Seasonal variation of serum 25-hydroxyvitamin D levels in adult patients with inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) are at risk of osteoporosis. Vitamin D (vitD) deficiency is known as a risk factor of osteoporosis. We observed low vitD blood levels in adult IBD patients both at the end of summer and winter. Furthermore, effects of oral vitD supplementation in (generally low) daily dosages were poor.

INTRODUCTION

Patients with IBD are at risk of osteoporosis. This study evaluates seasonal vitD status, determinants of vitD deficiency and effects of vitD supplementation in adult IBD patients.

METHODS

Patients were screened for vitD deficiency at the end of summer and winter using serum 25OHD(3) (cut-off point, <50 nmol/L) combined with routine laboratory tests. A standardized questionnaire was used for demographic/lifestyle data i.e. IBD activity, health behaviour and vitD intake through diet and ultraviolet light.

RESULTS

Late-summer, 39% of the included 316 patients were vitD deficient. Late-winter, 57% of the follow-up patients (n=281) were deficient. Independent protective determinants of vitD deficiency were oral vitD supplementation (summer/winter: odds ratio [OR], 0.52 [95% confidence interval [CI], 0.29-0.94]/OR, 0.44 [95% CI, 0.26-0.75]), recent sun holiday (summer: OR, 0.42 [95% CI, 0.24-0.74]) and regular solarium visits (summer/winter: OR, 0.28 [95% CI, 0.13-0.63]/OR, 0.17 [0.06-0.50]). IBD activity (p=0.031), red blood cell distribution width (RDW; p=0.04) and erythrocyte sedimentation rate (p=0.03) were associated with low vitD levels using univariate analyses of the extreme 25OHD quartiles. In a subgroup with vitD supplementation, still 30% (late-summer) and 44% (late-winter) were vitD deficient.

CONCLUSION

VitD deficiency is common in IBD patients, but prevalence might be comparable with the general population. Ultraviolet light is essential for adequate vitD levels. Effects of oral vitD supplementation in (generally low) daily dosages are poor. Determinants for low vitD levels were IBD activity and elevated inflammatory markers, suggesting that increased risk of osteoporosis in IBD might be more related to the inflammation than to vitD deficiency.

Plasma exchange in the treatment of heterozygous familial hypercholesterolaemia

Five patients with heterozygous familial hypercholesterolaemia, whose response to diet and medication was inadequate, received additional treatment with plasma exchange (PE). Two and a half to three liters of plasma were replaced by a 5% albumin solution once every 3 weeks. Treatment with diet and cholestyramine was continued. This resulted in a reduction of serum total cholesterol (Tot-c) by 21.8-52.2% compared to pretreatment values. Normocholesterolaemia was not achieved. Since the mean Tot-c curve after PE exceeded the upper limit of the normal range approximately 10 days after exchange, the PE frequency was increased to once every 10 days. Tot-c was reduced by 42.6-57.5% and normocholesterolaemia was achieved in most cases. We conclude that normocholesterolaemia can be achieved by treatment which includes PE in all patients with heterozygous familial hypercholesterolaemia and inadequate response to the usual therapy. Individual adjustment of the PE frequency, based on the mean Tot-c curve after PE, is advised.

Effects of plasma exchange on serum cholesterol levels in heterozygous familial hypercholesterolemia

This study describes the cholesterol-lowering effect of plasma exchange (PE) in seven patients with heterozygous familial hypercholesterolemia. All patients followed an identical protocol consisting of one PE per three weeks during 27 weeks. A cholesterol-lowering diet was prescribed in addition. No supporting cholesterol-lowering medication was given. PE leads to a momentary marked decrease in serum concentrations of both total cholesterol (Tot-c) and high density lipoprotein cholesterol (HDL-c). HDL-c concentration returns more rapidly to the plateau value than Tot-c concentration resulting in a transient favourable Tot-c/HDL-c ratio that disappears after 10-14 days. No reducing or increasing effect of PE on HDL-c concentration was observed after 27 weeks of treatment. Nor was any convincing reducing effect on Tot-c concentration observed.

Cardiovascular risk is more related to drinking pattern than to the type of alcoholic drinks

Many observational studies have shown an association between moderate alcohol consumption and a lower risk for cardiovascular morbidity and mortality. Some of these studies, whether or not inspired by the French paradox, suggest a more favourable effect of wine than of other alcoholic drinks. Certain polyphenols including the flavonoids, more abundant in red than in white wine, are held responsible for this 'bonus' effect. However, this conclusion seems premature, since no significant bioactive effect of wine polyphenols has been shown in humans so far. Furthermore, wine drinking proves to be associated with a healthier lifestyle profile than consumption of beer and liquor, and this may have a substantial influence on the outcome of studies. In contrast to moderate drinking, incidental heavy or binge drinking is associated with an increased cardiovascular risk by influences both on the electrical conduction system of the heart and the process of atherothrombosis. Although only prospective randomised intervention trials including a sufficient number of people will give definite answers, the chances are small that they will ever be performed given the ethical and practical objections of such studies. Available data so far justify the conclusion with regard to cardiovascular risk that the pattern of drinking is of more importance than the content of the bottle.

Binge drinking causes endothelial dysfunction, which is not prevented by wine polyphenols: a small trial in healthy volunteers

BACKGROUND

Binge drinking (the consumption of large quantities (>5 units) of alcohol in a short period) is associated with increased cardiovascular mortality. Wine polyphenols are considered to be protective against cardiovascular diseases. We conducted an experimental study to evaluate the acute effects of alcohol consumption on flow-mediated vasodilation and general cardiovascular parameters, using beverages with high polyphenolic content (HPC) and low polyphenolic content (LPC).

