Correction of vitamin D deficiency using sublingually administered vitamin D2 in a Crohn's disease patient with mal-absorption and a new ileostomy

Vitamin D deficiency has been shown to be associated with many adverse health problems. Studies have shown that patients with Crohn's disease who have low vitamin D levels have a poorer quality of life than those with more adequate levels. It has also been shown that patients with mal-absorption problems have a difficult time achieving normal vitamin D levels in spite of aggressive supplementation, and that exposure to UVB radiation may be the most effective treatment option for these patients. We present a case in which 25-hydroxyvitamin D levels were normalized within 2 weeks in a severely vitamin D deficient patient with Crohn's disease with mal-absorption and a new ileostomy, utilizing sublingually administered vitamin D2. A 58 year-old white female was admitted with a new ileostomy following partial bowel resection due to complications from Crohn's disease. She was found to be severely vitamin D deficient at the time of admission, with a level of 6.1ng/ml on hospital day 3. Her treatment with vitamin D was delayed for a few days. She was initially treated with 5000 units of vitamin D3 orally twice a day for 3days (days 7-10). After discussion with the patient and obtaining her consent, vitamin D3 was stopped, and she was then treated with a total of 8 doses of 50,000 units of vitamin D2 administered sublingually. She was given the first 3 doses on alternating days (days 11, 13, 15), and then 5 more doses on consecutive days (days 17-21). The rise in her 25-hydroxyvitamin D level in response to treatment with sublingual vitamin D2 was significant. On day 10, after receiving 3days of orally administered vitamin D3, her level was 9.8ng/ml. One week later, after receiving 3 sublingual doses of vitamin D2, it rose to 20.3ng/ml. It was then measured on alternating days twice over the next 4days, and it rose to 45.5ng/ml, and then to 47.4ng/ml on the day of discharge to home. The major finding of this study is that sublingual administration of vitamin D2 appears to work effectively when intestinal absorption is impaired. The optimal dosing regimen still needs to be determined for the average Crohn's disease patient.

Results of daily oral dosing with up to 60,000 international units (iu) of vitamin D3 for 2 to 6 years in 3 adult males

In the 1930's and 1940's, vitamin D was reported to be an effective treatment for a number of diseases, including asthma, psoriasis, rheumatoid arthritis, rickets and tuberculosis. High doses were used, 60,000 to 300,000 IU a day for asthma, and 200,000 to 600,000 IU a day for rheumatoid arthritis. Toxicity from hypercalcemia occurred after prolonged oral dosing with these supraphysiologic doses. Assays for measuring vitamin D in the blood were not available, and blood levels of vitamin D associated with hypercalcemia were unknown. A 2011 report on vitamin D toxicity showed that hypercalcemia resolved when 25-hydroxyvitamin D (25OHD) blood levels dropped below 400ng/ml in 2 patients with blood levels ranging from 645ng/ml to 1220ng/ml after accidental ingestion of massive doses of vitamin D. We now know that vitamin D is made in the skin in amounts ranging up to 25,000 IU a day with exposure to UVB radiation. There is little data on the safety and blood levels of 25OHD and calcium after prolonged daily intake of amounts of vitamin D in this range. In this report, one subject took increasing daily doses of vitamin D3 for 6 years starting in April 2009: 6500 IU for 6 months; increasing to 10,000 IU for 13 months; 20,000 IU for 24 months; 40,000 IU for 12 months; 50,000 IU for 10 months, and 60,000 IU since October 2014. 25OHD blood levels were 28, 81, 204, 216, 225, 166, and 218ng/ml. Subject 2 began 10,000 IU in Nov 2011, increased to 20,000 IU in Feb 2014, 25,000 IU in June 2014, and 30,000 IU in Oct 2014, and then decreased to 20,000 IU in June 2015. 25OHD blood levels were 96.6, 161.1 and 106.9ng/ml. He reported marked clinical improvement in his asthma. Subject 3 started on daily 10,000 IU in Sept 2013, increasing to 20,000 IU on Nov 2013. 25OHD blood levels were 31.4, 102, 164, 148, and 143ng/ml. No one developed hypercalcemia or any adverse events. The major finding of this case series is prolonged daily dosing of vitamin D3 with doses of 10,000 to 60,000 IU was safely tolerated.

