Vitamin E deficiency neuropathy in children with fat malabsorption. Studies in cystic fibrosis and chronic cholestasis

Antioxidant supplementation for lung disease in cystic fibrosis

BACKGROUND

Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF) and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, beta-carotene and selenium) or N-acetylcysteine (NAC) as a source of glutathione, may therefore potentially help maintain an oxidant-antioxidant balance. Glutathione or NAC can also be inhaled and if administered in this way can also have a mucolytic effect besides the antioxidant effect. Current literature suggests a relationship between oxidative status and lung function. This is an update of a previously published review.

OBJECTIVES

To synthesise existing knowledge on the effect of antioxidants such as vitamin C, vitamin E, beta-carotene, selenium and glutathione (or NAC as precursor of glutathione) on lung function through inflammatory and oxidative stress markers in people with CF.

SEARCH METHODS

The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies. We also searched online trials registries.Last search of Cystic Fibrosis Trials Register: 08 January 2019.

SELECTION CRITERIA

Randomised and quasi-randomised controlled studies comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care in people with CF.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted study investigators to obtain missing information. If meta-analysed, studies were subgrouped according to supplement, method of administration and the duration of supplementation. We assessed the quality of the evidence using GRADE.

MAIN RESULTS

One quasi-randomised and 19 randomised controlled studies (924 children and adults) were included; 16 studies (n = 639) analysed oral antioxidant supplementation and four analysed inhaled supplements (n = 285). Only one of the 20 included studies was judged to be free of bias.Oral supplements versus controlThe change from baseline in forced expiratory volume in one second (FEV₁) % predicted at three months and six months was only reported for the comparison of NAC to control. Four studies (125 participants) reported at three months; we are uncertain whether NAC improved FEV₁ % predicted as the quality of the evidence was very low, mean difference (MD) 2.83% (95% confidence interval (CI) -2.16 to 7.83). However, at six months two studies (109 participants) showed that NAC probably increased FEV₁ % predicted from baseline (moderate-quality evidence), MD 4.38% (95% CI 0.89 to 7.87). A study of a combined vitamin and selenium supplement (46 participants) reported a greater change from baseline in FEV₁ % predicted in the control group at two months, MD -4.30% (95% CI -5.64 to -2.96). One study (61 participants) found that NAC probably makes little or no difference in the change from baseline in quality of life (QoL) at six months (moderate-quality evidence), standardised mean difference (SMD) -0.03 (95% CI -0.53 to 0.47), but the two-month combined vitamin and selenium study reported a small difference in QoL in favour of the control group, SMD -0.66 (95% CI -1.26 to -0.07). The NAC study reported on the change from baseline in body mass index (BMI) (62 participants) and similarly found that NAC probably made no difference between groups (moderate-quality evidence). One study (69 participants) found that a mixed vitamin and mineral supplement may lead to a slightly lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low-quality evidence). Nine studies (366 participants) provided information on adverse events, but did not find any clear and consistent evidence of differences between treatment or control groups with the quality of the evidence ranging from low to moderate. Studies of β-carotene and vitamin E consistently reported greater plasma levels of the respective antioxidants.Inhaled supplements versus controlTwo studies (258 participants) showed inhaled glutathione probably improves FEV₁ % predicted at three months, MD 3.50% (95% CI 1.38 to 5.62), but not at six months compared to placebo, MD 2.30% (95% CI -0.12 to 4.71) (moderate-quality evidence). The same studies additionally reported an improvement in FEV₁ L in the treated group compared to placebo at both three and six months. One study (153 participants) reported inhaled glutathione probably made little or no difference to the change in QoL from baseline, MD 0.80 (95% CI -1.63 to 3.23) (moderate-quality evidence). No study reported on the change from baseline in BMI at six months, but one study (16 participants) reported at two months and a further study (105 participants) at 12 months; neither study found any difference at either time point. One study (153 participants) reported no difference in the time to the first pulmonary exacerbation at six months. Two studies (223 participants) reported treatment may make little or no difference in adverse events (low-quality evidence), a further study (153 participants) reported that the number of serious adverse events were similar across groups.