METHODS

Two groups of ten volunteers were asked to drink two different kinds of beverages. in 45 minutes, three units of red wine or an alcoholic beverage with a low polyphenolic count were consumed. Then 45 minutes were allowed for complete uptake of the alcohol or polyphenolic compounds. Next, all volunteers underwent blood pressure readings, ECG and flow-mediated vasodilation. Blood samples were taken at the same time for routine chemistry, inflammation parameters and lipids. Then the entire cycle was repeated once (in total six units of alcohol in 180 minutes).

RESULTS

No differences were found between the two drinks. Alcohol itself dose-dependently increased forearm blood flow by vasodilation of both arterioles and distribution arteries. However, flow-mediated vasodilation (FMD) for the LPC group (n=10) decreased from 7.31 +/- 4.78 (% +/- sd) to 2.82 +/- 2.9 after three drinks and 1.21 +/- 3.25 after six drinks. The FMD values for the HPC group (n=10) decreased from 8.61 +/- 1.78 to 1.78 +/- 3.71 and 1.19 +/- 2.6. There were no significant changes between the LPC and the LPC group at the three time points.

CONCLUSION

Although ethanol produces vasodilation at the level of the distribution artery as well as at an arteriolar level, it causes a decrease in flow-mediated vasodilation. This endothelial dysfunction is not corrected by the polyphenols present in wine.

[The practice guideline 'Problematic alcohol consumption' (second revision) from the Dutch College of General Practitioners; a response from the perspective of internal medicine]

The prevalence of problem drinking in the Dutch population, affecting about 750,000 persons, is much higher than that of abuse or addiction and contributes substantially to healthcare workload and costs. However, recognition, not only in primary care but also in the hospital environment, can be difficult. The symptoms are often non-specific and are not always immediately related to the use of alcohol. Even in cases of overt abuse, like in injuries and trauma, routine drinking histories are recorded poorly and identification and signalling are inadequate. It is estimated that up to 16% of all emergency room patients have consumed alcohol within six hours before their visit. Since a patient will benefit not only from the treatment of his symptoms but also from the uncovering of the underlying problem, more emphasis should be laid on the early identification of problem drinking. Especially in the early phase of problem drinking, interventions, in most cases by primary-care physicians or nurse practitioners, may be successful. Since the revised version of the practice guideline 'Problematic alcohol consumption' from the Dutch College of General Practitioners contains clear and practical advice on the early recognition and management of problem drinking, its use is recommended not only to primary-care physicians but also to hospital-specialist staff.

Substance use among emergency room patients: Is self-report preferable to biochemical markers?

AIM OF STUDY

To explore the validity of self-reported substance use among emergency room populations and the processes of sample selection bias, to establish their influence on the prevalence rates found.

METHODS

Self-reported alcohol and illicit drug use of patients in the emergency room is compared with results from an alcohol breath analyser and urine toxicology.

RESULTS

Variations in reported substance use occur when comparing self-report measures with alcohol breath analyser results and urine toxicology. Self-reported alcohol use was found among 7.5% of the patients compared with 4.7% based on alcohol breath analysers. Illicit drug use was reported by 9.0% of the patients whereas urine toxicology resulted in 30% patients positive for illicit drug use. Patients that voluntarily participate in the study differ from those that do not participate. Patients who refuse an alcohol breath analyser report slightly more alcohol use prior to the injury (difference not significant), and patients who provide a urine sample report more illicit drug use prior to the injury compared to those that refuse.

DISCUSSION

Differences in prevalence rates can be explained partly by the measurements used and partly by sample selection bias. Self-reported alcohol use and self-reported illicit drug use are preferable to the "gold standard" when used among emergency room patients, because both measures provide more accurate information on the actual use. Sample selection bias also influences the prevalence rates.

Association of furunculosis and familial deficiency of mannose-binding lectin

BACKGROUND

Polymorphisms in the mannose-binding lectin gene reduce serum mannose-binding lectin levels and are associated with enhanced risk of infection. In a family with recurrent staphylococcal disease presenting as furunculosis or carbuncles, an association with mannose-binding lectin deficiency was investigated.

MATERIALS AND METHODS

Levels of functional mannose-binding lectin were estimated and the genotypes of the mannose-binding lectin gene were analysed on blood samples, collected from the members of one particular family with a high prevalence of furunculosis.

RESULTS

Functional mannose-binding lectin levels in sera of 13 of the 28 members of one family showed deficiency. Furunculosis or carbuncles appeared to be present in nine of the 28 family members, seven of which showing the pBly allele and mannose-binding lectin deficiency. Four young family members of the second generation were pBly positive and mannose-binding lectin deficient, but had not shown furunculosis yet.

CONCLUSION

Members of a particular family suffering from furunculosis differ from their 'healthy' relatives as to mannose-binding lectin genotypes, indicating the relevance of normal mannose-binding lectin levels in the defence against staphylococcal disease.

PR and OTc interval prolongation on the electrocardiogram after binge drinking in healthy individuals

BACKGROUND

Acute, excessive alcohol intake has been associated with an increased cardiovascular mortality in otherwise healthy individuals. It predisposes to accelerated atherosclerosis resulting in acute coronary events but also arrhythmias have been described, such as atrial fibrillation and life-threatening re-entrant ventricular arrhythmias. QTc prolongation is associated with an increased risk of ventricular tachyarrhythmias and an independent risk factor for sudden cardiac death. The aim of the study is to investigate the effect of binge drinking on the conduction intervals in healthy individuals.

METHODS

Ten of the volunteers drank red wine while the other ten volunteers drank a sweet designer drink. A follow-up of blood pressure, heart rate, ECG and laboratory findings was performed at an ethanol level of 0, 0.4 and 0.8%, respectively.

