European Journal of Internal Medicine

Editorial Board

2012-06-01

The search of a common path in internal medicine

E. Bartoli, P.M. Mannucci — 2012-03-30

This issue of the European Journal of Internal Medicine features a paper by Porcel and co-workers , which has the major merit of opening a fruitful discussion on the mission and competencies of Internal Medicine in Europe. Our journal is willing to take the opportunity to publish as Letters to the Editor contributions to such discussion (no longer than 1000 words and 5 references if needed) stemming from the national societies of Internal Medicine and related academic groups of Europe, and to act as collector of this process which starts with the publication from the Spanish internists.

From stress to functional syndromes: An internist's point of view

Daniela Lucini, Massimo Pagani — 2011-12-26

Abstract: In this brief review we address schematically the relationship between two emerging issues in clinical medicine: stress and functional syndromes. It is becoming increasingly clear that they demand a multidimensional approach, considering simultaneously elements of behavioral therapy with traditional pharmacological treatment, guided by a better physiopathological understanding including autonomic assessment. New techniques, based on innovative analysis of continuous segments of electrocardiogram and non invasive arterial pressure recordings capable to extract hidden oscillations, provide quantitative indices of sympathetic and vagal modulation of the cardiovascular system. This more complete diagnostic process facilitates explanation of symptoms and reassurance of patients, based on functional evidence. The described clinical approach implies in addition an active collaboration of patients requiring the implementation of a creative alliance. Physical exercise, eating habits and muscular–mental relaxation are combined with pharmacological tools as needed.

Respiratory High-Dependency Care Units for the burden of acute respiratory failure

Raffaele Scala — 2011-12-02

Abstract: The burden of acute respiratory failure (ARF) has become one of the greatest epidemiological challenges for the modern health systems. Consistently, the imbalance between the increasing prevalence of acutely de-compensated respiratory diseases and the shortage of high-daily cost ICU beds has stimulated new health cost-effective solutions.Respiratory High-Dependency Care Units (RHDCU) provide a specialised environment for patients who require an “intermediate” level of care between the ICU and the ward, where non-invasive monitoring and assisted ventilation techniques are preferentially applied. Since they are dedicated to the management of “mono-organ” decompensations, treatment of ARF patients in RHDCU avoids the dangerous “under-assistance” in the ward and unnecessary “over-assistance” in ICU. RHDCUs provide a specialised quality of care for ARF with health resources optimisation and their spread throughout health systems has been driven by their high-level of expertise in non-invasive ventilation (NIV), weaning from invasive ventilation, tracheostomy care, and discharging planning for ventilator-dependent patients.

Fibrates: Therapeutic potential for diabetic nephropathy?

2012-01-19

Abstract: Despite intensive glucose-lowering treatment and advanced therapies for cardiovascular risk factors, such as hypertension and dyslipidaemia, diabetes mellitus with its macro- and microvascular complications remains a major health problem. Especially diabetic nephropathy is a leading cause of morbidity and mortality, and its prevalence is increasing. Peroxisome proliferator-activated receptor-α (PPAR-α), a member of a large nuclear receptor superfamily, is expressed in several tissues including the kidney. Recently, experimental data have suggested that PPAR-α activation plays a pivotal role in the regulation of fatty acid oxidation, lipid metabolism, inflammatory and vascular responses, and might regulate various metabolic and intracellular signalling pathways that lead to diabetic microvascular complications. This review examines the role of PPAR-α activation in diabetic nephropathy and summarises data from experimental and clinical studies on the emerging therapeutic potential of fibrates in diabetic nephropathy.

Statin induced myotoxicity

Sivakumar Sathasivam — 2012-02-10

Abstract: Statins are an effective treatment for the prevention of cardiovascular diseases and used extensively worldwide. However, myotoxicity induced by statins is a common adverse event and a major barrier to maximising cardiovascular risk reduction. The clinical spectrum of statin induced myotoxicity includes asymptomatic rise in creatine kinase concentration, myalgia, myositis and rhabdomyolysis. In certain cases, the cessation of statin therapy does not result in the resolution of muscular symptoms or the normalization of creatine kinase, raising the possibility of necrotizing autoimmune myopathy. There is increasing understanding and recognition of the pathophysiology and risk factors of statin induced myotoxicity. Careful history and physical examination in conjunction with selected investigations such as creatine kinase measurement, electromyography and muscle biopsy in appropriate clinical scenario help diagnose the condition. The management of statin induced myotoxicity involves statin cessation, the use of alternative lipid lowering agents or treatment regimes, and in the case of necrotizing autoimmune myopathy, immunosuppression.

