Misleading normal TSH and persistently elevated creatine kinase: clues to the diagnosis of chronic Sheehan's syndrome.

A 53-year-old woman was referred for medical evaluation of therapy-resistant dyslipidaemia accompanied by elevated creatine kinase levels. Because cessation or alteration of her medication did not improve laboratory abnormalities, hypothyroidism was considered, despite the fact that thyroid stimulating hormone levels were within the reference interval. On further evaluation, she was found to have panhypopituitarism and empty sella turcica as shown by MRI. These findings were unexpected since there was no clinical suspicion during detailed evaluation. When supplementary questions were asked, she brought up a history of severe postpartum haemorrhage 30 years ago, for which she underwent a hysterectomy. Based on these findings, the patient was diagnosed with Sheehan's syndrome. This syndrome is a rare but potentially life-threatening complication of postpartum haemorrhage, characterised by varying degrees of hypopituitarism that are most commonly presented many years after delivery. The patient recovered after adequate hormone replacement therapy.

Measurement of the enriched stable isotope 58Fe in iron related disorders- comparison of INAA and MC-ICP-MS.

As a safer alternative for the use of radioactive tracers, the enriched stable 58Fe isotope has been introduced in studies of iron metabolism. In this study this isotope is measured with instrumental neutron activation analysis (INAA) in blood samples of patients with iron related disorders and controls after oral ingestion of a 58Fe containing pharmaceutical. Results were compared with those derived from MC-ICP-MS, applied on the same samples, and analytical and practical aspects of the two techniques were compared. Both techniques showed an increased absorption and incorporation in red blood cells of the 58Fe isotope in iron deficient patients in contrast to the controls. In all individuals results of INAA measurements were in good agreement with those of MC-ICP-MS (|zeta| < 2). Uncertainties in INAA are substantially higher than those achievable by MC-ICP-MS but the INAA technique offers a high specificity and selectivity for iron close to 100%. In contrast to INAA, sample preparation before measurement is very critical in MC-ICP-MS and interferences with 58Ni and 54Cr may hamper the measurement of 58Fe and 54Fe respectively. Since it takes at least five days after irradiation to reduce the activity of interfering radionuclides (mainly 24Na), INAA is a more time consuming procedure; the need of a nuclear reactor facility makes it also less accessible than MC-ICP-MS. Costs are comparable. Both INAA and MC-ICP-MS are able to adequately measure changes in iron isotope composition in blood when an enriched stable iron isotope is applied in clinical research. Although MC-ICP-MS is more sensitive, is faster and has easier access, in INAA preparative steps before measurement are simpler and there are hardly demands on the kind and size of the samples. This may be relevant working with biomaterials in a clinical setting.

[The fragile yellow jersey: bone health in cyclists]. / De broze gele trui: botstatus van wielrenners.

Although cycling has positive health effects, including improvement of cardiovascular fitness, it does not have a favourable effect on bone health. In professional cyclists, the bone mineral density (BMD) will actually have decreased at the end of an intensive season. As a professional cyclist's career progresses, there will be a further decrease in BMD particularly in the hip and lumbar spine. The forward leaning position, the repetitive movement at low intensity, and the fact that body weight is carried by the bicycle all contribute to non-stimulation of bone formation. The cyclists' low body weight, which is desirable for climbers in particular, and possibly their dietary pattern may exacerbate this negative effect. To reduce the risk of fractures both during and after a cycling career, it is desirable that more attention is paid to strengthening of the bones. The effectiveness of training programmes to strengthen the bones should be investigated in carefully designed research studies.

Large-sample neutron activation analysis in mass balance and nutritional studies.

Low concentrations of elements in food can be measured with various techniques, mostly in small samples (mg). These techniques provide only reliable data when the element is distributed homogeneously in the material to be analysed either naturally or after a homogenisation procedure. When this is not the case or homogenisation fails, a technique should be applied that is able to measure in samples up to grams and even kilograms and regardless of the distribution of the element. An adaptation of neutron activation analysis (NAA), called large-sample NAA, has been developed and proven accurate and may be an attractive alternative in food research and mass balance studies. Like standard NAA, large-sample NAA can be used to measure both toxic and trace elements relevant for nutrition.