RESULTS

Fifteen volunteers showed a prolongation of the PR interval, 13 of the QRS complex, 9 of the QT interval and 13 of the QTc interval. PR interval increased from 149 +/- 16 ms to 163 +/- 11 ms (p < 0.05). The heart rate-adjusted QT interval increased from 400 +/- 24 ms to 426 +/- 52 ms (p < 0.05). Heart rate and systolic blood pressure did not significantly change due to the ingestion.

CONCLUSION

Acute ingestion of alcohol in a healthy population can induce prolongation of PR and QTc interval.

Alcohol and polyphenolic grape extract inhibit platelet adhesion in flowing blood

BACKGROUND

Moderate and prolonged alcohol consumption has been associated with decreased cardiovascular morbidity and mortality. Inhibition of platelet function in suspension attributes to these effects. Whether alcohol, red wine, or polyphenolic grape extracts (PGE) inhibit platelet adhesion is not known. We investigated platelet adhesion to fibrinogen and collagen in whole blood under standardised flow.

MATERIALS AND METHODS

Before perfusion was started, citrated whole blood from 95 volunteers was preincubated for five min with different alcohol concentrations, unfractioned red wine and PGE. Then, blood was perfused in a single-passage flow chamber over coverslips coated with human fibrinogen or collagen type III at shear rates of 300 s(-1) and 1600 s(-1).

RESULTS

Alcohol inhibited platelet adhesion to human fibrinogen at high shear rate (concentrations > or = 0.15 per thousand) and low shear rate (only at a concentration of 4.8 per thousand), whereas red wine (concentrations > or = 0.15 per thousand) inhibited platelet adhesion to human fibrinogen at both shear rates. In contrast, PGE (concentrations > or = 0.0225 g L(-1)) inhibited platelet adhesion to human fibrinogen only at low shear rate. None of these incubations affected adhesion to collagen.

CONCLUSIONS

Alcohol, red wine and PGE inhibit adhesion to fibrinogen but not to collagen. This inhibition might contribute to the cardioprotective effects of moderate alcohol consumption.

Determinants of insulin sensitivity in chronic heart failure

OBJECTIVE

To describe the determinants of insulin sensitivity (IS) in chronic heart failure (CHF), we created a model in which the influence of lifestyle factors and etiology of heart failure on IS were incorporated concomitantly with age, left ventricular ejection fraction (LVEF) and parameters of body composition.

DESIGN

Observational cohort study.

SETTING

Outpatient clinic for chronic heart failure.

PATIENTS

Fifty-seven male CHF patients [NYHA class II-III, age 61+/-9 years, body mass index (BMI) 26.9+/-3.3 kg/m2 (mean+/-S.D.)].

INTERVENTIONS

Euglycemic hyperinsulinemic clamp, cycle ergometry, anthropometric measurements, LVEF and a physical activity questionnaire.

MAIN OUTCOME MEASURES

A model explaining the variance of IS in CHF.

RESULTS

IS was 18.2+/-8.6 microg.kg(-1).min(-1).mU(-1).l(-1), fasting insulin level was 15.9+/-11.0 mU/l and fasting glucose level was 5.5+/-0.6 mmol/l. Peak VO2 was 19.1+/-4.9 ml.kg(-1).min(-1) and LVEF 26.2+/-7.1%. IS was inversely associated with fasting insulin concentration (r=-0.50, P<0.001) and BMI (r=-0.54, P<0.001). After controlling for BMI, IS also revealed a correlation with age (r=-0.36, P<0.01). The model explained 60% of variance in IS: BMI contributed 20%, smoking 17%, age 17% and physical activity in daily life (DPA) 16% (all P<0.05) to the variance of IS, whereas LVEF (9%) and etiology of heart failure (8%) contributed moderately.

CONCLUSIONS

In CHF patients, IS is for a major part predicted by BMI, smoking, age, daily physical activity, LVEF and etiology of heart failure.

[Nutrition and health--favorable effect of wine and wine flavonoids on cardiovascular diseases]

Epidemiological studies have shown a favourable effect of moderate alcohol consumption with regard to atherosclerotic disorders. In addition to alcohol, wine contains a large number of other components including polyphenols. These polyphenols mainly originate from the skins and seeds of grapes and, because of differences in vinification, their variety and concentration is higher in red wine than in white wine. In vitro and ex vivo studies have shown that some of these polyphenols are able to slow down LDL-cholesterol oxidation, stimulate NO production, influence prostaglandin synthesis and inhibit platelet aggregation. However, little is known about their resorption, bioavailability and effectiveness in vivo. Since data from intervention studies with wine polyphenols are also lacking, no statement can yet be made about any clinically relevant effect of these components, in either red or white wine, in terms of cardiovascular diseases.

[How much alcohol is too much and why? Comments on socially accepted but excessive alcohol drinking patterns]

Many modern societies increasingly seem to accept drinking patterns that should be qualified as excessive from a health care point of view. This does not concern alcoholism or alcohol addiction but a daily intake of three to eight glasses and the pattern of binge drinking. Although a lot of data are available on the physical consequences of alcohol abuse, little is known about the impact of these drinking patterns on peoples' health. According to the J-shaped curve between alcohol consumption and mortality, an increase in morbidity and mortality can be noticed from two to three drinks a day. This is largely caused by an increase in accidents, malignancies, cardiovascular diseases and neurological disorders. However, data on pathophysiological mechanisms and on the contribution of these drinking patterns in medical consumption are scarce. Because of the estimated extent of the problem and societies' interest, more support should be given to scientific programs and research into this matter. This may not only contribute to a better monitoring of the problem but also guide the development of strategies for education and prevention.

