Gustavo Adolpho Moreira Faulhaber

Hypomagnesemia and Proton Pump Inhibitors: Below the Tip of the Iceberg

Severe magnesium deficiency associated with proton pump inhibitors (PPIs) has been described recently with clinical presentations varying from life-threatening conditions to muscle cramps and paresthesias. Probably milder cases go undetected. We report an asymptomatic case of hypomagnesemia associated with chronic use of PPIs in a 67-year-old woman. She had had symptoms of gastroesophageal reflux disease for several years, which abated partially with PPIs, and denied any other symptoms or medications. Her initial evaluation showed an unexplained hypomagnesemia with a very low magnesium excretion rate in urine. Serum calcium, phosphorus, potassium, and glucose levels and renal function were normal. After PPI withdrawal, serum and urinary magnesium levels normalized.

Expression of CD55 and CD59 on peripheral blood cells from systemic lupus erythematosus (SLE) patients.

CD55 and CD59 are glycosylphosphatidylinositol-anchored proteins with complement inhibitory properties. CD55 inhibits the formation of C3 convertases, and CD59 prevents the terminal polymerisation of the membrane attack complex. It has been reported that SLE patients seems to have an acquired deficiency of these proteins associated with secondary autoimmune haemolytic anaemia and lymphopenia. The aim of this study was to evaluate the presence of altered CD55 and CD59 expression on peripheral blood cells from SLE patients. Flow cytometric analyses were performed on red and white blood cells from 23 SLE patients and 23 healthy controls. We observed more CD55- and CD59-lymphocytes (p=0.005 and p=0.019, respectively), and CD59-granulocytes (p=0.045) in SLE patients than in controls. These results suggest there is an altered pattern of CD55 and CD59 expression on the peripheral blood cells of SLE patients, and it may play a role in the cytopenias in these patients.

Vitamin B12 in metformin-treated diabetic patients: a cross-sectional study in Brazil

OBJECTIVE The objective of this study was to evaluate the presence of vitamin B12 deficiency and the factors associated with serum vitamin B12 levels in a sample of metformin-treated Brazilian diabetic patients. METHOD Cross-sectional study. RESULTS 144 patients were included. Serum vitamin B12 levels were low (< 125 pmol/L) in 10 patients (6.9%) and possibly low (125 - 250 pmol/L) in 53 patients (36.8%). Serum vitamin B12 levels were negatively associated with age (B = -3.17; β= -0.171; p = 0.037) and duration of metformin use (B= -33.36; β= -0.161; p = 0.048), and positively associated with the estimated intake of vitamin B12 (B= 67.96; β= 0.249; p = 0.002). CONCLUSION The present findings suggest a high prevalence of vitamin B12 deficiency in metformin-treated diabetic patients. Older patients, patients in long term treatment with metformin and low vitamin B12 intake are probably more prone to this deficiency.

Low bone mineral density is associated with insulin resistance in bone marrow transplant subjects

Post-BMT subjects have an increased bone fracture risk. Additionally, several factors were associated with osteopenia and osteoporosis in these individuals. We aimed to identify other factors associated with osteopenia and osteoporosis in allogeneic post-BMT subjects. We conducted a cross-sectional study with 47 allogeneic post- BMT subjects. Serum 25-hydroxyvitamin D (25(OH)D), parathyroid hormone, ferritin, vitamin B12, insulin, glucose, cholesterol and triglyceride levels were measured. Insulin resistance and secretion were estimated through the homeostatic model assessment for insulin resistance (HOMA-IR) and homeostatic model assessment for β-cell function (HOMA-B), respectively. A bone densitometry (BMD) was also obtained. The median time after BMT was 47.7 (12–115) months. Osteoporosis was identified in 17.0% of the subjects and osteopenia in 19.7%. The mean serum ferritin (P=0.002), insulin (P<0.0001), glucose (P=0.003) and triglyceride (P=0.018) levels were higher in individuals with osteopenia/osteoporosis. HOMA-IR (P<0.0001) and HOMA-B (P<0.0001) were increased in post-BMT subjects with osteopenia/osteoporosis. There was no other factor associated with the outcome. After adjustments ferritin, serum 25(OH)D and HOMA-IR remained independently associated with osteopenia/osteoporosis; however triglycerides no longer were. In conclusion, in the present study, low serum 25(OH)D levels, high serum ferritin levels and insulin resistance were associated with osteopenia/osteoporosis in post-BMT subjects.

