Clinical vignette: VIPoma as a cause of persistent diarrhea

A 48-year-old man originally presented with a 5-day history of watery, nonbloody diarrhea without recent travel or contact with ill people. His medical history was significant for a prolonged course of Clostridium difficile diarrhea 1 year earlier. On physical exam, he had orthostatic hypotension, dry mucous membranes, mild right lower quadrant tenderness to palpation, and hyperactive bowel sounds. Laboratory testing revealed a sodium level of 130 mEq/L, a potassium level of 1.7 mEq/L, a chloride level of 102 mEq/L, a bicarbonate level of 13 mEq/L, a blood urea nitrogen level of 43 mg/dL, a creatinine level of 1.6 mg/dL, and a calcium level of 11.4 mg/dL. Despite several liters of IV hydration and aggressive potassium repletion, he remained severely hypokalemic with a potassium level of 1.5 mEq/L. He was admitted to the medical ICU for further resuscitation. Stool testing was negative for C. difficile and other infectious organisms. The patient\u27s symptoms resolved before additional evaluation, and he was discharged with a presumed diagnosis of severe viral gastroenteritis. The patient returned 1 week later with recurrence of profuse diarrhea. His physical examination was notable for a blood pressure of 104/59 mm Hg (nonorthostatic) and a pulse of 106 beats/min, again with dry mucous membranes and mild tenderness to palpation of the right lower quadrant. Serum chemistry panel revealed a sodium level of 137 mEq/L, a potassium level of 2.3 mEq/L, a chloride level of 111 mEq/L, a bicarbonate level of 10 mEq/L, a blood urea nitrogen level of 38 mg/dL, a creatinine level of 2.3 mg/dL, and a calcium level of 10.4 mg/dL. Testing was again negative for an infectious source of diarrhea, and colonoscopy was not suggestive of inflammatory bowel disease. An abdominal CT revealed a 5-cm pancreatic tail mass. The patient was later found to have an elevated vasoactive intestinal peptide (VIP) level of 1,765 pg/mL (reference range, 0 to 60 pg/mL). Fecal osmolality was not obtained. The tumor was resected, and histology confirmed a neuroendocrine tumor

Improving Supplement Documentation through Powerchart

To build a Powerchart database for supplements and herbs in order to improve feasibility of complete medication reconciliation documentation, improved ease, safety and efficacy of supplement prescription by practitioners, and improved patient safety through minimization of medical error

Homocysteine, Cobalamin and Folate Status and their Relations to Neurocognitive and Psychological Markers in Elderly in Northeastern of Iran

Objective(s): Incidence of neurocognitive and psychological disorders may be related to serum homocystein (Hcy), cobalamin (vitamin B12 ) and folate levels in old people. The aim of this study was to assess the relation between Hcy, cobalamin, folate and neurocognitive and/or psychological disorders in the elderly.   Materials and Methods: In this cross-sectional study, 280 subjects with ≥ 65 years old, were evaluated. The subjects were selected from 12 regions of Mashhad, Iran, over March to October 2009. After blood sampling, data were collected by questionnaire, face to face interview and performing neurocognitive and psychological tests. The sera of 250 persons were analyzed for cobalamin and folate by RIA method. Amongst the aforementioned samples, 78 cases with cobalamin Results: Amongst the people, 126 (45%) were male and 154 (55%) were female. The prevalence of hyperhomocysteinemia (HHcy) was 59.5% and 37.1% in male and female respectively (P -value =0.049). Hcy inversely correlated to cobalamin (r=-0.282, P=0.014) and to folate (r=-0.203, P=0.014). Hcy, cobalamin and folate correlations to neurocognitive and psychological impairments were not statically significant. Conclusion: Hyper Hcy or low cobalamin and folate in the elderly, are prevalent but their relationships with neurocognitive and psychological impairments is controversial. If these relationships had been confirmed, performing a single serum Hcy or cobalamin test would have been enough to diagnose and prevent neurocognitive impairments and inversely, neurocognitive-psychological sign and symptoms could have meant probable tissue vitamin deficiencies. However methods of assessing neurocognitive and psychological markers with validity and reliability of clinical and laboratory tests for finding aforementioned relationships should be revised