Regular alcohol intake and fibrinolysis

BACKGROUND

Light to moderate alcohol consumption is associated with a reduced risk of coronary heart disease. Stimulation of fibrinolysis has been suggested as one of the mechanisms involved. The present study analyses the effect of regular alcohol consumption on various parameters of fibrinolysis. The question whether the alcohol-induced plasma increase of plasminogen activator inhibitor (PAI-1) may originate from thrombocytes was also addressed.

METHODS

Six healthy male volunteers consumed three glasses of red wine daily during two periods of a week, with a week of abstinence from alcohol in between. PAI-1 antigen and activity levels, t-PA antigen and activity levels and plasmin antiplasmin (PAP) complexes were measured on days 1, 3, 8, 15, 17 and 22 of the experiment period. On the first day, PAI-1 antigen and activity before and after alcohol consumption was also measured in platelet-rich plasma (prp).

RESULTS

Although some slight shifts in the various parameters could be noticed during the drinking periods, all favouring impairment rather than stimulation, no significant effect of regular moderate alcohol use could be observed on fibrinolysis. Alcohol did not trigger a release of PAI-1 from platelets.

CONCLUSIONS

Regular moderate alcohol consumption has no significant effect on fibrinolysis. The alcohol-induced increase of plasma PAI-1 does not originate from thrombocytes. The cardioprotective effect of moderate alcohol consumption cannot be explained by a beneficial influence on fibrinolysis.

[Ketoacidosis after cessation of chronic alcohol consumption]

A 52-year-old man was admitted with diarrhea, near dehydration and dyspnoea. After many years of alcohol consumption, he had stopped drinking alcohol over a very short space of time and had eaten very little or nothing. He had tachypnoea, hypotension and an enlarged liver. Laboratory analysis revealed metabolic acidosis with an elevated anion gap, ketone bodies in the urine, increased free fatty acid levels and beta-hydroxybutyrate in the serum, fitting the picture of alcoholic ketoacidosis. The syndrome is explained by metabolic changes induced by chronic alcohol consumption and ketogenesis as the result of fasting and dehydration. Treatment consisted of correction of the fluid deficit and administration of glucose, after which the patient made a rapid recovery.

Blessings of the grape

Numerous epidemiological studies have shown an inverse correlation between moderate consumption of alcoholic drinks and the risk of coronary heart disease. Wine, especially red wine, may be more favorable in this respect than beer or spirits because of its high content of flavonoids. These polyphenols originate from the skins, seeds, and vine stems of the grapes while some are formed during the process of vinification. In nature they exhibit a wide range of biological effects as antioxidants, antimicrobials, and modulators of various enzyme systems. Potential beneficial effects for humans have been demonstrated in experimental studies and include influences on the oxidation of LDL-cholesterol, on platelet aggregation, and on prostaglandin and nitric oxide metabolism. However, most of these studies concern semi in vivo experiments and research in animal models; data from human intervention trials are scarce. Furthermore, little is known about the absorption, bioavailability, and bioactivity of most of these compounds because of difficulties in reliable quantification in biological fluids. Until these issues are well addressed, and despite the enthusiasm and faith of many believers, evidence-based medicine justifies a critical attitude towards the application of these compounds outside the context of scientific research. Yet, there is no need to deny their potential, nor should we close our eyes to the blessings of the grape.

Acute inhibitory effect of alcohol on fibrinolysis

In contrast to a reduced risk of coronary heart disease (CHD) with light to moderate alcohol consumption, heavy alcohol intake and binge drinking are associated with increased cardiovascular mortality. Alcohol has an acute and profound effect on fibrinolysis that may be relevant to the pathogenesis of CHD. The short-term effects of a low (two glasses, 250 mL, 20 g ethanol) and a high (six glasses, 750 mL, 60 g ethanol) intake of red wine were studied in male volunteers and compared to the intake of mineral water. To find a threshold for inhibition of fibrinolysis and to study a binge effect, a second experiment was performed comparing the intake of four (500 mL, 40 g ethanol) and eight (1000 mL, 80 g ethanol) glasses of red wine with mineral water. Plasminogen activator inhibitor-1 (PAI-1), tissue-type plasminogen activator (t-PA), plasmin-antiplasmin (PAP) complexes and clot lysis time were measured. In contrast to the circadian rhythm with an enhanced fibrinolysis in the evening that was found in the mineral water group, an intake above four glasses of wine inhibited fibrinolysis significantly. After the intake of two glasses no significant disturbance of the circadian rhythm was observed. Five hours after the consumption of six glasses of wine, a dramatic increase occurred of PAI-1 antigen (77 +/- 42 microg L-1 vs. - 5 +/- 10 microg L-1 in the mineral water controls; P < 0.001) and PAI-1 activity (27 +/- 15 U mL-1 vs. - 2 +/- 3 U mL-1 in mineral water controls; P < 0.001). Despite a rise in t-PA antigen, t-PA activity dropped (- 0.5 +/- 0.2 U mL-1 vs. - 0.1 +/- 0.2 in controls; P < 0.001) as did PAP complexes (- 103 +/- 55 microg L-1 vs. - 26 +/- 57 microg L-1 in controls; P < 0.01). After the consumption of eight glasses of wine, the clot lysis assay indicated continued inhibition of fibrinolysis the following morning. Drinking a large amount of alcohol in the evening results in an acute inhibition of fibrinolysis, persisting the following morning. This may predispose to accelerated atherosclerosis and set the stage for thrombotic coronary events, explaining the higher cardiovascular mortality risk in binge drinkers.

Total hip replacement surgery does not influence RBC survival

BACKGROUND

RBC survival may be affected by mechanical or oxidative stress as well as the inflammatory effect of surgery, and thus may contribute to postoperative anemia.

STUDY DESIGN AND METHODS

RBC survival was studied in otherwise healthy patients who underwent total hip replacement (THR). RBCs of five patients scheduled for elective THR surgery were labeled with (51)Cr 2 weeks before the surgical procedure. The disappearance of (51)Cr-labeled RBCs was calculated for the preoperative period and for the period from postoperative Day 4 on, when blood loss had ceased.

