Contraceptive steroids increase hepatic uptake of chylomicron remnants in healthy young women

In an investigation of alterations in cholesterol metabolism during contraceptive steroid use, we studied plasma clearance of chylomicron remnants. Six healthy women were studied on and off contraceptive steroid therapy. Remnant clearance was measured from the disappearance of retinyl palmitate administered intravenously in plasma endogenously labeled with retinyl palmitate. We also measured cholesterol in HDL and its subfractions and postheparin lipoprotein lipase and hepatic triglyceride lipase activities. Plasma decay of retinyl palmitate was biexponential. The rapid component, reflecting chylomicron remnant removal, accounted for about 90% of the total clearance in all studies. During contraceptive steroid intake, both rapid and slow decay constants and the calculated plasma clearance rates were significantly increased (mean values: rapid decay constant, control 0.048 versus treated 0.101 min-1, P less than 0.05; slow decay constant, 0.004 versus 0.014 min-1, P less than 0.01; plasma clearance 74 versus 115 ml/min, P less than 0.025) indicating enhanced hepatic uptake of chylomicron remnants and probably an increased hepatic uptake of higher density lipoproteins (d greater than 1.006 g/ml). Total postheparin lipolytic activity and lipoprotein lipase activity were depressed in all six women (P less than 0.05) and hepatic triglyceride lipase activity was increased in four of five subjects. Contraceptive steroids also caused a decrease in the HDL2/HDL3 cholesterol ratio (P less than 0.05), implying impaired peripheral lipoprotein triglyceride hydrolysis and/or increased HDL2 clearance by hepatic triglyceride lipase. In conclusion, during intake of contraceptive steroids, the plasma clearance of chylomicron remnants and higher density lipoproteins was increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Regulation of bile acid synthesis via direct effects on the microsomal membrane

Rats treated with ethinylestradiol (5 mg kg-1 day-1 for 5 days) secrete de novo synthesized bile acids at a markedly reduced rate (-57%). Administration of the nonionic detergent Triton WR-1339 to estradiol-treated rats rapidly restored the rate of secretion of de novo synthesized bile acids to control levels. In contrast, when Triton was administered to control rats, the secretion rate of bile acids was unaffected. The reduction in bile acid synthesis displayed by estradiol-treated rats was similar to the 50% decrease in the activity of hepatic microsomal 7 alpha-hydroxylase. The activity of 7 alpha-hydroxylase was also restored to control levels by the administration of Triton to estradiol-treated rats. We examined the possibility that estradiol acts directly on the hepatic microsomes. Adding increasing amounts of estradiol to microsomes obtained from control rats resulted in decreasing activities of 7 alpha-hydroxylase. The inhibition by estradiol of 7 alpha-hydroxylase obtained in vitro occurred with amounts of estradiol that were found to accumulate in the liver via in vivo treatment. Double-reciprocal analysis showed that at and below 50 micrograms of estradiol/0.5 mg of protein uncompetitive inhibition was displayed. Additional experiments showed that adding Triton to microsomes obtained from estradiol-treated rats increased the activity of 7 alpha-hydroxylase to control levels. In contrast, Triton did not increase the activity of 7 alpha-hydroxylase when it was added to control microsomes. These data show for the first time that the estrogenic steroid estradiol acts directly on the microsomes and inhibits both the activity of 7 alpha-hydroxylase and the rate of bile acid synthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Obstructive cholangitis secondary to mucus secreted by a solitary papillary bile duct tumor

A middle-aged woman had repeated episodes of common bile duct obstruction and cholangitis caused by profuse secretion of mucus by a solitary papillary tumor in the left hepatic duct. This complication usually occurs only with papillomatosis. The tumor initially appeared to be benign but subsequently was proven to be an invasive adenocarcinoma. Although the tumor recurred after surgical resection, her course remained uneventful without spread of the neoplasm for 3 yr.

Gastrointestinal transit time in human pregnancy: prolongation in the second and third trimesters followed by postpartum normalization

Fifty-nine studies of gastrointestinal transit time were performed in 27 healthy women during pregnancy and postpartum. Gastrointestinal transit time was defined as the time of the first sustained rise in breath hydrogen concentration after ingestion of 10 g of lactulose. Gastrointestinal transit time was significantly prolonged in both the second and third trimesters of pregnancy (125 +/- 48 min and 137 +/- 58 min, respectively) when compared with either the first trimester of pregnancy or the postpartum period (99 +/- 39 min and 75 +/- 33 min, respectively). Transit times measured in the first trimester were not significantly different from those postpartum. Because the prolongation of transit time in late pregnancy is transient, it is probably due to hormones (perhaps progesterone) or other metabolic effects of pregnancy.

