Treatment of Wilson's disease

On the basis of literature review and own experience we presented the method of treatment of Wilson's disease. Causative treatment has been impossible so far, although gene therapy could be real in the future. Nowadays the principle of treatment is the elimination of the excess of easily mobilized copper by chelating agents or blocking the intestinal absorption of copper. Chelation therapy, aimed at mobilizing copper from the affected organs and promoting its excretion in the urine or stool is the most important. The major chelating agent is d-penicillamine, which is quite effective but not without some side effects. Alternative chelating agents such as trientine and tetrathiomolybdate have also been successfully employed. Zinc salts are also of therapeutic value. They promote copper excretion by inducing the synthesis of metallothionein in the intestine, thereby blocking copper absorption from the gut. Zinc salts have almost no side effects. They cannot be used as an initial treatment, but are very effective for maintenance therapy. The chelation therapy is ineffective in patients with acute liver failure with encephalopathy and hemolysis. In these cases, liver transplantation is the only hope for survival. Liver transplantations in patients with dominating psychoneurological symptoms are open to discussion.

Serum selenium levels in alcoholic liver disease

BACKGROUND

The pathomechanism of liver damage in chronic alcoholic liver disease has not been fully elucidated yet. It seems undoubted that one of the mechanisms of alcohol-induced liver damage involves free radical reactions leading to peroxidation of proteins and lipids. The most important defense mechanisms are associated with the activity of antioxidative enzymes, among which glutathione peroxidase (GSH-Px), belonging to so-called 'free radical scavengers' should be mentioned. Selenium, regarded as a bioelement, is present in GSH-Px. Involved in numerous redox reactions, it belongs to the factors protecting the organism from oxidative shock. The aim of the study was to determine the selenium levels in blood serum of chronic alcohol abusers and to find potential correlations with the parameters of liver damage.

MATERIAL/METHODS

The study was carried out in a group of 25 subjects (21 males, 4 females), treated in the Clinic or Outpatient Department of Hepatology for chronic alcoholic liver disease. At the time of the study, the patients had abstained from drinking for a period from one month to a year. Selenium was determined with atomic absorption spectroscopy method, using the hydride generation technique. The control group consisted of 11 males and 7 females.

RESULTS

Statistical analyses of the control group indicated a significantly higher blood serum selenium level in males than in females. The patients demonstrated elevated aminotransferase activity, normal Falk, markedly increased GGTP. Mean INR was 1.4 and albumin concentration 3.3 g/l. Blood serum selenium levels in male patients were significantly lower in comparison with normal values. The analysis of correlations between some liver function parameters and selenium levels demonstrated a positive correlation between the levels of albumin and selenium. Serum selenium level was inversely proportional to ALAT activity. No correlations between selenium levels and INR levels, or GGTP activity were found.

CONCLUSIONS

1. Serum selenium levels differ in male and female populations. In healthy men, the level of Se in the serum is higher. 2. Antioxidative activity measured by serum Se level is low in men with chronic alcoholic liver disease (during the abstinence period). 3. Increased selenium level in the hair may indicate the presence of certain antioxidative reserve, which requires further studies.

Results of treatment of Wilson's disease--own observations

BACKGROUND

Causative treatment of genetically determined Wilson's disease (WD) has been impossible so far, although gene therapy could be real in the future. Nowadays the principle of treatment is the elimination of the excess of easily mobilized copper, bound by chelating agents, the most important of which is d-penicillamine, through the kidneys. Blocking of the intestinal absorption of copper by administration of zinc preparations, which additionally induce hepatic metallothionein synthesis, is also possible. The aim of our study was to present own observations and results of treatment of Wilson's disease.

MATERIAL/METHODS

During the last 16 years, we have observed 33 patients aged 13-60 (mean age 27 years) with various forms of WD. The studied group consisted of 11 females and 21 males, admitted to hospital or seen at the Specialistic Outpatient Department of Hepatology with various diagnoses. In addition to standard laboratory tests, the levels of ceruloplasmin, serum and urine copper, as well as the activity of some hepatic enzymes, proteins and HBV/HCV infection markers were determined. The patients were also examined by a neurologist and an ophthalmologist, with psychiatric consultation if necessary. Taking into account the overall clinical presentation, the patients were divided into the following groups according to the form of the disease: fulminant, acute, hepatic, hepatic with neurological and psychiatric symptoms, neuropsychiatric, asymptomatic.