Chikungunya fever

Eugene J. Kucharz, Ilona Cebula-Byrska — 2012-03-07

Abstract: Chikungunya fever (CF) is an acute illness caused by Chikungunya virus (CHIKV) belonging to the alphavirus genus of the Alphaviruses (Togaviridae) family. The virus is transmitted by Aedes mosquitoes. CF is primarily tropical disease occurring in Africa, Asia and Indian Ocean islands but in the last decade an outbreak of CHIKV autochthonous infections were reported in Italy and France. It is associated with viral genome mutations facilitating transmission of the disease by Aedes albopictus, a mosquito occurring in several European countries.The CF is highly symptomatic, characterized by fever, cutaneuos rash and severe athralgia and arthritis. In some patients severe neurological or hemorrhagic manifestations occur. The disease is self-limiting but a part of the patients suffers from a long-lasting arthritis akin to rheumatoid arthritis.Treatment is only symptomatic. Prevention includes reduction of mosquito bite (mosquito net, repellent) or application of measures against mosquito larvae. Vaccination is not currently available but investigations are in progress.CF presents a significant worldwide health problem affecting in the last decade millions of person, and currently dangerous also for European countries.

Herbal medicine, Chaplin, and “The Kid”

Maurizio Pandolfi, Lucilla Zilletti — 2012-03-05

Abstract: At variance with other largely safe complementary alternative medicines like homeopathy and acupuncture, which only carry the risk of inducing patients to shun effective treatment, herbal remedies are real, albeit impure, drugs and therefore fully capable of producing undesirable consequences if misused. The advantages they offer are uncertain since genuine evidence of efficacy and effectiveness is present in only a few cases. A result of this imbalance is that studies in this field are considerably more meaningful when they deal with untoward effects than with therapeutic uses. This disproportion has suggested to us the curious similarity with the situation portrayed in the film “The Kid” where the essential task of the protagonist (Chaplin) is to repair the windows his stone-throwing child has just broken.

Association between venous and arterial thrombosis: Clinical implications

Massimo Franchini, Pier Mannuccio Mannucci — 2012-03-14

Abstract: Venous and arterial thromboses have traditionally been regarded as separate diseases with different causes. However, recent epidemiological studies have documented an association between these vascular complications, probably due to the presence of more overlapping risk factors than previously recognized. This narrative review first focuses on the risk factors associated with both arterial and venous thrombotic events. In addition, it summarizes the more recent data on the risk of incident venous thromboembolism in patients with asymptomatic atherosclerosis or clinical manifestations of atherothrombosis, as well as on the risk of incident atherothrombotic events in patients with previous manifestation of venous thromboembolism. The potential clinical implications are also discussed.

Core competencies in Internal Medicine

2012-03-29

Abstract: The working group on Competencies of Internal Medicine from the Spanish Society of Internal Medicine (SEMI) proposes a series of core competencies that we consider should be common to all European internal medicine specialists. The competencies include aspects related to patient care, clinical knowledge, technical skills, communication skills, professionalism, cost-awareness in medical care and academic activities. The proposal could be used as a working document for the Internal Medicine core curriculum in the context of the educational framework of medical specialties in Europe.

Evaluation of transient hyperglycemia in non-diabetic patients with febrile neutropenia

2012-01-19

Abstract: Background: We aimed to examine the effect of transient hyperglycemia in non-diabetic patients with febrile neutropenia.Methods: A total of 86 patients with febrile neutropenia were evaluated between June 2006 and December 2009. After measuring random blood glucose level at admission, cases with stress hyperglycemia were included in the study. Stress hyperglycemia was defined as documented random blood glucose level of 140mg/dl and above without known diabetes mellitus, impaired glucose tolerance and impaired fasting glucose. A Multinational Association for Supportive Care in Cancer (MASCC) scoring system was used for the prediction of low and high risk patients according to medical complications at the onset of the febrile episode.Results: There were more patients with stress hyperglycemia than the patients with normoglycemia in the high risk group (p=0.001). The growth of gram negative bacteria and fungi was higher in patients with stress hyperglycemia than with normoglycemia (p=0.001). The patients receiving antifungal therapy had a higher rate of stress hyperglycemia than the patients without receiving antifungal therapy (p=0.009). The patients with stress hyperglycemia had higher mortality rates than the patients with normoglycemia (p=0.007). According to the MASCC risk-index, stress hyperglycemia increased 3.35 fold in the high risk patients compared to the low risk patients (p=0.046) and 4.14 fold in the patients treated with antibacterial and antifungal agents compared to the patients treated with only antibacterial agents (p=0.038).Conclusion: Patients with stress hyperglycemia had more adverse clinical outcomes than patients with normoglycemia. We think further studies are needed to evaluate the relationship between stress hyperglycemia and febrile neutropenia.

