during either treatment. In conclusion, treatment with sulfasalazine is superior to treatment with omega-3 fatty acids in patients with mild to moderate active ulcerative colitis.     

Nitrogen balance of healthy Dutch women before and during pregnancy

BACKGROUND: Experimental studies including longitudinal nitrogen balance studies could provide insight into protein metabolism in pregnancy. OBJECTIVE: Our aim was to determine the development of nitrogen balance during pregnancy compared with nitrogen balance before pregnancy in women consuming imposed constant diets. We also tracked changes in muscle mass and lean body mass by measuring urinary 3-methylhistidine (3-MeH) and urinary creatinine. DESIGN: Nitrogen balance was determined over 8 d in 12 healthy Dutch women before pregnancy and at weeks 12, 23, and 34 of gestation. Complete daily diets were supplied during each balance period so that each subject's energy, protein, and macronutrient intakes were similar in amount and composition in all 4 balance periods. RESULTS: Throughout pregnancy there was no significant change in loss of nitrogen in feces and therefore no change in protein digestibility. The amount of nitrogen excreted in urine in late pregnancy (11.0 +/- 1.4 g/d) was significantly (P < 0.01) less than in early pregnancy (12.6 +/- 1.3 g/d). Nitrogen retention increased toward term, even though energy balance became progressively negative. The difference between the first (-0.4 +/- 1.7 g N/d) and third (1.2 +/- 1.6 g N/d) trimester was significant (P < 0.05). No differences were found in either 3-MeH or creatinine excretion between trimesters. CONCLUSIONS: These urinary nitrogen excretion and nitrogen retention data show that when the dietary supply remains constant, nitrogen balance increases toward the end of pregnancy, suggesting a more efficient use of dietary protein later in pregnancy. Urinary 3-MeH and creatinine excretion indicated no change in protein metabolism.     

Body composition, nitrogen metabolism, and energy utilization with feeding of mildly restricted (4.2 MJ/d) and severely restricted (2.1 MJ/d) isonitrogenous diets.

To determine the effects on weight loss of feeding isonitrogenous diets in mildly restricted (4.2 MJ/d) and severely restricted (2.1 MJ/d) amounts, we measured body composition, weight loss-energy deficit ratio, and nitrogen metabolism in 14 obese women housed in a metabolic ward consuming hypoenergetic diets for 21 d. Subjects consumed either a 4.2-MJ/d diet (50 g protein, 175 g carbohydrate) or a 2.1-MJ/d diet (50 g protein, 75 g carbohydrate). Body composition and leucine oxidation and turnover were determined before and after weight loss. Energy deficit was calculated from resting metabolic rates. Subjects fed the 2.1-MJ/d diet showed a greater weight loss (6.1 +/- 0.5 vs 4.5 +/- 0.5 kg; mean +/- SE, P less than 0.05) and fat loss (3.9 +/- 0.3 vs 3.0 +/- 0.3 kg, P less than 0.05). Weight loss-energy deficit ratio was the same with both diets. Nitrogen balance and leucine oxidation and turnover were similar in both groups. We conclude that with feeding of isonitrogenous hypoenergetic diets, severe restriction of energy content (2.1 MJ/d, 75 g carbohydrate) will enhance weight and fat loss without increasing nitrogen loss compared with mild restriction of energy (4.2 MJ/d).     

Clinical reasoning and decision-making in practice. A man with inexplicable joint pain and subsequent poor clinical condition

A 52-year-old man presented with polyarthritis and was negative for rheumatoid factor, anti-CCP and ANA. He was treated with low-dose methotrexate, the drug of first choice in rheumatoid arthritis. The arthritis disappeared, but the patient developed fever, progressive dyspnoea, appetite loss and weight loss. Upon hospital admission his medication was stopped and community-acquired pneumonia was diagnosed. The fever persisted despite antibiotic treatment. The tentative diagnosis of rheumatoid arthritis was changed to systemic lupus erythematosus, based on the change in clinical condition that could not be explained by polyarthritis and seroconversion to ANA- and anti-dsDNA-positive. The patient was treated with high-dose steroids and azathioprine and remained in remission for more than 1 year after treatment. The ANA test remained strongly positive, whereas anti-dsDNA was no longer detectable. This case stresses the limited value of classification criteria for the diagnosis of rheumatoid arthritis. To differentiate between rheumatoid arthritis and systemic lupus erythematosus, tests for autoantibodies against citrullinated peptides can be used. To differentiate between systemic lupus erythematosus and infection, tests for anti-dsDNA antibodies, antinuclear antibodies, C-reactive protein and complement can be used.     

Dietary patterns in patients with advanced cancer: implications for anorexia-cachexia therapy

BACKGROUND: Severe malnutrition and wasting are considered hallmarks of advanced malignant disease, and clinical research into anorexia-cachexia therapy and nutritional support for cancer patients is ongoing. However, information on typical dietary intakes and food choices for this population is notably lacking; proposed therapies for anorexia and wasting are not framed within the context of current intake. OBJECTIVE: The objective of the study was to characterize the food intake patterns of patients with advanced cancer. DESIGN: Patients with advanced cancer (n = 151) recruited from a regional cancer center and palliative-care program completed a 3-d dietary record a mean (+/-SD) 8 +/- 7 mo before death. Food items were categorized according to macronutrient content and dietary use and subsequently entered into cluster analysis. RESULTS: Wide variations in intakes of energy (range: 4-53 kcal . kg body wt(-1) . d(-1); x +/- SD: 25.1 +/- 10.0 kcal . kg body wt(-1) . d(-1)) and protein (range: 0.2-2.7 g . kg body wt(-1) . d(-1); x +/- SD: 1.0 +/- 0.4 g . kg body wt(-1) . d(-1)) were observed. Even the subjects with the highest intakes had a recent history of weight loss, which suggests that the diets of those persons were consistently inadequate for weight maintenance. Cluster analysis found 3 dietary patterns that differed in food choice and caloric intake. Low intakes and a high risk of weight loss were associated with decreased frequency of eating and dietary profiles with little variety and unusually high proportions of liquids. CONCLUSION: These data provide a glimpse into dietary habits toward the end of life. Unique dietary patterns were found in this nutritionally vulnerable patient population.