Severe Infections are Common in Thiamine Deficiency and May be Related to Cognitive Outcomes: A Cohort Study of 68 Patients With Wernicke-Korsakoff Syndrome.

BACKGROUND: Wernicke encephalopathy can have different clinical outcomes. Although infections may precipitate the encephalopathy itself, it is unknown whether infections also modify the long-term outcome in patients developing Korsakoff syndrome. OBJECTIVE: To determine whether markers of infection, such as white blood cell (WBC) counts and absolute neutrophil counts in the Wernicke phase, are associated with cognitive outcomes in the end-stage Korsakoff syndrome. METHOD: Retrospective, descriptive study of patients admitted to Slingedael Korsakoff Center, Rotterdam, The Netherlands. Hospital discharge letters of patients with Wernicke encephalopathy were searched for relevant data on infections present upon hospital admission. Patients were selected for further analysis if data were available on WBC counts in the Wernicke phase and at least 1 of 6 predefined neuropsychological tests on follow-up. RESULTS: Infections were reported in 35 of 68 patients during the acute phase of Wernicke-Korsakoff syndrome-meningitis (1), pneumonia (14), urinary tract infections (9), acute abdominal infections (4), sepsis (5) empyema, (1) and infection "of unknown origin" (4). The neuropsychological test results showed significant lower scores on the Cambridge Cognitive Examination nonmemory section with increasing white blood cell counts (Spearman rank correlation, ρ = -0.34; 95% CI: -0.57 to -0.06; 44 patients) and on the "key search test" of the behavioral assessment of the dysexecutive syndrome with increasing absolute neutrophil counts (ρ= -0.85; 95% CI: -0.97 to -0.42; 9 patients). CONCLUSIONS: Infections may be the presenting manifestation of thiamine deficiency. Patients with Wernicke-Korsakoff syndrome who suffered from an infection during the acute phase are at risk of worse neuropsychological outcomes on follow-up.

Need for early diagnosis of mental and mobility changes in Wernicke encephalopathy.

Korsakoff syndrome is a chronic form of amnesia resulting from thiamine deficiency. The syndrome can develop from unrecognized or undertreated Wernicke encephalopathy. The intra-individual course of Wernicke-Korsakoff syndrome has not been studied extensively, nor has the temporal progression of gait disturbances and other symptoms of Wernicke encephalopathy. Here we present the detailed history of a patient whose acute symptoms of Wernicke encephalopathy were far from stable. We follow his mobility changes and the shifts in his mental status from global confusion and impaired consciousness to more selective cognitive deficits. His Wernicke encephalopathy was missed and left untreated, being labeled as "probable" Korsakoff syndrome. Patients with a history of self-neglect and alcohol abuse, at risk of or suffering with Wernicke encephalopathy, should receive immediate and adequate vitamin replacement. Self-neglecting alcoholics who are bedridden may have severe illness and probably active Wernicke encephalopathy. In these patients, mobility changes, delirium, or impaired consciousness can be an expression of Wernicke encephalopathy, and should be treated to prevent further damage from the neurologic complications of thiamine deficiency.

Is vitamin D deficiency a confounder in alcoholic skeletal muscle myopathy?

BACKGROUND: Excessive intake of alcohol is often associated with low or subnormal levels of vitamin D even in the absence of active liver disease. As vitamin D deficiency is a well-recognized cause of myopathy, alcoholic myopathy might be related to vitamin D deficiency. Chronic alcoholic myopathy affects approximately half of chronic alcoholics and is characterized by the insidious development of muscular weakness and wasting. Although alcohol or its metabolites may have a direct toxic effect on muscles, the relationship between alcoholic myopathy and vitamin D deficiency has not been examined extensively. METHODS: We reviewed the literature on alcoholic myopathy and hypovitaminosis D myopathy and compared the pathophysiological findings to designate possible mechanisms of vitamin D action in alcohol-related myopathy. RESULTS AND CONCLUSIONS: Given the strong interdependency of suboptimal levels of vitamin D, phosphate, and magnesium in chronic alcohol abuse, we hypothesize that combined deficiencies interfere with membrane and intracellular metabolic processes in chronic alcohol-related myopathy; however, it is not yet possible to define exact mechanisms of interaction.