Contribution of Hla-B51 in the susceptibility and specific clinical features of Behcet's disease in Tunisian patients

2012-01-30

Abstract: Background: Many researchers have tried to investigate the association of HLA-B51 with the severity and the clinical features of BD with conflicting results.Methods: We aimed at investigating the association of HLA-B51 with demographical and clinical manifestations as well as the severity of BD, by studying 178 native Tunisian BD patients, fulfilling the International Study group criteria for the BD classification recruited from the Department of Internal Medicine, Rabta Hospital in Tunis and compared with 125 native Tunisian healthy age and sex matching volunteers.Results: According to our findings, the frequency of HLAB 51 was significantly higher in BD patients than in controls (p<0.001). Positive pathergy test (PPT) (p=0.01) and retinal vasculitis (p=0.045), were significantly more frequent in HLA B51(+) patients, while the frequency of arterial aneurysms (p=0.009) and neurological involvement, especially the parenchymal involvement (p<0.001), were significantly and clearly higher in HLA B51(−) patients. The patients without HLA B51 had a significantly less severe disease (p=0.001).Discussion/conclusionWe conclude that HLA B51 is a predisposing marker for BD in our population as in most ethnic groups. It seems to be associated with a subgroup of BD patients characterized by a higher frequency of ocular involvement and PPT, but a lower frequency of arterial aneurysm and neurological involvement, and a less severe disease course.

Increased oxidative DNA damage and impaired antioxidant defense system in patients with gastrointestinal cancer

Aymelek Gönenç, Aysun Hacışevki, Sabahattin Aslan, Meral Torun, Bolkan Şimşek — 2012-03-09

Abstract: Background: Highly active intermediates are formed in aerobic metabolism which in turn leads to cellular damage. It is increasingly proposed that free radicals play a key role in human cancer development. The aim of this study was to investigate changes in 8-hydroxy-deoxyguanosine, nitrite+nitrate, total glutathione, total antioxidant capacity levels and superoxide dismutase, catalase, glutathione peroxidase activities in operative patients with gastrointestinal cancer before and after surgery and compare with inoperative patients.Methods: Oxidative stress parameters were measured in 59 gastrointestinal cancer patients and 20 controls. 8-hydroxy-deoxyguanosine was quantitated by Elisa method. Superoxide dismutase, catalase, glutathione peroxidase were assayed with colorimetric methods; Nitrite+nitrate, total glutathione and total antioxidant capacity were assayed with spectrophotometric methods.Results: 8-hydroxy-deoxyguanosine levels in cancer patients were higher than those of control group (p<0.01). Similarly, glutathione levels were increased compared with controls (p<0.01). However, nitrite+nitrate, total antioxidant capacity levels and superoxide dismutase and catalase activities were decreased in cancer patients compared with controls (p<0.01, p<0.01, p<0.05, p<0.01, respectively). The patients were divided into two groups; operative (n=30) and inoperative (n=29). A significant difference was found in inoperative group compared with postoperative group according to glutathione peroxidase activity (p<0.05).Discussion: Our results demonstrate that the oxidant/antioxidant balance was altered in favor of free radicals and DNA damage in gastrointestinal cancer patients. Significant increases in 8-hydroxy-deoxyguanosine, glutathione and decreases in nitrite+nitrate, SOD, CAT activities and antioxidant molecules suggest the possible involvement of oxidative stress in gastrointestinal cancer. Glutathione peroxidase activities in postoperative patients were higher compared to inoperative patients.

Time to change the glomerular filtration rate estimating formula in primary care?