Plasma decay of chylomicron remnants is not affected by heparin-stimulated plasma lipolytic activity in normal fasting man

In an earlier study it was shown that retinyl palmitate appeared to be a satisfactory label for the core of chylomicrons and their remnants. When chylomicrons were endogenously labeled with retinyl palmitate and pulse-injected into healthy donors, retinyl palmitate was cleared from plasma by a first order process. Its fractional decay constant was very similar to the fractional catabolic rate of VLDL triglycerides, a lipoprotein lipase-dependent process, and 2-3 times slower than hepatic chylomicron remnant uptake in experimental animals. We, therefore, investigated whether plasma clearance of retinyl palmitate-labeled chylomicrons is accelerated by enhanced plasma triglyceride hydrolysis produced by heparin administration. Five healthy subjects took retinyl palmitate by mouth and 5-6 hr later two units of plasma were obtained by plasma-pheresis. After storage for 42 hr, the units were pooled and separated into two equal volumes. The first half was injected into the donor and plasma retinyl palmitate and chylomicron triglyceride were measured for 3.5 hr (control study). Heparin was then given intravenously as a bolus followed by an infusion for 7 hr. A second retinyl palmitate clearance (postheparin study) was performed during the heparin infusion. Plasma lipolytic activity and retinyl palmitate and chylomicron triglyceride concentrations were measured serially. Total plasma lipolytic activity and hepatic triglyceride lipase activity were increased approximately 500-fold during postheparin studies, enhancing triglyceride decay 2.5- to 3-fold. Retinyl palmitate plasma decay, however, was unaffected. Retinyl palmitate plasma decay was a biexponential concentration-dependent function in eighty of ten pre- and postheparin studies with the first, rapid exponential accounting for 90 +/- 4% of total plasma retinyl palmitate decay.(ABSTRACT TRUNCATED AT 250 WORDS)

[Success and failure rate in peridural anesthesia. A 1-year study]

The real significance of epidural anaesthesia is determined by its practicability in the daily routine. The present paper shows, that about 20% of all operations which will be anaesthetized by a large anaesthesia department can be done under epidural anaesthesia. In 84,6% of all patients under epidural anaesthesia, anaesthesia was satisfactory; 4.7% of epidural anaesthesias were failures. The difficulty of epidural puncture and of advancing the epidural catheter were examined, as well as the degree of the necessary sedation. The main complication is puncture of the dura, in our series in 1,7% of the cases. We also examined the results achieved in relation to the state of training and in special cases of epidural anaesthesia. In the most interesting special case, namely patients requiring repeated epidural anaesthesia the success rate decreased significantly and the number of complications increased. The dosage-scheme for local anaesthetic given by Bromage has been confirmed in our patients. A simplified diagram and an approximate formula for calculation of dosage are given.

Plasma clearance of chylomicrons labeled with retinyl palmitate in healthy human subjects

To estimate hepatic uptake of chylomicron remnants in humans, chylomicrons and intestinal very low density lipoproteins (VLDL) were endogenously labeled with retinyl esters, harvested by plasmapheresis, and pulse-injected into the donor 44 hr after plasmapheresis. Plasma decay of retinyl palmitate was measured in eight healthy volunteers. Retinyl palmitate plasma disappearance obeyed an apparent first order function in seven studies and, in one study, a biexponential function with the second, slow exponential accounting for only 13% of the retinyl palmitate plasma decay. The mean fractional removal of rate was 0.037 +/- 0.037 min-1 (mean +/- SD) in a one-compartment model. The apparent volume of distribution, Vd, was 109 +/- 25% of the estimated plasma volume. Plasma clearance of retinyl palmitate was 130 +/- 97 ml/min calculated as Vd x Ke. Mean T 1/2 was 29 +/- 16 min. Both in vitro and in vivo the retinyl palmitate remained largely within chylomicrons and intestinal VLDL. Only 4.3% was transferred from chylomicrons to other lipoprotein classes during in vitro incubation for 5 hr. After plasma was stored for 42 hr, 5% was transferred to higher density lipoproteins. During 12 hr after a test meal containing retinyl palmitate, only 6.4 +/- 1.5% of the retinyl palmitate absorbed was found in the LDL fraction and 3.1 +/- 3.8% in the d 1.063 g/ml lipoproteins. We conclude that retinyl palmitate is a useful marker for chylomicrons and their remnants in humans and that the plasma clearance of retinyl palmitate-labeled chylomicrons is probably an estimate of chylomicron remnant plasma clearance in man.

