[Psychosocial problems of adolescents and adults with congenital heart defects]

Despite successful medical treatment and hemodynamic good results after surgical correction, relevant psychosocial problems occur in adult patients with congenital heart disease. 146 patients in Germany with simple but also with complex congenital heart defects were examined by means of a questionnaire to look into these problems. Although most of the patients belonged to Ability Index I or Ability Index II of J. Somerville, almost 60% felt not healthy and impaired. The level of education was above average. 98% had attended a regular school, 23% a secondary school, and 15% had attended university. The congenital heart disease negatively affected the choice of occupation for 25% of the patients, but only 8.6% had difficulties when they applied for a job. The majority of patients was employed and satisfied with their occupation. Most of them were working in physically less demanding jobs. Sporting activities were widespread, although half of the patients felt impaired by the congenital heart disease when performing sports. All patients had some kind of health insurance. Most of them were enrolled in the common public health insurance plan. The insurers paid for almost all expenses caused by the congenital heart disease. More than 30% were not accepted by life insurance companies. Only 1.4% were members of a self-help-group for congenital heart disease. The knowledge of these occurring problems may help to improve the treatment of adult patients with congenital heart disease and, moreover, infants and adolescent patients who still have to reach adulthood may later benefit from this information.

Management of clinically relevant bleeding following endoscopic sphincterotomy

We report here on our experience of clinically relevant bleeding after endoscopic sphincterotomy (ES). Relevant bleeding was defined by the occurrence of (a) hematemesis or melena and (b) at least a two-point drop in hemoglobin, with no other bleeding source on endoscopy. These two criteria were met in 16 patients between 1983 and 1992. They represented 0.65% of all ES procedures performed during this period. Bleeding occurred immediately after ES in five cases, and was delayed in 11 cases from one to eight days (mean two days). Patients were retrospectively classified into three groups according to the severity of bleeding and subsequent clinical management. In six cases (group 1), bleeding developed slowly without shock and stopped spontaneously. In five cases (group 2), bleeding developed rapidly with melena and a drop in hemoglobin, but without shock. These patients were successfully managed with sclerotherapy without any further complications. The five patients in Group 3 had brisk bleeding with hematemesis and shock. Endoscopic hemostasis could not be performed; emergency arteriography disclosed active bleeding in four patients, and embolization of the gastroduodenal artery was performed. Bleeding stopped in all patients. Billroth II anastomosis appeared to be the only factor associated with an increased risk of clinically relevant bleeding. It was possible to control bleeding following ES using endoscopic or angiographic hemostasis, surgery being avoided in all cases.

Cloning of a gene involved in rRNA precursor processing and 23S rRNA cleavage in Rhodobacter capsulatus

In Rhodobacter capsulatus wild-type strains, the 23S rRNA is cleaved into [16S] and [14S] rRNA molecules. Our data show that a region predicted to form a hairpin-loop structure is removed from the 23S rRNA during this processing step. We have analyzed the processing of rRNA in the wild type and in the mutant strain Fm65, which does not cleave the 23S rRNA. In addition to the lack of 23S rRNA processing, strain Fm65 shows impeded processing of a larger 5.6-kb rRNA precursor and slow maturation of 23S and 16S rRNAs from pre-23S and pre-16S rRNA species. Similar effects have also been described previously for Escherichia coli RNase III mutants. Processing of the 5.6-kb precursor was independent of protein synthesis, while the cleavage of 23S rRNA to generate 16S and 14S rRNA required protein synthesis. We identified a DNA fragment of the wild-type R. capsulatus chromosome that conferred normal processing of 5.6-kb rRNA and 23S rRNA when it was expressed in strain Fm65.

[Cardiopulmonary capacity in patients before and after prosthetic valve replacement]

In this study we wanted to investigate if noninvasive cardiopulmonary exercise testing can be securely, accurately applied in patients with acquired cardiac valve disease pre- and postoperatively with any convenience. Furthermore, we looked if the cardiopulmonary exercise capacity (anaerobic threshold, etc.) was improved postoperatively (3 and 6 months) in 15 patients suffering from severe mitral valve disease as compared to the preoperative condition. The symptom-limited cardiopulmonary exercise testing was performed on a bike in a semi-supine position using a ramp program (+20 W/min). The following parameters were continuously monitored, and the breath-by-breath gas exchange values documented: cardiocirculatory parameters (heart rate; blood pressure; surface ECG; exercise capacity in Watts); gas-exchange parameters (O2-uptake VO2; CO2-production VCO2; respiratory anaerobic threshold VO2 AT; gas-exchange ratio VCO2/VO2; O2-pulse VO2/HR; aerobic capacity delta VO2/delta WR) and ventilatory parameters (respiratory rate; tidal volume Vt; minute ventilation VE; equivalent for O2: VE/VO2 and CO2: VE/VCO2). The 155 cardio-pulmonary exercise tests in 115 patients were practicable, safe (no emergency case) and accurate. In 100 patients late postoperatively (68.3 +/- 53.0 -102.9 +/- 41.2 months) after aortic or mitral valve replacement or both without signs of significant hemolysis or prosthetic valve dysfunction the NYHA classification was too imprecise to characterize the actual exercise capacity of the patients (e.g., NYHA class II: Weber class B to E). Patients with aortic valve prosthesis had a significantly better anaerobic threshold (57.4 +/- 19.1% pred. value max. VO2) as compared to those with mitral valve replacement (mean: 35.9% pred. value max. VO2).(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiopulmonary capacity in patients with coronary heart disease]

