960

LETTERS

TO

THE

Reply

to P FUrst

My

statement nitrogen

a “view.”

that

nitrogen

balance

and

nonprotein

balance

It is a restatement

protein

nitrogen

Hence, balance

to derive protein when glutamine

is the

algebraic

nitrogen

is clearly

urea

or not glutamine considerations. nitrogen

nitrogen and urea

and

balance

12.

Alanyl-glutamine

and

The report concerning (residency) education

with

in graduate

nutrition Weinsier

by

characteristics ofinstitutions nutrition training for residents”

nutrition of curricula

not

such

any

suggest

based tings.”

that

programs “a

major

deficit

approaches to disease prevention This conclusion cannot be made

in graduate

medical

programs,

the United have drawn nutrition

education

especially

without

because

30%

States is provided by family conclusions prematurely education

depletion

of free

glutamine

and

included

for residents, (2) however,

ofall

in-

The

probably

Johns

glutamine

nitrogen

site

partially,

balance

or related

relative

contribution in the

when

that about (or sepsis)

resulting

compounds

balance, not protein only to the short-term

diminishes

Hopkins

acutely

is explicable nitrogen studies

balance. that have

ofglutamine long

term;

nitrogen such

data

MD

are

Walser

University

School of Medicine Department of Pharmacology Baltimore,

and

Molecular

Sciences

21205

education

medical that the clinicalis biased They been

including they did visits.

The

nutritionally

family-medi-

ambulatory

care

in

physicians. The authors by not investigating the

in family-medicine

positive

nitrogen apply

published.

balance lacking.

in the ambulatory setfor nutrition training including

ofthe ofglutamine

statements

been

authors showing

medical

is teaching

tissue

!tIacken:ie

glutamine

as these by others

study’s

restores

glutamine

authors cite themselves. training programs have

in the

more

infusion

These

nitrogen.

training in graduate et al (1) suggests

education guidelines;

infusion

as nonprotein

total nitrogen it is necessary

judged to provide “strong be described. This report

for reasons the that family-medicine

active in developing the development authors

halfor

from

(or protein) Most of non-

and

glutamine

We

include

the

it has become depleted. To repeat, the literature shows halfthe short-term negative nitrogen balance oftrauma

Sir:

and incomplete acknowledge

counteracts

the postoperative decline in protein synthesis in skeletal muscle. Ann Surg 1990;212:637-44. I 3. Vinnars E, Hammarqvist F, Von der Decken A, Wernerman J. Role ofglutamine and its analogs in posttraumatic muscle protein amino acid metabolism. JPEN 1990; 14:125S-9S.

The

creases tissue glutamine above normal values, claim I did. Rather, I quoted work by them and

training

of

is not of mass.

glutamine

balance from stores change,

corrections for urea nitrogen balance. It is that simple. not suggest that supplementation

Nutrition

sum

balance

of the law of conservation

It has nothing to do with whether is an end product or with static

grams.

1 1.

that

protein

cine

10.

et al

Sir:

to apply nitrogen I did

9.

residency

pro-

believe

that

the

Committee

and Residency Education Nutrition needs to complete gest identifying program that residents.

The

patient

only

in which

nutrition

features

highlights

ambulatory

training

they

described

those training

is present

and

as important

challenged,

including

I) the

2) the

for a 4-wk

experience

need

Medical/Dental

School

components of a clinical-nutrition likely to be effective in teaching

discussion

training

bulatory the

the are

on

of the American Society for Clinical the work it started before they sugtraining nutrition to elements

of in-

is absent.

If am-

effective,

several

of

to training

could

be

physician-nutritionist to learn

role assessment

model, and

port, and 3) the superiority of locally developed report notes that a “rich academic and research

materials. environment

key

faculty

to attracting

little

direct

Perhaps

with

strong

if a research care given

impact

and

retaining

on residents’

this survey described nutrition-research

strong

nutrition

supThe is

despite

education.” the characteristics of institutions reputations. It remains to be seen

reputation is the key to the American public.

to improving We believe

the that

nutrition primary-

Downloaded from https://academic.oup.com/ajcn/article-abstract/56/5/960/4715596 by Washington University, Law School Library user on 12 February 2019

I . Walser M. Misinterpretation of nitrogen balances when glutamine stores fall or are replenished. Am J Clin Nutr 199 1;53:l337-8. 2. Hundal HS, Babij P, Taylor PM, Watt PW, Rennie MJ. Effects of corticosteroid on the transport and metabolism of glutamine in rat skeletal muscle. Biochim Biophys Acta 199 l;1092:376-83. 3. F#{252}rst P. Intracellular muscle free amino acids-their measurement and function. Proc Nutr Soc 1983;42:45 1-62. 4. Rennie Mi. Muscle protein turnover and the wasting due to injury and disease.Br Med Bull 1985;41:257-64. 5. Ardawi MSM, Majzoub MF. Glutamine metabolism in skeletal muscle of septic rats. Metabolism 199140:155-64. 6. Souba WW. Glutamine: a key substrate for the splanchnic bed. Annu Rev Nutr 1991;l 1:285-308. 7. Jepson MM, Bates PC, Broadbent P. Pell JM, Millward Di. Relationship between glutamine concentration and protein synthesis in rat skeletal muscle. Am J Physiol 1988;255:E166-72.

Dear

Jepson MM, Millward DJ. Impact ofglutamine infusions on muscle protein synthesis in fasted and endotoxin treated rats. Clin Nutr I 99 1 ;10(suppl):43-6. Barua JM, Wilson E, Downie 5, Weryk B, Cuschieri A, Rennie Mi. The effect of alanyl-glutamine peptide supplementation on muscle protein synthesis in post-surgical patients receiving glutamine-free amino acids intravenously. Proc Nutr Soc l992;51:l 15. Ardawi MSM. Effect ofglutamine-enriched total parenteral nutrition on septic rats. Clin Sci 199l;81:215-22. Stehle P, Zander J, Mertes N, et al. Effect of parenteral glutamine peptide supplements on muscle glutamine loss and nitrogen balance after major surgery. Lancet 1989;l:231-3. Hammarqvist F, Wernerman J, Von der Decken A, Vinnars E.

8.

References

Dear

EDITOR