AUTHORS' CONCLUSIONS

With regards to micronutrients, there does not appear to be a positive treatment effect of antioxidant micronutrients on clinical end-points; however, oral supplementation with glutathione showed some benefit to lung function and nutritional status. Based on the available evidence, inhaled and oral glutathione appear to improve lung function, while oral administration decreases oxidative stress; however, due to the very intensive antibiotic treatment and other concurrent treatments that people with CF take, the beneficial effect of antioxidants remains difficult to assess in those with chronic infection without a very large population sample and a long-term study period. Further studies, especially in very young children, using outcome measures such as lung clearance index and the bronchiectasis scores derived from chest scans, with improved focus on study design variables (such as dose levels and timing), and elucidating clear biological pathways by which oxidative stress is involved in CF, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn. The benefit of antioxidants in people with CF who receive CFTR modulators therapies should also be assessed in the future.

Nutrition Support of Children With Chronic Liver Diseases: A Joint Position Paper of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Chronic liver disease places patients at increased risk of malnutrition that can be challenging to identify clinically and treat. Nutrition support is a key aspect of the management of these patients as it has an impact on their quality of life, morbidity, and mortality. There are significant gaps in the literature regarding the optimal nutrition support for patients with different types of liver diseases and the impact of these interventions on long-term outcomes. This Position Paper summarizes the available literature on the nutritional aspects of the care of patients with chronic liver diseases. Specifically, the challenges associated with the nutritional assessment of these subjects are discussed, and recently investigated approaches to determining the patients' nutritional status are reviewed. Furthermore, the pathophysiology of the malnutrition seen in the context of chronic liver disease is summarized and monitoring, as well as treatment, recommendations are provided. Lastly, suggestions for future research studies are described.

The influence of droplet size on the stability, in vivo digestion, and oral bioavailability of vitamin E emulsions

Vitamin E (α-tocopherol) is a nutraceutical compound, which has been shown to possess potent antioxidant and anticancer activity.

Antioxidant supplementation for lung disease in cystic fibrosis

BACKGROUND

Airway infection leads to progressive damage of the lungs in cystic fibrosis and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, ß-carotene and selenium) or glutathione may therefore potentially help maintain an oxidant-antioxidant balance. Current literature suggests a relationship between oxidative status and lung function.

OBJECTIVES

To synthesize existing knowledge of the effect of antioxidants such as vitamin C, vitamin E, ß-carotene, selenium and glutathione in cystic fibrosis lung disease.

SEARCH METHODS

The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies.Last search of Cystic Fibrosis Trials Register: 29 August 2013.

SELECTION CRITERIA

Randomized controlled studies and quasi-randomized controlled studies of people with cystic fibrosis comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted trial investigators to obtain missing information. Primary outcomes are lung function and quality of life; secondary outcomes are oxidative stress, inflammation, nutritional status, days on antibiotics and adverse events during supplementation. If meta-analysed, studies were subgrouped according to method of administration and the duration of supplementation.

MAIN RESULTS

One quasi-randomized and nine randomized controlled studies were included, with a total of 436 participants. Eight studies analyzed oral supplementation with antioxidants and two inhaled supplements.One study (n = 46) of an oral combined supplement demonstrated a significant difference in forced expiratory volume at one second expressed as per cent predicted after two weeks in favour of the control group, mean difference -4.30 (95% confidence interval -5.64 to -2.96); however a further study (n = 41) of oral supplementation with glutathione showed a significant improvement in this outcome and in forced vital capacity after six months from the treatment start, mean difference 17.40 (95% confidence interval 13.69 to 21.11) and 14.80 (95% confidence interval 9.66 to 19.94) respectively. The combined supplement study also indicated a significant improvement in quality of life favouring control, mean difference -0.06 points on the quality of well-being scale (95% confidence interval -0.12 to -0.01). Based on one study (n = 41) of oral glutathione supplementation in children, the supplements had a positive effect on the nutritional status (body mass index %) of the patients, mean difference 17.20 (95% confidence interval 12.17 to 22.23). In two studies (n = 83) that supplemented vitamin E, there was an improvement after two months in the blood levels of vitamin E, mean difference 11.78 μM/L (95% confidence interval 10.14 to 13.42).Based on one of the two studies of inhaled glutathione supplementation, there was an improvement in the forced expiratory volume at one second expressed as per cent predicted after three and six months (n = 153), mean difference 2.57 (95% confidence interval 2.24 to 2.90) and 0.97 (95% confidence interval 0.65 to 1.29) respectively. Only one of the studies reported quality of life data that could be analysed, but data showed no significant differences between treatment and control.None of the 10 included studies was judged to be free of bias.