Cardiopulmonary exercise testing (CPX) allows a non-invasive control of the cardiopulmonary exercise capacity. In this study, we wanted to investigate if the CPX can be securely, practicably, and accurately performed in patients with invasively documented coronary heart disease (CHD). Furthermore, we wanted to find out the clinical value of CPX in CHD diagnosis. The CPX measurements (symptom-limited; ramp program with 20 Watts increase/min; semi-supine position; continuous registration of the cardio-circulatory parameters (HR, RR, ECG), of the gas exchange parameters (O2, CO2) and of the ventilation) in 101 patients have shown that CPX is secure, accurate, and practicable. The day-to-day reproducibility is high (r > 0.8). The respiratory anaerobic threshold can be manually evaluated by means of the PET O2 criterion in 95% of the cases. The CCS-classification of angina pectoris could not accurately describe the cardiopulmonary exercise capacity as compared to the Weber-classification. The disadvantage of the Weber-classification is that it does not respect the age-, sex- and weight-dependent differences of the normal values. Our own data and results from the literature demonstrate that the anaerobic threshold, the maximum VO2 and the maximum O2-pulse are the more reduced the more coronary arteries are involved, the more reduced the left ventricular function is. But, nevertheless, the range of values shows large overlaps so that an exact differentiation, based upon these parameters, is not possible. Patients with similar functional results or degree of reduced exercise capacity have different morphological alterations. Most patients demonstrated typical ischemic cascade with anaerobic threshold, ST-segment alterations, angina pectoris and, finally, reduced max. VO2. In conclusion, CPX does not replace the traditional methods of non-invasive and invasive ischemia detection, but enables secure, practicable, and accurate measurements of the individual cardiopulmonary exercise capacity and the interaction between muscles, heart, circulation, and lungs. Possibly, CPX can be used in the near future for identifying CHD patients with low, medium or high risk.

[Effect of a single blood donation on ergo-spirometrically determined cardiopulmonary performance capacity of young healthy probands]

Autologous blood donation is an established method for an effective reduction of the blood-transfusion-associated infectious diseases (hepatitis, HIV infections, etc.) in elective surgical procedures. The aim of the study was to investigate the effects of a blood donation of 450 ml on the cardiopulmonary exercise capacity in 16 apparently healthy young subjects. The 24 cardiopulmonary exercise tests were performed on a bicycle ergometer (Ergoline 900) in a semisupine position, using a ramp program (+20 watt/min) 1-7 days before and 2 days after blood donation. By means of continuous breath-by-breath measurements of the gas exchange (VO2, VCO2) and ventilation parameters (minute ventilation VE), as well as of the routine parameters (heart rate, blood pressure, work rate) during incremental exercise the respiratory anaerobic threshold VO2AT, the maximum VO2 (VO2max and the maximal working capacity (max. WR) were determined. Serum hemoglobin concentration was significantly (p < 0.0005) reduced from 14.5 +/- 1.0 to 13.0 +/- 1.4 g/dl after blood donation. The ventilatory anaerobic threshold (before: 68.5 +/- 17.0; after: 52.0 +/- 20.3% pred. max. VO2), the max. VO2 (before: 124.2 +/- 21.3; after: 110.2 +/- 23.2% pred. max. VO2) and max. WR (before: 287.1 +/- 75.6; after 265.5 +/- 76.2 watt) fell significantly (VO2AT: p < 0.0005; max. VO2: p < 0.0005; max. WR: p < 0.025). Heart rate and minute ventilation showed a steeper increase (dHR/dWR: before: 0.31 +/- 0.06; after: 0.34 +/- 0.05 beats/min/watt; dVE/dWR: before: 0.29 +/- 0.05; after: 0.31 +/- 0.05 l/watt) in relation to the increase in WR after blood donation as compared to the test before.(ABSTRACT TRUNCATED AT 250 WORDS)

Potassium currents and effects of vitamin D-3 metabolites and cyclic GMP in rat osteoblastic cells

A K+ current (IK1), activated by depolarization above -20 mV, showing voltage-dependent inactivation within a few seconds and reduced by 40% by 1 mM TEA, was observed in all cells. In a few cells, we also observed a progressive K(+)-current increase during cell dialysis. The developing current (IK2) was not sensitive to 1 mM TEA and did not inactivate. It was detectable over the whole voltage range and slowly increased during 10 s depolarizations. 1,25-(OH)2D3 and 24,25-(OH)2D3 did not affect IK1, but induced a small K(+)-current increase in some cells showing no IK2. This effect was not mimicked by cyclic GMP analogs which, on the contrary, induced a K(+)-current decrease. 24,25-(OH)2D3 (even at 10(-11)M, but not 1,25-(OH)2D3, strongly reduced IK2. The results further document the diversity of voltage-gated currents of osteoblastic cells, confirm the existence of immediate effects of vitamin D-3 metabolites, which are independent of classical 1,25-(OH)2D3 receptors.