RESULTS

All the patients were initially treated with d-penicillamine. In most of them, no side effects were observed. The treatment was continued according to the levels of copper excreted with urine (for 10 years at the longest). After obtaining clinical improvement with reduced amount of copper excreted with 24-h urine, we tapered d-penicillamine doses or even discontinued the drug, introducing zinc preparations. In asymptomatic carriers, zinc preparations were used throughout the period of treatment.

CONCLUSIONS

Early institution of chelation treatment is associated with good prognosis both in hepatic and neurological forms of WD. Zinc preparations are effective and safe in neurological and oligosymptomatic forms of the disease.

[Paracervical non-caries defects]

The aim of the study was the description of origin and treatment of paracervical, non-caries defects. Dental plaque is involved in the formation of caries defects, while those of non-caries origin are produced due to the action of mechanical and chemical factors. The treatment consists in wide fluoride prophylaxis (elimination of causes) and in the application of mineralization procedures and restoration of missing dental tissue using modern dental highly-adhesive materials. At the same time occlusion disorders and parafunctions are eliminated.

Histochemical and ultrastructural study of the effect of natrium fluoride on glycogen content in rat hepatocytes

The aim of the study was to evaluate the effect of natrium fluoride (NaF) on glycogen content in hepatocytes of the offspring rats receiving fluoridated water, basing on histochemical (PAS reaction) and ultrastructural examinations. The experiment used 90 rats obtained from 30 mothers. The animals were given fluoridated water in two different concentrations: 10.6 mg NaF/l and 32.0 mg NaF/l. Material for analysis consisted of liver specimens collected on day 4, 14, 30, 60, 90 and 120 of rats' life. The rats were exposed to fluoride from the intrauterine life, during lactation, till full maturity. The experiment revealed the effect of super-optimal concentrations of natrium fluoride on carbohydrate metabolism of the rat.

Learning a morphological system without a default: the Polish genitive

The acquisition of the English past tense inflection is the paradigm example of rule learning in the child language literature and has become something of a test case for theories of language development. This is unfortunate, as the idiosyncratic properties of the English system of marking tense make it a rather unrepresentative example of morphological development. In this paper, I contrast this familiar inflection with a much more complex morphological subsystem, the Polish genitive. The genitive case has three different markers, each restricted to a different subset of nouns, in both the singular and the plural. Analysis of the spontaneous speech of three children between the ages of 1;4 and 4;11 showed that they generalized, and overgeneralized, all three singular endings. However, error rates were extremely low and there is no evidence that they treated any one ending as the 'default'. The genitive plural, on the other hand, showed a strikingly different pattern of acquisition, similar to that seen in English-speaking children learning the past tense. It is argued that in the latter two cases, the default-like character of one of the affixes is attributable to the properties of the relevant inflectional subsystems, not to the predispositions that children bring to the language-learning task.

Effect of high fiber vegetable-fruit diet on the activity of liver damage and serum iron level in porphyria cutanea tarda (PCT)

BACKGROUND

During the treatment of coronary heart disease with a vegetable-fruit diet, we have observed the positive effect of the treatment on PCT patients. Therefore, we have now examined the short-term results of the diet on the selected PCT activity parameters. The study was approved by our Review Board.

MATERIAL AND METHODS

A group of 13 male PCT patients (mean age 52 years) was evaluated. We assessed the body mass index (BMI), serum iron level, activity of transaminases (ALT, AST), severity of skin symptoms, and urinary prophyrins excretions, before and after a three-week period of vegetable-fruit diet. The diet was of natural vegetable/fruit products, and its daily caloric content was ca. 500 kcal/day.

