William R. Swaim

Impaired Assimilation of EGG CO57 Vitamin B12 in Patients With Hypochlorhydria and Achlorhydria and After Gastric Resection

Abstract Patients who have undergone gastric resection and those with simple gastric hypochlorhydria and achlorhydria may have low serum B 12 concentrations with normal absorption of radiocyanocobalamin. Impaired assimilation of food vitamin B 12 , but not of the crystalline Co 57 B 12 , may be the cause for this phenomenon. This hypothesis was tested by comparing the assimilation of Co 57 B 12 incorporated into eggs in vivo with that of crystalline Co 57 B 12 . As judged by the urinary excretion test, 10 patients with gastric resection having low serum B 12 , values and normal absorption of crystalline B 12 , absorbed on the average 9% of that observed in 11 normal control subjects when the egg Co 57 B 12 was administered. Similarly, 5 patients with achlorhydria or severe hypochlorhydria absorbed on the average 12% of that seen in normal subjects. There was no difference in the absorption of the crystalline Co 57 B 12 in these groups. An equally poor assimilation of nonlabeled food B 12 may explain the low serum B 12 concentrations found in postgastrectomy patients, and achlorhydric subjects with low serum B 12 and normal absorption of crystalline radiocyanocobalamin. Patients with pernicious anemia and those with gastric resection showing low serum B 12 concentrations and B 12 absorption values had extremely poor assimilation of both food Co 57 B 12 and crystalline Co 57 B 12 .

Acquired von Willebrand's disease, platelet-release defect and angiodysplasia

A previously healthy elderly man with gastrointestinal bleeding was found to have criteria for von Willebrands disease. The late clinical onset of the disorder and negative family studies suggest that the von Willebrands disease may be acquired. The findings in the patient were similar to the abnormalities reported in the small number of other patients thought to have acquired von Willebrands disease. An inhibitor of factor VIII could not be demonstrated in this patient. This patient also had platelet aggregation abnormalities that are atypical for patients with congenital or acquired von Willebrands disease. Vascular abnormalities were also found in this patient and in several other previously described patients with von Willebrands disease.

Prospective, randomized trial of autotransfusion after routine cardiac operations

To study the effectiveness of autotransfusion of shed mediastinal blood in decreasing the need for homologous blood transfusion in the routine cardiac surgical patient, we prospectively randomized 35 consecutive patients into two groups. The experimental group (n = 18) received autotransfusion for 12 hours after completion of the operative procedure. The control group (n = 17) was treated with standard chest drainage and fluid replacement. Both groups received homologous blood transfusion when the hemoglobin level fell to less than 8.0 g/dL. Students t test, chi 2 analysis, and multivariate logistic regression analysis were used where appropriate. Packed red blood cells were required postoperatively in 6 of the 17 control and 6 of the 18 autotransfusion patients (p = not significant). Postoperative colloid fluid replacement (excluding autotransfusion fluid) in the autotransfusion group (333 +/- 78 mL; 95% confidence bounds, 168 to 498 mL) was less than in the control group (615 +/- 114 mL; 95% confidence bounds, 372 to 857 mL; p = 0.048). Total homologous blood product exposure tended to be higher in autotransfusion patients (83%) than in control patients (47%) (p = 0.057). Fibrin split products were elevated only in the serum of the autotransfusion patients (p < 0.002). No transfusion-related complications were apparent in either group. Although the sample size is small, autotransfusion of shed mediastinal blood does not appear to decrease the need for homologous blood transfusion in the routine cardiac surgical patient.

Disseminated Intravascular Coagulation in the Urologic Patient

Gram-negative septicemia and metastatic prostatic cancer are frequent causes of disseminated intravascular coagulation. The clinical manifestations of this condition as well as the laboratory data vary considerably, depending on the patients compensatory mechanisms in relation to the magnitude and duration of the thromboplastin or endotoxin release. Treatment centers primarily on correcting the underlying disorder. Secondly, deficient clotting factors and platelets should be replaced in the appropriate patient. Heparinization is often unnecessary. The use of drugs that inhibit the protective fibrinolytic mechanism is contraindicated in disseminated intravascular coagulation.

Diagnosis and Outcome of 100 Consecutive Patients with Extreme Granulocytic Leukocytosis

PURPOSE To determine the clinical features, causes, and prognostic significance of extreme leukocytosis in adults. PATIENTS AND METHODS Medical records of 100 consecutive patients who presented at the Minneapolis Veterans Affairs Medical Center between March 1993 and January 1994 with more than 25,000 leukocytes/microL blood and with more than 50% granulocytes were reviewed. Demographic, clinical, and outcome information was recorded, and a cause of extreme leukocytosis was sought in each case. RESULTS Extreme leukocytosis was attributed to infection in 48 cases, advanced malignancy in 13 cases, hemorrhage in 9 cases, glucocorticoids in 8 cases, and other causes in 22 cases. Four patients had previously diagnosed conditions resulting in chronic leukocytosis. Higher leukocyte counts were associated with malignancy (chi2 for trend=12.5, P <0.002). Fever was more common in patients with infection (weighted rate ratio=3.7, 95% Confidence interval [CI]=2.2 to 6.2). Mortality was high overall (31%), and was greater in patients with noninfectious diagnoses compared with infected patients, an association which persisted after stratification by leukocyte count (weighted rate ratio=2.5, 95% CI=1.2 to 4.9). CONCLUSION Clinicians should be aware that extreme leukocytosis with a predominance of granulocytes is associated with infection in only 48% of cases. The presence of fever increases the likelihood that infection is the cause. Mortality is high, particularly in patients without infection.