RESULTS

The half-life of (51)Cr-labeled RBCs did not change if estimated before (29.0 +/- 4.4 days) and after (27.4 +/- 3.6 days, p = 0.55) surgery. This indicates that the lifespan of RBCs is not influenced by the surgical procedure.

CONCLUSION

A decrease in RBC survival does not contribute to the pathogenesis of the anemia found after THR surgery.

Response of erythropoiesis and iron metabolism to recombinant human erythropoietin in intensive care unit patients

OBJECTIVES

Critically ill patients often are anemic, which may impair oxygen delivery. Transfusion of red cells and supplementation with vitamins or iron are the usual therapeutic strategies, whereas only sporadic data are available on the use of epoetin alfa in these patients. We investigated endogenous erythropoietin (EPO) production and the response to epoetin alfa in anemic intensive care unit (ICU) patients.

DESIGN

Randomized, open trial.

SETTING

Multidisciplinary ICU in a single secondary care center.

PATIENTS

Thirty-six critically ill patients admitted to the ICU who became anemic (hemoglobin concentration, <11.2 g/dL or <12.1 g/dL in case of cardiac disease) were randomized to one of three study groups.

INTERVENTIONS

All patients received folic acid (1 mg) daily. The control group received no additional therapy, the iron group received 20 mg of iron saccharate intravenously (iv) daily for 14 days. The EPO group received iv iron and epoetin alfa (300 IU/kg) subcutaneously on days 1, 3, 5, 7, and 9.

MEASUREMENTS AND MAIN RESULTS

Blood and reticulocyte counts were measured daily for 22 days. Serum EPO, C-reactive protein, serum transferrin receptor, and iron variables were measured on days 0, 2, 6, 10, and 21. Blood loss and red cell transfusions were recorded. Serum EPO concentrations were inappropriately low for the degree of anemia at baseline, with no difference between patients with and without renal failure. Exogenous administration of EPO increased EPO concentrations from 23+/-13 to a maximum of 166+/-98 units/L on day 10 (p < .05). Reticulocyte count increased exclusively in the EPO group from 56+/-33 x 10(9)/L to a maximum of 189+/-97 on day 13 (p < .05). Serum transferrin receptor rose only in the EPO group from 3.7+/-1.4 to 8.6+/-3.1 mg/L on day 10 (p < .05) and remained elevated on day 21, indicating an increase in erythropoiesis. Hemoglobin concentration and platelet count remained identical in the three study groups.

CONCLUSION

Endogenous EPO concentrations are low in critically ill patients. The bone marrow of these patients is able to respond to exogenous epoetin alfa, as shown by elevated concentrations of reticulocytes and serum transferrin receptors.

[Diverticulosis of the small bowel]

A 77-year-old man known with chronic abdominal complaints and a malabsorption syndrome presented with ileus, peritonitis and air in the abdominal cavity. Surgery showed perforation of a jejunal diverticulum and extensive small bowel diverticulosis. The pathologic segment was surgically removed but the patient died afterwards of septic shock, diffuse intravascular coagulation and multi-organ failure. Small bowel diverticulosis has a prevalence of 0.3-2.5% and symptoms are present only in the minority of the cases. Apart from bacterial overgrowth and malabsorption, complications include bleeding, mechanical obstruction, volvulus and perforation. Diagnosis is difficult and mostly made by double-contrast radiology of the small bowel or during laparotomy. Treatment can be conservative in most patients; only in case of severe and persistent symptoms or complications like ileus, bleeding, perforation or volvulus, resection of the affected bowel segment is indicated.

The role of alcohol in the anti low density lipoprotein oxidation activity of red wine

Oxidation of low density lipoprotein cholesterol (LDL-c) is supposed to play a role in the generation of atherosclerotic lesions. Grape derived beverages supply a large number of nutritional antioxidants because of their high content of polyphenols. This might be one of the mechanisms behind the supposed beneficial effect of red wine. Wine also contains alcohol and its role in oxidation processes especially in vivo is unclear. In this study the effect of daily red wine consumption for 2 weeks on oxidizability status of LDL was investigated. The role of alcohol in LDL oxidation was further explored in in vitro experiments. After abstinence from alcoholic beverages, grape juices and tea for a week, seven healthy male volunteers consumed 375 ml of red wine (30 g alcohol) per day during 2 weeks. At the start and end of the drinking period blood samples were taken and the susceptibility of LDL-c to copper-induced oxidation was analyzed with the addition of distilled water (control) and dilutions of a 12% alcohol solution, white wine and red wine. Although red wine at concentrations achievable in vivo caused a significant prolongation of the lag-time of metal ion dependent LDL oxidation in vitro (85.9+/-23.0-114.1+/-30.8 min, P<0. 001), a significant shortening of lag-time was found in vivo after the 2 weeks of wine consumption (56.3+/-13.0 min, P<0.001). A shorter lag-time compared to the control was found for both alcohol and white wine in vitro. The changed oxidizability status of LDL after 2 weeks of wine consumption made it more susceptible for the in vitro antioxidant effect of red wine. At low dilutions red grape juice extended lag-time as well, which was not influenced by the addition of alcohol. Red wine has a strong inhibitory effect on copper-induced oxidation of LDL in vitro, while red grape juice has a minor effect, an effect which should be attributed to the non alcohol components in the beverages. In vivo, however, this effect can be overshadowed by the prooxidant influence of alcohol. The balance between alcohol and polyphenols of a wine may be critical for its in vivo effect on LDL oxidation.