Päivi E. Korhonen, Hannu Kautiainen, Salme Järvenpää, Sirkka-Liisa Kivelä — 2012-01-30

Abstract: Background: The most commonly used equation for estimated glomerular filtration rate (eGFR) is nowadays the four-variable Modification of Diet in Renal Disease (MDRD) equation. This formula was derived from patients with non-diabetic chronic kidney disease (CKD) with mean GFR 40ml/min.Methods: We compared the MDRD study equation and the recently developed Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation by applying the two formulas in 1747 middle-aged cardiovascular risk persons in primary care.Results: The prevalence of renal insufficiency defined as eGFR<60ml/min was 6.7% (95% CI 5.6–8.0) according to the MDRD formula, and 3.6% (95% CI 2.8–4.6) according to the CKD-EPI formula. The subjects who were classified as having CKD according to the MDRD equation, but no-CKD according to the CKD-EPI formula, were mostly women (86%) and slightly younger than the subjects having CKD according to both formulas.Conclusion: The characteristics of the subjects commonly treated in primary care resemble more closely the population from which the CKD-EPI than the MDRD study equation was derived from. Thus, we suppose that in general practice, the CKD-EPI equation is more suitable for estimating renal function than the MDRD equation.

Sepsis-induced acute respiratory distress syndrome with fatal outcome is associated to increased serum transforming growth factor beta-1 levels

2011-11-07

Abstract: Background: TGF-β1 is a promoter of pulmonary fibrosis in many chronic inflammatory diseases. TGF-β1 circulating levels in patients with sepsis-induced Acute Respiratory Distress Syndrome (ARDS) have not been established.Methods: In this prospective pilot cohort study, serum bioactive TGF-β1 concentration, determined by sandwich ELISA, was analyzed in 52 patients who fulfilled criteria for septic shock at admission and on days 3 and 7.Results: Of the 52 patients enrolled in the study, 46.1% fulfilled the criteria for ARDS on admission. At ICU admission, there were not statistical differences in TGF-β1 concentrations between septic shock patients with or without ARDS. After 7days of follow-up in ICU, circulating TGF-β1 levels were significantly higher in patients with sepsis and ARDS than in those without ARDS [55.47 (35.04–79.48pg/ml) versus 31.65 (22.89–45.63pg/ml), respectively] (p=0.002). Furthermore, in septic shock associated ARDS patients, TGF-β1 levels were significantly higher in nonsurvivors than in survivors [85.23 (78.19–96.30pg/ml) versus 36.41 (30.21–55.47pg/ml), respectively] (p=0.006) on day 7 of ICU follow-up.Conclusions: In patients with septic shock, persistent ARDS is accompanied with increased circulating TGF-β1 levels. Furthermore, ARDS patients with fatal outcome show higher TGF-β1 concentrations than survivors. These results suggest the relevance of TGF-β1 levels found in the pathogenesis of persistent sepsis-induced ARDS.

In routine UK hospital practice T-SPOT.TB™ is useful in some patients with a modest pre-test probability of active tuberculosis

2012-02-10

Abstract: Objective: to assess the usefulness of the T-SPOT.TB™ interferon-gamma release assay (IGRA), as used in a regional hospital infectious diseases unit in Northwest England, for the diagnosis of active tuberculosis.Design: Retrospective case series.Results: T-SPOT.TB™ test was applied to a group of 64 patients, 20 of whom had tuberculosis (mostly extra-pulmonary tuberculosis). The T-SPOT.TB™ test had a sensitivity of 83.3% and a specificity of 75% for the diagnosis of active tuberculosis, compared with culture. A positive IGRA approximately doubled the pre-test probability of disease from 0.23 to 0.5. This doubling of probability was true regardless of HIV status, though for HIV+ patients the sensitivity was lower (sensitivity 66.7%, post test probability 0.4 for a positive IGRA result). When extrapolated to the local population the test was most useful for exclusion of disease; post test probability 0.006 (or 1 in 167) for a negative IGRA result.Conclusion: Although it can add weight to a clinical diagnosis, T-SPOT.TB™ assay is not reliable for the diagnosis of active tuberculosis in a real world setting where the test is often used in patients with smear negative or extra-pulmonary disease. The test is useful for ruling out disease in HIV negative patients.

Clinical significance of sCD105 in angiogenesis and disease activity in multiple myeloma