Controlled trial of medical therapy for active upper gastrointestinal bleeding and prevention of rebleeding

This multicentered, placebo-controlled trial evaluated the efficacy of medical therapy to stop bleeding in 285 patients with active upper gastrointestinal bleeding (bleeding phase) and 194 patients who had ceased gastrointestinal bleeding and in whom therapy was instituted to prevent rebleeding during the same hospitalization (prevention phase). Patients in the bleeding phase were given cimetidine (300 mg every six hours) or intravenous placebo. There was no significant overall difference between intravenous cimetidine (71 percent) and placebo (77 percent) in stopping acute upper gastrointestinal bleeding. There was also no significant difference noted between intravenous cimetidine and placebo when specific bleeding lesions were evaluated. Once gastrointestinal bleeding had stopped, recurrence of bleeding while receiving prevention therapy (cimetidine tablets 300 mg one three times a day and at bedtime, or Mylanta II liquid 30 ml every hour, or cimetidine plus hourly antacids, or placebo) was evaluated in 194 of the patients in the bleeding phase. Twenty-four percent (12 of 51 patients) rebled while receiving cimetidine, 13 percent (five of 39 patients) rebled while receiving hourly antacids, 11 percent (six of 54 patients) rebled while receiving cimetidine plus hourly antacids, and 26 percent (13 of 50 patients) rebled while receiving placebo. None of these prevention regimens reached statistical significance (p = 0.13). Evaluation of specific bleeding lesions within this group also failed to show any significant value of prevention therapy.

IN CONCLUSION

(1) intravenous cimetidine offers no advantage over placebo in stopping active upper gastrointestinal bleeding; (2) the occurrence of rebleeding during the same hospitalization does not appear to be significantly affected by any of the medical regimens used for prevention. These findings would suggest that the cessation of active bleeding and the prevention of recurrent upper gastrointestinal bleeding during a single hospitalization appear to be unaffected by therapy directed at acid neutralization or reduction.

Coordination of gastric and gallbladder emptying after ingestion of a regular meal

The relationship of gallbladder emptying and refilling to gastric emptying of solids, gastrointestinal transit time, and human pancreatic polypeptide response was examined after ingestion of a standard breakfast (40% fat) in 12 healthy men and women. Gallbladder volume, emptying, and refilling was measured by real-time ultrasonography, and gastric emptying of solids was measured scintigraphically by the disappearance from the stomach of egg labeled with 99mTc-sulfur colloid. Gastrointestinal transit time was defined as the time of initial rise in breath hydrogen following ingestion of 10 g of lactulose. Serum human pancreatic polypeptide level was measured by radioimmunoassay. Gallbladder emptying was biphasic, initially 0.015 +/- 0.003 min-1 and later 0.005 +/- 0.001 min-1, and gallbladder volume remained small until refilling began at 249 +/- 67 min. Gallbladder refilling was 70% complete at 335 +/- 57 min. The slower rate of gallbladder emptying and tonic gallbladder contraction occurred during gastric emptying of solids. Gallbladder refilling began when approximately 13% of solids remained in the stomach. Serum human pancreatic polypeptide showed the expected biphasic response to the meal and returned to basal levels at approximately the time of initiation of gallbladder refilling. The gastrointestinal transit time of women was twice that of men (73.6 +/- 20.2 vs. 37.5 +/- 22.7, p = 0.025). No other sex-related differences were detected. We conclude that gastric emptying of the solid portion of a meal containing fat maintains tonic gallbladder contraction through continued release of humoral mediators from small bowel and pancreas. When gastric emptying nears completion, humoral stimulation ceases and the gallbladder refills. Human pancreatic polypeptide does not appear to be responsible for gallbladder refilling.

[Epidural buprenorphine for postoperative analgesia after hip operations]

Two groups of 20 patients each were given immediately after hip-operation an epidural injection of 0,15 or 0,3 mg buprenorphine. Effects and side effects are compared with those observed in two groups of patients having the same type of operation, and given either 4 mg of morphine or saline (placebo) by epidural injection. Buprenorphine in both doses produced a shorter duration of analgesia than 4 mg of morphine. In no case did respiratory depression occur. Urinary retention after buprenorphine was barely more frequent than in the placebo group. Nausea and vomiting occurred in 35-45% of patients. We do not see an advantage in replacing morphine by buprenorphine for epidural opiate-analgesia, because the same high rate of nausea/vomiting is associated with a significantly shorter duration of analgesia after buprenorphine. We are convinced that epidural opiate-analgesia is most valuable for postoperative pain relief but should be reserved for selected cases.