Three novel mutations at serine 314 in the thyroid hormone beta receptor differentially impair ligand binding in the syndrome of resistance to thyroid hormone

The syndrome of resistance to thyroid hormone is associated with diverse mutations in the ligand-binding domain of the thyroid hormone beta receptor, localizing to three clusters around the hormone binding cavity. Here, we report three novel resistance to thyroid hormone mutations (S314C, S314F, and S314Y), due to different nucleotide substitutions in the same codon, occurring in six separate families. Functional characterization of these mutant receptors showed marked differences in their properties. S314F and S314Y receptor mutants exhibited significant transcriptional impairment in keeping with negligible ligand binding and were potent dominant negative inhibitors of wild-type receptor action. In contrast, the S314C mutant bound ligand with reduced affinity, such that its functional impairment and dominant negative activity manifest at low concentrations of thyroid hormone, but are more reversible at higher T3 concentrations. The degree of functional impairment of mutant receptors in vitro may correlate with the magnitude of thyroid dysfunction in vivo. Modelling these mutations using the crystal structure of thyroid hormone receptor beta shows why ligand binding is perturbed and why the phenylalanine/tyrosine mutations are more deleterious than cysteine.

Aphthous ulcers and vitamin B12 deficiency

Aphthous ulcers of the oral cavity are frequently encountered in general practice. Although the exact pathophysiology remains obscure, many factors can contribute to the pathogenesis of these lesions, such as immunological factors, local trauma, smoking, stress, hormonal state, family history, food hypersensitivity, and infection. We describe three patients in whom a clear relationship appeared to exist between recurrent aphthous ulcers and a deficiency of vitamin B12. It is concluded that in all patients with recurrent aphthous ulceration, deficiency of vitamin B12 should be considered.

Alcohol and insulin sensitivity

Compared to heavy drinking and abstinence, a moderate consumption of alcohol is associated with lower mortality rates due to coronary heart disease. About half of the protective effect of alcohol on cardiovascular risk can be explained by its ability to raise HDL-cholesterol. Alcohol can influence HDL metabolism at more than one site. Since light-to-moderate alcohol intake is associated with enhanced insulin sensitivity and improvement of insulin sensitivity results in higher HDL-cholesterol levels, it is suggested that this is one of the routes taken by alcohol to act upon HDL metabolism. Whether interrelated or not, both the HDL-cholesterol increase and enhanced insulin sensitivity are considered to have a beneficial effect on the process of atherosclerosis. Because of the well-known adverse consequences of excess alcohol use, these facts have not changed public health policy. On the other hand, they may have an impact on advice to selected patients, diabetics or non-diabetics.

Iron metabolism and erythropoiesis after surgery

BACKGROUND

This was a prospective study comparing the effect of major and minor surgery on haematological variables concerning erythropoiesis, iron metabolism and acute-phase response proteins.

METHODS

Thirty-one otherwise healthy patients, 15 having major orthopaedic surgery and 16 undergoing minor surgery, were studied. Blood samples were taken before surgery and 1, 4, 10 and 28 days after operation.

RESULTS

Haemoglobin concentration was decreased for up to 4 weeks after surgery. Serum erythropoietin concentration and reticulocyte count were raised after major surgery only. Serum iron concentration dropped the day after major (to 23 per cent of its preoperative level) and minor (to 46 per cent of its preoperative level) surgery and remained lower for up to 28 days after major surgery. Serum transferrin concentration and transferrin saturation decreased after both types of surgery while ferritin concentration increased. Serum transferrin receptor concentration increased only 4 weeks after major surgery (P < 0.01). The interleukin 6 peak (day 1) was greater after major than minor surgery, as was the C-reactive protein peak (day 4).

CONCLUSION

Both major and minor surgery induce a state of hypoferraemia in the presence of adequate iron stores. The degree of this transient form of 'anaemia of chronic disease' is related to the extent of surgery. Iron supplementation in the first weeks after surgery (if iron stores were normal before operation) is ineffective.

Carcino-embryonic antigen--no help with the differential diagnosis

Two patients who were referred because of an increase in serum carcino-embryonic antigen (CEA) were diagnosed after a number of years as having a medullary thyroid carcinoma. The relationship between CEA and medullary thyroid carcinoma is discussed. The serum level of CEA is neither sensitive nor specific enough to serve as a diagnostic tool. Its determination, however, is useful in the follow-up of patients with carcinoma of the breast, colo-rectal carcinoma and medullary thyroid carcinoma.

Collection of autologous blood before elective hip replacement. A comparison of the results with the collection of two and four units

The need for allogeneic blood can be reduced effectively with the use of preoperatively donated autologous blood. However, this collection also results in the waste of autologous blood in a considerable number of patients. In order to reduce overcollection, we requested that the amount of autologous blood donated before a total hip replacement be decreased from four units to two units. We then compared the amount of allogeneic blood required for fifty patients who had donated two units of autologous blood with that of fifty historical controls who had donated four units. The patients were matched for sex, initial hemoglobin concentration, and blood loss. There was no significant difference in the percentage of autologous donors who received additional allogeneic blood; 20 per cent (ten) of the patients who had donated two units and 16 per cent (eight) of the patients who had donated four units required allogeneic blood (p = 0.12). Eighteen autologous units from the patients who had donated two units and fifty-one units from the patients who had donated four units were discarded. The erythropoietic response, measured by the increase in the reticulocyte count, was comparable for the two groups. Iron stores, measured as the serum ferritin concentration, were lower after the drawing of four units (33 +/- 39 micrograms per liter) compared with after the drawing of two units (49 +/- 29 micrograms per liter) (p = 0.03). The donation of two units of blood does not increase the exposure to allogeneic blood compared with the exposure after the donation of four units by patients who are going to have a total hip replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Lower homologous blood requirement in autologous blood donors after treatment with recombinant human erythropoietin