2012-03-02

Abstract: Background: Τhe importance of angiogenesis in malignancies' growth is well recognized. CD105 (Endoglin), a proliferation-associated glycoprotein, is a powerful marker of neovascularization. Elevated amounts of solubleCD105 (sCD105) have been identified in selected solid tumors. The aim of the study was to estimate circulating levels of sCD105 and soluble transforming growth factor-β1 (sTGF-β1), in multiple myeloma (MM) patients, to determine their significance in tumor progression and to investigate the correlation between sCD105 and markers of disease activity.Methods: We studied 50 newly diagnosed MM patients. Twenty-five of them were also investigated in plateauphase. Twenty patients with monoclonal gammopathy of undetermined significance (MGUS) were enrolled in this study. As control group 28 healthy persons were studied. We determined sCD105, sTGF-β1 and interleukin-6 (IL-6) in the serum, Ki-67 proliferation index (Ki-67 PI) expression and microvascular density(MVD) in bone marrow with immunohistochemistry.Results: The mean concentrations of sCD105 and IL-6 were higher in MM and MGUS patients compared to controls, whereas serum levels of sTGF-β1 were lower in MM patients compared to MGUS patients and controls. sCD105 levels, were significantly different among disease stages, with higher values in advanced stages. It was found that sCD105 correlated with Ki-67 PI, MVD and IL-6.Conclusions: CD105 seems to play an important role in angiogenesis and tumor progression. Circulating levelsof sCD105 could detect patients with more advanced disease and might help in evaluating the response to treatment.

Effect of beta blocker therapy on survival of patients with heart failure and preserved systolic function following hospitalization with acute decompensated heart failure

2012-02-29

Abstract: Background: The importance of heart failure with preserved ejection fraction is being increasingly recognized. However, there is a paucity of data about effective treatment for this condition. The present study investigated the impact of beta blocker therapy for 3months before admission on the two-year survival of patients with heart failure and preserved systolic function hospitalized due to decompensated heart failure.Methods: We performed a retrospective cohort analysis of 345 consecutive patients with heart failure with preserved systolic function older than 18years hospitalized due to decompensated heart failure. Two groups of patients were compared: those who received beta blockers within 3months before admission (BB) and those who did not (NBB). The primary outcome was two year all cause mortality (maximal follow-up available in all subjects). To adjust for a potential misbalance between BB and NBB groups in baseline characteristics, a propensity score for beta blocker therapy was incorporated into the survival model.Results: 154 patients (44.6%) received beta blockers prior to admission. Overall two year mortality rate in the BB group was 50% vs. 62.8% in the NBB group, log-rank test p=0.016. Beta blockers showed protective effect on two-year survival after adjustment for comorbidities and propensity score (hazard ratio [HR], 0.69; 95% CI 0.47–0.99).Conclusions: Therapy with beta blockers may have protective effect on survival of patients with heart failure with preserved systolic function.

Residual pulmonary thromboemboli after acute pulmonary embolism

2011-09-12

Abstract: Background: After an acute pulmonary embolism (PE), the complete resolution of thromboemboli may not be routinely achieved. The rate of persistence may depend on the time and the diagnostic technique used for evaluation.Patients and methods: Patients were diagnosed with acute PE by means of computed tomography angiography (CTA). While they were receiving anticoagulant therapy, a second CTA was used to explore the rate of persistence of residual thromboemboli. During the initial episode, the plasma levels of Troponin I and natriuretic peptide, patient demographics, and hemodynamic and gas exchange data were evaluated as risk factors for persistence of pulmonary thromboemboli.Results: In this study 166 patients were diagnosed. A second CTA was not made in 46 (28%) patients for different reasons. In 120 (72%) patients a second CTA was made 4.5 [SD2.34] months after the initial episode (range 2–12months). Complete clearance of thrombi occurred in 89 (74%, 95% CI 65–81) patients. Residual thrombi remained in 31 (26%, 95% CI 18–34) patients. In 6%, 13% and 81% of the patients the size of the residual thrombi was greater, similar to and smaller than initially diagnosed, respectively.The risk factors for residual thrombi included the thrombotic burden (OR 1.95), the alveolar to arterial difference of oxygen (OR 1.64), and the clinical antecedents of venous thromboembolic disease (OR 0.65).Conclusions: After 4.5months of anticoagulant therapy, residual pulmonary thromboemboli persisted in 26% of the patients. The risk factors for residual thromboemboli include a greater initial thrombotic burden, a deeper gas exchange disturbation and a history of previous venous thromboembolism.

Changes in body mass index on a gluten-free diet in coeliac disease: A nationwide study

2012-01-30

Abstract: Objective: The clinical presentation of coeliac disease has changed and patients are often overweight at diagnosis. There is concern that patients might gain further weight while on a gluten-free diet (GFD). The aim of the study was to evaluate the impact of a GFD on the body mass index (BMI) in a nationwide cohort of coeliac patients and to determine variables predictive of favourable or unfavourable BMI changes.Methods: We prospectively investigated weight and disease-related issues in 698 newly detected adults diagnosed due to classical or extraintestinal symptoms or by screening. BMI at diagnosis and after one year on a GFD were assessed and compared with that in the general population.Results: At diagnosis, 4% of subjects were underweight, 57% normal, 28% overweight and 11% obese. On a GFD, 69% of underweight patients gained and 18% of overweight and 42% of obese lost weight; in the rest BMI remained stable. Changes were similar in both symptom- and screen-detected patients. The coeliac group had a more favourable BMI pattern than the general population. Favourable BMI changes were associated with subjects' self-rated expertise on GFD and young age at diagnosis, but not dietary counselling received.Conclusions: BMI improved similarly in screen- and symptom-detected coeliac disease patients on a GFD.