Gallbladder and small intestinal regulation of biliary lipid secretion during intraduodenal infusion of standard stimuli

The gallbladder and small intestine are reservoirs for the bile acid pool during its enterohepatic circulation and, as such, may regulate biliary secretion of bile acid. During studies of biliary bile acid secretion, a stimulus to gallbladder contraction is continuously infused into the duodenum. Under these conditions, it is assumed that the gallbladder is tonically contracted and that the rate of bile acid secretion into the duodenum equals the hepatic bile acid secretion rate. However, secretion rates vary by as much as 100%, depending upon which of two standard stimuli is used. Therefore, we studied the role of gallbladder emptying and small intestinal transit in determining biliary lipid secretion rate and composition during infusion of these stimuli in five healthy subjects. Each subject was studied with a liquid formula containing 40% of calories as fat, and with an amino acid solution for 10 h. Bile acid, phospholipid, cholesterol, and markers were measured in duodenal bile and hourly secretion rates were calculated by marker dilution technique. Real-time gallbladder sonographs and serum pancreatic polypeptide levels were obtained every 30 min. Small bowel transit time was estimated levels were obtained every 30 min. Small bowel transit time was estimated by the breath hydrogen response after giving lactulose intraduodenally.During liquid formula infusion, gallbladder emptying was more complete, small intestinal transit was faster, and pancreatic polypeptide levels were higher. Secretion rates of all lipids were greater and molar percent cholesterol was lower. For the combined data from both infusions, the secretory relationships of cholesterol to bile acid, cholesterol to phospholipid, and phospholipid to bile acid were curvilinear. We conclude that more complete gallbladder emptying and faster intestinal transit increase the enterohepatic cycling of bile acids and lower the molar percent cholesterol of bile. Some of the fluctuation observed in biliary lipid secretion rates, especially during amino acid infusion, is due to gallbladder refilling and emptying.

The biliary tract in inflammatory bowel disease

In summary, the biliary tract seems particularly vulnerable to damage in patients with chronic inflammatory bowel diseases. The intrahepatic histological features of the common entity, pericholangitis, and the uncommon lesion, sclerosing cholangitis, overlap and, some feel, may be different manifestations of the same hepatobiliary insult. The potentially important role for cholangiography in distinguishing between usually banal and frequently serious disease is evident. Not knowing the cause of either lesion, appropriate preventive measures or treatment are not available. The role of the inflammatory disease in the potential development of cholangiocarcinoma is not clear. Cholelithiasis secondary to ileal dysfunction is usually independent of the other three processes.

Biliary lipids, bile acids, and gallbladder function in the human female: effects of contraceptive steroids

Individuals who take contraceptive steroids or estrogens are at increased risk of developing cholesterol gallstones. The mechanisms of the increased stone formation are incompletely understood. In this study we report biliary lipid composition and secretion, bile acid composition and kinetics, and gallbladder function in a group of healthy, nonobese women taking a contraceptive steroid preparation. A comparable group of healthy women served as controls. Bile-rich duodenal fluid was obtained after stimulation of gallbladder contraction; bile acid, phospholipid, and cholesterol concentrations were determined. Biliary lipid secretion rate was measured by the marker perfusion technique. Bile acid distribution was determined by gas-liquid chromatography. The pool size, FTR, and synthesis rate of each bile acid were measured by using CA and CDCA labeled with the stable isotope of carbon, 13C. In some of the subjects gallbladder storage and emptying were measured during the kinetic study, by real-time ultrasonography. Contraceptive steroid use was associated with a significant increase in biliary cholesterol saturation and in the lithogenic index of bile. The rate of cholesterol secretion in the contraceptive steroid group was 50% greater than in the control (p much less than 0.001) and the rate of bile acid secretion was reduced (p less than 0.02). The total bile acid pool size was significantly increased by contraceptive steroids. The major increase occurred in the CA pool (p less than 0.04). The daily rate of enterohepatic cycles of the bile acid pool was decreased by contraceptive steroids from 6.6 to 4.3 (p less than 0.01). The only effect of contraceptive steroids on gallbladder function was a slower emptying rate in response to intraduodenal amino acid infusion. No index of gallbladder function correlated significantly with any parameter of bile acid kinetics in this small group of subjects. The findings confirm the lithogenic effect of contraceptive steroids and indicate that its causes are an increase in cholesterol secretion and a decrease in bile acid secretion.

