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J Intern Med

Bone mineral density in patients with Crohns disease during long-term treatment with azathioprine.

Year 1998
Floren CH. Ahren B. Bengtsson M. Bartosik J. Obrant K.
Department of Internal Medicine, Malmo University Hospital, Lund University, Sweden.
OBJECTIVES: To ascertain whether patients with Crohn's disease treated with azathioprine maintained bone mineral mass better than patients treated with steroids alone. DESIGN: Retrospective study. SETTING: University Hospital of Malmo, Sweden. SUBJECTS: A total of 59 patients with ileocolonic, ileocaecal or colonic Crohn's disease. METHODS: Bone mass was assessed by dual photon X-ray absorptiometry at the level of L2-L4. RESULTS: Patients treated with a high lifetime dose of steroids (> 5 g prednisolone) had significantly (P = 0.011) lower Z-score of L2-L4 (-0.87 +/- 1.11; 11 SD) than steroid-treated patients, who had received a low dose of prednisolone (< 5 g) (0.08 +/- 1.16 SD). Azathioprine did not negatively influence the steroid effect on bone mineral density. CONCLUSIONS: Azathioprine does not seem to affect bone mineral density by itself. However, by being steroid-saving, it seems to conserve bone mineral mass in patients with Crohn's disease.

Screening for coeliac disease in adult insulin-dependent diabetes mellitus.

Year 1998
Sjoberg K. Eriksson KF. Bredberg A. Wassmuth R. Eriksson S.
Department of Medicine, University of Lund, University Hospital, Malmo, Sweden.
OBJECTIVES: To study, by sequential screening for gliadin antibodies (GA) and endomysial antibodies (EMA), the prevalence and clinical characteristics of coeliac disease (CD) in adult IDDM patients. SUBJECTS AND MEASUREMENTS: A series comprising 1664 diabetes patients [848 with IDDM, 745 with non-insulin-dependent diabetes (NIDDM) and 71 with secondary diabetes] were screened for GA. IgA- or IgG-GA positive sera were analysed for EMA. RESULTS: IgA-GA were more frequent in all the diabetes subgroups (13.7% in IDDM,12.3% in NIDDM and 23.9% in secondary diabetes, P < 0.001 in all three cases) than among healthy blood donors (4.7%). Two patients with NIDDM had CD. Of the IDDM group (n = 848), 8 had previously diagnosed CD and 14 more (of whom 7 could be biopsied) were EMA positive. All had villous atrophy. The minimum prevalence of CD (including probable cases) in IDDM was 2.6% (22/848). Patients with previously known CD had more symptoms (P < 0.001), more deficiency states (P < 0.001) and more autoimmune diseases (P < 0.04) than those identified by screening. IDDM patients with a diabetes duration of 31-40 years were characterised by a higher prevalence of CD than patients with a duration of less than 30 years (6.7% vs. 1.7%; P < 0.02). CONCLUSIONS: Serial analysis of GA and EMA confirmed a high prevalence of CD in adult IDDM (2.6%). False-positive IgA-GA test results are frequent in patients with diabetes, irrespective of type. EMA analysis is the preferable screening tool for CD in diabetes.

Identification of homozygous lipoprotein lipase gene mutation in a woman with recurrent aggravation of hypertriglyceridaemia induced by pregnancy.

Year 1998
Suga S. Tamasawa N. Kinpara I. Murakami H. Kasai N. Onuma T. Ikeda Y. Takagi A. Suda T.
Third Department of Internal Medicine, Hirosaki University School of Medicine, Aomori, Japan.
We herein report a case of a 40-year-old Japanese woman (patient IT) with a history of recurrent aggravation of hypertriglyceridaemia, pancreatitis and miscarriages in three previous pregnancies. However, strict dietary intervention was applied during a fourth pregnancy. As a result, acute pancreatitis was avoided, and the patient gave birth to a healthy infant. In patient IT, the underlying etiology of the recurrent aggravation of hypertriglyceridaemia during pregnancy was a lipoprotein lipase (LPL) gene aberration. She was homozygous for LPL deficiency due to a nonsense mutation (TGG1401 --> TGA/Trp382 --> Stop) in exon 8 of the LPL gene, which resulted in the absence of LPL activity and immunoreactive LPL mass. Our findings indicate that, in LPL deficiency, pregnancy seriously exacerbates hypertriglyceridaemia and increases the risk of acute pancreatitis, which endangers both the mother and fetus. Early diagnosis of LPL deficiency and appropriate management thereof are essential for normal childbirth.