The risk of blood-borne diseases has substantially increased the use of autologous blood transfusion. Many autologous donors, however, still need homologous transfusions. To find out whether recombinant erythropoietin (rhEPO) reduces requirements for homologous blood transfusion, we carried out a randomised, controlled trial, in which patients were stratified according to blood volume. We studied 95 autologous blood donors undergoing elective hip surgery. 50 patients were randomly assigned 500 U/kg rhEPO subcutaneously twice a week for 3 weeks, and 45 patients received no treatment (control group). The patients each donated two units of blood before surgery. Only 5 (10%) rhEPO-treated patients received homologous transfusions compared with 16 (36%) controls (p < 0.01). rhEPO was most useful in patients with a blood volume below 4 L and an estimated blood loss below 2 L or with a blood volume of 4-5 L and blood loss of 1-2 L. Continued administration of rhEPO caused no further increase in reticulocyte counts after the fourth injection, which was accompanied by a pronounced depletion of storage iron. rhEPO treatment had no effect on renal function, platelet count, or blood pressure. Subcutaneous rhEPO is an effective and safe way to reduce exposure to homologous blood in autologous donors. Its use can be restricted to a subpopulation of autologous blood donors, which improves the cost-effectiveness of this expensive approach.

The effect of recombinant human erythropoietin on hemostasis, fibrinolysis, and blood rheology in autologous blood donors

Treatment with recombinant human erythropoietin (rhEPO) for the anemia of end-stage renal disease has been associated with thrombotic complications. To detect prothrombotic changes in autologous blood donors given 500 U/kg rhEPO subcutaneously (twice weekly during a 3-week period), changes in variables of hemostasis and fibrinolysis and in blood rheology before and at the end of treatment were investigated. In 21 patients, platelet count increased from 272 +/- 55 x 10(9)/L to 313 +/- 55 x 10(9)/L (p < 0.05). Although activated partial thromboplastin time and protein C antigen decreased significantly during rhEPO treatment, these changes remained within normal ranges. No changes in the hemostatic variables prothrombin time, fibrinogen, factor V, von Willebrand factor antigen, antithrombin III activity, protein S antigen, and prothrombin fragments F 1 + 2 were found. Measurements of plasminogen activity, alpha 2-antiplasmin activity, tissue plasminogen activator, and plasminogen activator inhibitor-1, representing variables of fibrinolysis, were normal and constant during the study. In 5 patients no changes in red cell deformability and whole blood viscosity, corrected for differences in hematocrit, were observed. Plasma viscosity showed a slight but clinically not relevant increase in 4 out of 5 patients. The absence of evident (pro)thrombotc changes in this study confirms the safety of high-dose rhEPO therapy in autologous blood donors, who donate 2 units (i.e., 2 x 450 ml) of blood.

Red blood cell transfusions for total hip replacement in a regional hospital. A six-year analysis

To evaluate changes in the need for homologous blood and to assess the impact of autologous blood transfusion, red cell transfusions in unilateral total hip replacement surgery, performed electively in the period 1986-1991, were studied in a regional hospital. Transfusion data, perioperative blood loss and post-operative haemoglobin concentration of 495 patients were analysed. From 1986 to 1991, the percentage of patients not transfused with homologous blood increased from 18.5 to 45.5%. After the introduction of an autologous blood transfusion programme in 1987, 116 of 430 patients (27.0%) donated autologous blood. No increase in the percentage of autologous donors was observed during the study. Most common reasons for nonparticipation were the patient's age, doctors' underordering and logistic limitations. 81.9% of autologous donors had total hip replacement surgery without homologous transfusions. Mean blood loss reduced significantly from 1,373 +/- 781 ml in 1986 to 958 +/- 582 ml in 1991 (p < 0.001). Transfusion requirement in the nonautologous patients fell from 2.6 +/- 1.8 units in 1986 to 1.4 +/- 1.4 units per patient in 1989 and increased thereafter to 2.2 +/- 2.1 units in 1991 (p < 0.01) and showed a strong correlation with blood loss (r = 0.58; p < 0.001). No changes in postoperative haemoglobin concentration were observed throughout the study. In conclusion, collection of autologous blood is effective, albeit still underutilized, to reduce homologous blood requirement. The close correlation between blood loss and transfusion requirement accentuates the role of surgical practice in the reduction of homologous transfusions.

The efficacy of subcutaneous recombinant human erythropoietin in the correction of phlebotomy-induced anemia in autologous blood donors

The efficacy of subcutaneous recombinant human erythropoietin (rhEPO) (500 U/kg; administered twice a week during the 3 weeks before surgery) in the recovery of preoperative hemoglobin concentrations within a 3-week period was studied in 40 patients, each of whom donated 2 units (900 mL) of blood for their own use before total hip replacement surgery. Twenty autologous blood donors received rhEPO (EPO group) and 20 were not treated (control group). The initial hemoglobin concentration (14.0 +/- 1.0 g/dL [140 +/- 10 g/L]) was completely recovered before surgery (14.0 +/- 1.6 g/dL [140 +/- 16 g/L]) in the EPO group, while a decrease from 13.8 +/- 1.1 to 12.2 +/- 1.3 g per dL (138 +/- 11 to 122 +/- 13 g/L) was observed in the control group. The preoperative reticulocyte count showed more than sixfold increase in the EPO group, whereas a twofold to threefold increase was found in the control group. Serum ferritin concentration fell to 42 +/- 29 micrograms per L in the EPO group and to 54 +/- 35 micrograms per L in the control group. The postoperative serum erythropoietin concentration in the EPO group was significantly lower than that in the control group, but it did not differ from the pretreatment value and was attended by a higher hemoglobin concentration after surgery. Only transient flu-like symptoms were mentioned by patients who were treated with rhEPO. Changes in blood pressure or platelet count or other adverse events were not observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Relevance of pretransfusion incubation of platelets at 37 degrees C

The effect of pretransfusion incubation of platelets at 37 degrees C was assessed because of the controversial reports about its relevance. A dual-label technique (111indium and 114mindium) was applied in 10 healthy subjects receiving warmed and unwarmed autologous platelets simultaneously. Fresh platelet concentrates were infused into five subjects, whereas the other five subjects received stored platelet concentrates. The mean platelet volume decreased in all platelet concentrates during incubation, reflecting the restoration of the discoid shape of the platelets. The mean decrease was 0.35 fL (P = .003). However, the initial recovery and the mean platelet life-span were not improved by this procedure. It was concluded that there is no evidence that brief warming of platelets has any beneficial effect on platelet viability in healthy volunteers.