AUTHORS' CONCLUSIONS

There appears to be conflicting evidence regarding the clinical effectiveness of antioxidant supplementation in cystic fibrosis. Based on the available evidence, glutathione (administered either orally or by inhalation) appears to improve lung function in some cases and decrease oxidative stress; however, due to the very intensive antibiotic treatment and other treatments that cystic fibrosis patients receive, the beneficial effect of antioxidants is very difficult to assess in patients with chronic infection without a very large population sample and a long-term (at least six months) study period. Further studies, especially in very young patients, examining clinically relevant outcomes, dose levels, timing and the elucidation of clear biological pathways by which oxidative stress is involved in cystic fibrosis, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn.

An excellent delivery system for improving the oral bioavailability of natural vitamin E in rats

This study set out to develop a novel and stable nanoemulsion formulation of natural vitamin E with increased oral bioavailability. The natural vitamin E nanoemulsion was prepared by a modified emulsification technique. The physicochemical characteristics of natural vitamin E nanoemulsion were characterized and its pharmacokinetics study was performed as well. The experimental results showed droplet diameters ranging from 20 to 400 nm (average, 87.7 nm) with a negative electrostatic potential (-23.5 ± 1.5 mv). The pharmacokinetics study of this nanoemulsion and corresponding soft capsule was carried out using noncompartment model method. Compared with the marketed soft capsule, the C (max) of the natural vitamin E nanoemulsion was higher, while the T (max) was shorter. Thus, plasma concentration-time profiles in rats dosed with nanoemulsion showed a 1.6-fold enhancement in the area under the curve of natural vitamin E compared with the marketed soft capsule. The antioxidative effects of the natural vitamin E nanoemulsion and the marketed soft capsule were also evaluated by the levels of superoxide dismutase (SOD) activity and malondialdehyde (MDA) concentration in serum and liver tissue. According to the SOD activity and the MDA concentration determined, the nanoemulsion was superior to the marketed soft as an antioxidative agent. The overall results demonstrated that the nanoemulsion drug delivery system could be a promising strategy for the delivery of natural vitamin E, which showed great potential for clinical application.

Antioxidant micronutrients for lung disease in cystic fibrosis

BACKGROUND

Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF), partly due to oxidative stress. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, ß-carotene and selenium) may help maintain an oxidant-antioxidant balance. Current literature suggests a relationship between oxidative status and lung function.

OBJECTIVES

To synthesize existing knowledge of the effect of vitamin C, vitamin E, ß-carotene and selenium in CF lung disease.

SEARCH STRATEGY

The Cochrane CF and Genetic Disorders Group CF Trials Register, PubMed, CINAHL and AMED were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies.Last search of CF Trials Register: 09 September 2010.

SELECTION CRITERIA

Randomized controlled trials and quasi-randomized controlled trials of people with CF with explicitly stated diagnostic criteria, comparing vitamin E, vitamin C, ß-carotene and selenium (individually or in combination) to placebo or standard care.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data and assessed risk of bias. We contacted trialists to obtain missing information. Primary outcomes are lung function and quality of life; secondary outcomes are oxidative stress, inflammation, body mass index, days on antibiotics and adverse events during supplementation. If meta-analysed, studies were subgrouped according to combined or single antioxidant supplementation.

