Do gastroenterologists monitor their patients taking 5-amino-salicylates following initiation of treatment.

BACKGROUND: 5-Amino salicylate (5-ASA) medications may rarely be associated with a significant decline in renal function and interstitial nephritis. British Society of Gastroenterology guidelines advise regular renal function monitoring for patients taking these drugs. AIM: To assess whether gastroenterologists in Kent were following best practice guidelines regarding the monitoring of their patients on 5-ASA therapy. METHODS: Using longitudinal community and regional pathology databases for the Kent population, our renal unit regularly screens a total population of 300 000 for evidence of renal disease. The data extracted are analysed using an automated computerised system to identify patients requiring intervention for kidney disease. All patients taking 5-ASA medication were identified from a population of 300 000. The pathology database was studied to identify the patients on 5-ASA treatment and whether they had had renal function tests. RESULTS: 800 adult patients were identified taking 5-ASA therapy. 612 patients received 5-ASAs for 3 months or more, and these were included in the final analysis. 293 patients had no renal function checks while on treatment. 79 patients had renal function tests less than once every 4 years and 36 patients once every 2-4 years. 204 patients had renal function measurements in 50% or more of years of treatment, of whom 116 were checked every year. Some patients were started on treatment with abnormal results at baseline and some with identified kidney disease continued on their 5-ASAs. CONCLUSIONS: The majority of patients receiving 5-ASA compounds do not have regular renal function monitoring. Clinicians are failing to follow best practice guidelines.

Endoscopy and the Risk of Venous Thromboembolism: A Case-Control Study.

Background and Study Aims To assess whether there was an association between endoscopy and the risk of venous thromboembolism (VTE). Patients and Methods Retrospective case - control study of patients diagnosed with VTE over a 3-year period. Each was age- and sex-matched to one of three controls who attended an outpatient appointment on the same date as that of the diagnosis of VTE in the patients. Patients who had undergone endoscopy within 90 days of VTE were included. On a second analysis, patients who were hospitalized and those with inflammatory bowel disease or malignancy were excluded. The difference in occurrence of endoscopy between cases and controls was examined using the McNemar test. The risk of VTE occurring following endoscopy was quantified by means of odds ratios. Results Forty-five of 436 patients (10.3 %) had undergone an endoscopy in the VTE group compared with 14 /436 controls (3.2 %; P < 0.001). The odds ratio for developing a VTE after an endoscopic procedure was 3.58 (95 % CI 1.86 - 7.46) for patients relative to controls. When the 10 hospitalized patients and respective controls were excluded, the odds of VTE remained nearly 3 times as large for patients undergoing endoscopy as for controls (2.92 [95 % CI 1.51, 5.62]; P = 0.001). When patients with inflammatory bowel disease or malignancy were also excluded, no difference was found between patients undergoing endoscopy and controls (1.92 [0.95, 3.85]; P = 0.07). Ten percent of patients with VTE underwent endoscopy in the 3 months before the diagnosis compared with 3 % of controls (P < 0.001). No significant difference was found between the type of endoscopy performed and VTE risk. Conclusions When those with known risk factors for VTE were excluded, no significant increased risk of VTE was found.

The new oral anticoagulants: practical management for patients attending for endoscopic procedures.

Guidelines published by the British Society of Gastroenterology have standardised the care of patients attending for endoscopy procedures, taking aspirin, clopidogrel and warfarin. Two new oral anticoagulant drugs, Rivaroxaban and Dabigatran, are licensed and National Institute of Clinical Excellence (NICE) approved for use in the UK. Unlike warfarin, these drugs do not require regular monitoring, and are at least as effective in preventing stroke in non-valvular atrial fibrillation. As such, they are likely to become popular among patients and clinicians alike. This paper summarises the practical management of patients taking these drugs attending for endoscopic procedures.

The evaluation of spells.

The differential diagnosis of spells is broad and includes both innocent and life-threatening conditions with a considerable overlap in clinical presentation. Extensive diagnostic testing is often performed, without reaching a final diagnosis, or resulting in false-positives. A thorough medical history, including family history and medication, and physical examination are required to obtain clues about the cause of a spell. An overview of spells with their stereotypic phenotype in general internal medicine practice is presented in this article. Besides, a diagnostic approach is proposed for the clinical evaluation of spells.

Clinical course of pain in acute osteoporotic vertebral compression fractures.