Gallbladder function in the human female: effect of the ovulatory cycle, pregnancy, and contraceptive steroids

We have previously shown that in pregnancy fasting gallbladder volume is increased and emptying after a small volume liquid meal is incomplete. In this study we measured gallbladder volume throughout day and night in healthy women ingesting regular meals. Pregnant women, postpartum women, contraceptive-steroid users, and controls in both phases of the ovulatory cycle were studied. After an overnight fast gallbladder volume was measured by realtime ultrasonography in the fasting state and every 5-10 min for 90 min after breakfast. Residual volume was the lowest volume achieved and the rate constant of gallbladder emptying was calculated from the ln/linear regression of gallbladder volume vs. time. Gallbladder volume was also measured hourly from 11 AM to midnight while subjects ate regular, standard meals, allowing the determination of an average hourly volume. There was no effect of phase of the ovulatory cycle on any measure of gallbladder function. Fasting, residual, and average hourly volume were increased in all trimesters of pregnancy, but tended to return to normal in the postpartum period. Women taking contraceptive steroids had an increased fasting volume. Two distinct rates of emptying after breakfast, an early and a late one, were identified. The early rate was the same in all groups. Pregnant women had a slower late rate of emptying, but women taking contraceptive steroids had emptying rates similar to controls. Retention of bile in the gallbladder may be one reason for the increased risk of cholesterol cholelithiasis in pregnant women and in those taking contraceptive steroids.

[Postoperative analgesia with epidural morphine after hip operations (author's transl)]

80 patients undergoing hip surgery under lumbar epidural block have been studied (double blind) for postoperative analgesia. There were 4 groups, of 20 patients each, who received a single epidural injection of 0 mg, 2 mg or 4 mg morphine in 1 ml of saline added to 6 ml bupivacaine 0.5% or 4 mg morphine in 6 ml saline. In the morphine groups analgesia lasted between 37 and 50 hours. No neurological side-effects or severe respiratory depression have was observed; but a significant rise of paCO2 was found. Other side-effects were nausea/vomiting and the need for catheterisation in about 50% of patients. We conclude, that the indications for epidural analgesia with morphine have to be chosen carefully.

A method for the accurate measurement of isotope ratios of chenodeoxycholic and cholic acids in serum

A method for the extraction of bile acids from serum is described that enables the stable isotopic content of chenodeoxycholic acid and cholic acid to be determined accurately to levels as low as the natural 13C abundance. The method uses Sep-Pak C18 reverse phase cartridges both for extraction and purification procedures. Free bile acids, bile acid conjugates, and 3-monosulfated bile acid conjugates are recovered in high yield from the Sep-Pak in methanol-water 75:25 after first removing impurities with hexane and methanol-water 40:60 washes. Other important features of the method include the use of enzymatic rather than alkaline hydrolysis of bile acid conjugates, the use of ammonia as the reagent gas for chemical ionization mass spectrometric measurement of isotopic ratios, and the exclusion of all extraneous components in the final sample from the ion source. This method should be applicable to kinetic studies of bile acids using bile acids labeled with stable isotopes and serum measurements, and provides an alternative sampling point in the enterohepatic circulation to conventional duodenal bile samples requiring intubation.

Biliary lipids, bile acids, and gallbladder function in the human female. Effects of pregnancy and the ovulatory cycle

To study the events that might lead to an increased risk of cholesterol gallstones, we examined biliary lipid composition and secretion and bile acid composition and kinetics at different stages of pregnancy or ovulation in young, nonobese, healthy women. Lipid composition and bile acid distribution were determined in duodenal fluid obtained in the fasting state and after stimulation of the gallbladder. Biliary lipid secretion was measured by the marker-perfusion technique. Bile acid kinetics were determined with cholic and chenodeoxycholic acids labeled with carbon13, by measuring the relative abundance of 13C in duodenal bile acids for 4--5 d. In a subset of patients we measured gallbladder storage and emptying during the kinetic study. The phase of the ovulatory cycle had no effects, but there were significant changes during pregnancy. The lithogenic or cholesterol saturation index of fasting hepatic and gallbladder bile increased during the second and third trimesters. The mean secretion rate of biliary lipids was not altered, but in the last two-thirds of pregnancy, cholesterol secretion increased in relation to bile acid and phospholipid secretion. There was a progressive decrease in the percentage of chenodeoxycholic acid and a similar increase in the percentage of cholic acid. The pool size of each major bile acid increased in the first trimester. Chenodeoxycholic acid and deoxycholic acid pools, but not cholic acid pools, subsequently decreased. The fractional turnover rate of both primary bile acids was slower during pregnancy. The synthesis rate of chenodeoxycholic but not cholic acid decreased in a linear manner during the first 20 wk of pregnancy. The rate of enterohepatic cycling of the bile acid pool was reduced throughout pregnancy. The volume of the fasting gallbladder and the residual volume after a physiologically stimulated contraction were directly correlated with bile acid pool size. The residual volume was also directly related to total bile acid synthesis.