MAIN RESULTS

Four randomized controlled trials and one quasi-randomized controlled trial were included; only three trials (87 participants) presented data suitable for analysis. Based on two trials, there was no significant improvement in lung function; one trial indicated significant improvement in quality of life favouring control, mean difference -0.06 points on the quality of well-being scale (95% confidence interval -0.12 to -0.01). Based on two trials, selenium-dependent glutathione peroxidase enzyme significantly improved in favour of combined supplementation, mean difference 1.60 units per gram of haemoglobin (95% CI 0.30 to 2.90) and selenium supplementation, mean difference 10.20 units per gram of haemoglobin (95% CI 2.22 to 18.18). All plasma antioxidant levels, except vitamin C, significantly improved with supplementation.

AUTHORS' CONCLUSIONS

There appears to be conflicting evidence regarding the clinical effectiveness of antioxidant supplementation in CF. Based on the evidence, antioxidants appear to decrease quality of life and oxidative stress; however, few trials contributed data towards analysis. Further trials examining clinically important outcomes and elucidation of a clear biological pathway of oxidative stress in CF are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn.

Statin adverse effects : a review of the literature and evidence for a mitochondrial mechanism

HMG-CoA reductase inhibitors (statins) are a widely used class of drug, and like all medications, have potential for adverse effects (AEs). Here we review the statin AE literature, first focusing on muscle AEs as the most reported problem both in the literature and by patients. Evidence regarding the statin muscle AE mechanism, dose effect, drug interactions, and genetic predisposition is examined. We hypothesize, and provide evidence, that the demonstrated mitochondrial mechanisms for muscle AEs have implications to other nonmuscle AEs in patients treated with statins. In meta-analyses of randomized controlled trials (RCTs), muscle AEs are more frequent with statins than with placebo. A number of manifestations of muscle AEs have been reported, with rhabdomyolysis the most feared. AEs are dose dependent, and risk is amplified by drug interactions that functionally increase statin potency, often through inhibition of the cytochrome P450 3A4 system. An array of additional risk factors for statin AEs are those that amplify (or reflect) mitochondrial or metabolic vulnerability, such as metabolic syndrome factors, thyroid disease, and genetic mutations linked to mitochondrial dysfunction. Converging evidence supports a mitochondrial foundation for muscle AEs associated with statins, and both theoretical and empirical considerations suggest that mitochondrial dysfunction may also underlie many nonmuscle statin AEs. Evidence from RCTs and studies of other designs indicates existence of additional statin-associated AEs, such as cognitive loss, neuropathy, pancreatic and hepatic dysfunction, and sexual dysfunction. Physician awareness of statin AEs is reportedly low even for the AEs most widely reported by patients. Awareness and vigilance for AEs should be maintained to enable informed treatment decisions, treatment modification if appropriate, improved quality of patient care, and reduced patient morbidity.

Vitamins A and E and pulmonary exacerbations in patients with cystic fibrosis

BACKGROUND

Increased levels of oxidative stress result in pulmonary damage contributing to the development of chronic lung disease in cystic fibrosis (CF). The aim of this study was to investigate the longitudinal effect of serum vitamin A and E levels on the incidence of pulmonary exacerbations in pancreatic insufficient (PI) and pancreatic sufficient (PS) patients with CF.

MATERIALS AND METHODS

Patient records were retrospectively examined over a 3-year period and serum vitamin A and E levels were retrieved. Subsequently, levels of vitamin A and E were prospectively measured over a 2-year period at the onset of intravenous antibiotic therapy for acute exacerbation and at the first recovery visit.

RESULTS

Retrospectively, 597 pulmonary exacerbations were identified in 102 patients, 74 PI and 28 PS, with a mean age of 11.1 +/- 6.4 years (range, 1.5-27 y). An increased number of exacerbations was directly correlated with lower vitamin A and E levels, even within the normal range. Prospectively, 62 exacerbations were analyzed (43 PI patients and 19 PS patients). At onset of exacerbation, vitamin A and E levels were reduced in the PI patients (P < 0.001; P < 0.001) and the PS patients (P < 0.005; P < 0.07).

