Poor diet causes blindness in a young 'fussy eater'

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. Poor diet causes blindness in a young "fussy eater"

Abstract: http://annals.org/aim/article/doi/10.7326/L19-0361
URLs go live when the embargo lifts

A poor diet caused a young patient's blindness, according to a case report published in Annals of Internal Medicine. According to the authors, nutritional optic neuropathy should be considered in any patient with unexplained vision symptoms and poor diet, regardless of BMI.

The risks for poor cardiovascular health, obesity, and cancer associated with junk food consumption are well known, but poor nutrition can also permanently damage the nervous system, particularly vision. Nutritional optic neuropathy is a dysfunction of the optic nerve usually caused by malabsorption, drugs, or poor diet combined with alcoholism and/or smoking. It is rare in developed countries. The condition is potentially reversible if caught early. But if left untreated, it leads to permanent blindness.

Researchers from Bristol Eye Hospital, Bristol, United Kingdom report the case of a 14-year-old patient who first visited his family physician complaining of tiredness. Aside from being labeled a "fussy eater," the boy had a normal BMI and took no medications. Tests showed macrocytic anemia and low vitamin B12 levels, which were treated with vitamin B12 injections and dietary advice. By age 15 years, the patient had developed sensorineural hearing loss and vision symptoms, but no cause was found. By age 17, the patient's vision had become progressively worse, to the point of blindness. The physicians investigated the patient's nutrition and found vitamin B12 deficiency, low copper and selenium levels, a high zinc level, and markedly reduced vitamin D level and bone mineral density. The patient confessed that since elementary school, he had avoided foods with certain textures and only ate French fries, Pringles, white bread, processed ham slices, and sausage. By the time his condition was diagnosed, the patient had permanently impaired vision.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the corresponding author, Dr. Denize Atan, please contact Caroline Clancy at caroline.clancy@bristol.ac.uk or + 44 (0)117 428 2407.

2. Haloperidol shows no clear benefit for preventing or treating delirium in hospitalized patients
Second generation antipsychotics may offer some delirium prevention benefits in postoperative settings

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1859
Abstract: http://annals.org/aim/article/doi/10.7326/M19-1860
URLs go live when the embargo lifts

Compared to placebo, first-generation antipsychotic, haloperidol, shows no clear benefit for treating or preventing delirium in hospitalized patients. Second-generation antipsychotics may offer some prevention benefits in postoperative settings. Findings from two systematic reviews are published in Annals of Internal Medicine.

Delirium is an acute disorder marked by impairments in attention and cognition, caused by an underlying medical problem. It often occurs after an acute illness or surgery and may affect up to 50 percent of hospitalized older adults. Antipsychotics are used to prevent and treat delirium, but their benefits and harms are unclear.

Researchers from Johns Hopkins University School of Medicine reviewed 14 randomized controlled trials (RCTs) to examine the benefits and harms of haloperidol or second-generation antipsychotics for preventing delirium in adults, and 16 RCTs and 10 observational studies to examine the benefits and harms of haloperidol or second-generation antipsychotics for treating delirium in adults. With regard to prevention, the researchers found little or no evidence to determine the effects of antipsychotics on cognitive function, delirium severity, caregiver burden, or sedation. Haloperidol did not appear to prevent delirium, although the research suggests that there may be some benefit with second-generation antipsychotics in postoperative settings. With regard to treating delirium, both haloperidol and second-generation antipsychotics did not demonstrate any clear benefit compared to placebo. Using haloperidol or second-generation antipsychotics to prevent or treat delirium did not decrease length of hospital stay and made little or no difference in sedation or neurologic side effects but potentially harmful cardiac side effects did occur more frequently. According to the study authors, future trials should use standardized outcome measures, as more research is needed to assess the effects of antipsychotics on patient agitation and distress, subsequent memories of delirium, caregiver burden and distress, inappropriate continuation of antipsychotic therapy, and long-term cognitive functional outcomes.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with author Karin Neufeld, MD, MPH, please contact Vanessa McMains vmcmain1@jhmi.edu.