Serum magnesium and proton-pump inhibitors use: a cross-sectional study

OBJECTIVE The aim of this study was to evaluate the association of serum magnesium levels with proton pump inhibitors (PPIs) use and other factors. METHODS This was a cross-sectional study of 151 patients admitted with acute diseases in the Internal Medicine Division of the Hospital de Clinicas de Porto Alegre, after the exclusion of conditions that are commonly associated with hypomagnesemia: diarrhea; vomiting; chronic alcohol use; severely uncompensated diabetes mellitus; and chronic use of laxatives, diuretics or other drugs causing magnesium deficiency. RESULTS All patients had normal serum magnesium levels. Serum albumin and creatinine levels were positively associated with serum magnesium levels, after adjusting for confounders. There was no difference between mean serum magnesium levels of PPI users and non-users, nor between men and women; there was also no correlation among age, serum phosphorus, and potassium levels with serum magnesium levels. Limitations of this study include the absence of an instrument for measuring adherence to PPI use and the sample size. CONCLUSION The association of PPI use and hypomagnesemia is uncommon. Congenital defects in the metabolism of magnesium may be responsible for hypomagnesemia in some patients using this drug class.

Effect of High- versus Low-Fat Meal on Serum 25-Hydroxyvitamin D Levels after a Single Oral Dose of Vitamin D: A Single-Blind, Parallel, Randomized Trial

Background/Aims. Vitamin D3 is liposoluble, so dietary fat could increase its oral absorption. Our aim was to compare serum 25-hydroxyvitamin D [25(OH)D] after the oral intake of cholecalciferol with a high- or low-fat meal. Methods. In a single-blind, parallel clinical trial, 32 healthy physicians were divided into two groups. In the same day, they ingested 50,000 IU (1.25 mg) of vitamin D3 with food: group 1 (G1): lipids: 25.6 g and group 2 (G2) lipids: 1.7 g. Serum 25(OH)D (0, 7, and 14 days), and parathyroid hormone (PTH), and calcium (0 and 14 days) were measured. Results. Baseline mean serum 25(OH)D levels were 42.7 ± 19.0 nmol/L in G1 and 36.4 ± 19.0 nmol/L in G2 (P = 0.38). After cholecalciferol, mean serum 25(OH)D was higher in G1 (P < 0.001): 7 days: G1 = 46.2 (38.4–53.9) nmol/L and G2 = 33.7 (25.4–40.1) nmol/L; 14 days: G1 = 53.7 (45.2–62.1) nmol/L and G2 = 33.7 (25.2–42.2) nmol/L. Serum PTH and 25(OH)D were negatively correlated before and after the intake of vitamin D3, respectively, r = −0.42 (P = 0.02) and r = −0.52 (P = 0.003). Conclusions. A high-fat meal increased the absorption of vitamin D3, as measured by serum 25(OH)D.

Association of Busulfan and Cyclophosphamide Conditioning with Sleep Disorders after Hematopoietic Stem Cell Transplantation

