Rheumatic manifestations and immunological abnormalities in patients with chronic hepatitis C. A study in the Middle East

Hepatitis C virus infection and rheumatic disorders are both common in the Middle East and share many clinical and immunological manifestations, raising diagnostic problems. We compared the prevalence of extrahepatic clinical manifestations and immunological disorders in 40 patients with chronic hepatitis C and in 42 carefully matched healthy controls. Polyarthralgia or polyarthritis was the most common rheumatic manifestation (35%) in the cases, followed by cutaneous vasculitis (15%). Glomerulonephritis and xerophthalmia were uncommon, and none of the cases had systemic vasculitis. Immunological abnormalities included serum rheumatoid factor (47.5%), cryoglobulins (30%), and one or more antitissue antibodies (37.5%). The prevalences of polyarthralgia, cutaneous vasculitis, rheumatoid factor, cryoglobulinemia, and anti-tissue antibodies were significantly higher in the hepatitis C group than in the control group. Our data suggest that patients in the Middle East who present with features of rheumatic or autoimmune diseases should be screened for hepatitis C.

Isoflurane hepatotoxicity in a patient with a previous history of halothane-induced hepatitis

Halogenated volatile anesthetics have been associated with liver injury. Most reported cases have been linked to halothane and enflurane. Cross-sensitization between the latter agents has also been documented. Isoflurane hepatitis is extremely rare, and only a few convincing cases have been published. Moreover, clinical cases of cross-sensitization of isoflurance with other haloalkanes have not been reported. We describe a case of hepatic dysfunction 2 weeks after isoflurance anesthesia in a 35-year-old obese woman with a previous history of halothane hepatitis. The diagnosis was made on the basis of exposure to isoflurance, the delay between the time of exposure and the onset of jaundice, and the exclusion of other causes of liver dysfunction. This case reiterates the recommendation that patients who sustain liver injury from one haloalkane should not be exposed to another.

Alfa-interferon therapy for chronic hepatitis B virus infection in Kuwaiti patients

Alfa-interferon is the standard treatment of chronic hepatitis B. However, the response rate varies widely in patients from different parts of the world, reflecting differences in the natural history of the disease and the immune reactivity of the population studied. The aim of this study is to assess the efficacy of alfa-interferon in the treatment of Kuwaiti patients with chronic replicative hepatitis B infection. Twenty-two adult Kuwaiti patients with biopsy-proven chronic hepatitis B were treated with alfa-interferon after an observation period of six months. All patients had abnormal transaminase levels and were HBeAg and HBV-DNA positive. Alfa-interferon-2b, 5 million units, was administered five days a week for 16 weeks. Patients were followed for at least 12 months after completing therapy. One of the 22 patients dropped out of the study after a single dose of interferon, because of side effects. Of the remaining 21 patients, three (14%) had a sustained loss of HBV-DNA and HBeAg. None of the patients lost HBsAg. There were no episodes of hepatic decompensation or deaths during the study. One patient developed hepatocellular carcinoma 28 months after completing treatment with interferon. Overall, Kuwaiti patients with chronic replicative hepatitis B responded poorly to interferon therapy.

Monoamine oxidase inhibitors and the cheese effect

The behavior of inhibitors of monoamine oxidase-A (MAO-A) is considered in terms of the possibility of having an effective antidepressant that does not give rise to hypertensive interactions with dietary tyramine. Studies with punch-biopsy samples of human intestine and rat intestinal samples show MAO-A to be the predominant form of the enzyme in both species. Transport studies with everted rat intestinal preparations indicate that tyramine is extensively metabolized during transport through the intestine. Selective inhibition of MAO-A by clorgyline results in a large increase in the amount of unchanged tyramine transported, whereas selective inhibition of MAO-B with L-deprenyl (selegiline) has no significant effect. The behavior of reversible MAO-A inhibitors can significantly reduce, but not entirely eliminate, these effects on the intestinal metabolism of tyramine, but only if the inhibition is competitive in nature.