3. People inadvertently ingest thousands of tiny plastic particles every year
Bottled water may be one of the strongest contributors to microplastics ingestion

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0618
Editorial: http://annals.org/aim/article/doi/10.7326/M19-2474
URLs go live when the embargo lifts

A study of human stool samples reveals that people inadvertently eat thousands of tiny plastic particles every year. Various types of microplastics were detected in fecal matter, suggesting that plastic particles are present in many different sources. Findings from a prospective case series, which were presented last year at the United European Gastroenterology Week, are now published in Annals of Internal Medicine.

More than 350 million tons of plastic are produced each year and some of it pollutes the environment. Microplastics, or plastic particles smaller than 5 mm, may be ingested by marine organisms where they can then enter the food chain.

Researchers from the Medical University of Vienna and the Environment Agency Austria studied human feces samples from 8 adults living in Europe and Asia to look for the presence of microplastics and to determine whether humans involuntarily ingest them. All 8 stool samples tested positive for microplastics, with a median of 20 microplastics per 10 g of human stool (daily stool excretion of an average adult is approximately 100 g). Polyethylene and polyethylene terephthalate accounted for the largest share of plastics found in human stool. The researchers also detected 7 other plastic types, suggesting that there are many different sources of ingestion. According to the literature, the estimated annual intake of microplastics is 123 to 11,000 particles from shellfish; 37 to 1,000 particles from salt; and 4,400 to 5,800 particles from tap water. Airborne fallout accounts for 13,731 to 68,415 swallowed particles per year and, bottled water may also be a strong contributor to microplastic ingestion, with an average of 118 to 325 particles per liter, for a total of 90,000 microplastics annually if the recommended water intake comes entirely from bottled sources.

The scientists emphasize that further research is needed to determine the effects of plastic ingestion on human health.

Notes and media contacts:

The abstract presented at the United European Gastroenterology Week led to many international reports on this research. For the first time, this research is published as a peer-reviewed paper and accessible in Annals of Internal Medicine. For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Philipp Schwabl, MD, please contact thorsten.medwedeff@meduniwien.ac.at.

4. Patients with LMNA mutations likely to face life-threatening neurologic or cardiologic conditions

Abstract: http://annals.org/aim/article/doi/10.7326/M18-2768
URLs go live when the embargo lifts

Patients with the LMNA (lamin A/C) gene will likely face life-threatening cardiac and neuromuscular conditions in their lifetime, with neuromuscular conditions starting at a much earlier age. The clinical care team for these patients should include at least a cardiologist and neurologist. Findings from an observational study are published in Annals of Internal Medicine.

Mutations in the LMNA gene have been associated with neuromuscular and cardiac manifestations. Although skeletal myopathy may occur apart from heart disease, life-threatening arrhythmias, and dilated cardiomyopathy have been described in patients with skeletal muscle disease, and sudden cardiac death accounts for up to 30 percent of all deaths. However, because LMNA-related disease is so rare, not enough is known about its natural history.

Researchers from Vita-Salute University and San Raffaele Hospital (Milan, Italy) presented results of a national study on 164 patients with LMNA mutations enrolled at 13 referral centers, to learn more about the natural history of LMNA-related disease. They found neuromuscular manifestations preceded cardiac signs by a median of 11 years. However, by the end of the 10-year follow-up, 90 percent of the patients had relevant cardiac arrhythmias followed by structural heart disease. According to the researchers, these findings show for the first time that the link between neuromuscular and cardiac features can be used to predict risk of sudden arrhythmic death and heart failure in LMNA patients. Based on their findings, the researchers believe that clinicians who care for patients with LMNA mutations should always consider including cardiologists and neurologists on the clinical team. An advantage to this approach might be earlier identification of high-risk patients who might benefit from protective strategies, such as implantable cardioverter-defibrillator therapy and referral to heart transplant centers.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Giovanni Peretto, MD, please contact him directly at peretto.giovanni@hsr.it.

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Also new in this issue:

In the Clinic: Dementia Update
Esther S. Oh, MD, PhD; Peter V. Rabins MD, MPH
In The Clinic
Abstract: https://annals.org/aim/article/doi/10.7326/AITC201909030