The Effect of Vitamin K2 Supplementation on PIVKA-II Levels in Patients with Severe Motor and Intellectual Disabilities Undergoing Long-Term Tube Feeding

Nutritional support is essential for patients with severe motor and intellectual disabilities (SMID) to ensure the smooth provision of medical care. These patients often require long-term tube feeding with enteral formulas, potentially leading to deficiencies in vitamins and trace elements. Additionally, frequent antibiotic use for infections often disrupts gut microbiota, inhibiting vitamin K2 production by intestinal bacteria. We assessed the serum protein induced by vitamin K absence or antagonists-II (PIVKA-II) and undercarboxylated osteocalcin (ucOC) levels to assess the vitamin K status in 20 patients with SMID (median age: 44.1 years, 11 men and 9 women) undergoing long-term tube feeding for durations ranging from 3 to 31 years. Thirteen (65%) and nine (45%) patients had elevated PIVKA-II (<40 mAU/mL) and serum ucOC levels (reference value < 4.50 ng/mL), respectively. Dietary vitamin K1 intake did not differ between patients with and without elevated PIVKA-II levels. Vitamin K2 supplementation for 3 months decreased serum PIVKA-II levels near those within the reference range. Approximately half of the patients with SMID on tube feeding had subclinical vitamin K deficiency. Further studies are needed to ascertain if long-term vitamin K2 supplementation effectively prevents vitamin K deficiency-induced hypercoagulation, osteoporosis, and vascular calcification in patients with SMID.

Isolated neutropenia caused by copper deficiency due to jejunal feeding and excessive zinc intake: A case report

BACKGROUND

Percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) is often used to treat patients with neurological impairment and difficulty in swallowing. However, these patients often develop copper deficiency. This report describes a case of isolated neutropenia, which is a rare manifestation of copper deficiency.

CASE SUMMARY

Our patient was a 19-year-old boy with neurological impairment and gastroesophageal reflux. He received PEG-J feeding, including an enteral supplement containing copper and zinc. However, as his serum zinc level was low (53 μg/dL) at the age of 19 years and 2 mo, we changed to a zinc-rich supplement containing 22 mg/d of zinc and 1.0 mg/d of copper. The supplement comprised a mixture of isocal 1.0 junior (5 packs/d), Tezon [2 packs (250 mL)/d], and cocoa powder. Seven months later, he had neutropenia (606/mm³) with a serum copper level of 16 μg/dL. There were no other manifestations of copper deficiency, including anemia. Copper deficiency and neutropenia both improved following the administration of cocoa powder and Tezon.

CONCLUSION

In patients receiving long-term PEG-J feeds, white blood cell counts, hemoglobin, and serum levels of copper and zinc should be regularly monitored.

Gastric and Jejunal Enteral Feeding Differently Affect Vitamin B12 Status in Subjects with Severe Motor and Intellectual Disabilities

The absorption of vitamin B₁₂ is a complex process involving gastric acid and intrinsic factor as the indispensable components. In this study, we have investigated the effects of the administration site in enteral feeding on vitamin B₁₂ status in subjects with severe motor and intellectual disabilities (SMID). This is a cross-sectional study conducted from January to June 2016. Blood concentrations of vitamin B₁₂, folate, vitamin B₆, and homocysteine (Hcy) were measured in a total of 82 subjects (38 men, 44 women). Also, nutrients intake was assessed. Subjects with enteral feeding (EF) had significantly higher intakes of vitamin B₁₂, folate, and vitamin B₆ than those with oral ingestion (OI). Serum folate and vitamin B₆ concentrations in subjects with EF were significantly higher than those with OI. Among the EF subjects, serum vitamin B₁₂ concentration was significantly higher in those fed with gastric tube than those fed with jejunal tube in spite of similar vitamin B₁₂ intakes. No significant difference was observed between the two groups regarding the circulating concentrations of folate, vitamin B₆, or Hcy. Although each administration route has its own benefit, gastric tube is advantageous in the absorption of vitamin B₁₂.

Deep Vein Thrombosis in Severe Motor and Intellectual Disabilities Patients and Its Treatment by Anticoagulants of Warfarin Versus Edoxaban

Objective: Patients with severe motor and intellectual disabilities (SMID) often develop complications, including paralysis of the extremities due to abnormal muscular tonicity. Furthermore, the incidence of sudden death, which may be caused by pulmonary thromboembolism (PTE), is approximately 4.2%. Deep vein thrombosis (DVT) is attracting attention as an embolic source. In this study, DVT was confirmed in SMID patients by lower extremity venous ultrasound. The oral anticoagulant, warfarin, and novel oral anticoagulant, edoxaban tosilate hydrate, were administered, and their efficacies and safeties were evaluated.