Breast conserving surgery for breast cancer involving the nipple

We present two cases of invasive breast carcinoma with involvement of the dermis and epidermis of the nipple areolar complex (NAC), which were treated with an immediate breast reconstruction. Oncoplastic techniques were utilised in both cases: Latissimus Dorsi Mini Flap in the first and therapeutic reduction mammaplasty in the second. Both methods were used to fill the defect and also to recreate the NAC. We believe these techniques have an expanding role in the repertoire of surgical options for treating breast carcinoma.

Metformin reduces weight, centripetal obesity, insulin, leptin, and low-density lipoprotein cholesterol in nondiabetic, morbidly obese subjects with body mass index greater than 30

We studied 31 nondiabetic, habitually (> or =5 years) morbidly obese subjects (mean +/- SD body mass index [BMI] 43 +/- 8.7, median 43). Our specific aim was to determine whether metformin (2.55 g/d for 28 weeks) would ameliorate morbid obesity and reduce centripetal obesity; lipid and lipoprotein cholesterol, insulin, and leptin levels; and plasminogen activator inhibitor activity (PAI-Fx), risk factors for coronary heart disease (CHD). The patients were instructed to continue their prestudy dietary and exercise regimens without change. After 2 baseline visits 1 week apart, the 27 women and 4 men began receiving metformin, 2.55 g/d, which was continued for 28 weeks with follow-up visits at study weeks 5, 13, 21, and 29. Daily food intake was recorded by patients for 7 days before visits then reviewed with a dietitian. Kilocalories per day and per week were calculated. At each visit, fasting blood was obtained for measurement of lipid profile, insulin, leptin, and PAI-Fx. The mean +/- SD kilocalories consumed per day, 1,951 +/- 661 at entry, fell by week 29 to 1,719 +/- 493 (P =.014) but did not differ at weeks 5, 13, and 21 from that at week 29 (P >.2). Weight fell from 258 +/- 62 pounds at entry to 245 +/- 54 pounds at week 29 (P =.0001). Girth was reduced from 51.8 +/- 6.2 to 49.2 +/- 4.5 inches (P =.0001). Waist circumference fell from 44.0 +/- 6.4 inches to 41.3 +/- 5.9 (P =.0001). The waist/hip ratio fell from 0.85 +/- 0.09 to 0.84 +/- 0.09 (P =.04). Fasting serum insulin, 28 +/- 15 microU/mL at entry, fell to 21 +/- 11 microU/mL at week 29 (P =.0001), and leptin fell from 79 +/- 33 ng/mL to 55 +/- 27 ng/mL (P =.0001). On metformin, there were linear trends in decrements in weight, girth, waist circumference, waist/hip ratio, insulin, and leptin throughout the study period (P <.007). Low-density lipoprotein (LDL) cholesterol, 126 +/- 34 mg/dL at study entry, fell to 112 +/- 43 mg/dL at week 29 (P =.001), with a linear trend toward decreasing levels throughout (P =.036). By stepwise linear regression, the higher the entry weight, the larger the reduction in weight on metformin therapy (partial R(2) = 31%, P =.001). The greater the reduction in kilocalories consumed per day, the greater the decrease in weight on metformin therapy (partial R(2) = 15%, P =.011). The higher the waist/hip ratio at entry, the greater its reduction on metformin therapy (partial R(2) = 11%, P =.004). The higher the entry serum leptin, the greater its reduction on metformin therapy (partial R(2) = 29%, P =.002). The greater the reduction in insulin on metformin, the greater the reduction in leptin (partial R(2) = 8%, P =.03). The higher the entry PAI-Fx, the greater the reduction in PAI-Fx on metformin (partial R(2) = 43%, P =.0001). Metformin safely and effectively reduces CHD risk factors (weight, fasting insulin, leptin, LDL cholesterol, centripetal obesity) in morbidly obese, nondiabetic subjects with BMI > 30, probably by virtue of its insulin-sensitizing action.