RESULTS

The mean BMI before and after the diet period were 26.8 +/- 4.7 vs. 25.8 +/- 4.3 (p = 0.001), the serum activities of ALT 122.0 +/- 60.7 U/l vs. 75.6 +/- 31.8 U/l, and of AST 91.8 +/- 56.0 U/l vs. 55.2 +/- 14.2 U/l (p = 0.001), respectively. The mean serum iron levels were 188.6 +/- 75.7 mg/dl vs. 140.2 +/- 56.4 mg/dl, serum ferritin concentrations 574 +/- 351 vs. 499 +/- 340 ng/ml (p = 0.04), respectively. Severity of skin lesions and urinary coproporphyrins excretion were significantly diminished during the diet; urinary uroporphyrins excretion was also lowered, but not to a statistically significant level.

CONCLUSION

In our group of PCT patients, we noticed the beneficial effect of the vegetable-fruit diet on selected disease parameters. The diet may be useful in the treatment of PCT and diseases associated with PCT.

Porphyria cutanea tarda, hepatitis C virus and selected symptoms of cholestasis

BACKGROUND

The influence of hepatitis C virus (HCV) infection on the development of porphyria cutanea tarda (PCT) was recently detected, but the status of trace elements in etiology of the diseases is relatively poorly recognized. Individually observed symptoms of cholestasis do not seem to be related to the above conditions.

MATERIAL AND METHODS

A group of 22 PCT patients (37-73 years old, mean 54.9 years), including 10 cases (45.5%) of serum HCV-RNA positive, as evaluated by automatic Cobas AmplicorTM Hepatitis C ver. 2.0 assay (Roche Diagnostics), was assessed. None of the patients have recently abused alcohol. Serum levels of copper and bilirubin, activity of gammaglutamyltranspeptidase (GGTP) and alkaline phosphatase (ALP) were measured in all patients.

RESULTS

We have found statistically significant differences between both mean serum activity of GGTP (145.9 U/l vs. 58.3 U/l, p = 0.004) and mean serum copper levels (131.9 mg/dl vs. 79 mg/dl, p = 0.003) in patients infected with HCV compared to the other PCT patients, respectively. Mean serum ALP activity was also higher, but the difference was not of statistical importance (106.9 U/l vs. 90.9 U/l, p = 0.24); mean serum bilirubin concentration was significantly lower in HCV-infected patients (0.55 mg/dl vs. 0.85 mg/dl, respectively, p = 0.035).

CONCLUSION

In our group of PCT patients we have noticed a higher serum copper level and higher activity of both GGTP and alkaline phosphatase, but lower level of serum bilirubin in patients infected with HCV as compared with those not infected. This observation does not confirm suggestions concerning the role of HCV in promotion of cholestatic liver disease in PCT patients. The influence of HCV infection on the metabolism of copper and GGTP activity is connected rather with the inflammatory lesions in the liver of PCT patients infected with HCV. Bilirubin metabolism in PCT patients requires further studies for its elucidation.

Influence of hepatitis C virus (HCV) infection on porphyrin and iron metabolism in porphyria cutanea tarda (PCT) patients

BACKGROUND

Porphyria Cutanea Tarda (PCT) is the most common form of porphyria. It is characterised by lowered activity of uroporphyrinogen decarboxylase. It seems possible that the hepatitis C virus (HCV) infection triggers the symptoms of PCT.

MATERIAL AND METHODS

A group of 29 PCT patients (33-73 years old, mean 54 years) was evaluated. In these patients the serum HCV-RNA (by mean of automatic Cobas AmplicorTM Hepatitis C ver. 2.0 assay, Roche Diagnostics), activity of transaminases (ALT, AST), serum protein fractions, iron, total iron binding capacity (TIBC), ferritin, transferrin, transferrin saturation, and urinary porphyrins excretion were assessed.