An analytical electron microscopic investigation of precipitation in an Al-Cu-Zn-Mg-Ag alloy

The distribution, morphology, chemistry, and crystallography of the precipitates formed during aging of an Al-Cu-Zn-Mg-Ag alloy have been studied using analytical transmission electron microscopy. The first precipitates to appear during aging at 150 degrees C were thin hexagonal-shaped plate-like precipitates which formed on the (111)Al planes. These precipitates had a face-centred orthorhombic crystal structure and their composition was essentially CuAl2 although they contained a trace of silver. At peak hardness the microstructure consisted of the plate-like precipitates on (111)Al planes and theta' precipitates on (100)Al planes. Overaging resulted in the precipitation of equilibrium theta, CuAl2, which exhibited a lath morphology and an orientation-relationship with the matrix (210)Al magnitude of (110)gamma; (001)Al misoriented from (001)gamma by approximately 6 degrees. Prolonged overaging at 250 degrees C resulted in the formation of cuboid-shaped Al5(Cu,Zn)6Mg2 precipitates which had a cubic crystal structure and a cube:cube orientation-relationship with the matrix.

Diverticulum of the inferior vena cava: a case report

Anomalies of the inferior vena cava are rare. We describe a case of diverticulum arising from the inferior vena cava, which has not been described to date.

Prevalence of antibodies to hepatitis C virus among patients with cryptogenic chronic hepatitis and cirrhosis

Many cases of chronic hepatitis and cirrhosis cannot be attributed to a known cause and are collectively referred to as cryptogenic chronic liver disease. We have evaluated the role of the hepatitis C virus in the pathogenesis of this condition in a retrospective serum analysis for antibody to hepatitis C virus in 129 patients with cryptogenic liver disease. Other causes of chronic hepatitis and cirrhosis were ruled out by clinical, serum biochemical and serological techniques. All 129 patients were HBcAg negative, but 28 (22%) had antibody to HBcAg. Sera were tested by radioimmunoassays using recombinant peptides for antibodies to nonstructural (C100-3 and C33c) and structural regions (C22) of HCV. Among the 129 patients, 61 (47%) had antibody to C100-3, 76 (59%) had antibody to C33c and 74 (57%) had antibody to C22. Seventy-nine (61%) were reactive with at least one and 76 (59%) were reactive with at least two HCV peptides (this is the criterion used for hepatitis C virus antibody reactivity). A proportion of patients with chronic hepatitis and cirrhosis (55 of 91; 60%) similar to that of patients without cirrhosis (21 of 38; 55%) had hepatitis C virus antibody. No significant clinical, serum biochemical or histological differences were noted between the group of patients with hepatitis C virus antibody and those without this antibody reactivity. Thus more than half the patients with cryptogenic chronic liver disease had hepatitis C virus antibody, suggesting that chronic HCV infection plays a major role in the origin of cryptogenic chronic hepatitis and cirrhosis.

The role of endoscopic sclerotherapy in the management of esophageal varices

Endoscopic sclerotherapy of esophageal varices has gained worldwide popularity. There is a consensus that sclerotherapy is an effective treatment for temporarily controlling acute variceal hemorrhage. Sclerotherapy has no place in the routine prophylaxis before the index bleed. The role of long-term sclerotherapy to prevent rebleeding is debatable. It is our bias that once patients with cirrhosis suffer a variceal hemorrhage, they should be considered for liver transplantation. If they are not suitable candidates for transplantation and have mild to moderate hepatic dysfunction, then portosystemic shunting provides definitive secondary prophylaxis against rebleeding. Sclerotherapy should be reserved for patients with advanced decompensated cirrhosis.

Uterine leiomyomata in pregnancy

Sixty cases with uterine leiomyomata in pregnancy are presented. The incidence was 1 in 1033 deliveries. The median age of the patients was 33.4 years. The majority were primigravidae (60%). A significant number of patients gave a history of infertility (43%) and spontaneous abortions (25%). The commonest antenatal complication was malpresentation and in all these patients the myomata were larger than 6 cm. Typical features of red degeneration occurred in 10% of cases. The cesarean section rate was 73%, the commonest indication being obstructed labor. Severe hemorrhage was encountered at cesarean section in 10 patients, 3 of whom needed hysterectomy. There were no perinatal deaths.

