Smoking is Associated With Extra-intestinal Manifestations in Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Smoking affects the course of disease in patients with ulcerative colitis (UC) and Crohn's disease (CD). We aimed to study the association between smoking and extra-intestinal manifestations (EIMs) in inflammatory bowel disease (IBD). METHODS: We cross-sectionally explored the association between smoking and EIMs in IBD in three cohort studies: (1) the COIN study, designed to estimate healthcare expenditures in IBD; (2) the Groningen study, focused on cigarette smoke exposure and disease behaviour in IBD; and (3) the JOINT study, evaluating joint and back manifestations in IBD. RESULTS: In the COIN, Groningen and JOINT cohorts, 3030, 797 and 225 patients were enrolled, of whom 16, 24 and 23.5% were current smokers, respectively. Chronic skin disorders and joint manifestations were more prevalent in smoking IBD patients than in non-smokers (COIN, 39.1 vs 29.8%, p <0.01; Groningen, 41.7 vs 30.0%, p <0.01) in both CD and UC. In the JOINT cohort, smoking was more prevalent in IBD patients with joint manifestations than in those without (30.3 vs 13.0%, p <0.01). EIMs appeared to be more prevalent in high- than in low-exposure smokers (56.0 vs 37.1%, p = 0.10). After smoking cessation, the prevalence of EIMs in IBD patients rapidly decreased towards levels found in never smokers (lag time: COIN cohort, 1-2 years; Groningen cohort, within 1 year). CONCLUSIONS: There is a robust dose-dependent association between active smoking and EIMs in both CD and UC patients. Smoking cessation was found to result in a rapid reduction of EIM prevalence to levels encountered in never smokers.

[Tubercular granulomas of the liver in a Somalian patient notwithstanding a chronic hepatitis C]. / Granulomen in de lever bij een Somalische patiënt met chronische hepatitis C toch veroorzaakt door tuberculose.

A 44-year-old male Somalian immigrant was admitted to hospital for evaluation of upper abdominal pain and painful joints (neck and shoulders). Chronic active hepatitis caused by hepatitis C virus was diagnosed. Further examination was instituted because of the simultaneous finding of granulomas in a liver biopsy. In hepatitis C liver granulomas may be found. Infection by Mycobacterium tuberculosis was established, however, after extensive investigation. Treatment was started with tuberculostatic drugs, after which the complaints of the patient disappeared, liver enzyme levels decreased and granulomas in the liver disappeared. No side effects of the tuberculostatic treatment were seen on the course of the hepatitis C.

Dieulafoy's disease: endosonographic detection and endosonography-guided treatment.

BACKGROUND: To investigate whether endosonography can help in the detection and treatment of Dieulafoy's disease, we examined eight patients with suspicion of Dieulafoy's disease. METHODS: Between December 1992 and April 1995, eight patients were referred because of suspicion of Dieulafoy's disease. Seven presented with upper gastrointestinal bleeding and one with a tiny ulcer. In all eight patients the stomach was examined with an Olympus GF-UM20 echoendoscope. The stomach was filled with 200 to 400 ml of water after which the body, fundus, and cardia were carefully visualized. RESULTS: In all eight patients a clearly visible, relatively large caliber (2 to 3 mm) vessel was seen to penetrate the muscularis propria and could be followed running through the submucosa for 2 to 4 cm. Subsequently four patients received sclerotherapy, three under endosonographic guidance. Follow-up of all patients (median 10 months), showed recurrent bleeding in two patients, 3 and 5 months after sclerotherapy. One was then diagnosed with a duodenal ulcer and one with recurrent bleeding from the Dieulafoy's lesion. CONCLUSIONS: Endosonography is useful in the detection of Dieulafoy's disease in patients with unexplained upper gastrointestinal bleeding. Sclerotherapy can be performed during the same procedure, with endosonography-guided injection of the sclerosing agent near the abnormal vessel.

New approaches to endoscopic therapy for a haemostasis upper GI bleed.

Haematemesis and/or melaena are the most common presentations of upper gastrointestinal bleeding. Endoscopic haemostasis after diagnosis still remains a challenge to the gastroenterologist. Most variceal and peptic ulcer bleeding episodes stop spontaneously, and then prevention of rebleeding might be indicated by endoscopic techniques. In the present article, four less well-known endoscopic haemostasis techniques are discussed and, if available, comparative studies are reviewed.

New approaches to endoscopic therapy for hemostasis of upper GI bleed.

Hematemesis and/or melena are the most common presentations of upper gastrointestinal bleeding. Endoscopic hemostasis after diagnosis still remains a challenge to the gastroenterologist. Most variceal and peptic ulcer bleeding episodes stop spontaneously, and then prevention of rebleeding might be indicated by endoscopic techniques. Four not so well known endoscopic hemostasis techniques are discussed and comparative studies are reviewed.

[Wishes of residents in internal medicine with relation to working week, part-time work, career length and practice pattern]. / De wensen van assistent-geneeskundigen in opleiding tot internist met betrekking tot werkweek, deeltijdarbeid, carrièreduur en vestigingsvorm.

To investigate the wishes and ideas about length of working week, part-time work, length of career and future kind of establishment, a questionnaire was sent to all Dutch registrars of internal medicine. In the opinion of more than 70 percent of the registrars, the length of a full-time working week of an internist should be less than 50 hours. Of all registrars (62% men and 38% women), 68% would decide in favour of part-time work if the length of a full-time working week of an internist were to remain at about 68 hours (common length of a working week of Dutch internists nowadays). 33% would still like to work part-time when the length of a full-time working week became as they desired (about 47 hours). The preferred length of their career was for most registrars less than 30 years. The majority preferred a tenure to a position in a partnership. In conclusion, the wishes about the future of the registrars of internal medicine differ markedly from the current situation.

Postoperative hemostatic profile in relation to gram-negative septicemia.

Gram-negative septicemia presents a particular problem in the ICU. Septicemia is usually diagnosed by fever, chills, and shock. Results of blood cultures become available a few days later. Major surgery induced a marked decline in antithrombin III (AT III) and plasminogen (PLG) to a mean level of 0.60 U/ml (normal value: 0.80-1.40 U/ml) on the 2nd and 3rd postoperative days. Around the 5th postop day, these values again attained mean preoperative levels. Seventy-six surgical ICU patients were investigated preoperatively and for 10 days postoperatively to relate postop septicemia to changes in the hemostatic profile. In 15 patients with gram-negative septicemia verified by positive culture, AT III and PLG barely recovered from the postop decrease and remained significantly lower (p less than 0.05) after the 3rd postop day, compared to 61 surgical ICU patients without septicemia. The behavior of alpha 2antiplasmin (alpha 2AP) values was equal in both groups. This difference in hemostatic profile preceded the clinical manifestations of septicemia and the results of blood culture by several days. Leucocyte or platelet counts provided no reliable information on the early development of septicemia in these surgical patients. It is concluded that persistent low plasma AT III and PLG levels in the postop phase are early indicators of a developing gram-negative septicemia.