New indications and conditioning regimens for hematopoietic stem cell transplantation (HSCT) have emerged in the last 10 years. Previous studies have shown the association of HSCT with late effects such as sleep disorders. The aim of this study was to determine the prevalence and factors associated with sleep disorders following HSCT in a population considering these new trends. Sixty-one individuals 1–10 years after allogeneic HSCT were surveyed using the DSM-IV-TR criteria for sleep disorders. Factors related to conditioning and graft-versus-host disease were collected from medical records. A prevalence of sleep disorders of 26.2% was found. Busulfan-cyclophosphamide conditioning was an independent risk factor in a multivariate analysis (relative risk, RR: 3.74, 95% CI: 1.1–12.6; p = 0.03), which also included sex (RR: 2.37, 95% CI: 1.0–5.7; p = 0.05) and age (RR: 1.03, 95% CI: 0.99–1.07; p = 0.11). Sleep disorders were frequent following HSCT. Patients who were treated with busulfan-cyclophosphamide had a higher risk of developing this complication. Female sex was also possibly a risk factor.

Prevalence of low bone mineral density in adolescents and adults with cystic fibrosis

OBJECTIVE The aim of this cross-sectional study was to evaluate the prevalence of low bone mass density in cystic fibrosis patients as well as to evaluate the factors associated with bone mass in such patients. METHODS Bone mass density was measured by dual-photon X-ray absorptiometry of lumbar spine (L1-L4), in patients ≤19 years old, or lumbar spine and femur (total and neck) in patients ≥20 years old. Evaluations of nutritional status, biochemical parameters, and lung function were performed. Medication data were obtained from medical records. RESULTS Fifty-eight patients were included in the study (25 males/ 33 females), mean age 23.9 years (16-53 years). The prevalence of bone mass below the expected range for age at any site was 20.7%. None of the subjects had history of fracture. Lumbar spine Z-score in cystic fibrosis patients correlated positively with body mass index (r= 0.3, p=0.001), and forced expiratory volume in the first second (% predicted) (r=0.415, p=0.022). Mean lumbar spine Z-score was higher in women (p=0.001), in patients with no pancreatic insufficiency (p=0.032), and in patients with no hospitalization in the last 3 months (p=0.02). After multivariate analysis, body mass index (p= 0.001) and sex (p=0.001) were independently associated with Z-score in lumbar spine. CONCLUSION Low bone mass is a frequent problem in patients with CF, being independently associated with body mass index, and male sex.

Adrenal Failure due to Adrenal Metastasis of Lung Cancer: A Case Report

We report a case of a patient with adrenal failure due to bilateral adrenal metastasis of lung cancer. This is a rare presentation of lung cancer. We review the differential diagnosis of weight loss and how to make diagnosis of adrenal insufficiency.

Quantitative flow cytometric evaluation of CD200, CD123, CD43 and CD52 as a tool for the differential diagnosis of mature B-cell neoplasms

Background Distinction between mature B-cell neoplasms can be difficult due to overlapping of immunologic features and clinical manifestations. This study investigated whether quantifying mean fluorescence intensity of four monoclonal antibodies in a flow cytometry panel is useful for the differential diagnosis and characterization of these disorders. Methods The expressions of CD52, CD200, CD123 and CD43 were analyzed in samples from 124 patients with mature B-cell neoplasms. The quantitative estimation of these antigens was assessed by mean fluorescence intensity. Results The cases included were 78 chronic lymphocytic leukemias, three atypical chronic lymphocytic leukemias, six marginal zone lymphomas, 11 splenic marginal zone lymphomas, nine lymphoplasmacytic lymphomas, six mantle cell lymphomas, two hairy cell leukemias, two hairy cell leukemias variant, five follicular lymphomas, one Burkitt lymphoma and one diffuse large B-cell lymphoma. The mean fluorescence intensity of CD200 was higher in atypical chronic lymphocytic leukemia, chronic lymphocytic leukemia and hairy cell leukemia cases. CD123 showed higher mean fluorescence intensities in hairy cell leukemia cells. Chronic lymphocytic leukemia, atypical chronic lymphocytic leukemia and mantle cell lymphoma had higher expression of CD43 and all follicular lymphoma cases had very low mean fluorescence intensity values. CD52 expression was consistently positive among all cases. Conclusion Quantitative evaluation of these markers can be a useful additional tool to better identify some types of mature B-cell neoplasms.