[Clinical experiences with four newly developed, surface modified stimulation electrodes]

Newly developed pacing electrodes with so-called porous surfaces promise a significantly improved post-operative pacing and sensing threshold. We therefore investigated four newly developed leads (ELA-PMCF-860 n = 10; Biotronik-60/4-DNP n = 10, CPI-4010 n = 10, Intermedics-421-03-Biopore n = 6) connected to two different pacing devices (Intermedics NOVA II, Medtronic PASYS) in 36 patients (18 men, 18 women, age: 69.7 +/- 9.8 years) suffering from symptomatic bradycardia. The individual electrode maturation process was investigated by means of repeated measurements of pacing threshold, electrode impedance in acute, subacute, and chronic phase, as well as energy consumption and sensing behavior in the chronic phase. However, with the exception of the 4010, the investigated leads showed largely varying values of the pacing threshold with individual peaks occurring from the second up to the 13th week. All leads had nearly similar chronic pacing thresholds (PMCF 0.13 +/- 0.07; DNP 0.25 +/- 0.18; Biopore 0.15 +/- 0.05; 4010 0.14 +/- 0.05 ms). Impedance measurements revealed higher, but not significantly different values for the DNP (PMCF 582 +/- 112, DNP 755 +/- 88, Biopore 650 +/- 15, 4010 718 +/- 104 Ohm). Despite differing values for pacing threshold and impedance, the energy consumption in the chronic phase during threshold-adapted, but secure stimulation (3 * impulse-width at pacing threshold) were comparable.

[Palliative treatment by endoprosthesis of icterus caused by distal biliary tumoral obstruction]

Between March 1982 and December 1987, 466 patients (256 women, 210 men, mean age 73 years) with tumor obstruction of the common bile duct were referred to our department. The causes of obstruction were carcinoma of the pancreas (298 patients), carcinoma of the ampulla of Vater (32 patients) and carcinoma of the common bile duct (136 patients). Endoscopical insertion of a biliary prosthesis was initially possible in 377 patients (81%). In case of failure, patients were referred to the radiologist for percutaneous drainage. Successful drainage was obtained in 58 patients with an overall success rate of 93% (435 patients). Endoscopic replacement was necessary in 170 cases for 114 patients and was successful in 155 (91%). Pruritus was relieved in 89% of the patients. Serum bilirubin levels decreased more than 75% after initial endoscopic endoprosthesis, repeated endoscopic endoprosthesis and percutaneous prosthesis insertion in 80%, 79%, and 62% of the patients, respectively. Short term complications of endoscopic endoprosthesis occurred in 28% of patients with a mortality rate of 8%. Percutaneous prosthesis complications occurred in 33% of patients with a mortality rate of 11%. In the long term, cholangitis was the main complication and occurred in 27% of patients with a delay of 103 +/- 105 days. Intestinal obstruction was observed in 7% of patients. The average life expectancy of endoscopic endoprosthesis and percutaneous prosthesis was 109 +/- 157 and 92 +/- 101 days, respectively. The average life expectancy of patients was 163 +/- 224 days.(ABSTRACT TRUNCATED AT 250 WORDS)

[Septicemias after endoscopic retrograde cholangiopancreatography. Risk factors and antibiotic prophylaxis]

The infection following endoscopic retrograde cholangiopancreatography (ERCP) is one of the most severe complications. The aim of the present study was to assess the prevalence and the prognosis of this complication, to look for the risk factors and to define bacterial ecology in order to put forward the most appropriate antibiotherapy. Two thousand and ten patients were included in this study. Among these, 51 (2.5%) had a septic complication following ERCP. Endoscopy biliary drainage was complete in 24 cases, incomplete in 19 and lacking in 8. Transhepatic biliary drainage was carried out in 17 cases. Sixteen patients (31%) with tumor obstructions died within 30 days after ERCP. Four risk factors were isolated when comparing infected patients with other patients: the completeness of biliary obstruction (90 vs 48%, P < 0.001); multiple cannulation attempts (1.76 +/- 1.12 vs 1.25 +/- 0.70, P < 0.001); the malignant nature of the obstruction (80 vs 23%, P < 0.002) and the lack of satisfactory drainage following endoscopy (53 vs 23%, P = 0.009). Pseudomonas aeruginosa was the most frequently isolated species, both from blood cultures (30%) and bile samples (23%). The preventive therapy of septic complications following ERCP must include strict rules concerning the disinfection of endoscopic material.(ABSTRACT TRUNCATED AT 250 WORDS)

[Colorectal villous tumors. Treatment by electro-resection and laser photocoagulation. 134 cases]

Endoscopic snare resection prior to Nd:YAG laser photocoagulation was used to treat benign colorectal villous adenoma. One hundred and thirty four patients were included in the study: 72 with surgical contraindications, 61 for whom surgical resection appeared to be too drastic and 1 who refused surgery. Treatment sessions were repeated every fifteen days until total tumour destruction was achieved. A carcinoma was detected in biopsy specimens obtained during endoscopic treatment of seven patients. Eight patients were lost to follow up. Treatment results could be analysed in 119 patients. A successful treatment was achieved in 108 patients. Tumour destruction was complete in 85.4 percent of the cases with lesions of at least 4 cm in diameter and in 94.3 percent of the cases with smaller lesions. During the average 101 weeks follow up period, 15.7 percent of the patients with total tumour destruction had recurrence. The risk of recurrence was correlated with the number of initial treatment sessions and previous surgical treatment. It would appear that endoscopic resection prior to Nd:YAG laser photocoagulation is a safe and effective method for the destruction of colorectal villous adenomas.