Hepatitis C-associated hepatocellular carcinoma

In the United States, a large percentage of patients with hepatocellular carcinoma are serologically negative for hepatitis B. We conducted a retrospective study to determine the prevalence of hepatitis C antibody in the sera of 59 patients with hepatocellular carcinoma who were HBsAg-negative and had no evidence of alcoholic liver disease, primary biliary cirrhosis, autoimmune hepatitis, hemochromatosis or alpha 1-antitrypsin deficiency. Twenty patients (34%) were hepatitis C antibody-positive and hepatitis B core antibody-negative. All twenty patients had underlying cirrhosis, and seven (35%) had histories of transfusions. Eleven (19%) additional patients were also hepatitis C antibody-positive but were hepatitis B core antibody-positive as well. Twenty-one (36%) patients were both hepatitis C antibody- and hepatitis B core antibody-negative and seven (12%) were hepatitis C antibody-negative but hepatitis B core antibody-positive. The prevalence of hepatitis C antibody was also determined among three other population groups serving as controls and found to be 14% in 28 HbsAg-positive patients with hepatocellular carcinoma, 44% in 76 patients with cryptogenic cirrhosis and 0.5% in 200 consecutive volunteer blood donors. We conclude that hepatitis C antibody is prevalent among patients with hepatocellular carcinoma and may therefore be a common causative agent of this disease. A significant number of patients with and without cirrhosis, negative for hepatitis C antibody and hepatitis B core antibody, remain without a discernible cause for this malignancy. Perhaps a second- or third-generation test will detect hepatitis C antibody in some of these patients.

The effect of low level lead exposure on the postnatal structuring of the rat cerebellum

Exposure of rat pups to lead (less than 45 micrograms/dl blood) caused no alterations in the rate of cerebellar cell acquisition, migration or final number when compared with age-matched controls. The rate of DNA biosynthesis was higher in the lead-exposed animals compared to controls and remained elevated until postnatal day 10. This observation suggests lengthening of the cell cycle. The expected increase in DNA biosynthetic rate was delayed in neuron-enriched fractions obtained from lead-exposed pups. This may have been due to the isolation procedure specifically selecting internal granular layer cells which migrated precociously during a protracted G1 phase in a lead-impaired cell cycle. Morphometric studies revealed no difference in the number, viability and migration of cells within and from the external granular layer of the cerebellum of lead-exposed animals. It is concluded that chronic low level lead exposure has no significant effect on the early structuring of the developing cerebellum.

Esophageal pressure monitoring: a practical adjuvant to hemodynamic monitoring with positive end-expiratory pressure

With positive end-expiratory pressure (PEEP)-induced reduction in cardiac output, measurement of ventricular filling pressure assists in proper therapeutic decision-making. Because PEEP may increase pleural and juxtacardiac pressure, central venous pressure (CVP) and left atrial pressure (LAP) measurements during PEEP may not simply reflect ventricular filling, but rather reflect the sum of intracardiac and extracardiac forces. Monitoring devices placed within the central circulation use saline solution-filled lumens and transducer systems for pressure monitoring. Therefore, any device designed to estimate the extracardiac influence of PEEP on intraluminal monitoring devices would be expected to reflect such changes best when the device is also filled with saline solution. In the present study, esophageal pressure (Pes) was measured with a saline solution-filled balloon-equipped nasogastric tube to estimate the extracardiac influence of PEEP on CVP and LAP. Pes, CVP, LAP, and cardiac index (CI) were measured in 17 patients subjected to 0, 5, 10, 15, 20 cm H2O PEEP. Comparing 0 with 20 cm H2O PEEP, CVP (7 +/- 1.0 mm Hg to 13.4 +/- 1.3 mm Hg), LAP (6.3 +/- 1.1 mm Hg to 11.7 +/- 1.4 mm Hg), and Pes (6.1 +/- 1.4 mm Hg to 12.1 +/- 1.5 mm Hg) all increased significantly as CI fell (2.72 +/- 0.14 L/min/m2 to 2.20 +/- 0.15 L/min/m2).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical intensive care unit pneumonia

With use of an objective numerical rating system for the assessment of the presence or absence of pneumonia on a chest x-ray film, 81 patients in the surgical intensive care unit with positive sputum cultures were assigned to either colonization (C; 39 patients) or pneumonia (P; 42 patients) groups. Respiratory failures preceding the first positive sputum culture and hepatic and/or renal failure were more frequent in the P group. Escherichia coli and Pseudomonas species, as well as polymicrobial sputa, were more common in the P group. Positive blood or pleural cultures with the same organism found in the sputum were noted in 10 of 11 P patients and only 3 of 10 C patients. Broad-spectrum antibiotic therapy directed at all sputum pathogens decreased mortality in the P group but not in the C group. We conclude that an objective rating system for chest x-ray diagnosis provides a reasonable method for separating patients with pneumonia from those with colonization. We recommend antibiotic therapy directed at all sputum pathogens in patients in surgical intensive care units. For such therapy to be successful, however, diagnostic criteria must be precise and exclude patients with colonized pathogens.

