Admin note

Posts will be sparse or nonexistent for the next day or so while I sort out why I can't publish outgoing links in new posts. My web site host (Squarespace) has upgraded to a new version and I may need to use a new template.

Vitamin K & warfarin (Coumadin)

 

Image of  Fractal broccoli (Public domain)

 

Broccoli is a rich source of Vitamin K with 220 micrograms per 125 mL (1/2 cup) serving.

 

Here are two helpful resources I used in a counseling session recently:

• Warfarin interactions with drugs, natural health and food products (Heath Canada handout)
• Food Sources of Vitamin K (PEN handout) (note: subscription required)
  

What  resources or specific advice do you give your clients who are on warfarin?  Feel free to share these in the comments section.

Discovery Tuesday: "Well"

Note: The credits for all 12 Creative Commons-licensed photos in this post are listed at the end. You'll need to read the featured article to determine which photo does not belong -- that is, it didn't make the list of the 11 best foods you may or may not be eating.

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Last week while reading an online article on gardening, I glanced to the right side of the screen where seven words in tiny type instantly diverted my thoughts from July planting to wondering if I was missing out on the latest nutrition wisdom:

The 11 Best Foods You Aren't Eating

Could any dietitian resist checking out an article with this title? Not I.  So I stopped reading about what seeds to sow for late summer bounty and clicked on the link so I could reassure myself I was eating some if not all of those "best foods." 

Except for sardines, which will never pass my lips, I discovered my diet incorporates the  items, although the frequency varies from rarely (tumeric) through occasionally (pomegranate juice) to often when in season (blueberries, pumpkin).

But I'm not sharing this article with you because I think it's the best best foods list.  Although eleven is a manageable number and one more than the ubiquitous top ten lists, I'd like to see a few more foods added, especially in this season of abundant fresh produce.  Also,  I agree with several commenters' concerns about the list-maker's credentials. To supplement these 11 or 10 foods  (no sardines for vegetarians, please!)  you could refer to Leslie Beck's page of Featured Foods.  And I highly recommend compiling Kelly Rossiter's Planet Green posts on Farmers' Markets:  you will have a week-by-week list of  fruits and vegetables -- some of which might be unfamiliar -- to purchase and prepare in new and delicious ways.  Of course  I also need to give a shout-out to Melanie of Dietriffic whose lists are consistently practical, interesting to read,  well-researched and based on the latest nutrition science.

No, the main reason I've highlighted this particular post is to introduce you to Well, the blog in which it was published. It's new to me and perhaps to you, also.  Here's the description of this  blog:

Healthy living doesn't happen at the doctor's office. The road to better health is paved with the small decisions we make every day. It's about the choices we make when we buy groceries, drive our cars and hang out with our kids. Join columnist Tara Parker-Pope as she sifts through medical research and expert opinions for practical advice to help readers take control of their health and live well every day.

I wish I had stumbled upon Well about 10 months ago when it was launched. Now I have quite a bit of catch-up reading to do. Here are just a few of the past posts I want to read. Perhaps they will pique your interest, too:

• Why Children Are Not Little Adults
  
• Should Doctors Lecture Patients About Their Weight
• More on Wasted Food (podcast)
• Getting the Most Out of Vegetables
• Look for a Few Good Cookbooks (Mark Bittman asks for readers' help)
  

Now that I've finished reading the Best 11 Foods and writing this post I can return to the gardening article.  Earlier I stated this "top 11 list" distracted me from planning my summer-to-fall garden but in fact it actually helped my decision-making:  I'll be adding  Swiss chard to the list of seeds to sow this week.
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Photo credits (left to right):
Top row - Beets me; Morning Dew; Day of the Chard; Cinnamon Craze
Middle row - Pomegranate 1; prunes italie noires; pumpkin seeds; sardines
Bottom row - Tumeric; Blueberry Lemonade - Frozen blueberries; Spiced Roast Pumpkin Soup; sweet potatoes

Fluid & Electrolyte Balance -- Reference Values

Found at Surgical Tutor, a helpful resource to check when designing enteral feeding regimens with and without concomitant iv therapy:

Fluid and electrolyte balance

Daily requirements

• For the ‘average’ 70 Kg man
  • Total body water is 42 L (~60% of body weight)
  • 28 L is in the intracellular and 14 L in the extracellular compartments
  • The plasma volume is 3 L
  • The extravascular volume is 11 L
  • Total body Na⁺ is 4200 mmol  (50% in ECF)
  • Total body K⁺ is 3500 mmol  (only about 50-60 mmol in ECF)
  • Normal osmolality of ECF is 280 –295 mosmol/kg

Fluid replacement

When calculating fluid replacement for a patients need to consider:

Maintenance requirements

• Daily maintenance fluid requirements vary between individuals.
  70 Kg male = 2.5 - 3.0L water, 120 – 140 mmol sodium and 70 mmol potassium
  40 Kg woman = 2.0L water,70 – 90 mmol sodium and 40 mmol potassium
• Daily maintenance fluid requirements for children
  • 0-10 kg is 100 ml/kg
  • 10-20 kg is 1000 ml + 50 ml/kg for each kg > 10
  • >20 kg is 1500 ml + 25 ml/kg for each kg > 20

Replacement of losses

• Pre-operative or pre-admission
• Ongoing losses
• Nasogastric aspirate
• Vomit, diarrhoea
• Stoma, drains, fistula etc
• Most ‘surgical ‘ ongoing losses are rich in sodium and should be replaced with 0.9% saline

Insensible losses

• Faeces approximately 100 ml/ day
• Lungs approximately 400 ml/ day
• Skin approximately 600 ml/ day

Composition of crystalloids

	Hartmann’s Solution	Normal Saline	Dextrose   Saline
Sodium  (mmol/l)	131	150	30
Chloride (mmol/l)	111	150	30
Potassium (mmol/l)	5	Nil	Nil
Bicarbonate (mmol/l)	29	Nil	Nil
Calcium (mmol/l)	2	Nil	Nil

[Note:  Hartman's Solution --  a solution containing sodium chloride, sodium lactate, and phosphates of calcium and potassium; used intravenously as a systemic alkalizer and as a fluid and electrolyte replenisher. ]

Click here to view the full table and notes. 

Wernicke's Encephalopathy

FIGURE 1  Fluid-attenuated inversion-recovery image showing mild symmetrical hyperintensity in the bilateral medial thalami (arrows).  From the following article: Wernicke's encephalopathy: beyond alcoholism Robin K Wilson, Ralph W Kuncl and Andrea M Corse Nature Clinical Practice Neurology (2006) 2, 54-58.

Recently the Neurology physicians consulted me about a patient (Mr. X) with Wernicke's Encelphalopathy. They made this diagnosis based on Mr. X's response to iv thiamine -- his clinical symptoms resolved. This was my first consultation of this type in a few years and I had a student observing me (always a good motivator to make sure you know your stuff)  so I reviewed some resources to prepare for the assessment.  The patient's nutrition history supported the diagnosis and although I'm not a physician and therefore am reluctant to refine the diagnosis,  I believe Mr. X had a relative rather than absolute thiamine deficiency. He reported recent significant wt loss (7 kg), decreased intake (1 meal per day), minimal intake of grains, vegetables and fruits, and regular although apparently not excessive alcohol consumption (2 beers or 2 glasses of wine every evening).  Because he has been looking after the needs of an aging family member as well as working fulltime, he has been neglecting his self-care, including diet. There were some other barriers to intake but through discussion, he and his wife came up with realistic solutions based on the ideas and resources I offered to them.

Here are the resources I used in my assessment and counselling:

• Nutritional Neuropathies.  Neurol Clin 25 (2007) 209-255.
• Wenicke's encephalopathy: beyond alcoholism.  Nature Clinical Practice Neurology 2 (2006)  54-58.
  
• Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management.  The Lancet Neurology  (2007) Volume 6, Issue 5  442-455.
• Food Sources of Thiamine   Note: You need a PEN subscription to access this Dietitians of Canada resource.
• Fast and Easy Meal Ideas