Management of malignant hilar biliary obstruction by endoscopy. Results and prognostic factors

Between January 1983 and December 1987, 103 patients who had hilar biliary obstruction (59 men, 44 women, median age 73 years) were referred to our institution. The causes of hilar biliary obstruction were carcinoma of the bile ducts (55), hepatic metastases or hepatocellular carcinoma (30), and carcinoma of the gallbladder (18). When endoscopic retrograde cholangiography was performed, the stricture was classified as type I in 28%, type II in 41%, and type III in 31% of the patients. In 92 patients, we tried to insert endoscopically a 10, 11, or 12 F Amsterdam type prosthesis; it proved possible in 66 (74%), and the prosthesis proved functional without further procedure in 49 cases (53%); no combined percutaneous and endoscopic method was used. At death or discharge, 45 patients (49%) had a successful drainage. Cholangitis was the main procedure-related complication and occurred in 25 patients. The 30-day mortality was 43%. Results varied according to type of stenosis: successful drainage was performed in 15% of the patients with type III stenosis, compared with 86% when the stenosis was of type I. Under a multivariate analysis the independent prognostic factors of 30-day mortality were: (1) development of infectious complications after endoscopic attempt at drainage (P less than 0.0001), and (2) absence of successful drainage (P less than 0.0001). In conclusion, endoscopic endoprosthesis placement allows a sufficient drainage in 53% of the cases. In type III stenosis, the high rate of 30-day mortality leads us the conclusion that endoscopic drainage must be avoided.

Association of juxtapapillary diverticula with choledocholithiasis but not with cholecystolithiasis

Juxtapapillary diverticula are often associated with biliary lithiasis. The aim of this study was to compare the prevalence of juxtapapillary diverticula in choledocholithiasis and in cholecystolithiasis without common bile duct stones. The results of 520 consecutive retrograde cholangiographies were retrospectively analysed. The prevalence of juxtapapillary diverticula was higher in patients with biliary lithiasis than in patients without: 26.0% vs 10.5% (p less than 0.001). However, juxtapapillary diverticula were more frequently encountered in patients with choledocholithiasis than in those with gallbladder lithiasis or previous cholecystectomy and a stone-free common bile duct: 40.0% vs 10.2% (p less than 0.001). There was no significant difference between the patients with cholecystolithiasis alone and those without biliary lithiasis. Among the patients with previous cholecystectomy or with gallbladder lithiasis, common bile duct stones were more frequently found in patients with juxtapapillary diverticula than in those without: 80.3% vs 40.6% (p less than 0.001). These data suggest that juxtapapillary diverticula are associated only with choledocholithiasis and not with gallbladder lithiasis.

Two-stage endoscopic removal of a foreign body from the common bile duct

We describe the application of a new two-stage endoscopic procedure for removal of a retained stent in the common bile duct (Type 1 foreign body in Ban's classification). The technique involves sphincterotomy and placement of the endoprosthesis.

Endoscopic treatment by snare electrocoagulation prior to Nd:YAG laser photocoagulation in 85 voluminous colorectal villous adenomas

The association of endoscopic resection with Nd:YAG laser photocoagulation was used to treat benign colorectal villous adenomas. Eight-five patients were included: 49 with surgical contraindications, 35 for whom surgical resection appeared to be too hazardous, and 1 who refused surgery. Forty-five tumors had an axial extension between 1 and 3 cm, and 40 tumors had an axial extension of at least 4 cm. Diathermic snare resection was performed to remove large tumoral fragments prior to laser photocoagulation of the residual flat lesions. Treatments were repeated every 15 days until total tumor destruction was achieved. A carcinoma was detected in biopsy specimens obtained during endoscopic treatment of five patients. Two patients were lost to follow-up. Treatment results could be analyzed in 78 patients. Successful treatment was achieved in 67 patients. Tumor destruction was complete in 77 percent of patients who had lesions of at least 4 cm diameter and in 93 percent of patients with smaller lesions. The axial extension of the tumor was the main factor affecting the results of treatment. No major complications occurred. During the average 103-week follow-up period, 21 percent of the patients with total tumor destruction had a recurrence. The risk of recurrence was correlated with the number of initial treatment sessions and previous surgery treatment. It would appear that the treatment with endoscopic resection prior to Nd:YAG laser photocoagulation is a safe and effective method in the destruction of colorectal villous adenomas.

Endorectal sonography in the management of rectal villous tumours

Thirty-seven patients with rectal villous tumours were investigated by endorectal sonography to assess the integrity of the rectal muscularis propria at the tumour level. In four cases assessment of invasion was impossible. In 24 patients, endosonography revealed an ultrasonically superficial lesion not infiltrating the muscular layer. This was confirmed either, in the case of laser treatment, by the absence of malignant recurrence during the follow-up period or by histological examination after surgical resection. In nine patients, endosonography showed infiltration of the muscular layer. This was histologically confirmed in five operated patients. In the remaining four, laser destruction was performed: in two, a rectal adenocarcinoma was present 3 and 6 months later, respectively. These findings show that endosonography has a place in the management of rectal villous tumours, demonstrating invasive cancer in cases where other forms of assessment were wrongly reassuring.