PURPOSE: The authors prospectively determined the natural course of pain in patients with conservatively treated acute osteoporotic vertebral compression fractures (VCF). In addition, the type of conservative therapy that these patients received was assessed. MATERIALS AND METHODS: Patients older than 50 years, referred for spine radiography for acute back pain, were asked to complete a baseline clinical questionnaire. Patients with an acute VCF were followed up at 6 and 23 months with a questionnaire that included a Visual Analog Score (VAS) and type of pain medication and other conservative treatment. Significant pain relief was defined as a decrease in VAS of 50% or more. RESULTS: Forty-nine patients (mean age, 78 years; range, 51-95) with acute VCF were followed up for almost 2 years. Significant pain relief was noted in 22 of 35 patients (63%) at 6 months and in 25 of 36 (69%) at 23 months. In patients with persisting pain at 23 months (mean VAS 6.4), some decrease in VAS was apparent at 6 months but not in the 6-23 months interval. No predictors for significant pain relief could be identified. Patients with significant pain relief used less pain medication and had less physical therapy. CONCLUSIONS: In most patients with an acute VCF, pain decreases significantly with conservative therapy, predominantly in the first 6 months. However, almost 2 years after an acute VCF, a third of patients still had severe pain necessitating pain medication and physical therapy in the majority. No predictors for transition from acute to chronic pain could be identified.

Clinical trial: music reduces anxiety levels in patients attending for endoscopy.

BACKGROUND: Patients attending for endoscopy are generally anxious and worried. AIMS: To examine whether music reduced anxiety levels in patients attending for endoscopic procedures. METHODS: Prospective randomized controlled trial of 180 patients (M:F 81:99). The effect of age (< or = or >51 years) and procedure (gastroscopy or flexible sigmoidoscopy/colonoscopy) on anxiety levels (state-trait anxiety inventory) on arrival in the unit and immediately before the endoscopy procedure, after listening to music or no music (control group) for the same period. RESULTS: At baseline, anxiety levels were not influenced by age (< or =51 years, n = 56:42.21 +/- 9.18; >51 years, n = 124:39.99 +/- 10.13 (P = 0.15) or procedure: gastroscopy, n = 87:39.43 +/- 9.9, flexible sigmoidoscopy/colonoscopy: n = 93:41.86 +/- 9.75 (P = 0.98). No difference was found in anxiety scores in the control group (n = 88) at baseline and immediately pre-endoscopy (P = 0.243), but music led to a significant reduction in anxiety scores (n = 92), which was maintained for all age groups irrespective of procedure (all P < 0.0001). CONCLUSIONS: Anxiety levels in patients attending for endoscopy were not influenced by age or procedure, but were significantly reduced by listening to music compared to controls. The availability of music within the endoscopy unit is a simple strategy that will improve the well-being of patients.

Thyroid function disorders--Guidelines of the Netherlands Association of Internal Medicine.

Thyroid function disorders are common with a female to male ratio of 4 to 1. In adult women primary hypothyroidism and thyrotoxicosis have a prevalence of 3.5/1000 and 0.8/1000, respectively. This guideline is aimed at secondary care providers especially internists, but also contains relevant information for interested general practitioners and gynaecologists. A multidisciplinary working group, containing delegates of professional and patient organisations, prepared the guideline. According to principles of 'evidence-based medicine' available literature was studied and discussed. Considering the availability and quality of published studies a practical advice was formulated. For a full overview of the literature and considerations the reader is referred to the original version of the guideline (accessible through NIV-net). In this manuscript we have aimed to provide the practicing internist with practical and 'as evidence-based as possible' treatment guidelines with respect to thyroid function disorders.

VERTOS II: percutaneous vertebroplasty versus conservative therapy in patients with painful osteoporotic vertebral compression fractures; rationale, objectives and design of a multicenter randomized controlled trial.

BACKGROUND: The standard care in patients with a painful osteoporotic vertebral compression fracture (VCF) is conservative therapy. Percutaneous vertebroplasty (PV), a minimally invasive technique, is gaining popularity as a new treatment option. Many prospective and retrospective studies have reported on the effectiveness and safety of PV, but no large randomized controlled trial (RCT) has been published. OBJECTIVE: To estimate cost-effectiveness of PV compared to conservative therapy in terms of: pain reduction, quality of life, complications, secondary fractures and mortality. MATERIALS AND METHODS: The VERTOS II study is designed as a prospective, multicenter RCT. Patients with a painful VCF with bone edema on MR imaging, local back pain for 6 weeks or less, osteopenia and aged 50 years or older, after obtaining informed consent are included and randomized for PV or conservative therapy. In total 200 patients will be enrolled. Follow-up is at regular intervals during a 1-year period with standard questionnaires, addressing: clinical symptoms, pain medication, Visual Analogue Scale (VAS) score, quality of life and cost-effectiveness. Secondary fractures, necessary additional therapies and complications are recorded. CONCLUSION: The VERTOS II study is the first methodologically sound RCT designed to assess the cost-effectiveness of PV compared to conservative therapy in patients with an acute osteoporotic VCF. TRIAL REGISTRATION: http://www.clinicaltrials.gov, NCT00232466.