The effect of alcohol on postprandial and fasting triglycerides.

Alcohol has a significant additive effect on the postprandial triglyceride peak when it accompanies a meal containing fat, especially saturated fat. This results from a decrease in the breakdown of chylomicrons and VLDL remnants due to an acute inhibitory effect of alcohol on lipoprotein lipase activity. Furthermore, alcohol increases the synthesis of large VLDL particles in the liver, which is the main source of triglycerides in the hypertriglyceridemia associated with chronic excessive alcohol intake. In case of chronic consumption, lipoprotein lipase activity seems to adapt itself. The effect of alcohol on adipose tissues is less clear. Sometimes, a severe hypertriglyceridemia induced by alcohol (SHIBA) can be observed, especially in patients with type 2 diabetes mellitus and/or obesity increasing the risk of pancreatitis.

[Dance, art and top performance sport with specific injuries]. / Dans: kunst en topsport met specifieke letsels.

Professional theatre dance has high and specific physical demands, comparable to top sport. Dance injuries are often caused by faulty technique due to compensation for physical limitations. Knowledge of these limitations and professional teaching can prevent many problems. Dance injuries mostly involve the lower limbs, especially the ankles and knees. Dance injuries require that the medical professional has knowledge of dance technique and respects the passion of the dancer. The advice to stop dancing has hardly ever to be given. Scientific, prospective dance medical research is recommended.

Severe hypertriglyceridemia influenced by alcohol (SHIBA).

AIMS: This study was conducted to examine the relationship between triglyceride (TG) levels and a history of excessive drinking in patients with severe hypertriglyceridemia (HT). METHODS: Alcohol intake as well as other risk factors associated with HT were searched for in case records of 300 patients known to the laboratory to have had a TG level over 11.3 mmol/l. RESULTS: The majority of severe HT could be attributed to obesity, diabetes mellitus, excessive alcohol consumption or combinations of these. Excessive alcohol intake (over 210 g/week for males; over 140 g/week for females) was recorded for 24% of the total, and for 43% in the highest TG quartile. TG levels were significantly higher in the excessive drinkers (P < 0.001) and in patients with acute pancreatitis (P = 0.001). The incidence of pancreatitis in this cohort was 4% and limited to very high TG levels. CONCLUSION: Excessive alcohol consumption was recorded in a quarter of patients with severe HT. Patients with the combination of obesity, diabetes and alcohol excess are prone to develop extremely high TG values.

[Shedding new light on vitamin D--reassessment of an essential prohormone]. / Nieuw licht op vitamine D.

Vitamin-D deficiency is no longer to be seen only as a cause of osteomalacia, rickets and osteoporosis. There is a causal relationship with muscle function and also with the functioning of our immune system. Furthermore, vitamin-D deficiency is associated with a higher risk of autoimmune diseases and several forms of malignancy, such as prostate, colon and breast cancer. Optimal serum concentration is under discussion which has already led to modification of the recommendations on vitamin-D supplementation. At present, European consensus on 25-hydroxyvitamin-D serum concentrations seems to be a minimum of 50 nmol/l and a target of 75 nmol/l. The majority of the elderly and of non-Western immigrants are deficient or severely deficient in vitamin D and correction of such a deficiency with bolus therapy should be considered. Awareness of a vitamin-D deficiency is needed in unexplained complaints of muscle weakness or muscle pain, and in the risk groups, such as the elderly, non-Western immigrants, the chronically ill, indoor living and institutionalized, those who habitually use sun protection cream, and severely obese patients.

[Medical problems of musicians]. / Medische problemen bij musici.