Chloride current activated by cyclic AMP and parathyroid hormone in rat osteoblasts

In primary cultures of rat osteoblasts, studied with the whole-cell configuration of the patch-clamp technique, 8-bromo-cyclic AMP (8BrcAMP) forskolin (FS) and 1-34 parathyroid hormone (PTH) were shown to activate a Cl conductance. This conductance shows a pronounced outward rectification, even with symmetrical Cl concentrations. It is blocked partially and reversibly by 4,4'-diisothiocyanatostilbene 2,2'-disulfonic acid (DIDS) or diphenylcarboxylate (DPC). The blockade induced by DIDS is time- and voltage-dependent. The Cl responses to FS and PTH develop slowly, after a delay of several seconds and are very slowly reversible. These responses were observed only in a fraction of the cells tested and their detection was favoured by cell dialysis. This Cl current should be taken into account for studying possible modulations of the voltage-gated Ca currents of osteoblasts. It is suggested that its physiological role may be related to the well-known morphological changes induced by PTH in osteoblasts. The cyclic AMP-sensitivity, the outward rectification and the sensitivity to dialysis of this Cl current are reminiscent of the properties of the cystic fibrosis-sensitive Cl channels of epithelial cells.

[Cholestasis caused by an intradiverticular bezoar. Endoscopic treatment]

A 49 year old woman presented with fever. Blood chemistry showed cholestasis. Sonography and abdominal computed tomography showed a dilated biliary tract and a fluid collection in the head of the pancreas. A large, interposed, diverticulum of the second duodenum, filled with a bezoar, was documented by duodenoscopy. The bezoar was fragmented and removed by biopsy forceps. Retrograde visualization of the common bile duct then showed a normal biliary tree with good clearance of contrast material. The ulterior course was uncomplicated. This is the second reported case for cholestasis due to an intradiverticular bezoar in an interposed duodenal diverticula. Diagnosis and treatment were made by duodenoscopy.

Corticosteroid-induced changes in the responsiveness of human osteoblast-like cells to parathyroid hormone

We investigated the in vitro effect of corticosteroids on the responsiveness of human cells of osteoblast lineage to parathyroid hormone (PTH). Prior to corticosteroid treatment, the cells demonstrated only a small increase in cAMP production and no measurable change in transmembrane potential in response to PTH. Exposure of cells to dexamethasone resulted in a 5-fold increase in PTH-induced cAMP production and in measurable PTH-induced membrane depolarization in all cells studied. The effect of corticosteroids on cAMP production was specific for PTH (not seen with PGE1 or forskolin), occurred in a time- and dose-dependent fashion and in the absence of cell proliferation. Most of the cells were of osteoblast lineage as determined by the presence of alkaline phosphatase activity and BGP secretion. These findings further support the idea that corticosteroids increase the sensitivity of cells of osteoblast lineage to PTH, perhaps by transforming cells which initially have a low responsiveness to PTH to a state of high responsiveness.

Do skin tags constitute a marker for colonic polyps? A prospective study of 100 asymptomatic patients and metaanalysis of the literature

Several reports have suggested that skin tags may be a marker for the presence of colonic polyps in symptomatic patients referred for colonoscopy. In a prospective study of 100 asymptomatic patients, we found no association between skin tags and colonic polyps. A review of the literature and results of a metaanalysis show a significant association between skin tags and colonic polyps in 777 symptomatic patients, but no association in 268 asymptomatic patients. To explain this discrepancy, several possible biases are analyzed. As skin tags constitute a marker for colonic polyps only in symptomatic patients for whom a colonoscopy is already indicated, their detection is of no diagnostic value in asymptomatic patients.

Early effects of parathyroid hormone on membrane potential of rat osteoblasts in culture: role of cAMP and Ca2+

Microelectrodes were used to investigate the possible involvement of cAMP and Ca2+ ions in the parathyroid hormone's, bPTH(1-34), effect on the membrane potential of rat osteoblasts in primary culture. Parathyroid hormone (10(-7) M) depolarized cell membrane by 25.0 +/- 6.1 mV (mean +/- standard deviation, SD; n = 17). Blocking Ca2+ influx with the Ca channel blocker cobalt revealed two phases in the hormone effect: a rapid and slight membrane hyperpolarization followed by sustained depolarization. In addition, cobalt significantly (p less than 0.01) decreased the magnitude of the PTH depolarizing action. The addition of dibutyryl-cAMP (10(-3) M) to the perfusion solution also resulted in a biphasic effect. At a lower concentration (10(-4) M), dibutyryl-cAMP produced only membrane hyperpolarization, suggesting a cAMP dose dependence of the opposite membrane potential changes. Forskolin (10(-5) M) and the phosphodiesterase inhibitor isobutylmethylxanthine (IBMX) (10(-4) M) mimicked the depolarizing effect of PTH. IBMX at a low concentration (5 x 10(-6) M) potentiated the depolarizing effect of PTH. Increases in [Ca2+]i using Ca2+ ionophore A23187 and intracellular injection of CaCl2 or inositol trisphosphate decreased the PTH depolarizing action, whereas intracellular injection of EGTA enhanced this effect. These results indicate that PTH evokes a biphasic change in rat osteoblast membrane potential that seems to be mediated by an increase in cAMP and modulated by intracellular calcium.

