LLL 44-4 : Micronutrients in acute disease and critical illness.

Micronutrients (MN), i.e. trace elements and vitamins, are essential components of the diet in relatively small amounts in any form of nutrition, with special needs in critically ill patients. Critical illness is characterised by the presence of inflammation and oxidative stress. MNs are tightly involved in antioxidant and immune defences. In addition, some conditions, and treatments result in large losses of biological fluids containing MNs: therefore, acute renal injury requiring renal replacement therapy, acute intestinal failure, and major burns and trauma are at high risk of acute depletion of body stores, and of deficiency. MN requirements are increased above standard DRI. Blood level interpretation is complicated by inflammation: some biomarkers assist the status determination. Due to the acute challenges of critical illness, it of utmost importance to cover the needs to maintain the organism's endogenous immune and antioxidant defences, and capacity to repair tissues. Practical strategies are proposed

LLL 44 - 2 - Micronutrients in clinical nutrition: Vitamins.

Vitamins are essential organic molecules, which are required in the diet in relatively small amounts in any form of nutrition (oral, enteral, parenteral). Despite the small amounts that are required, the vitamins are essential both for maintenance of health, growth, and treatment of disease. After reminding about the principal function of all the vitamins, their needs and the clinical consequences of their deficit, the text present some common clinical problems: the impact of inflammation on the assessment of status. The reasons and diseases which cause increased requirements are presented, with the indications to monitoring of blood levels which remain the classical way to assess status in clinical settings. The text summarises the most relevant clinical manifestations of vitamins depletion and deficiency, the difficulties in assessing status, and makes recommendations for provision for medical nutrition therapy

Utilization of statins and LDL-cholesterol target attainment in Turkish patients with type 2 diabetes - a nationwide cross-sectional study (TEMD dyslipidemia study)