The role of serum ferritin in the diagnosis of iron deficiency anaemia in patients with liver cirrhosis.

Year 1998
Intragumtornchai T. Rojnukkarin P. Swasdikul D. Israsena S.
Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
OBJECTIVES: To determine the diagnostic values of serum ferritin and other conventional laboratory tests in the diagnosis of iron deficiency anaemia in patients with liver cirrhosis. DESIGN: Cross-sectional study for diagnostic tests. SETTING: University hospital. SUBJECTS: Seventy-two consecutive patients with liver cirrhosis in whom the haemoglobin level was less than 13.0 g dL(-1) for men and 12.0 g dL(-1) for women. The diagnosis of liver cirrhosis was based on characteristic clinical and hepatic ultrasonographic findings. MAIN OUTCOME MEASURES: By using absence of bone marrow iron as the standard criterion, the diagnostic powers of mean corpuscular volume, transferrin saturation, serum ferritin and the presence of hypochromic red cells in the diagnosis of iron deficiency were compared by analysing the likelihood ratios, the area under the receiver operating curves (ROC) and the stepwise logistic regression associated with each test. RESULTS: Twenty-nine patients (40.3%) demonstrated no stainable iron in the bone marrow. The likelihood ratios, the area under the ROC and the stepwise logistic regression indicated that serum ferritin was the most powerful test predictive of iron deficiency. Other tests added little further diagnostic values. The likelihood ratios associated with the serum ferritin levels were as follows: 400 microg L(-1),

Clostridium difficile colitis associated with a triple regimen, containing clarithromycin and metronidazole, to eradicate Helicobacter pylori.

Year 1998
Archimandritis A. Souyioultzis S. Katsorida M. Tzivras M.
Department of Pathophysiology, University of Athens Medical School, Laiko General Hospital, Greece.
We describe a 54-year-old man with Helicobacter pylori (+) duodenal ulcer who developed Clostridium difficile associated colitis, 5 days after commencing a 'triple' regimen consisting of omeprazole 20 mg b.d., metronidazole 500 mg b.d. and clarithromycin 500 mg b.d., to eradicate H. pylori. Despite the fact that oral metronidazole did not prevent the disease, the patient did well after treatment with oral metronidazole plus a yeast preparation (Saccharomyces bulardii). No relapse occurred.

Lethal pulmonary hypertension in a young woman caused by unrecognized haemangiosis carcinomatosa.

Year 1998
Canova CR. Kuhn M. Allemann J. Reinhart WH.
Department of Internal Medicine, Kantonsspital, Chur, Switzerland.
A 38-year-old female is described, who was admitted with increasing respiratory distress, cough and visible blood stasis in the jugular veins. The most likely diagnosis in this young women taking oral contraceptives was pulmonary embolism, however, a ventilation-perfusion lung scan was normal. Echocardiography showed a dilated right ventricle and increased systolic pulmonary pressure. Despite administration of oxygen and intravenous heparin the patient died in circulatory collapse before further investigations could be initiated. Post-mortem examination revealed diffuse adenocarcinoma of the stomach (linitis plastica) with metastasis to local lymphnodes, lymphangiosis carcinomatosa of the liver, pancreas and spleen and tumour cell masses within the lumen of small pulmonary arteries leading to variable occlusions of the vessels. Fibrocellular intimal proliferation was found, leading to further obstruction and increased resistance to flow through the pulmonary vascular bed and to subacute cor pulmonale.

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