Effect of antral instillation of bile salts on fasting serum gastrin levels

There have been several reports that bile salts instilled into a dog's alkalinized antral pouch cause acid secretion in a denervated fundic pouch. Antral gastrin release was assumed, but serum gastrin levels were not measured. In a randomized crossover study, serum gastrin levels were measured by radioimmunoassay during the infusion of a solution of bile salts (5 mM, pH 5.5, 280 mOsm, 37 degrees C), or an identical saline solution without bile salts, into the pH-controlled (5.5) antrum of 8 volunteers. The mean baseline serum gastrin level (+/- SE) was 18.7 +/- 1.0 and 20.5 +/- 0.9 pg/ml for the bile salt and control periods, respectively (NS). The serum gastrin rose promptly after bile salt infusion, but not after saline. The mean (+/- SE) integrated gastrin response was 81 +/- 17 pg . min/ml during the bile salt infusions, but essentially zero (-3.3 +/- 22 pg . min/ml) during control infusions (P less than 0.02). The 40% rise in serum gastrin in the initial 15-min bile salt period was higher than in the control period (P = 0.016). Thus we have shown, for the first time, an increase in serum gastrin during the antral instillation of bile salts in man. The potential physiologic and/or pathologic importance of this finding has not been established.

Drug-induced pancreatitis: a critical review

We critically reviewed the English language literature pertaining to drug-induced pancreatitis and attempted to determine whether the reported association between each drug and pancreatitis was valid. The following drugs seem to cause pancreatitis: azathioprine, thiazides, sulfonamides, furosemide, estrogens, and tetracycline. Less convincing, but suggestive evidence exists for: 1-asparaginase, iatrogenic hypercalcemia, chlorthalidine, corticosteroids, ethacrynic acid, phenformin, and procainamide. Evidence implicating other drugs is either inadequate or contradictory. Little is known about the pathogenesis of drug-induced pancreatitis. Ethanol was not considered in this review.

Effects of pregnancy and contraceptive steroids on gallbladder function

We used real-time ultrasonography to study gallbladder kinetics in 11 nonpregnant women, 17 women using steroid contraceptives, and 33 pregnant women. Gallbladder volume was determined after an overnight fast and serially for 90 minutes after a standard liquid meal. After the first trimester of pregnancy, gallbladder volume during fasting and residual volume after contraction were twice as large as in control subjects. The rate of emptying and the percentage emptied were reduced. In early pregnancy the only important abnormality was a 30 per cent decrease in emptying rate. Gallbladder function was not affected by contraceptive steroids. Incomplete empyting of the gallbladder in late pregnancy leaves a large residual volume and may cause retention of cholesterol crystals, a prerequisite for cholesterol-gallstone formation. These findings are consistent with the view that pregnancy increases the risk of cholesterol gallstones. The increased incidence of gallstones associated with contraceptive steroids does not involve abnormal gallbladder kinetics.

National Cooperative Crohn's Disease Study: study design and conduct of the study

The design and execution of the National Cooperative Crohn's Disease Study are described in this paper. The Study incorporated several noteworthy features developed to meet specific demands of the disease and its therapy. A standard clinical grading system, the Crohn's Disease Activity Index (CDAI) was developed to allow uniform decentralized clinical evaluation and decision-making throughout the 5 yr of the study. All three drugs in widespread clinical use in Crohn's disease were studied both for suppressive and prophylactic efficacy and for toxicity. The study employed a scheme for double-blind evaluation of patient progress which allowed adjustment of prednisone dose according to the degree of illness and ensured continuous monitoring for serious toxicity of any study drug. Results were analyzed primarily by ranking the clinical outcome of every patient according to a uniform and detailed scheme and applying Wilcoxon nonparametric statistics. Outcome was also analyzed by life-table methods. Eleven hundred nineteen patients were entered and 604 patients were randomized at 14 study centers during the 5-yr duration of the study. Twenty patients were eliminated from analysis as not meeting diagnostic criteria for Crohn's disease, and another 15 patients were eliminated as not meeting other preestablished criteria for analysis. Nine percent of randomized patients, equally distributed in the four treatment groups, withdrew as noncompliant. Ninety percent of patients completed all or all but one protocol-specified visits, and 95% completed the final radiologic and sigmoidoscopic evaluation.