Most individuals enjoy making music, but pleasure may be diminished by physical complaints. The most common complaints in musicians include injuries of the upper part of the body including the shoulder and spine, skin disorders and hearing problems. Injuries are not so much related to the extent of rehearsing and playing but are mostly the result of a wrong position and misuse of the instrument. Adequate preparation before playing and professional coaching to avoid injuries or to detect problems at an early stage are exceptions rather than the rule. Because of the large number of amateur and professional musicians in the Netherlands, music medicine deserves a more prominent role.

Polyphenolic grape extract inhibits platelet activation through PECAM-1: an explanation for the French paradox.

BACKGROUND: Moderate and prolonged consumption of red wine is associated with decreased cardiovascular morbidity and mortality. Inhibition of platelet functions by ingredients in red wine is thought to be one of the causes. However, the molecular mechanism of this inhibition has remained unexplained. MATERIALS AND METHODS: We measured aggregation, changes in cytosolic Ca(2+) and tyrosine phosphorylation of the inhibitory receptor platelet endothelial cell adhesion molecule-1 (PECAM-1) in platelets stimulated with thrombin receptor (PAR-1) activating peptide (TRAP) and ADP and investigated the effects of alcohol-free polyphenolic grape extract (PGE), alcohol, and the polyphenols catechin, epi-catechin, resveratrol, trans-resveratrol, and gallic acid. RESULTS: Polyphenolic grape extract induced dose-dependent inhibition of TRAP-induced and ADP-induced platelet aggregation and Ca(2+) mobilization. Inhibition was accompanied by activation of PECAM-1. Apart from a slight inhibition by catechin, ethanol or other individual polyphenols failed to inhibit aggregation or activate PECAM-1. CONCLUSIONS: Red wine inhibits platelet functions through its PGE content, which stimulates the inhibitory receptor PECAM-1, thereby attenuating platelet activation.

Alcohol and illicit drug use among emergency room patients in the Netherlands.

AIMS: To clarify alcohol and illicit drug use within the emergency room population in three different regions in The Netherlands, focusing on whether interventions for these substances should be region specific. METHODS: Alcohol and illicit drug use were assessed using a self-report questionnaire filled in by the patients, and by combining self-report with staff judgement on alcohol and illicit drug use. RESULTS: Data on alcohol use (self-reported and staff judgement combined) resulted in prevalence rates of 4.9-18.2%. Patients positive for alcohol are more likely to be male, aged 48-58 years, more likely to be a frequent excessive drinker, and to have injuries as a result of violence. Patients positive for illicit drugs are more likely to be male, aged 28-38 years, unemployed, and frequent excessive drinkers. Among men aged 18-35 years with a Dutch cultural background, some differences emerge regarding alcohol consumption between the various hospitals, but most variation exists in the case of illicit drug use. CONCLUSIONS: This paper confirms that the emergency room seems to provide an opportunity to initiate interventions regarding alcohol use and seems to suggest that this is independent of the region concerned. However, in the case of illicit drug use interventions seem to be more region specific.

Self-reported alcohol use among Dutch emergency room patients: variations in prevalence rates owing to methodological differences.

AIMS: This study compared different methods of assessing self-reported alcohol use among emergency room patients in order to explain the variations in reported prevalence rates. METHODS: Alcohol use prior to patient's injury or illness was assessed in one hospital by a self-report questionnaire in three different ways: (i) administered by emergency room staff, (ii) administered by research staff, or (iii) sent to the patient's home by post. RESULTS: Results show variations in self-reported alcohol use 6 h prior to the injury or illness ranging from 4.6 to 9.1%; these variations may be explained by sample selection bias and characteristics of the included study populations. When self-report is combined with staff judgement the corresponding prevalence rates are 6.8% for research staff and 16.2% for emergency room staff. This shows that the latter judge the patient's alcohol use more efficiently than the research staff. Using research staff 24 h a day resulted in almost no sample bias. Data collection via emergency room staff leads to the highest alcohol use prevalence rates and to the highest sample bias; this was influenced by the emergency room characteristics. A retrospective mail survey results in an older sample with age-related (lower) alcohol use and emergency room characteristics related to this age group. CONCLUSIONS: Future studies using patient self-report among emergency room samples should consider carefully the influence of sample selection bias. The combination of the research staff handing out the questionnaire and the emergency room staff giving their judgement on the patient's alcohol use seems to be a useful method.