Reaction of [3H]meproadifen mustard with membrane-bound Torpedo acetylcholine receptor

The Torpedo nicotinic acetylcholine receptor (AChR) contains a binding site for aromatic amine noncompetitive antagonists that is distinct from the binding site for agonists and competitive antagonists. To characterize the location and function of this allosteric antagonist site, an alkylating analog of meproadifen has been synthesized, 2-(chloroethylmethylamino)-ethyl-2, 2-diphenylpentanoate HCl (meproadifen mustard). Reaction of [3H]meproadifen mustard with AChR-rich membrane suspensions resulted in specific incorporation of label predominantly into the AChR alpha-subunit with minor incorporation into the beta-subunit. Specific labeling required the presence of high concentration of agonist and was inhibited by reversible noncompetitive antagonists including proadifen, meproadifen, perhydrohistrionicotoxin (HTX), and tetracaine when present at concentrations consistent with the binding affinity of these compounds for the allosteric antagonist site. No specific alkylation of the AChR alpha-subunit was detected in the absence of agonist, or in the presence of the partial agonist phenyltrimethylammonium or the competitive antagonists, d-tubocurarine, gallamine triethiodide, or decamethonium. Reaction with 35 microM meproadifen mustard for 70 min in the presence of carbamylcholine produced no alteration in the concentration of [3H]ACh-binding sites, but decreased by 38 +/- 4% the number of allosteric antagonist sites as measured by [3H]HTX binding. This decrease was not observed when the alkylation reaction was blocked by the presence of HTX. These results lead us to conclude that meproadifen mustard alkylates the allosteric antagonist site in the Torpedo AChR and that part of that site is associated with the AChR alpha-subunit.

Assignment by 13-C-NMR spectroscopy of configuration at C-5 in 17 alpha-ethylestran-17 beta-ol, an impurity in the anabolic steroid ethylestrenol

The stereochemistry at C-5 in 17 alpha-ethylestran-17 beta-ol, found as an impurity in ethylesterenol, was assigned by 13C-NMR spectroscopy. The hydrogen atom attached to C-5 is in the alpha-configuration. Resonance assignments were confirmed by partial deuteration, off-resonance 13C-(1H)-decoupling, and comparison with model compounds.

Molecular motion and order in single-bilayer vesicles and multilamellar dispersions of egg lecithin and lecithin-cholesterol mixtures. A deuterium nuclear magnetic resonance study of specifically labeled lipids

Deuterium (2H) nuclear magnetic resonance (NMR) quadrupole splittings and relaxation times have been measured for a variety of specifically deuterated lipids intercalated in lamellar-multibilayer dispersions and single-bilayer vesicles of egg lecithin and lecithin-cholesterol mixtures. The deduced order parameters and relaxation times vary with position of deuteration, acyl chain length, unsaturation, and temperature. The order parameters and spinlattice relaxation times T1 indicate rapid intramolecular motions of restricted amplitude in both the choline head group and hydrocarbon chains. The ordering profile for the acyl chains is similar to that predicted by statistical-mechanical theory. The order parameters yield estimates of the bilayer thickness and linear coefficient of expansion in close agreement with the x-ray determinations. A comparison of the deuterium and electron spin resonance spinprobe order parameters demonstrates the perturbation of the bilayer by the bulky nitroxide probe. The transverse relaxation time T2 for single-bilayer vesicles is quantitatively accounted for by a simple modification of classical relaxation theory which takes into account the modulation of the static quadrupole interaction by rapid local molecular motions and the modulation of the residual quadrupole interaction by the slower overall tumbling of the vesicle. It is unambiguously demonstrated that molecular motion and order in single-bilayer vesicles are very similar to those in lamellar multibilayers. Significant differences occur only for a few segments near the terminal methyl groups of the acyl chains, where the order parameters for vesicles are 10-30% smaller than those found for lamellae. The incorporation of cholesterol in lecithin bilayers is shown to increase the degree of orientational order in vesicles and lamellae, and to increase the hydrodynamic radius of vesicles. Thus, single-bilayer vesicles and multilamellar dispersions of phospholipids are equally useful models for biological membranes. They yield equivalent information about the internal organization and mobility of lipid bilayers, when the spectral manifestations of overall vesicle motion are correctly taken into account.