RESULTS

The presence of HCV-RNA was detected in 12 cases (41.4%). Statistically important differences between currently HCV infected patients and other PCT patients concerned the following parameters: mean body mass (68.5 vs. 78.0 kg, p = 0.02), mean body mass index (22.4 vs. 26.8 kg/m2, p = 0.007), mean serum activities of ALT (112.6 vs. 65.4 U/l, p = 0.02) and AST (85.0 vs. 56.5 U/l, p = 0.038), total serum protein concentration (78.0 vs. 71.6 g/l, p = 0.016) and serum alpha-2 protein concentration (7.2 vs. 5.5 g/l, p = 0.009), respectively. Some other not significant differences were also found: mean serum iron level 182 vs. 169 micrograms/dl, transferrin concentration 2.77 vs. 2.56 g/l, transferrin saturation 43 vs. 45%, serum TIBC 445 vs. 397 mg/dl and ferritin concentration 394 vs. 400 micrograms/l, respectively. The mean urinary uroporphyrin concentrations were 643 micrograms/l vs. 366 micrograms/l (p = 0.16) and those of coproporphyrins were 190 micrograms/l vs. 136 micrograms/l (p = 0.37), respectively.

CONCLUSION

In the group of PCT patients investigated no significant relationship between current HCV infection and iron or porphyrin metabolism was noted. Nevertheless, HCV infection significantly influences the symptoms of liver damage and seems to influence other metabolic parameters in PCT patients.

Acute haemolytic syndrome and liver failure as the first manifestations of Wilson's disease

Acute liver failure and haemolytic syndrome appeared quite suddenly as the first manifestations of Wilson disease (WD) in five of our patients previously regarded as healthy persons (although an interview showed that 2-4 weeks prior to the illness the patients complained of several non-specific symptoms, such as abdominal pain, headaches, fever, weakness or behavioural changes). All the patients were young women (17-23 years), none of them had any history of liver disease. They were admitted with icterus, nausea, vomiting and symptoms of increasing haemolysis. The diagnosis of WD was given as disturbed copper metabolism. After a short period of observation ascites and anasarca occurred, haemorrhagic diathesis and other symptoms of liver failure increased. Levels of clotting factors decreased rapidly. Despite treatment with D-penicillamine, plasmapheresis, and symptomatic drugs, three of the women died in irreversible liver coma, due to the unavailability of liver transplantation. The fourth woman was carried to the Transplantation Centre, due to aggravation of the symptoms of liver failure, where liver transplantation was performed. Histopathologically micronodular cirrhosis was shown in all these cases. The fifth patient survived having undergone the above treatment without liver transplantation. The main differences between the patient who survived and those who died or underwent transplantation were relatively higher activity of alkaline phosphatase (26 U/l vs. 10-20 U/l), slightly higher levels of clotting factors and prothrombin time, which never fall below 68% of the control (versus 14-44% in other patients). Only in the surviving patient was the Kayser-Fleischer ring present. In four of our patients we found family members who were carriers of WD.

[Liver transplantation in a patient with hemolytic syndrome in the course of fulminant Wilson's disease]

The case report of a 20 year old woman with fulminant liver failure and hemolytic syndrome was described. Huge amounts of copper excreted in the urine (3555 mg/12 h without, and 5180 mg/12 h after d-penicillamine provocation, respectively) confirmed the diagnosis of fulminant Wilson's disease. Because the patient's general condition worsened rapidly (hemolysis, diathesis hemorrhagic, ascites, encephalopathy increased during 3 days of clinical observation) orthotopic liver transplantation was performed. After the transplantation, ischemic type biliary lesion (ITBL) II stage was diagnosed. The woman is still being treated with Prograf and Urso-Falk. The patient returned to her normal life, continues to work and was married. Two years after OLT she gave birth to a healthy boy. The liver function tests are normal with the exception of GGTP and FALK activities elevation. Copper and ceruloplasmin level, as well as copper excretion in the urine are within the normal values.

Submicron emulsions as drug carriers. Studies on destabilization potential of various drugs

Few drugs have been successfully formulated as submicron emulsions. The physicochemical stability of submicron emulsions on admixture of drugs is the main factor limiting a wider use of this type of vehicle for parenteral or other routes of administration. In a short-term stability studies we have investigated 35 drugs with regard to their compatibility with 20 or 5% parenteral fat emulsions. The study has shown that interaction of drugs with submicron emulsions is complex in nature. Taking into consideration the physicochemical properties of a drug e.g. lipophilicity or ionization, it is difficult to predict changes in the physical stability of the system. If destabilization occurs it is maximal at saturated concentrations and the presence of even significant amounts of the solid phase formed by undissolved drug does not influence the short-term stability of the system. Due to the increased ratio of emulgator to oil, emulsions containing 5% of oily phase are less susceptible to destabilization than 20% emulsions.