Rapid intake of alcohol (binge drinking) inhibits platelet adhesion to fibrinogen under flow.

BACKGROUND: Moderate alcohol consumption is associated with decreased mortality from cardiovascular disease. Drinking large amounts in a short period (binge drinking) is associated with increased cardiovascular morbidity. We tested whether rapid consumption of a large dose of alcohol affects platelet aggregation and adhesion. METHODS: Healthy volunteers (n = 20) were asked to drink three glasses of alcohol or red wine in a 45-min period. Thereafter, another 45 min was allowed for absorption of alcohol. Ninety minutes after the start of the experiment, blood was collected. This entire cycle was repeated once, resulting in consumption of six alcohol-containing drinks in 3 hr. Adenosine-diphosphate (ADP)-induced aggregation was measured and platelet adhesion to fibrinogen and collagen was measured in a perfusion chamber at shear rates of 300/sec and 1600/sec. Platelet coverage and aggregate size were measured. RESULTS: Acute alcohol intake significantly increased platelet aggregation in suspension when stimulated with low concentrations of ADP (0.1 and 0.5 microg/ml). This effect was not observed when consuming red wine. In contrast, adhesion to fibrinogen was significantly inhibited by alcohol but not red wine at high shear rate after six drinks (p = 0.025). The inhibition was accompanied by a reduction in aggregate size at 90 and 180 min after the start of the experiment. Adhesion to collagen was not altered by either alcohol or red wine. CONCLUSIONS: Rapid intake of alcohol increases platelet aggregation, which might contribute to the increased mortality associated with binge drinking. Red wine does not show increased platelet aggregation, which might support the reduction of cardiovascular disease in red wine consumers. However, alcohol inhibits platelet adhesion to fibrinogen-coated surface under flow. The diminished adhesion might contribute to the cardioprotective effects of alcohol.

Drink to prevent: review on the cardioprotective mechanisms of alcohol and red wine polyphenols.

Moderate alcohol consumption has convincingly been associated with decreased cardiovascular mortality in epidemiological studies and metaanalyses. This decreased mortality has been attributed to changes in lipid profiles, decreased coagulation, increased fibrinolysis, inhibition of platelets, increased nitric oxide, and antioxidant capacities of alcoholic beverages. Most of these laboratory and animal studies, as well as small intervention trials in human volunteers, have revealed many interesting mechanisms that contribute to the cardioprotective effects of alcohol, red wine, or red wine polyphenolic compounds. An update on putative mechanisms is presented in this review.

Diabetes mellitus and alcohol.

Alcohol influences glucose metabolism in several ways in diabetic patients as well as in non-diabetic patients. Since alcohol inhibits both gluconeogenesis and glycogenolysis, its acute intake without food may provoke hypoglycaemia, especially in cases of depleted glycogen stores and in combination with sulphonylurea. Consumed with a meal including carbohydrates, it is the preferred fuel, which may initially lead to somewhat higher blood glucose levels and hence an insulin response in type 2 diabetic patients. Depending on the nature of the carbohydrates in the meal, this may be followed by reactive hypoglycaemia. Moderate consumption of alcohol is associated with a reduced risk of atherosclerotic disorders. Diabetic patients benefit from this favourable effect as much as non-diabetic patients. Apart from effects on lipid metabolism, haemostatic balance and blood pressure, alcohol improves insulin sensitivity. This improvement of insulin sensitivity may also be responsible for the lower incidence of type 2 diabetes mellitus reported to be associated with light-to-moderate drinking. In case of moderate and sensible use, risks of disturbances in glycaemic control, weight and blood pressure are limited. Excessive intake of alcohol, however, may not only cause loss of metabolic control, but also annihilate the favourable effects on the cardiovascular system.