Locally acquired hepatitis E in the Netherlands: Associated with the consumption of raw pig meat?

We here present 2 patients who developed hepatitis E, without having been abroad or in contact with anyone who did, indicating locally acquired hepatitis E. We point out that the consumption of raw pig meat could be of relevance in HEV-associated hepatitides in the Netherlands.

Two patients with osteoporosis: initial presentation of systemic mastocytosis

In two patients with osteoporosis, systemic mastocytosis ultimately turned out to be the underlying disease. Both patients had a history of anaphylactic reactions caused by wasp stings but did not have any skin or other symptoms. This observation reflects the need for careful history taking and physical examination in patients with osteoporosis to identify possible underlying diseases, such as systemic mastocytosis.

Clinical practice of nutritional support in Dutch intensive care units: a survey

INTRODUCTION: Nutritional support in intensive care units (ICUs) has received increasing attention in the last few decades. We performed a national survey to establish the current practice with respect to nutritional support in Dutch ICUs. METHODS: A questionnaire was sent to all Dutch ICUs. The design of the study was a 1-day point prevalence study. RESULTS: The response rate of the ICUs was 51% (74/144). Eighty-eight percent of the questionnaires returned (65/74) were suitable for data analysis. The total number of patients present on the ICU on the given day was 354 and their mean age was 59.2+/-1.0 years. Sixty-nine percent of the patients (246) received nutritional support: enteral in 206 patients (58%), parenteral in 59 patients (17%), and a combination of the two in 19 patients (5%). The percentage of patients receiving nutritional support and the route of administration were dependent on the reason for admission to the ICU. Nutritional support was started after a mean of 1.3+/-0.1 days after admission to the ICU. One hundred and four patients (29%) received no nutritional support after a mean admission period of 1.6+/-0.1 days. For 193 patients (54%), the nutritional support met the nutritional requirements, for 145 patients (41%) it did not, and 17 respondents (5%) had no opinion. CONCLUSION: Nutritional support is provided to the majority of critically ill patients. Enteral feeding is more common than parenteral nutrition.

Cholecystogastric fistula presenting with haematemesis: diagnosed by endoscopic retrograde cholangiography

The case is reported of a 72-year-old woman suffering from morbid obesity, who presented with haematemesis while on anti-coagulant therapy. The source of the bleeding proved to be the gastric exit of a cholecystogastric fistula. Subsequent cholangitis was successfully treated by endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy (ES) while simultaneously the extent of the fistula was established. Cholecystectomy and closure of the fistula was contraindicated because of her morbid obesity. She remained well for 6 months but then presented with a gallstone ileus while another stone was found to be escaping from the gastric fistula. Her morbid obesity resulted in surgical procrastination, which eventually proved fatal. This patient experienced both of the most common types of complication in cholecysto-enteral fistulation, cholangitis and gallstone ileus. Although cholecysto-enteral fistulas (CEF) are probably less common than several decades ago, they are now most likely to be diagnosed during ERC. Gastroenterologists therefore need to be aware of their potential to contribute to the diagnosis and treatment of this surgical condition.

Neurologic symptoms due to possible chromium deficiency in long-term parenteral nutrition that closely mimic metronidazole-induced syndromes

BACKGROUND

We previously described a patient on home parenteral nutrition (HPN) who developed glucose intolerance and neuropathy that only responded to an infusion of chromium. A patient on HPN who had neuropathy and glucose intolerance was studied. He was also on metronidazole, which could have caused the neuropathy, but the symptoms and signs persisted.

METHODS

Baseline clinical examination, nerve conduction studies, serum vitamin and trace element levels, and glucose tolerance were measured. Then, 250 micrograms of trivalent chromium as the chloride salt was infused daily for 2 weeks. The above studies were repeated.

RESULTS

The patient at baseline had peripheral neuropathy of the axonal type and was glucose intolerant. Serum chromium was raised in this patient above the reference range. Despite raised serum levels, the infusion of chromium resulted in clinical remission that was marked 4 days after starting the infusion. Normalization of nerve conduction also occurred within 3 weeks of the initial study.

CONCLUSIONS

Neuropathy and glucose intolerance may occur despite increased serum chromium levels and respond to chromium infusion. The previous use of drugs such as metronidazole should not exclude chromium as a potential treatment for neuropathy in HPN patients.

Harry M. Vars Research Award. Increase in lumbar spine bone mineral content in patients on long-term parenteral nutrition without vitamin D supplementation

BACKGROUND

We had previously shown that short-term withdrawal of vitamin D in patients with metabolic bone disease complicating home parenteral nutrition (HPN) corrected osteomalacia. We therefore conducted a prospective study of the effect of long term withdrawal of vitamin D in patients on home parenteral nutrition.

METHODS

Baseline measurements of bone mineral content, serum levels of calcium, phosphorus, parathormone, 25-OH and 1,25 (OH)2D; urinary calcium; and bone mineral density were measured. Then all parenteral vitamin D was withdrawn and the above parameters were followed for a mean of 4.5 years.

RESULTS

Lumbar spine bone mineral content (LSBMC) was 0.79 +/- 0.06 g/cm2 at the start of the study, well below the reference value, 1.16 +/- 0.13 g/cm2. Parathyroid hormone (PTH) (0.48 +/- 0.24 pmol/L) and 1,25-(OH)2D levels (22.8 +/- 7.9 pmol/L) were low and 25-hydroxyvitaniin D levels were normal (33.3 +/- 5.5 nmol/L) before removing vitandn D from the HPN solutions. After withdrawal of vitamin D for 4.5 +/- 0.2 years LSBMC increased from 0.79 +/- 0.06 to 0.93 0.07 g/cm2 (p < 0.005). Calcium phosphorus, magnesium and 25-hydroxyvitamin D did not change significantly, 1,25(OH)2D, and PTH levels became normal after withdrawal of vitamin D.

CONCLUSIONS

In selected patients with depressed PTH levels, long-term withdrawal of vitamin D during HPN increases LSBMC and levels of PTH and 1,25(OH)2D. There is no reduction of the mean level of 25-hydroxyvitamin D.

[The treatment of myocardial infarction during the hospital stage and shortly thereafter: now and 10 years ago]

OBJECTIVE

Comparison between the early and the late eighties of the application of thrombolysis and revascularisation in the acute phase of a myocardial infarction.

LOCATION

University Hospital, Rotterdam.

DESIGN

Prospective with historical comparison.

METHODS

All patients admitted between May 1987 and May 1990 with a myocardial infarction and aged up to 71 years were included (n = 430). Numbers of procedures and survival during the following year were compared with data of patients admitted from 1981 to the end of 1983 (n = 706).

RESULTS

In 1981-1983 thrombolytics were administered to 9% of the patients, in 1987-1990 to 40%. Revascularisation procedures during the next year were performed in 17% and 50% of the patients respectively. Hospital mortality decreased from 14% to 10% (p < 0.05), one-year survival increased from 75% to 83% (p < 0.05). For patients from 1987-1990 one-year survival was higher after thrombolysis treatment: 90% versus 78% without (p < 0.01), and after revascularisation: 94% versus 87% without (p < 0.01).

CONCLUSION

Compared with 1981-1983 the treatment is at present more directed towards reperfusion and revascularisation of the ischaemic myocardium, resulting in invasive treatment in 50% of the patients now as opposed to 25% in the early eighties. The survival rate during the first year has improved.