[Dilatation of the common bile duct without visible obstruction at endoscopic retrograde cholangiography. Description and development]

The aim of this study was to specify the signs and course of patients with a dilated common bile duct without obstruction. We included patients with a dilated common bile duct of more than 12 mm on endoscopic retrograde cholangiography, and we excluded patients with stones, tumor or other visible obstruction. Two hundred and seven patients (8.4 p. 100 of endoscopic retrograde cholangiography) were included. One hundred and nineteen (57.5 p. 100) had undergone cholecystectomy. Sixty-five p. 100 of patients had signs suggesting biliary tract disease, and 78 p. 100 had biological signs of cholestasis. The size of the common bile duct was not different whether the patient had been cholecystectomized (16.2 +/- 0.3 mm.M +/- SEM) or not (16.2 +/- 0.4 mm). Forty-one patients in the non cholecystectomized group had gallbladder stones. Thus, 47 of our 207 patients (23 p. 100) had neither gallbladder stones nor previous cholecystectomy. Endoscopic retrograde cholangiography was completed by endoscopic sphincterotomy in 130 patients, either in the intent of not missing obstruction, or for therapeutic purposes. Follow-up more than one month after endoscopic retrograde cholangiography was available for 159 patients (77 p. 100). The median survival was 73 months. One hundred and ten patients (69 p. 100) were asymptomatic, 36 (23 p. 100) had atypical abdominal pain while 13 (8 p. 100) patients had episodes of biliary colic and/or fever and/or jaundice. During follow-up, an initially unrecognized obstacle was discovered in 8 patients: 5 common bile duct stones, 2 ampullary tumors and one pancreatic tumor.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prevention of hemorrhagic recurrence in cirrhotic patients. Is sclerotherapy better than propranolol?]

The effectiveness of oral propranolol and sclerotherapy in preventing recurrent bleeding after an endoscopically proven haemorrhage from oesophageal varices was compared in Pugh's grade B and C patients divided into two successive therapeutic groups. Group I patients (n = 32) were given oral propranolol, while sclerotherapy was performed in group II patients (n = 32), 23 of whom simultaneously received propranolol. There was no difference between groups I and II in the severity of the initial bleeding and liver failure (Groups I/II, B 19/18, C 13/14), in the withdrawal of alcohol (group I 25, group II 17) and in compliance with either treatment (group I 25, group II 27). Obliteration of the oesophageal varices was achieved in 69 p. 100 of group II patients within a median number of 4 courses and 46 days, and in 84 p. 100 of the patients of this group who survived for more than 3 months. One year after the beginning of treatment rebleeding had occurred in 43 p. 100 of either group I or group II patients. The 1-year survival rate was 72 p. 100 in group I and 62 p. 100 in group II (non significant). The causes of death were the same in both groups. Irrespective of the treatment assigned, death was 2.1 times more frequent (P = 0.02) and rebleeding was 1.2 time more frequent (P = 0.08) in grade C than in grade B patients.

Voltage-gated sodium and calcium currents in rat osteoblasts

1. The whole-cell voltage-clamp mode of the patch-clamp technique was used to investigate the presence of voltage-gated inward currents in osteoblasts from newborn rat calvaria. 2. In K+-free solutions, three kinds of inward currents could be activated by depolarization: a voltage-gated Na+ current and two different types of Ca2+ currents. 3. The Na+ current was activated by depolarization above -40 mV in all the cells. It was reduced by half by 10 nM-TTX (tetrodotoxin). 4. In an isotonic Ba2+ external solution containing TTX, and with a Cs-EGTA internal solution buffered at pCa 8, depolarizing jumps induced both a transient Ba2+ current and a sustained Ba2+ current. The relative proportions of these two currents varied greatly among cells. 5. The transient and sustained Ba2+ currents differ with respect to their time course and their voltage dependence. 6. The depolarization-activated inward currents were also observed under more physiological conditions, in the presence of only 2 mM-external Ca2+ and with a K+ internal solution buffered at pCa 7. 7. A few records obtained in current clamp showed that it is possible to induce action potentials in osteoblasts.

[Lithiasis of the common bile duct in the aged subject treated with endoscopy (227 patients)]

One hundred and sixteen patients aged from 65 to 80 years (first group including 39 previously cholecystectomized patients) and 161 patients aged over 80 years (second group, including 31 previously cholecystectomized patients) underwent endoscopic papillotomy for choledocholithiasis. We compared clinical, biochemical and morphological features of choledocolithiasis with early results of endoscopic papillotomy. Clinical symptoms were not different between the old and very old patients, cholecystectomized or not. Charcot's triade was observed in one third of patients. Biochemical data just before endoscopic retrograde cholangiography were not different according to groups: 21 p. 100 of the 277 patients had a biological cholestasis without elevation of bilirubin and 10 p. 100 of the patients had no abnormality of the liver function. Diagnosis of choledocholithiasis was accurately suspected in 90 p. 100 of patients. Complete removal of gallstones after endoscopic papillotomy was obtained in 95 p. 100 of patients in the first group and 93 p. 100 of patients in the second group. Morbidity and mortality rates related to endoscopic papillotomy were not different between the 2 groups (6.9 and 0.8 p. 100 in the first group and 8.7 and 3.1 p. 100 in the second group, the first group and 8.7 and 3.1 p. 100 in the second group, respectively). These results suggest that clinical and biochemical features of choledocholithiasis, and early results of endoscopic treatment do not present any particularities in the elderly.