CONCLUSIONS

Reduced serum levels of vitamin A and E even in the normal range are associated with an increased rate of pulmonary exacerbations in CF. Further studies are required to confirm the necessity of supplementation of vitamins A and E to PS patients.

The absorption of vitamin E is influenced by the amount of fat in a meal and the food matrix

Vitamin E absorption requires the presence of fat; however, limited information exists on the influence of fat quantity on optimal absorption. In the present study we compared the absorption of stable-isotope-labelled vitamin E following meals of varying fat content and source. In a randomised four-way cross-over study, eight healthy individuals consumed a capsule containing 150 mg 2H-labelled RRR-α-tocopheryl acetate with a test meal of toast with butter (17·5 g fat), cereal with full-fat milk (17·5 g fat), cereal with semi-skimmed milk (2·7 g fat) and water (0 g fat). Blood was taken at 0, 0·5, 1, 1·5, 2, 3, 6 and 9 h following ingestion, chylomicrons were isolated, and 2H-labelled α-tocopherol was analysed in the chylomicron and plasma samples. There was a significant time (P<0·001) and treatment effect (P<0·001) in 2H-labelled α-tocopherol concentration in both chylomicrons and plasma between the test meals. 2H-labelled α-tocopherol concentration was significantly greater with the higher-fat toast and butter meal compared with the low-fat cereal meal or water (P<0·001), and a trend towards greater concentration compared with the high-fat cereal meal (P=0·065). There was significantly greater 2H-labelled α-tocopherol concentration with the high-fat cereal meal compared with the low-fat cereal meal (P<0·05). The 2H-labelled α-tocopherol concentration following either the low-fat cereal meal or water was low. These results demonstrate that both the amount of fat and the food matrix influence vitamin E absorption. These factors should be considered by consumers and for future vitamin E intervention studies.

Physiological factors influencing vitamin E biokinetics

Limited information is available on factors that can influence vitamin E bioavailability. In several studies we have investigated the influence of dietary, biochemical, and genetic factors on vitamin E biokinetics. In these studies, subjects ingested a capsule containing 150 mg deuterated RRR-alpha-tocopheryl acetate, blood was taken up to 48 hr, and tocopherols were analyzed by liquid chromatography and mass spectroscopy. There was significantly greater plasma-labeled alpha-tocopherol concentrations when the capsule was consumed with a high-fat meal (17.5 g) versus a low-fat meal (2.7 g), and there was also a difference between a high-fat toast and butter and a cereal with full-fat milk meal (both 17.5 g fat), indicating that both the amount of fat and food matrix is important for vitamin E absorption. Dyslipidemic subjects displayed a reduced plasma uptake of newly absorbed alpha-tocopherol, and differences were also apparent in individual lipoproteins. A decreased uptake of labeled alpha-tocopherol was also observed in erythrocytes, platelets, and lymphocytes of dyslipidemics. Following vitamin E supplementation (400 mg/day, 4 weeks), the uptake of newly absorbed alpha-tocopherol was decreased, presumably because of saturation of alpha-tocopherol transfer protein. We also found that apoE3 subjects displayed a considerably reduced uptake of newly absorbed labeled alpha-tocopherol compared to apoE4 subjects, which may be a consequence of the reduced low-density lipoprotein catabolic rate in these subjects. Taken together, these data show that several physiological factors influence the uptake of newly absorbed alpha-tocopherol, and that this is an important consideration in the design of future vitamin E supplementation studies.

Can changes in hydrophobicity increase the bioavailability of α–tocopherol?

BACKGROUND

Bioavailability of fat-soluble vitamins from conventional oral supplements is insufficient in some conditions in which fat digestion and absorption are chronically impaired (e. g. cystic fibrosis).

AIM OF THE STUDY

We used a water-soluble form of fatsoluble vitamin E (AQUANOVA solubilisate) to create a nutritional supplement (NS) in the form of vitaminized gummi bears (with micellised water-soluble alpha-tocopheryl acetate (100 IU) and 400 mg crystalline vitamin C). We assessed the bioavailability of the NS in comparison to conventional preparations.