Increased partitioning of pilocarpine to the oily phase of submicron emulsion does not result in improved ocular bioavailability

Submicron emulsions containing pilocarpine as ion-pair with mono-dodecylphosphoric acid were prepared. Physical stability of these preparations was confirmed during 4 months of storage at 4 degrees C. Approximately 50% of the drug was found in the aqueous phase of emulsion separated using an ultrafiltration technique, while the rest was present in the oily phase and interphase. The miotic effect observed in rabbits after application of the ion-pair in aqueous solution or in submicron emulsion was the same; indicating that the drug distribution into the oily phase of the colloidal vehicle does not improve ocular bioavailability.

Discriminatory power of MRI for differentiation of adrenal non-adenomas vs adenomas evaluated by means of ROC analysis: can biopsy be obviated?

The purpose of our study was to evaluate the discriminatory power of MRI in high-field magnet (1.5 T) for differentiation of adrenal non-adenomas vs adenomas assessing the following parameters separately and in combination: mean diameter of adrenal mass; previously described and new ratios as well as index calculated from signal intensity (SI) on SE T2-weighted images, chemical shift imaging (CSI), and Gd-DTPA-enhanced dynamic studies. One hundred eight adrenal masses (36 non-hyperfunctioning adenomas, 27 pheochromocytomas, 23 aldosterone-secreting adenomas, 20 malignant masses and 2 cortisol-secreting adenomas) in 95 patients were evaluated with SE sequences, CSI and Gd-DTPA dynamic studies. Indices and ratios of SI for all examined MRI methods were calculated and examined retrospectively for significance of differences between the groups with calculation of sensitivity and specificity. Receiver operating characteristics (ROC) analysis of calculated parameters in combination was performed. The multifactorial analysis of all four parameters, including size of the tumor, T2(liver) index, CSI ratio reflecting lipid content in the tumor and Wo(max/last) ratio reflecting maximal washout of contrast agent from the tumor had 100 % sensitivity and 100 % specificity in characterization of adrenal non-adenoma. The best performance of combination of mean tumor diameter with single MRI SI parameter was achieved in combination with T2(liver) index for all adrenal masses (area under ROC 0.987) and CSI ratio for non-hyperfunctioning adrenal masses (area under ROC 0.991). Magnetic resonance imaging enables sensitive and specific diagnosis of adrenal non-adenoma.

[Low zinc levels in metabolic X syndrome (mzX) patients measured by hair zinc composition analysis]

The hair zinc content in 16 patients with metabolic X syndrome (mzX) was measured by means of atomic absorption spectrometry method. The mean concentration (125.13 mg/kg) was lower than in the majority of other published studies. The differences among groups of patients with different sex or diseases (e.g. coronary heart disease, hypertension, type II diabetes mellitus) were not significant. It seems to be probably that deficiency of zinc plays a role in pathogenesis of mzX or that it is a consequence of mzX.

Intravital treatment of the pulp with simultaneous laser biostimulation

The aim of the study was clinical and radiological evaluation of the pulp treatment using direct capping and amputation under anaesthesia with simultaneous laser biostimulation. Thirty procedures were performed using laser and thirty-six without it. In all cases non-setting Ca(OH)2 was applied as a biological dressing. The results obtained provide justification for the application of laser biostimulation to biological treatment of the pulp.

[Porphyria cutanea tarda--new views on its pathogenesis and therapy]

Literature data and the results of our studies on the prevalence of the HCV infection markers in patients with porphyria cutanea tarda (PCT) are presented. We also present new views on the PCT pathogenesis in some cases, therapy of the cutaneous changes, and the use of interferon in the patients as a prevention of the hepatocellular carcinoma.