The effect of oral iron supplementation on erythropoiesis in autologous blood donors

The effect of oral iron supplementation on erythropoiesis was studied prospectively in 34 autologous blood donors. The subjects, all of whom were to undergo total hip surgery, had normal iron status at the start of the study. During the preoperative period, in which 4 units of blood were collected, 17 patients received oral iron supplementation with 287 mg of ferrous sulfate (105 mg of elemental iron/day), while 17 patients did not use any iron supplementation. Oral iron supplementation during the 4-week preoperative period lessened the decrease in ferritin levels after two phlebotomies. Neither the decrease in hemoglobin nor the increase in erythropoietin levels was influenced by iron supplementation. In both iron-supplemented and control patients, serum erythropoietin levels returned to initial values within a few days after surgery. In autologous blood donors with a normal iron status, the use of supplemental iron does not affect erythropoiesis and is insufficient to maintain iron stores.

A new dual-label technique for platelet survival studies with the use of 111indium and 114mindium tropolonate

A dual-label technique to study the survival of two different populations of platelets within one individual was developed using 111indium and 114mindium. The validity of the technique was demonstrated in seven individuals with an expected equal survival time of two platelet populations and in two persons with an expected difference in platelet survival time. Since the energy spectra of the two indium isotopes are very close, a well-type germanium semiconductor detector was applied. By adaptation of the counting time the effective dose equivalent of the dual-label procedure could be restricted to 1.6 mSv. The dual-label technique provides an instrument for studying the survival of two different populations of platelets simultaneously within one individual.

[Experiences in clinic and blood bank with a program for preoperative donation of autologous blood]

In the period from March 1987 to January 1988 a programme for donation of autologous blood was carried out within the existing cooperation between a regional blood bank and a general hospital. Various organizational problems were avoided by means of a special consulting hour and introduction of a special consultation form. Blood was taken a total of 144 times from 49 orthopaedic patients. No serious problems were encountered; three times, withdrawal of a unit of blood had to be refrained from. Of the 144 units of red cell suspension, 107 (73.3%) were reinfused, while seven patients still required administration of homologous blood. The variations of haemoglobin level, haematocrit, reticulocyte count and red cell distribution width suggest stimulation of erythropoiesis by repeated withdrawal of blood at brief intervals. In the preoperative phase, there were no pronounced differences in this respect between patients who were and those who were not given supplementary iron. Autologous blood transfusion constitutes a safe, valuable addition to the current transfusion forms and is possible within the existing organizations in The Netherlands.

Circulating IgA immune complexes and skin IgA deposits in liver disease. Relation to liver histopathology

Alcoholic liver disease (ALD) is characterized by elevated serum IgA concentrations, the presence of circulating immune complexes containing IgA, and IgA deposits along sinusoids in the liver. When combined with the presupposed IgA-clearance function of the liver, a causal association between IgA abnormalities and the liver disease in ALD can be suggested. This prompted us to study the presence and concentration of circulating IgA-containing immune complexes (IgA-CIC) in 41 patients with ALD and 41 patients with other nonalcoholic liver diseases having comparable serum IgA levels. We searched for relationships among IgA-CIC and history of alcohol abuse, liver histopathology, and IgA deposits in the liver. Using an anti-IgA inhibition binding assay, 56% of the patients exhibited IgA-CIC in polyethylene glycol precipitate of serum and 38% showed IgA-CIC in whole serum. The prevalence and concentration of IgA-CIC was lowest in cases with nonspecific changes or steatosis in the liver biopsy and highest in cases with hepatitis or cirrhosis (P less than 0.01). The occurrence of IgA-CIC was not related to a history of alcohol abuse or to the presence of IgA deposits along hepatic sinusoids (which occurred in 78% of ALD and 20% of non-ALD cases). A skin biopsy was available from 34 patients (19 with ALD and 15 with non-ALD). In 68% of these biopsies, IgA deposits were observed in superficial blood capillaries.(ABSTRACT TRUNCATED AT 250 WORDS)

A patient with a spontaneous factor VIII:C autoantibody: successful treatment with cyclosporine

A 65-year-old man was admitted to the hospital because of extensive spontaneous ecchymoses of the trunk and huge hematomas of the arms and legs. He had no personal or family history of a hemorrhagic diathesis. Coagulation studies revealed a prolonged APTT, no detectable factor VIII:C activity, and a high titer of anti-factor VIII:C antibodies. A diagnosis of acquired hemophilia was made. No underlying disorder could be found. The inhibitor was an IgG antibody. Long-term management of bleeding including immunodepletion by plasma exchange and immunosuppression by corticosteroids and cytotoxic drugs alone and in combination had no effect on the bleeding tendency and coagulation data. The administration of Cs (10 mg/kg/d) in combination with prednisone induced a remission. After a stormy course and a 5-month stay in the hospital the patient could be discharged. A relapse occurred after the Cs and prednisone dosages were reduced. Increasing the Cs dosage induced a remission again.