METHODS

The trial consisted of three study days (d0: NS sucked; d10: NS swallowed; d20: reference products swallowed). A total of 14 subjects (6 male/8 female), aged 25.3 (22.7-35.3) years, BMI 24.3 (19.0-31.7) kg/m(2) participated in the study. They had blood samples drawn after fasting for >or=12 hours and then 1, 5, 15, 30, 60, 120, 180, 240, 300 and 320 minutes after ingesting the vitamins. HPLC and a colorimetric method were used to determine vitamin E and vitamin C, respectively. Areas under the curve (AUC(0-320min)) and maximum increases in plasma concentrations (Delta concentration) were calculated to assess bioavailability.

RESULTS

The AUCs(0-320min) of alpha-tocopherol from d0 were significantly larger (p = 0.016) when compared to d20. Moreover, the maximum increase in alpha-tocopherol plasma concentrations was significantly higher for d0 (p = 0.023) and d10 (p = 0.002) when compared to d20.

CONCLUSIONS

Short-term bioavailability of AQUANOVA micellised fat-soluble vitamin E from our NS was significantly higher than from regular supplements. The NS will now be tested for its clinical efficacy in a randomized double-blind controlled intervention trial with CF patients.

Enrichment of rat hepatic organelles by vitamin E administered subcutaneously

Novel modes of administering antioxidants to improve delivery to targeted tissues or cells may be advantageous in preventing oxidant-induced pathologies. Vitamin E (alpha-tocopherol) has been shown to be protective in several models of liver injury. The objectives of this study were: (1) to determine if subcutaneously (s.q.) administered emulsified vitamin E enriched liver and hepatic subcellular fractions with the antioxidant and (2) to carry out a time-dependent analysis of serum and tissue vitamin E in rats receiving daily s.q. vitamin E. In the first experiment rats injected daily s.q. with emulsified vitamin E for 9 d increased serum, total liver, liver mitochondria, and liver microsomes by 8-, 16-, 30-, and 29-fold, respectively, compared with placebo injections. Similar enrichment was observed after intramuscular injections. In the second experiment, daily doses of s.q. vitamin E increased liver concentrations 40-fold by 9 d, which decreased to 22-fold by 18 d, whereas serum adjusted vitamin E levels maximized with a 24-fold increase by day 3 and plateaued thereafter. In conclusion, s.q. administration of emulsified vitamin E to rats resulted in substantially elevated serum and liver concentrations of alpha-tocopherol compared with levels achievable by dietary supplementation. The s.q. route of administration is a potentially effective parenteral mode of delivery of vitamin E for conditions in which hepatic oxidative stress is present.

Neurobehavioral aspects of antioxidants in aging

Both aging and age-associated neurodegenerative diseases are associated with various degrees of behavioral impairments, and among the prime candidates responsible for producing the neuronal changes mediating these behavioral deficits appear to be free radicals and the oxidative stress they generate. Therefore, there have been a number of studies which have examined the putative positive benefits of antioxidants in altering, reversing, or forestalling these neuronal/behavioral decrements, with varying degrees of success. Additional experiments have examined the effects of diets rich in fruits and vegetables or herbal extracts in reducing certain types of cancer and cardiovascular diseases, and evidence emerging from such experiments suggests that these kinds of dietary modifications may be beneficial in altering neuronal/behavioral deficits in aging, as well. These kinds of diets are particularly rich in antioxidants such as vitamins A, C, E, and bioflavonoids (such as flavones, tannins, and anthocyanins), and thus, there may be synergistic effects among them. The present paper will review studies concerning the influence of dietary and synthetic antioxidants on normal, pathological age-related, and reactive oxygen species-induced behavioral changes in human and animal subjects. The antioxidants reviewed are vitamin E, alpha-lipoic acid, and the phytochemicals contained in herbals, fruits and vegetables.