Mushroom poisoning: A study on circumstances of exposure and patterns of toxicity

2012-04-19

Abstract: Background: Picking wild mushrooms is a popular pastime in Switzerland. Correct identification of the species is difficult for laypersons. Ingestion of toxic mushrooms may result in serious toxicity, including death. The aim of the study is to analyze and describe the circumstances of exposure to mushrooms, and to define the clinical relevance of mushroom poisoning for humans in Central Europe.Materials and methods: We performed a retrospective case study and analyzed all inquiries concerning human exposures to mushrooms (n=5638, 1.2% of all inquiries) which were reported to the Swiss Toxicological Information Centre between January 1995 and December 2009.Results: The most frequent reason for contacting the poison center in cases of adult exposure was toxicity resulting from edible species. Pediatric exposure predominantly occurred from mushrooms found around the home. Severe symptoms have not only been observed after ingestion of non-amatoxin-containing toxic mushrooms, i.e. Boletus sp. and Cortinarius sp., but also after meals of edible species. The mortality of confirmed amatoxin poisonings was high (5/32) compared to other reports.Conclusions: Inquiries regarding mushroom poisoning were a relatively infrequent reason for contacting the poison center. Nevertheless, accidental ingestion of toxic mushrooms can be responsible for severe or fatal poisonings. Although pediatric exposure to mushrooms found around the home has not led to serious toxicity in this study, prevention of exposure is warranted. Inspection of wild mushrooms by a certified mushroom expert or a mycologist seems to be a safe procedure which should be recommended.

Mallory–Weiss syndrome: Clinical and endoscopic characteristics

Anning Yin, Yi Li, Yingan Jiang, Jun Liu, Hesheng Luo — 2012-03-06

Abstract: Background: Mallory–Weiss syndrome is defined by upper gastrointestinal bleeding from vomiting-induced mucosal lacerations at the esophago-gastric junction. This study was purposed to investigate the incidence, location, clinical manifestation, diagnosis and effectiveness of treatment (including endoscopic treatment and conservative medical treatment) of Mallory-Weiss syndrome in China.Methods: All patients who received emergency upper gastrointestinal endoscopy due to Mallory–Weiss syndrome from September 2007 to August 2011 at gastrointestinal endoscopy center of Renmin Hospital of Wuhan University were included in this study. The clinical presentation, medical history, location and characteristics of Mallory–Weiss syndrome methods and effectiveness of therapy of patients with Mallory–Weiss syndrome were retrospectively analyzed by chart reviews. Long-term follow-up data were collected at outpatient clinics or telephone interviews.Results: Sixteen patients were diagnosed with Mallory–Weiss syndrome, which account for 3.08% of 519 patients with acute non-variceal upper gastrointestinal bleeding. Common comorbidities were found in one patient with hepatic cirrhosis. Conservative medical treatment, local injection, hemoclipping, or multipolar electrocoagulation produced primary hemostasis in 87.5% (14/16) of patients.Conclusion: Mallory–Weiss syndrome is uncommon in China in comparison with reported experience in the west when the same group of patients is selected. Different approaches to treatment are to be recommended depending on whether or not active hemorrhage is present.

Prognostic value of increased B type natriuretic peptide in cases with acute pancreatitis

Mehmet Sait Bugdaci, Erkan Oztekin, Ekrem Kara, Ibrahim Koker, Ayhan Tufan — 2012-03-19