Comparative studies of membrane potentials of rat osteoblasts in situ and in primary culture

The aim of the present study was to compare the membrane potential, Vm, of rat calvarium osteoblasts in situ and during primary culture using electrophysiological techniques. For osteoblasts studied in situ the Vm (mean +/- S.D.) was found to be -42.0 +/- 10 mV, n = 32. Comparable values (-46.8 +/- 9.n, n = 152) were found for cultured osteoblasts during the first week. Thereafter when cells began to form multilayers an increase in Vm negativity was observed (-58.6 +/- 12.8, n = 82). The Vm of osteoblasts in situ and during the first week of culture were highly dependent on the Na+ diffusion potential and slightly influenced by the increase in extracellular [K+]. In contrast, the more negative Vm of the cells cultured 2 weeks were highly dependent on the K+ diffusion potential and were not influenced by changes in external [Na+]. Parathyroid hormone (bPTH(1-34], 240 nM, in the external solution, induced a rapid membrane depolarization in situ (+10.2 +/- 5.0, n = 18) as it does in cultured cells. Additional investigation on the possible effects of Ca2+ and PO4(2-) (since, in situ, mineralized matrix prevents such an approach) showed that low external [Ca2+] only slightly hyperpolarizes the membrane, whereas cell Vm was highly sensitive to changes in external [PO4(2-)].

[Pancreas divisum: clinical and therapeutic study in man. Apropos of 87 cases]

In order to evaluate the responsibility of pancreas divisum in the occurrence of pancreatitis, we studied retrospectively 1,808 endoscopic retrograde pancreatograms. Eighty-seven pancreas divisum (4.8 p. 100) were found in 50 males and 37 females, mean age 53.3 +/- 16.8 yrs. Acute pancreatitis was significantly more frequent (p less than 0.001) in this group (19.6 p. 100) than in the patients with fused pancreas (4.3 p. 100). The difference was also significant (p less than 0.01) for idiopathic recurrent acute pancreatitis. Histologic lesions in the dorsal pancreas were in favor of a retentional mechanism of pancreatitis. Sphincterotomy of the accessory papilla, proposed to improve the drainage of the dorsal pancreas, was performed in 11 patients (10 endoscopic, 1 surgical). This treatment, repeated in case of secondary stenosis of the accessory papilla, was successful in 5 out of 8 patients with acute pancreatitis followed up from 12 to 30 months. After reviewing the literature, secondary stenosis of accessory papilla was found significantly less frequently (p less than 0.05) after surgical sphincterotomy or sphincteroplasty (4 out of 46, 8.6 p. 100) than after endoscopic sphincterotomy (6 out of 22, 27.2 p. 100). Treatment, preferentially surgical, should be proposed only to patients with idiopathic recurrent pancreatitis before constitution of chronic non reversible pancreatitis.

Short-term effects of PTH on cultured rat osteoblasts: changes in membrane potential

The introduction of parathyroid hormone [bPTH (1-34)], 10(-8) M, into the medium of cultured rat osteoblasts results in rapid (less than 1 min) depolarization of the osteoblast membranes. Conventional and pH-sensitive microelectrodes were used to assess the mechanism underlying this change. PTH depolarized cell membrane independently of steady-state membrane potential (Vm). Blocking K+ conductance (Ba2+) and Ca2+-dependent K+ conductance (quinine) depolarized Vm by +13.1 +/- 4.6 (n = 6) and +14.8 +/- 6.7 mV (n = 6), respectively, and both abolished the effect of PTH on Vm. The rate of depolarization was reduced in low-Ca2+ medium. PTH inhibited low Na+-induced cell hyperpolarization, but intracellular pH was not altered by hormone addition. PTH-induced depolarization occurred even when the Na+-K+ pump was blocked with ouabain. A second slower response was seen in cells having a Vm lower than -60 mV, with an increase in negativity 5-15 min after hormone application. The results indicate that PTH rapidly modifies Vm by changes of K+ conductance, which may be the first step in hormonal stimulus-response coupling, and induces delayed, long-term changes in cell status.

Response to parathyroid hormone and 1,25-dihydroxyvitamin D3 of bone-derived cells isolated from normal children and children with abnormalities in skeletal development

In order to evaluate the role of intrinsic defects in osteoblast function in the pathogenesis of diseases of skeletal development, we developed techniques which permit the evaluation of the metabolic properties of bone-derived cells in vitro. Cells from control children demonstrated a variety of properties classically attributed to osteoblasts (presence of alkaline phosphatase positive cells and synthesis of bone gla protein) and responded to PTH (cAMP production) and to 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) ([3H]25-hydroxyvitamin D3 conversion into [3H]24,25-dihydroxyvitamin D3 and bone gla protein secretion). Using these techniques we evaluated the function of cultured bone cells from patients with three rare diseases of skeletal development. Cells from a patient with rickets resistant to 1,25(OH)2D3 were resistant to 1,25(OH)2D3 but responded normally to PTH. Cells from a patient with acroosteolysis with osteoporosis responded normally to PTH and 1,25(OH)2D3. Cells from a patient with hyperphosphatasia with osteoectasia responded normally to 1,25(OH)2D3 but did not respond to PTH. The results demonstrate that bone cell cultures can provide information about the role of osteoblast dysfunction in such diseases.