Electrophysiologic recovery after vitamin E-deficient neuropathy

A case report is presented of an electrophysiologic recovery from vitamin E-deficient neuropathy after treatment with water-soluble vitamin E in a patient with chronic hepatobiliary disease. The patient was a 64-year-old man who had experienced progressive difficulty in ambulation, with ataxia, over the previous 3 years. The symptoms were associated with pain, tingling sensation in the extremities, and reduced fine motor activity. The patient had chronic hepatobiliary disease, with recurrent cholangitis and external drainage of bile acid through a T-tube for more than 20 years. Vitamin E level was barely detectable (<0.5 mg/L). Sensory conduction was absent in both sural nerves. Other sensory and motor conduction studies in the upper and lower extremities showed decreased amplitude. The patient was treated with water-soluble vitamin E. After 4 months of therapy, his ambulation function improved, but pain and tingling sensation in both hands remained. Sensory nerve action potentials appeared in both sural nerves, and amplitudes of other sensory nerves were increased. In a second follow-up study after 9 months, all of the evaluated parameters in the nerve conduction studies, as well as the vitamin E level, were normal. The authors conclude that vitamin E-deficient neuropathy is reversible and electrophysiologic recovery can occur with water-soluble vitamin E therapy.

Deficiency of vitamins E and A in cystic fibrosis is independent of pancreatic function and current enzyme and vitamin supplementation

The aim of this study was to evaluate to what extent serum vitamins A and E cystic fibrosis are affected by the underlying disease, pancreatic sufficiency or insufficiency, meconium ileus, nutritional status, age and treatment (enzyme and vitamin supplementation). Serum vitamin A and E levels were determined by high performance liquid chromatography in 210 cystic fibrosis patients, subdivided according to clinical condition into four subgroups (unsupplemented pancreatic insufficiency, supplemented meconium ileus, pancreatic sufficiency, supplemented pancreatic insufficiency) and compared with 42 control subjects. Vitamin A and E levels were generally lower in cystic fibrosis patients than in controls (P < 0.002 and P < 0.001 respectively). Subjects with pancreatic insufficiency regularly receiving enzyme and vitamin supplementation had significantly lower vitamin A (P < 0.05) and vitamin E (P < 0.01) levels than controls. In subjects with pancreatic sufficiency only vitamin A was significantly lower than in controls (P < 0.01). Vitamin levels were not age-dependent in cystic fibrosis, and no significant correlation with standardized body weight (Z-score) was observed.

CONCLUSION

Cystic fibrosis patients show a clear tendency to vitamin A and E deficiency, irrespective of pancreatic function, body weight and standardized supplementation with pancreatic extract and liposoluble vitamins. Since the clinical significance of this deficiency is still not clear, longitudinal studies of cystic fibrosis patients with and without adequate vitamin supplementation are required.

Multicenter trial of d-alpha-tocopheryl polyethylene glycol 1000 succinate for treatment of vitamin E deficiency in children with chronic cholestasis

BACKGROUND

Malabsorption and deficiency of vitamin E causing neurological degeneration are common consequences of chronic childhood cholestatic liver disease. The objective of this study was to determine the long-term efficacy and safety of d-alpha-tocopheryl polyethylene glycol 1000 succinate (TPGS) in correcting vitamin E deficiency in children with chronic cholestasis who were unresponsive to other forms of oral vitamin E.

METHODS

Sixty vitamin E-deficient children with chronic cholestasis unresponsive to 70-212 IU.kg-1.day-1 of oral vitamin E were entered into a trial at eight centers in the United States. After initial evaluation, treatment was started with 25 IU.kg-1.day-1 of TPGS. Vitamin E status, neurological function quantitated by a specific scoring system, and clinical and biochemical parameters were monitored during therapy.

RESULTS

All children responded to TPGS with normalization of vitamin E status. Neurological function, which had deteriorated before entry in the trial, improved in 25 patients, stabilized in 27, and worsened in only 2 after a mean of 2.5 years of therapy. No adverse effects were observed.

CONCLUSIONS

TPGS (20-25 IU.kg-1.day-1) appears to be a safe and effective form of vitamin E for reversing or preventing vitamin E deficiency during chronic childhood cholestasis.