A trial of sulfasalazine as adjunctive therapy in Crohn's disease

The effect of the combination of sulfasalazine and prednisone has been compared with that of prednisone and placebo in 89 actively symptomatic patients with Crohn's disease in a double-blind, randomized, multicenter controlled trial. The combination was less effective than prednisone alone in treatment of active symptomatic disease. The probability of obtaining this result, if sulfasalazine truly has a clinically useful effect equal to or greater than that specified in the calculation, is less than 1%. Patients who were in remission at the end of 8 wk were rerandomized to receive either the two drugs together or prednisone plus placebo while repeated systematic attempts to withdraw prednisone were made over the next 6 mo. Sulfasalazine showed no prednisone-sparing effect as judged either by outcome ranking or total dose of prednisone consmed by the two treatment groups. However, in this comparison the probability is greater than 5% that, given the results observed, a clinically useful effect of sulfasalazine of specified minimum degree truly exists. It was possible to withdraw prednisone from 25% of patients at the first attempt and ultimately in 37%.

[Early diagnosis of small airways disease in young smokers (author's transl)]

Investigations during the past years have established that determinations of closing volume, flow-volume curves and frequency-dependent compliance are capable of detecting pathological changes in the bronchial system at a time when the customary lung function tests (FEV1.0 resistance as measured by bodyplethysmography) are still normal. These observations have been made use of to diagnose incipient damage in persons exposed to bronchial noxae. In the present investigation the effect of smoking on the airways was studied in a group of 25 persons aged 20-25 years by determining the closing volume and differences in ventilatory distribution (Thews method). The results were compared with those obtained in a group of 27 non-smokers in the same age group.

Binding of bile acids by dietary fiber

Binding of bile salts to food residue was studied in vitro and in vivo. In the in vitro experiments, residues of a number of foods were incubated with each of several bile salts at different concentrations and pHs. All food residues tested adsorbed more dihydroxy than trihydroxy bile salts. Bile salt binding increased as bile salt concentration increased and was greater at a low pH. The extent of bile salt adsorption to some food residues could be clinically important. In patients with short ileal resections, we compared the rates of fecal excretion of labelled cholic and chenodeoxycholic acids and of a nonabsorable marker during ingestion of an ordianry diet (approximately 5 g of fiber) and a residue-free liquid diet. Coefficients of bile salt adsorption were calculated. Both bile acids were absorbed more efficiently during the liquid diet. Chenodeoxycholic acid was preferentially bound to the particulate matter of stools of patients eating the fiber-containing diet. It seems possible that dietary fiber could affect the enterohepatic circulation of bile salts in certain patients with ileal resection.

Reversal by triton WR-1339 of ethynyloestradiol-induced hepatic cholesterol esterification

RATS TREATED WITH ETHYNYLOESTRADIOL HAVE MARKED HYPOLIPIDAEMIA: serum cholesterol is decreased to 5%, triacylglycerol to 10% and phospholipid to 70% of control concentrations. Loss of serum cholesterol follows an exponential decay, with a half-life of 1.13+/-0.09 days. After 4 days of treatment, serum cholesterol concentrations remain relatively constant (ranging from 1 to 20mg/100ml) for at least 30 days. There is a concomitant 20-fold decrease in the d<1.21 fraction of serum proteins and a similar decrease in serum apolipoproteins as measured by sodium dodecyl sulphate/10%-polyacrylamide-gel electrophoresis. The activity of hepatic microsomal acyl-CoA-cholesterol O-acetyltransferase (EC 2.3.1.26) was significantly increased by ethynyloestradiol treatment (P<0.05). This activation caused hepatic cholesteryl esters containing mainly C(18:1) fatty acids to increase linearly as serum cholesterol concentrations decreased (r=0.9675, P<0.001). Triton WR-1339, a non-ionic detergent that inhibits lipoprotein catabolism, was used to estimate hepatic lipid secretion by measuring the increment in serum lipids after its administration. At 15h after Triton WR-1339 administration, serum cholesterol concentrations were increased equally in both control and ethynyloestradiol-treated rats. In contrast, the increment of serum triacylglycerol of treated rats was 40% of that found in control rats, indicating that ethynyloestradiol inhibits hepatic triacylglycerol secretion. Triton WR-1339 inhibited the oestrogen activation of hepatic microsomal acyl-CoA-cholesterol O-acyltransferase and restored hepatic cholesteryl ester concentrations to normal values. These data suggest that ethynyloestradiol and its pharmacological ;antagonist' Triton WR-1339 alter hepatic triacylglycerol secretion via a mechanism associated with changes in hepatic cholesterol esterification.