Materials and Methods: DVT patients were randomly allocated to warfarin and edoxaban groups. The frequency of hemorrhagic events and incidence of adverse events were investigated to evaluate efficacy and safety.

Results: DVT was detected in 14 (8.4%) out of 167 patients. Four (0.067/person-month) hemorrhagic events occurred in the warfarin group from subcutaneous hemorrhage due to bruises caused by postural changes. Three (0.042/person-month) events occurred in the edoxaban group due to nasal hemorrhage caused by tracheal aspiration. There was no significant difference (p=0.5383) between groups.

Conclusion: No significant differences were observed in hemorrhagic events between SMID patients with DVT treated with warfarin and edoxaban.

Multicenter, Open-Label, Randomized Controlled Trial of Warfarin and Edoxaban Tosilate Hydrate for the Treatment of Deep Vein Thrombosis in Persons with Severe Motor Intellectual Disabilities

Sudden death in patients with severe motor and intellectual disabilities (SMID) is sometimes caused in part by pulmonary thromboembolism (PTE), and deep venous thrombosis (DVT) has drawn attention as a possible embolic source. Warfarin, which is a conventional therapeutic agent, is not easy to control appropriately, and daily management can be especially difficult in SMID patients. On the other hand, edoxaban tosilate hydrate, which has been newly approved for insurance coverage for the treatment of DVT, is not listed in the Guidelines for the Diagnosis, Treatment and Prevention of Pulmonary Thromboembolism and Deep Vein Thrombosis (DVT-PTE guidelines). The aim of this study is to evaluate the efficacy and safety of anticoagulation therapy (warfarin vs. edoxaban) in DVT treatment in SMID patients by means of an open-label, randomized controlled trial. The primary endpoint is the incidence of hemorrhagic events during 12 months of follow up.

[Management of nutrition in children and adults with severe motor and intellectual disabilities]

In children and adults with severe motor and intellectual disabilities (SMID), management of nutrition is very important. We investigated the problem of long-term use of tube feeding on which many of them depend because of swallowing dysfunction. Trace elements such as copper, zinc, selenium and long chain unsaturated fatty acid (omega-3 fatty acid) were often deficient. To evaluate their nutritional condition, we calculated the body fat mass by the method of Bioelectrical Impedance Analysis and measurement of subcutaneous fat thickness. Patients with the athetotic type of cerebral palsy had a lower level fat mass than those with the spastic type. Patients with a low body fat mass tended to require more energy than those with a high body fat mass. To improve the quality of life of persons with SMID, it is important to find clinical dysfunction related to the nutrition and to improve the nutritional condition immediately.

Histochemical study of mitochondrial enzymes in cerebellar cortex of macular mutant mouse, a model of Menkes kinky hair disease

The cerebellar Purkinje cells in the hemizygote of the macular mutant mouse contain numerous abnormal mitochondria which show a marked decrease in cytochrome c oxidase activity. Using histochemical methods we studied the activity of other mitochondrial enzymes, such as NADH diaphorase and succinic dehydrogenase, in the cerebellar cortex of this mutant mouse. Such activities were markedly increased in the Purkinje cells, especially in the soma and stem dendrite, from 10 days after birth in the hemizygote as compared with findings in normal littermates. These results were considered to be due to an increased number of abnormal mitochondria.

Neuropathological study on cerebellum of macular mutant mouse heterozygote

The hemizygote of the macular mutant mouse is clinically, biochemically and neuropathologically similar to a patient with Menkes kinky hair disease. The heterozygote of this mutant mouse was biochemically and neuropathologically examined. The copper content in the brain decreased in comparison with that in the normal littermate, although it was more than that in the hemizygote. In the Golgi study, abnormal Purkinje cells with somal sprouts, thick stem dendrites and dendritic focal swellings, which were seen in the hemizygote, were not observed in the heterozygote. Ultrastructurally, abnormal mitochondria were seen in the Purkinje cells in the anterior and middle cerebellar lobe of the heterozygote. Histochemically, cytochrome c oxidase activity decreased, especially at the anterior lobe in the cerebellar cortex of the heterozygote. This activity, as indicated by staining intensity, was in between that in the normal littermate and that in the hemizygote. The heterozygote did not show a mosaic pattern in the distribution of these neuropathological changes, although this mutant mouse shows x-linked recessive inheritance. Thus, our results lead to the conclusion that the neuropathological changes observed in this mutant mouse do not result directly from an abnormal gene in the Purkinje cell, but from the secondary effects of subsequent to presumptive copper deficiency.