[The surgical treatment of Graves' disease]. / Chirurgische behandeling van de ziekte van Graves.

A man aged 80 and three women aged 66, 26, and 39 years respectively, underwent surgery for Graves' disease. The first woman had pneumonia and experienced thyrotoxic storm. Euthyroidism was restored with antithyroid drugs (ATD) and thyroidectomy was performed as ablative treatment for hyperthyroidism. The man presented with thyrotoxicosis and had severe Graves' ophthalmopathy. After euthyroidism was restored with ATD, he underwent subtotal thyroidectomy. The second woman presented with severe thyrotoxicosis but was allergic to ATD. She was treated with iodine and beta-blockers after which subtotal thyroidectomy was done as an ablative procedure. Medical treatment for hyperthyroidism failed in the last patient and, as she had experienced severe psychological disturbances during a previous relapse, she too chose surgery as a definitive treatment option. In two patients the postoperative course was complicated by early hypocalcaemia and one of these patients experienced temporary recurrent laryngeal nerve paralysis. Surgery has a limited role in the treatment of Graves' disease. In pregnant women with severe ATD-resistant thyrotoxicosis, surgery is the only treatment option, while in patients with Graves' orbitopathy surgery may be preferable because of its neutral and perhaps even beneficial effects on eye symptoms. Large goitre size and thyroid nodules are concomitant reasons for choosing surgery, as are allergy to ATD and patients' preference. Lastly, in patients who have suffered from severe thyrotoxicosis, surgery provides rapid and definitive treatment. Early morbidity following surgery is common and should be discussed with the patient.

[Minimally-invasive parathyroidectomy: a good operative procedure for primary hyperparathyroidism even without the use of intraoperative parathyroid-hormone assessment or a gamma probe]. / Minimaal invasieve parathyreoïdectomie: ook zonder het gebruik van intraoperatieve parathormoonmeting of gammaprobe een goede behandeling voor primaire hyperparathyreoïdie.

OBJECTIVE: To evaluate the results of minimally-invasive parathyroidectomy without the use of intraoperative parathyroid-hormone assessment or a gamma probe. DESIGN: Retrospective. METHODS: In 2 community hospitals in the Netherlands, 49 patients with primary hyperparathyroidism in whom preoperative investigations had shown a solitary adenoma underwent minimally-invasive surgery by the lateral neck approach. In total 9 men and 40 women with an average age of 58 years (limits: 25-84) underwent this procedure. More extensive preoperative investigations were carried out at the Mesos Medisch Centrum (n = 29) including neck CT in 76% of patients as well as ultrasonography, and scintigraphy. At the Diakonessenhuis (n = 20) scintigraphy was the preferred method of adenoma localisation. Intraoperative parathyroidhormone assessment and a gamma probe were not used in the operative procedure. At the Diakonessenhuis intraoperative frozen-section investigations were done. RESULTS: In 44 of the 49 patients (90%) minimally-invasive parathyroidectomy resulted in normocalcaemia. In the remaining 5 patients a second procedure was necessary--a conventional neck exploration and also resulted in normocalcaemia. In 2 of these patients the adenomas had been missed during first procedure by the surgeon, while in 3 other patients preoperative examinations were falsely positive in the sense that the adenoma proved to be present but in an area other than that indicated by preoperative imaging. Permanent recurrent laryngeal-nerve paralysis complicated the postoperative course in 2 patients. The success rate of the minimally-invasive operation was the same for both groups. CONCLUSION: Without the use of intraoperative parathyroid-hormone assessment or a gamma probe minimally-invasive parathyroidectomy was successful in 90% of patients.

Experience of 5-aminosalicylate nephrotoxicity in the United Kingdom.