Differences in the Metabolism of Postprandial Lipoproteins After a High-Monounsaturated-Fat Versus a High-Carbohydrate Diet in Patients With Type 1 Diabetes Mellitus

There is little information comparing the effects of a high-monounsaturated (Mono)-fat versus a high-carbohydrate (CHO) diet in patients with type 1 diabetes mellitus. In the present study, the effects of these diets on a number of metabolic parameters were compared. Seventeen normolipidemic, nonobese patients with type 1 diabetes were provided with the diets for 4 weeks each in a randomized, crossover design. The percentages of Mono fat of the two diets were 25 Mono versus 9 CHO, with a corresponding total fat content of 40% versus 24% and a total CHO content of 45% versus 61%. At the end of each dietary period, parameters of glycemic control, coagulation factors, and fasting and postprandial lipoproteins were assessed. There were no differences in weight, glycemia, insulin dose, fasting lipid profile, or coagulation factors between the two diets. However, the metabolism of postprandial lipoproteins after a fat load differed; viz, after the Mono diet compared with the CHO diet, mean plasma triglyceride levels over 10 hours were higher (P=.0025, by repeated-measures ANOVA). The levels of triglyceride (P=.0045) and retinyl esters (P=.0046) in chylomicrons (Sf>400) and chylomicron remnants (Sf 100 to 400) (P=.0047 and P=.043, respectively), and the total particle number (apolipoprotein B levels) in chylomicron remnants (P=.001) and small, very low density lipoprotein (Sf 20 to 100, P=.016) were also higher. Our data suggest that in patients with type 1 diabetes, a CHO diet might be preferable to a Mono diet, since adherence to the former results in a lower number of circulating postprandial lipoprotein particles that are potentially atherogenic.

Hemolytic Anemia Due to Progressive Enlargement of Silastic Ball Component of Aortic Prosthesis

The patient described developed hemolytic anemia following insertion of a Starr-Edwards aortic valve prosthesis. No diastolic murmur was heard and no insufficiency was detected. The hemolytic anemia was progressively more severe and uncompensated despite various medical measures.The anemia was characterized by fragmented erythrocytes in the peripheral blood, reticulocytosis, elevation of plasma heme pigments augmented by exercise, increased fecal urobilinogen, and iron loss in the urine. Studies of chromium-51-tagged erythrocytes indicated an extracorpuscular mechanism of hemolysis.At reoperation the ball component of the prosthesis was found to be enlarged and obstructing blood flow. Chemical analysis of the ball showed significant cholesterol and lipid deposits. The hemolysis disappeared after the prosthesis was replaced with a homograft valve. Ferrokinetic studies showed rapid plasma clearance and incorporation into circulating erythrocytes. Triglycerides were elevated during the period of hemolysis. Red cell membrane lipids were normal.

IgM pyroglobulinemia with erythrocytosis presenting as hyperviscosity syndrome: I. Clinical features and viscometric studies

The hyperviscosity syndrome is described in a patient with erythrocytosis and an immunoglobulin M with kappa light chain (IgMK) macroglobulinemia. Viscometric studies were carried out on whole blood and demonstrated the contribution of both the increased hematocrit value and the macroglobulinemia to the whole blood viscosity. Clinical improvement followed phlebotomy and was accompanied by a decrease in whole blood viscosity. Continued treatment with chlorambucil has been associated with a long symptom-free period. The macroglobulin was characterized as a monoclonal IgMK pyroglobulin which retained its thermoprecipitability was reduced to 7S monomers. The presence of IgMK aggregates in the serum may have contributed to the increase in blood viscosity.

Hematologic alterations following partial gastrectomy

Serum and red blood cell (RBC) levels of vitamin B12 and folic acid together with serum iron and total iron binding capacity were followed in 142 patients with partial gastrectomy. Follow-up period was from two months to 25 years after surgery. Anemia was the primary hematologic alteration documented as a complication of surgery. Of the parameters followed, RBC depletion of vitamin B12 occurred before a significant decrease in circulating serum values. We believe we are the first to report on the separation of RBC depletion of vitamin B12 and folic acid in the presence of iron deficiency.

Can phenytoin lower plasma fibrinogen concentrations

A strong, independent and positive association between plasma fibrinogen concentrations and cardiovascular disease has been established. To determine if phenytoin lowers fibrinogen levels we measured plasma fibrinogen levels in a subset of participants enrolled in a randomized, placebo-controlled, double-blind clinical trial. Participants received placebo or 100 mg, 200 mg, or 300 mg/day of phenytoin for 14 weeks. Fifty-six subjects had post-treatment and 20 had pre- and post-treatment fibrinogen measurements. The phenytoin-treated subjects with post-treatment measurements had a 0.24 g/l (8%) reduction in mean fibrinogen levels compared to placebo (p = 0.3). Phenytoin may be capable of producing meaningful reductions in fibrinogen levels.