Effects of alimet on nutrient digestibility, bacterial protein synthesis, and ruminal disappearance during continuous culture

A dual effluent continuous culture system was used to investigate the effects of inclusion of Alimet (Novus International, Inc., St. Louis, MO) feed supplement [an 88% aqueous solution of dl, 2-hydroxy-4-(methylthio) butanoic acid (HMB)] in the diet on nutrient digestibility, bacterial protein synthesis and ruminal disappearance of HMB. Four fermenters were fed three times daily a basal diet that consisted of 50% grain mixture and 50% forage for 9 d. In experiment 1, four concentrations of HMB (0, 0.20, 0.77, and 1.43% DM basis) were added to the diet and fed to the fermenters twice daily. In experiment 2, two concentrations of dietary HMB (0 and 0.88% DM basis) were fed twice daily and evaluated with two solids retention times (16.7 vs. 25.0 h) and two liquid dilution rates (0.15 vs. 0.125 h(-1)). Increasing the amount of HMB in the diet did not affect nutrient digestibility, volatile fatty acid concentrations, or ruminal escape of HMB. Bacterial protein synthesis was improved with the addition of HMB during high and low retention times. The extent of HMB escaping ruminal degradation ranged from 21.6 to 43.2% and was highest at the lower retention time. It can be concluded that a fraction of HMB survives rumen microbial degradation and, therefore, provides a rumen-protected form of methionine at the same time that it improves bacterial protein synthesis.

Pancreatic insulin secretion in exocrine pancreatic cancer

Adenocarcinoma of the exocrine pancreas in man is associated with a high incidence of diabetes mellitus. Hyperglycemia in humans with pancreatic cancer is presumed to be caused by destruction of islets of Langerhans with a resultant impairment in pancreatic insulin secretion. This hypothesis was tested in an animal model of exocrine pancreatic cancer. Carcinoma of the pancreas was induced in male Syrian golden hamsters by weekly injection of N-nitrosobis(2-oxopropyl)amine. Using an ex vivo isolated perfused pancreas preparation, the capacity of cancer-bearing pancreata to secrete insulin in response to glucose and arginine was compared to normal animals of the same age. Animals with pancreatic cancer demonstrated a normal insulin secretory response to both glucose and arginine. Thus the hypothesis that exocrine pancreatic cancer causes diabetes by directly impairing insulin release must be questioned and alternative explanations for the association of diabetes and pancreatic cancer should be sought.

Ex-vivo isolated perfusion of the pancreas in the Syrian golden hamster

The technique of ex-vivo isolated pancreatic perfusion has been a valuable method for investigation of the physiology of the exocrine and endocrine pancreas. We have adapted the technique of isolated pancreatic perfusion for use in the Syrian golden hamster, an animal used widely in studies of pancreatic carcinogenesis. The technique involves surgical harvest of the pancreas with its aortic and portal venous blood supply intact and perfusion of the pancreas with a modified Krebs buffer at 37 degrees C. Physiological function of the perfused pancreas system was examined in 27 Syrian hamsters. In tests of endocrine function, the perfused pancreas responded by increasing insulin secretion within 1 min of elevating perfusate glucose concentration, and also secreted insulin promptly in response to 10 mM arginine. In exocrine studies, the flow of pancreatic juice was stimulated by the addition of 0.8 X 10(-9) M secretin to the perfusate, and amylase output was significantly increased by the addition of 0.2 X 10(-9) M cholecystokinin (CCK-8). The ex-vivo isolated perfused pancreas in the hamster thus appears to respond appropriately to physiological stimuli and is a valuable additional tool for studies of the hamster pancreas.