Background: Attaining acceptable levels of LDL Cholesterol (LDL-C) significantly improves cardiovascular (CV) outcomes in patients with type 2 diabetes mellitus (T2DM). The LDL-C target attainment and the characteristics of patients attaining these targets were investigated in this study. Furthermore, the reasons for not choosing statins and the physicians’ attitudes on the treatment of diabetic dyslipidemia were also examined. Methods: A nationwide, cross-sectional survey was conducted in tertiary centers for diabetes management. Adult patients with T2DM, who were under follow-up for at least a year in outpatient clinics, were consecutively enrolled for the study. LDL-C goals were defined as below 70 mg/dL for patients with macrovascular complications or diabetic nephropathy, and below 100 mg/dL for other patients. Data about lipid-lowering medications were self-reported. Results: A total of 4504 patients (female: 58.6%) were enrolled for the study. The mean HbA1c and diabetes duration was 7.73 ± 1.74% and 10.9 ± 7.5 years, respectively. The need for statin treatment was 94.9% (n = 4262); however, only 42.4% (n = 1807) of these patients were under treatment, and only 24.8% (n = 448) of these patients achieved LDL-C targets. The main reason for statin discontinuation was negative media coverage (87.5%), while only a minority of patients (12.5%) mentioned side effects. Physicians initiated lipid-lowering therapy in only 20.3% of patients with high LDL-C levels. It was observed that the female gender was a significant independent predictor of not attaining LDL-C goals (OR: 0.70, 95% CI: 0.59–0.83). Conclusions: Less than 50 % of patients with T2DM who need statins were under treatment, and only a quarter of them attained their LDL-C targets. There exists a significant gap between the guideline recommendations and the real-world evidence in the treatment of dyslipidemia in T2DM. © 2020, The Author(s).Ankara UniversitesiThe physicians and nurses in every TEMD study center who took role in recruitment of patients are acknowledged as the collaborators of TEMD Dyslipidemia Study (see supplementary data). The authors also appreciatively acknowledge the critical reviews and contributions of Professor Meral Kayikcioglu and Professor Ilker Tasci during the preparation of the manuscript. Consortium members and affiliations TEMD Study Group: Sibel Guldiken19, Semra Ayturk19, Murat Yilmaz20, Mehmet Asik21, Nevin Dinccag18, Ramazan Cakmak18, Fulya Turker18, Cemile Idiz18, Hulya Hacisahinogullari18, Elif Bagdemir18, Busra Yildiz18, Ozlem Haliloglu16, Seda Sancak22, Levent Ozsari23, Eylem Cagiltay23, Oguzhan Deyneli24, Eren Imre24, Sait Gonen25, S Nur Boysan19, Yuksel Altuntas26, Feyza Yener Ozturk26, Meral Mert27, Hamide Piskinpasa27, Hasan Aydin28, Sazi Imamoglu29, Ozen Oz Gul25, Sinem Kucuksarac Kiyici30, Berrin Cetinarslan31, Alev Selek31, Teoman Dogru32, Ali Kirik32, Belgin Efe14, Ahmet Kaya33, Ilker Cordan33, Suleyman Baldane34, Cem Onur Kirac34, Zehra Capa3, Mustafa Cesur35, Ilhan Yetkin36, Demet Corapcioglu37, Sule Canlar37, Okan Bulent Yildiz38, Suleyman Nahit Sendur38, Bekir Cakir9, Ahmet Corakci39, Mustafa Kutlu40, Neslihan Bascil Tutuncu41, Yusuf Bozkus41, Erman Cakal42, Berrin Demirbas43, Sibel Ertek44, Mustafa Altay45, Murat Dagdeviren45, Amir Hossein Abedi1, Sevki Cetinkalp46, Hatice Ozisik46, Guzide Gonca Oruk47, Serkan Yener48, Basak Ozgen Saydam48, Engin Guney49, Mustafa Unubol49, Guzin Fidan Yaylali50, Senay Topsakal50, Zeliha Hekimsoy51, Gulhan Akbaba52, Ibrahim Aslan53, Sefika Dalkiran13, Esen Akbay54, Kamile Gul55, Muge Ozsan Yilmaz6, Emre Bozkirli56, Seher Cetinkaya Altuntas12, Aysegul Atmaca57, Elif Tutku Durmu?57, Turkan Mete58, Faruk Kutluturk59, Ferit Kerim Kucukler60, Oguz Dikbas61, Safak Akin62, Irfan Nuhoglu63, Halil Onder Ersoz63, Taner Bayraktaroglu64, P?nar Sisman65, Ibrahim Sahin66, Sedat Cetin66, Ilyas Capoglu67, Emin Murat Akbas67, R?fk? Ucler68, Mehmet Ali Eren4, Alpaslan Kemal Tuzcu69, Zafer Pekkolay69, Mesut Ozkaya70, Mustafa Araz71.19Trakya University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.20Corlu REYAP Private Hospital, Department of Endocrinology and Metabolism, Turkey.21Canakkale 18 March University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.22University of Health Sciences, School of Medicine, Fatih Sultan Mehmet Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.23University of Health Sciences, School of Medicine, Sultanabdulhamit Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.24Marmara University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.25Istanbul Science University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.26University of Health Sciences, School of Medicine, Sisli Hamidiye Etfal Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.27University of Health Sciences, School of Medicine, ?stanbul Bak?rkoy Dr. Sadi Konuk Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.28Yeditepe University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.29Private Office.30University of Health Sciences, School of Medicine, Bursa Sevket Y?lmaz Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.31Kocaeli University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.32Balikesir University, School of Medicine, Department of Internal Medicine, Turkey.33Necmettin Erbakan University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.34Selcuk University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.35Private Guven Hospital, Department of Endocrinology and Metabolism, Turkey.36Gazi University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.37Ankara University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.38Hacettepe University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.39Ufuk University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.40Private Bay?nd?r Hospital, Department of Endocrinology and Metabolism, Turkey.41Baskent University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.42University of Health Sciences, School of Medicine, Diskapi Yildirim Beyazit Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.43TOBB University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.44Private Memorial Hospital, Department of Endocrinology and Metabolism, Turkey.45University of Health Sciences, School of Medicine, Kecioren Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.46Ege University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.47University of Health Sciences, School of Medicine, Izmir Ataturk Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.48Dokuz Eylul University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.49Adnan Menderes University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.50Pamukkale University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.51Celal Bayar University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.52Mugla University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.53University of Health Sciences, School of Medicine, Antalya Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.54Mersin University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.55Kahramanmaras Sutcu Imam University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.56Baskent University, Adana Training Hospital, Department of Endocrinology and Metabolism, Turkey.5719 May?s University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.58University of Health Sciences, School of Medicine, Samsun Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.59Gaziosmanpasa University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.60Hitit University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.61Giresun University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.62Recep Tayyip Erdogan University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.63Karadeniz Technical University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.64Bulent Ecevit University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.65Kars Harakani State Hospital, Department of Endocrinology and Metabolism, Turkey.66Inonu University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.67Erzincan University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.68Yuzuncu Yil University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.69Dicle University, School of Medicine, Department of Endocrinology and Metabolism, Turkey.70University of Health Sciences, School of Medicine, Gaziantep Ersin Arslan Research and Training Hospital, Turkey.71Gaziantep University, School of Medicine, Department of Endocrinology and Metabolism, Turkey

LLL 44-1 Micronutrients in clinical nutrition: Trace elements.