Abstract: Background: Acute pancreatitis (AP) is a systemic disease with a rising incidence. Cardiac dysfunction may occur as an early complication of AP. B type natriuretic factor (BNP) is a diagnostic and prognostic indicator of cardiac disorders. Therefore, in this study we aimed to assess the relationship between serum BNP concentrations and severity of AP.Methods: Patients with AP who were admitted to gastroenterology clinic of our center, were included in this study. BNP measurements were performed twice, once on admission to the hospital and another after clinical and laboratory remission of the disease. All patients underwent echocardiography, abdominal ultrasonography and/or computed tomography chest X-ray and routine biochemical assays. Disease severity was determined by Ranson, Balthazar and Glasgow scoring systems.Results: A total of 55 patients with AP (33 male, 60%) were enrolled in the study. Causes of AP were biliary in 32 patients (58%), alcoholic in 10 (18%), idiopathic in 8 (15%), hyperlipidemic in 4 (7%) and ERCP related in one patient (2%), respectively. Serum BNP levels in first 2days of admission and after the clinical and laboratory remission of disease were 444±295.9 and 124±109.5pg/ml, respectively (p<0.001). Increased serum BNP levels were positively correlated with severity of the disease (p<0.001). We could not find a difference between serum BNPe levels of edematous and necrotizing patients (P=0.683).Conclusion: Increased serum BNP levels might be a plausible indicator of severity of AP during the course of the disease.

Obesity and low target attainment rates in Chinese with type 2 diabetes

Xing-Bo Cheng, Yi-Ting Hsieh, Shih-Te Tu, Ming-Chia Hsieh — 2012-03-29

Abstract: Background: Although it is known that the prevalence of type 2 diabetes and obesity is increasing in China, there is little research into how obese or non-obese patients may differ in their attainment of treatment goals for type 2 diabetes. To do this, we assessed the attainment of American Diabetes Association (ADA)-recommended goals in Chinese with type 2 diabetes stratified by body mass index (BMI).Methods: This cross-sectional study enrolled 520 Chinese with type 2 diabetes to find out if they had attained the following ADA-recommended goals: HbA1c<7%, SBP<130mm Hg, DBP<80mm Hg, LDL-C<100mg/dl, TG<150mg/dl, HDL-C>40mg/dl for men and >50mg/dl for women.Results: Only 44.4% of all participants achieved the blood pressure goal, 20.8% the HbA1c goal, 44.8% the LDL-C goal, 43.3% the HDL-C goal, and 66.8% the triglyceride goal. Obese patients were less likely than normal weight patients to achieve the blood pressure goal (OR, 0.474; 95% CI, 0.231–0.973; p=0.01), the HDL goal (OR, 0.365; 95% CI, 0.163–0.817; p=0.01), or the triglyceride goal (OR, 0.416; 95% CI, 0.212–0.817; p=0.01), after adjusting for confounders. Compared to normal weight participants, the obese patients had a significantly higher prescription rates for statin, metformin and anti-hypertensive drugs.Conclusion: Obese diabetic patients were less likely to achieve the blood pressure, LDL-C, HDL-C and triglyceride targets even when they were receiving several drugs to help them meet their target treatment goals. More strategies are needed to improve the treatment of Chinese with type 2 diabetes, particularly those who are obese.

The longitudinal variability of serum 25(OH)D levels

Walid Saliba, Ofra Barnett, Nili Stein, Anne Kershenbaum, Gad Rennert — 2012-03-19

Abstract: Background: The extent to which a single serum 25(OH)D measurement represents long-term vitamin D status remains unclear. This study aims to assess the variability of serum 25(OH)D between tests taken at different time intervals.Methods: Using the computerized database of the largest healthcare provider in Israel, we identified subjects in whom a serum 25(OH)D test was performed on at least two different occasions between January 2008 and September 2011 (n=188,771). For these subjects we selected the first and the last dated tests, then we identified those who were not treated with supplements during the last 6months before the first and before the last test (n=94,418). Of these we analyzed subjects in whom the first and the last tests were performed in the same month of the year (n=8881).Results: The mean serum 25(OH)D level at the first test was 51.7±24.0nmol/L and was 56.7±24.7 at the last test (P<0.001); the overall correlation was 0.63 (P<0.001). For vitamin D status in two categories (<50 versus ≥50nmol/L), the percentage of agreement between the first and last tests was 74.4%, and was 50.8% for vitamin D status in four categories (<30, 30–49.9, 50–74.9, and ≥75nmol/L). The correlation decreased with increasing time between the tests ranging from 0.83 for tests done at the same year to 0.55 after 3years. The more the first levels were higher or lower, the more likely subjects remain in their first category (≥50 versus <50nmol/L).Conclusions: Long-term month specific serum 25(OH)D levels are relatively stable.