AIM: To study 5-aminosalicylate nephrotoxicity in patients with inflammatory bowel disease in the UK. METHODS: A detailed postal questionnaire was sent to all 1298 names in the British Society of Gastroenterology database and 290 consultant members of the Renal Association. The British Society of Gastroenterology reported new cases monthly, the Renal Association 6 monthly. Results were expressed as estimated glomerular filtration rate. RESULTS: Retrospective study: cases--British Society of Gastroenterology:Renal Association 202:87, aged 15-76 years. Median peak (range) creatinine (British Society of Gastroenterology:Renal Association) - 300:301 (78-1200) micromol/L. Prospective study - 59 cases, median age 52 years (M:F ratio: 47:12). Median pre-treatment estimated glomerular filtration rate: 76.9 (123.9-39), at diagnosis 28.4 (80.5-3.6, creatinine range: 92-1361 micromol/L), recovery 46.8 [111.2-end stage renal failure] mL/min/1.73 m2. Recovery of renal function was significantly improved for patients treated for < 12 months [n = 10, median recovery estimated glomerular filtration rate 70.5 (92-26.9) vs. > 12 months 38.4 (111.2-end stage renal failure) mL/min/1.73 m2, P = 0.028]. CONCLUSIONS: Regular monitoring of renal function may allow earlier detection of nephrotoxicity, particularly during the first year of therapy. Based on an inflammatory bowel disease prevalence in the United Kingdom of 412 x 10(5) with about 50% on treatment, we estimate that the incidence of clinical nephrotoxicity in patients taking 5-aminosalicylate therapy is approximately one in 4000 patients/year.

Renal tubular proteinuria in patients with irritable bowel syndrome.

OBJECTIVE: Irritable bowel syndrome (IBS) is a common condition that is poorly understood. We have previously demonstrated tubular protinuria in patients with inflammatory bowel disease. This study examined whether tubular proteinuria was a feature of IBS. METHODS: Eighty control subjects (male:female, 28:52; age range 20-65 years) and 21 patients with IBS (male:female, 9:12; age range 16-64 years) (not significant) were recruited. Patients with known renal disease, hypertension, diabetes or microbiological evidence of urinary infection were excluded. The IBS patients all fulfilled the ROME II criteria. None had preceding gastroenteritis. Urinary alpha1-microglobulin (alpha1-M) was measured in a second-voided morning urine sample and corrected for urinary concentration by measurement of creatine. Blood samples were analysed for haematochemical indices including C-reactive protein. Statistical analysis was by unpaired t test. RESULTS: None of the IBS patients were reclassified with inflammatory bowel disease over a 5-year follow up period. All had normal haematochemical parameters. Mean +/- standard deviation urinary alpha1-M concentrations were significantly higher in IBS patients than controls (IBS patients, 1.17 +/- 0.65 mg/mmol; controls, 0.75 +/- 0.36 mg/mmol; P < 0.01) and exceeded 1.5 mg/mmol (the upper reference limit) in seven patients. There was no difference in urinary alpha1-M concentrations in the diarrhoea-predominant and constipation-predominant groups (mean +/- standard deviation, 1.342 +/- 0.65 versus 0.76 +/- 0.48 mg/mmol; P = 0.062). CONCLUSIONS: Urinary alpha1-M concentration is commonly increased in IBS, suggesting the presence of renal proximal tubular injury.

There are no acute cardiac effects of a single iv dose of human ghrelin in severe growth hormone deficient patients.

It has previously been suggested that ghrelin mediates GH-independent biologic activities on the heart. We investigated the acute effects on cardiac contraction of a single iv administration of human ghrelin (in a dose of 1 microg/kg) in severe untreated GH deficient subjects. Prior to the ghrelin infusion, an echocardiographic examination was performed at rest (baseline), after physiologic saline and during dobutamine stress echocardiography (DSE) to exclude a preexisting (subclinical) myocardial dysfunction. To evaluate the acute cardiac effect of infusion and during DSE the velocity of left ventricular (LV) wall contraction was measured continuously by echocardiography. Despite severe GH deficiency we observed in all subjects a normal cardiac function at rest after physiologic saline and during DSE. No acute changes in cardiac performance or cardiac parameters could be observed after a single iv dose of ghrelin. Also, no important increase in GH secretion was detected after ghrelin administration. Our study suggests that, in contrast to hexarelin, a single iv administration of ghrelin in a physiological dose has no acute effects on cardiac function in severe GH deficiency. This suggests that GH-independent effects of ghrelin play no important role in the acute regulation of cardiac function in man.

[A pregnant woman with autoimmune thyroiditis and recurrent goiter]. / Een zwangere met auto-immuunthyreoïditis en recidiverend struma.