Trace elements are an essential component of metabolism and medical nutrition therapy, with key roles in metabolic pathways, antioxidation, and immunity, which the present course aims at summarizing. Medical nutrition therapy includes the provision of all essential trace elements. The clinical essential issues are summarized for Copper, Iron, Selenium, Zinc, Iodine, Chromium, Molybdenum, and Manganese: the optimal analytical techniques are presented. The delivery of all these elements occurs nearly automatically when the patient is fed with enteral nutrition, but always requires separate prescription in case of parenteral nutrition. Isolated deficiencies may occur, and some patients have increased requirements, therefore a regular monitoring is required. The clinicians should always consider the impact of inflammation on blood levels, mostly lowering them even in absence of deficiency. This text summarises the most relevant clinical manifestations of trace element depletion and deficiency, the difficulties in assessing status, and makes practical recommendations for provision for enteral and parenteral nutrition

Gut microbiota associations with chronic kidney disease: insights into nutritional and inflammatory parameters.

The gut barrier, comprising gut microbiota, plays a pivotal role in chronic kidney disease (CKD) progression and nutritional status. This study aimed to explore gut barrier alterations in hemodialyzed (HD) patients, non-HD (NHD) CKD patients, and healthy volunteers. Our cross-sectional study enrolled 22 HD patients, 11 NHD patients, and 11 healthy volunteers. We evaluated fecal microbiota composition (assessed via bacterial 16S rRNA gene sequencing), fecal IgA levels, surrogate markers of gut permeability, serum cytokines, appetite mediators, nutritional status, physical activity, and quality of life. HD patients exhibited significant alterations in fecal microbiota composition compared to healthy volunteers, with observed shifts in taxa known to be associated with dietary patterns or producing metabolites acting on human host. In comparison to healthy volunteers, individuals with HD patients exhibited elevated levels of inflammatory markers (CRP, IL-6 and TNF-α), glucagon-like peptide-2, and potential anorexigenic markers (including leptin and peptide YY). NHD patients had increased levels of CRP and peptide YY. Overall fecal microbiota composition was associated with height, soft lean mass, resting energy expenditure, handgrip strength, bone mineral content and plasma albumin and TNF-α. Compared to healthy volunteers, HD patients have an altered fecal microbiota composition, a higher systemic inflammation, and a modification in plasma levels of appetite mediators. While some differences align with previous findings, heterogeneity exists likely due to various factors including lifestyle and comorbidities. Despite limitations such as sample size, our study underscores the multifaceted interplay between gut microbiota, physiological markers, and kidney function, warranting further investigation in larger cohorts

Turkish nationwide survEy of glycemic and other Metabolic parameters of patients with Diabetes mellitus (TEMD study)

AIMS: Turkey has the highest prevalence of diabetes in Europe. It is therefore essential to know the overall cardiovascular risk and reveal the predictors of metabolic control in Turkish adults with diabetes mellitus. METHODS: A nationwide, multicenter survey consecutively enrolled patients who were under follow up for at least a year. Optimal control was defined as HbA1c < 7%, home arterial blood pressure (ABP) < 135/85 mmHg, or LDL-C < 100 mg/dL. Achieving all parameters indicated triple metabolic control. RESULTS: HbA1c levels of patients (n = 5211) were 8.6 ± 1.9% (71 ± 22 mmol/mol) and 7.7 ± 1.7% (61 ± 19 mmol/mol), in Type 1 and Type 2 diabetes, respectively. Glycemic control was achieved in 15.3% and 40.2%, and triple metabolic control was achieved in 5.5% and 10.1%, respectively. Only 1.5% of patients met all the criteria of being non-obese, non-smoker, exercising, and under triple metabolic control. Low education level was a significant predictor of poor glycemic control in both groups. CONCLUSIONS: Few patients with Type 2, and even fewer with Type 1 diabetes have optimal metabolic control in Turkey. TEMD study will provide evidence-based information to policy makers to focus more on the quality and sustainability of diabetes care in order to reduce the national burden of the disease