Effect of ethynylestradiol on biliary excretion of bile acids, phosphatidylcolines, and cholesterol in the bile fistula rat

The effects of ethynylestradiol on endogenous bile acids, their capacity to conjugate and excrete intravenously infused cholic acid, the concentrations of biliary cholesterol and lecithin, and the individual molecular species of phosphatidylcholine have been determined in male and female Sprague-Dawley rats. Endogenous biliary bile acids were analyzed by gas-liquid chromatography-mass spectrometry. Eleven bile acids were identified and several minor bile acids, primarily muricholates, could not be completely characterized. After 5 days of treatment with ethynylestradiol (1 mg/kg per day), the percentage of cholic acid decreased and the percentage of 6beta-hydroxylated bile acids, including several monounsaturated species, increased. Ethynylestradiol caused a decrease in bile acid-independent bile flow. Intravenous infusion of cholic acid at a high concentration caused cholestasis in control animals but, after ethynylestradiol treatment, cholestasis developed during the infusion of a much lower concentration of cholate, indicating a lowered threshhold for bile acid-induced cholestasis. In the treated rats, there was a slight increase in excretion of unconjugated endogenous bile acids, and a striking impairment of conjugation of intravenously administered cholic acid. One of the few sex-related differences observed was an increased concentration of biliary phospholipids in untreated male rats. Both phospholipid and cholesterol concentrations in the bile were higher in the treated animals. The molar percentage of cholesterol was always 1-2%, but it was slightly higher in treated animals, especially males. Ethynylestradiol treatment also affected biliary phospholipid by causing a marked increase of phosphatidylcholine species containing palmitic and oleic acid residues and a decrease of species containing stearic and linoleic acid residues. There was no increase in biliary excretion of long chain polyunsaturated species, which might have indicated damage to membranes, in response to ethynylestradiol either alone or with cholic acid infusion. Some of these ethynylestradiol-induced changes in biliary bile acid and lipid excretion are probably peculiar to the rat, but others, such as the increase in molar percentage of cholesterol and cholestasis, may be relevant to disorders in man, especially cholesterol gallstones and idiopathic cholestasis of pregnancy.

Increased sulfation and decreased 7alpha-hydroxylation of deoxycholic acid in ethinyl estradiol-induced cholestasis in rats

Deoxycholic acid conjugation, transport capacity, and metabolism were compared in control and ethinyl estradiol-treated rats. Control rats were found to have a lower capacity to transport deoxycholic acid than taurodeoxycholic acid, and both were decreased by ethinyl estradiol treatment. During [24-14C]sodium deoxycholate infusion, [14C]biliary bile acid secretion increased, but bile flow did not change significantly in either control or ethinyl estradiol-treated rats. Ethinyl estradiol-treated animals excreted significantly less 14C as taurocholic acid than did control animals, consistent with an impairment of 7alpha-hydroxylation of taurodeoxycholic acid. Ethinyl estradiol treatment did not impair conjugation of deoxycholic acid, but did result in an increase in sulfation of taurodeoxycholic acid from 1.5% in controls to nearly 4.0% (P less than 0.01). These results are consistent with the hypothesis that the rat has a poorer tolerance for deoxycholic acid than do certain other species. Furthermore, the rat converts deoxycholic acid, a poor choleretic, to taurocholic acid, a good choleretic. When this conversion is impaired with ethinyl estradiol treatment, sulfation may be an important alternate pathway for excretion of this potentially harmful bile acid.

Minimal bile acid malabsorption and normal bile acid breath tests in cystic fibrosis and acquired pancreatic insufficiency

This study was undertaken because of reports of a marked increase in fecal bile acid excretion by children with cystic fibrosis. We attempted to confirm this finding by performing [1-14C]cholylglycine breath tests and by measuring fecal bile acid and fat excretion in patients with cystic fibrosis and acquired pancreatic insufficiency. Studies were done when patients were taking pancreatic enzymes (Cotazym) and also without medication. 14CO2 excretion in breath was normal in patients with acquired pancreatic insufficiency and even lower in cystic fibrosis, both with and without Cotazym therapy. Fecal bile acid excretion was slightly elevated in both groups without Cotazym and became normal with Cotazym in patients with acquired pancreatic insufficiency. Steatorrhea was present in both patient groups and improved during Cotazym therapy. Bile acid malabsorption in cystic fibrosis and acquired pancreatic insufficiency is minimal and probably not clinically important.

Prednisone therapy for alopecia areata. A follow-up report

Eighteen patients treated with prednisone on alternate days for varying degrees of alopecia areata (AA) were examined a mean of 15 months after discontinuation of the drug. Despite an initial response to the therapy, long-term benefit was not thought to be substantial. Numerous side effects related either to systemic corticosteroids or to AA were apparent during the course of therapy, as well as at the time of the evaluation reported herein. Acne, obesity, lenticular opacities, mild hypertension, and impaired adrenocorticotropic hormone (ACTH) reserve were among the findings noted. Long-term treatment was not accompanied by an obvious beneficial change in the natural course of AA. Because of the potentially serious side effects and the lack of substantial improvement in the eventual course, alternate-day prednisone therapy is not recommended for long-term use in AA.