A 27-year-old woman was first referred at the age of 14 with cosmetic complaints due to an echographically diffuse, euthyroid goitre. Tests for antibodies against thyroid peroxidase and thyroglobulin were positive. Thyroid-suppression therapy with levothyroxine resulted in regression of the goitre. At the age of 26 there was a transitory recurrence of the goitre during a pregnancy, during which time the thyroid peroxidase antibodies became strongly positive. Six months post partum the goitre recurred again, accompanied by pain in the throat and fever. The C-reactive protein level was strongly elevated. Serology established the diagnosis of viral thyroiditis due to a Coxsackie-B virus. The size of the goitre decreased after treatment with acetylsalicylic acid and prednisone. Two months later the goitre again showed further growth, now in association with cervical lymphadenopathy and an enlarged left parotid gland. Histology revealed a non-Hodgkin lymphoma of the type diffuse large B-cell (stage II), very likely a primary thyroid lymphoma. The lymphoma was refractory to cyclophosphamide-doxorubicin-vincristine-prednisolone (CHOP); this was followed by intensive chemotherapy and autologous stem-cell transplantation, resulting finally in a complete remission. The goitre disappeared and thyroid peroxidase antibodies were no longer detectable. Primary thyroid lymphoma is a rare disease, but autoimmune thyroiditis appears to be an important predisposing factor.

[Three patients with gynaecomastia]. / Drie patiënten met gynaecomastie.

In three patients gynaecomastia was diagnosed: a 22-year-old man with concomitant thyrotoxicosis due to an extensively metastasized extragonadal choriocarcinoma, a 53-year-old man with hypogonadism due to Klinefelter's syndrome that was biochemically obscured due to medications leading to elevated prolactin levels, and a 62-year-old man with acromegaly and secondary hypogonadism due to a mixed prolactin and growth hormone secreting pituitary adenoma. Gynaecomastia calls for thorough evaluation.

Transvaginal electrical stimulation in the treatment of urinary incontinence.

OBJECTIVE: To determine the effectiveness of transvaginal electrical stimulation (TES) in treating urinary incontinence, and to assess the clinical improvement 6 months after ending the treatment. PATIENTS AND METHODS: In a double-blind randomized controlled clinical trial, 36 women (24 patients and 12 controls) with stress, urge or mixed urinary incontinence were chosen to use TES or placebo (identical equipment but with no electrical current). The patients had their treatment at home twice a day (20-min sessions) for 12 weeks. They completed a voiding diary and had a urodynamic study at the beginning and end of treatment. They were clinically re-evaluated after 6 months. RESULTS: The mean time of use of TES was similar in both groups (approximately 40 h); the treatment group had a significant increase in maximum bladder capacity (P < 0.02), a significant reduction in the total number of voids (over 24 h; P < 0.02), in the number of episodes of voiding urgency (P < 0.001) and, importantly, in the number of episodes of urinary incontinence (P < 0.001). At the first evaluation, after ending the treatment, 88% of the patients had a significant reduction in symptoms or went into remission. At the 6-month re-evaluation, a third of the patients required another therapeutic approach. CONCLUSION: TES is a practical alternative with few side-effects, and is effective for treating the main forms of female urinary incontinence.

Equipamento para cistometria / Equipment cystometry

This work evaluates a microprocessed cistometry equipment developed by the Biomedical Engineering Div. of the HCPA. The system provides an useful means of quantifying bladders pressures and volume during the filling of bladder...

Monitor de pressão e volume gástricos: estudo experimental em suínos / Monitor pressure and gastric volume: an experimental study in pigs

The gastric pressure monitor was developed by the Biomedical Engineering Div. of the HCPA. It helps to evaluate Gastric Yield Pressure (GYP) in a swine model for gastroesophageal reflux (GER). A dual lumen 20 Fr Foley catheter is passed through a gastrostomy into the swine stomach...

Consequences of autoimmune thyroiditis before, during and after pregnancy.

Autoimmune thyroiditis has important consequences for fertility, the occurrence of pregnancy complications, pregnancy outcome. Moreover autoimmune thyroiditis can aggravate during the postpartum period. Finally, the sequelae of autoimmune thyroiditis might have important consequences for the offspring. Several studies have shown an association between thyroid autoimmunity in earlyas opposed to beforepregnancy and subsequent "incidental" miscarriage. With respect to habitual abortion available data are more conflicting perhaps mild degrees of thyroid insufficiency - not detectable by routine thyroid testing - and not thyroid autoimmunity per se is causal in the association between the presence of thyroid antibodies and recurrent abortion. Autoimmune hypo- and hyperfunction during pregnancy are both related to obstetrical complications. It is important to note that treatment can - at least in part - reduce this excess risk associated with untreated hypo- or hyperthyroidism. Considering pregnancy outcome there are now data providing evidence that not only overt but also relatively mild and hitherto unrecognized states of thyroid failure are associated with persistent and significant impairment in neuropsychological performance of the offspring. Postpartum thyroiditis is clearly associated with the presence of TPO antibodies (i.e. autoimmune thyroiditis). Autoimmune thyroiditis is thus clearly associated with clinically relevant events, occurring before, during and after pregnancy. Screening should be considered; however further research is urgently needed.