Spontaneous haematomas and haematochezia due to vitamin C deficiency in a haemodialysis patient.

A man in his 50s with dialysis-dependent end-stage renal disease, several weeks history of progressive skin bruising and acute-onset gastrointestinal bleeding presented to the emergency department following a syncopal event during routine haemodialysis owing to profound hypotension. He was found to have a severe normocytic, normochromic anaemia requiring several blood transfusions. He followed a diet lacking fruits and vegetables and stopped taking renal multivitamins. All parameters of coagulation were unremarkable, but serum vitamin C level was undetectable, supporting a diagnosis of scurvy. Although typically associated with individuals who are at risk of malnourishment, such as those with alcohol use disorder, malabsorption, and those who experience homelessness, scurvy should be considered in patients receiving renal replacement therapy as vitamin C is removed during haemodialysis.

Outcomes and Management of the Ileal Pouch-Anal Anastomosis in the Elderly.

PURPOSE OF REVIEW: Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients undergoing colectomy to maintain intestinal continuity. Earlier studies have suggested that outcomes are worse in elderly patients who underwent IPAA. However, more recent reports have shown that IPAA outcomes in the elderly are comparable to younger patients. We review the recent medical literature regarding outcomes and treatments for common complications in elderly IPAA patients. RECENT FINDINGS: Compared to younger patients, IPAA in the elderly is not associated with increased major surgical complications, but is associated with increased length of stay and re-admission rate for dehydration in older patients. Rates of fecal incontinence after IPAA were similar between younger and older patients. Sacral nerve stimulation has shown early promise as a possible treatment for fecal incontinence after IPAA, but more research is needed. Pouchitis is a common complication, and antibiotics remain first-line treatment options. Other treatment options include mesalamines, steroids, immunomodulators, and biologics. The efficacy of newer biologics such as vedolizumab and ustekinumab has been reported, but more data is needed. IPAA is safe in the elderly with high self-reported patient satisfaction. However, the elderly IPAA patient warrants special consideration regarding outcomes and management.

Effects of a block in cysteine catabolism on energy balance and fat metabolism in mice.

To gain further insights into the effects of elevated cysteine levels on energy metabolism and the possible mechanisms underlying these effects, we conducted studies in cysteine dioxygenase (Cdo1)-null mice. Cysteine dioxygenase (CDO) catalyzes the first step of the major pathway for cysteine catabolism. When CDO is absent, tissue and plasma cysteine levels are elevated, resulting in enhanced flux of cysteine through desulfhydration reactions. When Cdo1-null mice were fed a high-fat diet, they gained more weight than their wild-type controls, regardless of whether the diet was supplemented with taurine. Cdo1-null mice had markedly lower leptin levels, higher feed intakes, and markedly higher abundance of hepatic stearoyl-CoA desaturase 1 (SCD1) compared to wild-type control mice, and these differences were not affected by the fat or taurine content of the diet. Thus, reported associations of elevated cysteine levels with greater weight gain and with elevated hepatic Scd1 expression are also seen in the Cdo1-null mouse model. Hepatic accumulation of acylcarnitines suggests impaired mitochondrial ß-oxidation of fatty acids in Cdo1-null mice. The strong associations of elevated cysteine levels with excess H2 S production and impairments in energy metabolism suggest that H2 S signaling could be involved.