Clinical remission or mucosal healing: A therapeutic dilemma of ulcerative colitis

Levent Filik — 2012-01-05

I read with great interest the recent article by Lopez-Palacios et al. . I appreciate the authors for the important results of their study. There are some issues to be considered. The authors pointed out persistence of endoscopic activity in patients with long-term clinical remission with monotherapy with azatioprine or mercaptopurine. So, this fact gives rise to the question of whether clinical relief or mucosal healing should be the treatment goal in ulcerative colitis. If only clinical relief is sought, this study means that current indexes especially C-reactive protein (CRP) should be reevaluated. Because, approximately half of the study patients have normal CRP although they have high Mayo endoscopic score. However, there are some exceptions. For example, 308GG homozygosity that may lead to normal CRP levels inspite of persistence of endoscopic disease could be remembered . Could the authors consider such genetic variations? On the other hand if mucosal healing is the ideal objective, this study means that mucosal healing is unattainable with azatioprine or mercaptopurine treatment.

Doubts about mucosal healing in ulcerative colitis

Natalia López-Palacios, Juan L. Mendoza Hernandez — 2012-02-15

I would like to thank the comments made about our recent paper by Filik . Mucosal healing is now considered a relevant end point in clinical trials in ulcerative colitis. There is also growing evidence that mucosal healing is an important treatment goal in clinical practice as it is associated with improved long-term outcomes (lower risk of relapse, a reduced risk of colorectal cancer, a decreased need for surgery, and improved quality of life) . But mucosal healing is still uncertain how it should be used in clinical practice. Further studies are needed to develop standardized endoscopic scoring systems for mucosal healing that will be validated in prospective clinical trials evaluating long-term outcomes for ulcerative colitis. In the next years, it is likely that endoscopy will be increasingly used in the future to guide therapeutic decision making.

Is testosterone or estrogen more important for male patients with coronary artery disease?

Xiaorong Hu, Kai Zhang, Hong Jiang — 2012-03-14

Sex hormones and gender differences have been reported to be involved in coronary artery disease (CAD) . Endogenous testosterone and/or estrogen have been shown to provide a protective role in the development of cardiovascular diseases in men . Kajinami et al. show that the imbalance of sex hormones exists in men with CAD, and the ratio of free testosterone level to highly-sensitive estrogen level was a significant imbalance in men with CAD. In addition, Akishita et al. indicated that a low testosterone level is an independent risk factor for cardiovascular disease events in middle-aged Japanese men with coronary risk factors. These suggested that endogenous testosterone provides a protective role in the development of cardiovascular disease in men. Recently, Hu et al. further showed that the testosterone level was lower and negatively correlated with the severity of coronary artery stenosis in middle-aged men with CAD; this result was consistent with previous studies . Meanwhile, they found that a lower testosterone level may contribute to more severe cardiovascular events, because they found that the levels of testosterone in unstable angina pectoris patients and acute myocardial infarction patients were significantly lower than that in stable angina pectoris patients; and the level of testosterone in acute myocardial infarction patients was significantly lower than that in unstable angina pectoris patients . In addition, Mathur et al. showed that long-term testosterone replacement therapy could attenuate angina threshold and promote plaque stability in men with CAD. These suggested that a lower testosterone level may be involved in the pathogenesis of middle-aged men with CAD.

Polypathological patients and prognostic scores. About the PROFUND index

2012-03-30

We have read with interest the letter of M. Marcucci , and fully agree with her arguments and conclusions. It does not matter how calibrated and discriminating a system may be in development, a system that can only predict outcomes in the sample in which it was developed is not useful. For a system to be generalizable, its accuracy (that is, calibration and discrimination) has to be reproducible and transportable. Reproducibility of PROFUND index was assessed by calculating its calibration and discrimination power in the validation cohort, which contained approximately half of the participating hospitals (from the east of Spain and the islands, while the derivation cohort contained the other half of hospitals and patients recruited in the west areas of Spain). A good calibration and a discrimination power with an area under the ROC curve of 0.7 were obtained ; this already well described methodology served us to assess its geographical transportability.

Anemia and osteoporosis: Causal association or epiphenomenon?

Eda Demir Onal, Alper Usluogulları — 2012-03-30

We read with great interest the article by Korkmaz et al. . They found that the presence of anemia was independently associated with low bone mass for spine after adjusting for body mass index and other confounders in postmenopausal Turkish women. They speculated that anemia was a risk factor for low bone mineral density in postmenopausal Turkish women. We think that an association between these two entities can be concluded from this study but a causal relationship can't be inferred. The authors have better included the etiology and classification of anemia in these patients which would have probably proved that anemia was an epiphenomenon in these patients with osteoporosis.