1,25 Dihydroxyvitamin D3 is required for growth-independent expression of alkaline phosphatase in cultured rat osteoblasts

Osteoblastic cells were isolated from periosteum-stripped parietal bones of neonatal rat calvaria, seeded at low density (5,000 cells/35 mm of Falcon dish), and cultured for 6 days in BGJ medium supplemented with 20% of vitamin D-depleted FCS or vitamin D and calcium-depleted FCS, with daily addition of 1,25 dihydroxyvitamin D3 (10(-9) M) or 24,25-dihydroxyvitamin D3 (10(-9) M). Plating efficiency, clonal growth (number and size distribution of the colonies formed), and the alkaline phosphatase phenotype were evaluated on days 2 and 6 of culture. (1) Culture for 6 days in media not supplemented with 1,25(OH)2D3 led to a significant (P less than 0.001) loss of the alkaline phosphatase phenotype of the osteoblastic cells; the loss was greater in proliferating cells than in nonproliferating ones and occurred in both 0.12 mM or 1.1 mM ionized calcium concentrations. (2) Daily addition of 1,25(OH)2D3 (10(-9) M) but not 24,25(OH)2D3 maintained the basal percentage of Alk Pase positive cell units in non-proliferating cells and significantly reduced the loss of this phenotype in proliferating colonies. (3) This effect did not stem from an action of the hormone on cell growth. 1,25(OH)2D3 was also found to enhance the adhesiveness of the seeded osteoblasts, irrespective of the medium calcium concentration.

Bone ultrastructure and x-ray microanalysis of aluminum-intoxicated hemodialyzed patients

In hemodialyzed patients aluminum (Al) intoxication may induce osteomalacic lesions which are mainly observed when plasma immunoreactive parathyroid hormone (iPTH) concentrations are low, and osteitis fibrosa absent. In this study, the bone tissue of eight hemodialyzed patients with elevated plasma and bone Al concentrations was examined by histomorphometry, electron microscopy, and x-ray microanalysis. Five patients (group 1) had osteomalacia and minimal osteitis fibrosa, three patients (group 2) had severe osteitis fibrosa. In group 1, Al was concentrated at the mineralizing front, in hexagonal structures measuring 200 to 1,000 A which also contained phosphorus, but not calcium. Hydroxyapatite needles had a normal aspect. Osteoblasts appeared inactive. In group 2, Al was also present at the mineralizing layer of osteoid, but, in these cases, in small clusters next to abnormal calcium deposits. Osteoblasts appeared very active. Their mitochondria contained calcium and phosphorus granules, or amorphous material, measuring 1,500 to 2,000 A, emitting x-rays characteristic for Al and phosphorus. These results suggest that secondary hyperparathyroidism, by stimulating the cellular activity, may increase the uptake and release of Al by the osteoblasts. The presence of Al within the mitochondria of these cells may be one of the factors inducing the mineralization defect.

[Acute alcoholic hepatitis and death of cirrhotic patients]

Alcoholic hepatitis (AH) seems to be less frequent and to play a lesser role in the death of cirrhotic patients than previously acknowledged. The purpose of this work was: 1) to study the cause of death of cirrhotic patients 2) to determine the prevalence of AH among these patients and 3) to describe the clinical and laboratory features of cirrhotic patients with AH. The data were collected from a series of 107 necropsies in cirrhotic patients without hepatocellular carcinoma. The statistical analyses were carried out with an IRIS 80 computer. Severe liver failure with jaundice and encephalopathy, hemorrhage and uncontrolled infection with septic shock represented 84 p. 100 of the causes of death in patients with cirrhosis. Seventy-nine out of 107 patients (74 p. 100) had no AH (group 1), and 28 (26 p. 100) had AH (group 2): AH was mild in 15 cases and severe in 13 cases. All patients with AH died from a complication directly related to their liver disease while 21.5 p. 100 of patients without AH died from a complication not related to cirrhosis. The clinical and laboratory features of the patients without AH and cirrhosis differed from those of patients without AH by: a more frequent presence of fever (p less than 0.01), the absence of important weight loss (p less than 0.001), the total absence of abstinence (p less than 0.05), a higher value of ASAT/ALAT ratio, of serum levels of total bilirubin (p less than 0.01) and conjugated bilirubin (p less than 0.05), gamma glutamyl transpeptidase (p less than 0.001) and total cholesterol (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Studies on the transport of anions and zwitterions of acidic amino acids in Streptomyces hydrogenans

In Streptomyces hydrogenans, acidic amino acids are taken up either as anions by a specific transport system or as zwitterions via a nonspecific one. Variations in the zwitterion concentration caused by changes in pH influence the uptake and exchange diffusion by the nonspecific system. Differences in pH-optima for L-glutamate and L-aspartate transport are due to the different pK2-values of these amino acids. The anion transport by the specific system is accompanied by a short hyperpolarization of the membrane potential followed by a secondary influx of potassium ions into the cells.

[Esophageal fistulas in mediastinal tuberculous adenopathies in adults]

An adenopathy perforated into the esophagus in a thirty-two-year old woman from black Africa with mediastinal and abdominal tuberculous adenopathies. The fistula was disclosed upon endoscopic examination in the absence of esophageal symptoms. The characteristics of such fistulas are recalled: location in the middle third of the esophagus, inconspicuousness of symptoms, scarcity of complications among which digestive hemorrhage is the most significant, usually favorable course under medical management alone. The latency of fistulas between tuberculous adenopathies and the esophagus warrants routine fiberoptic endoscopy in patients with mediastinal tuberculous adenopathies.

Effects of 25-hydroxycholecalciferol on bone lesions of children with terminal renal failure

Quantitative histology was performed on serial iliac crest biopsies obtained from 14 children with terminal renal failure. A long-term study on the comparative effects of vitamin D2 and 25-hydroxycholecalciferol [25-(OH)D3], in five patients with severe lesions of osteomalacia and/or osteitis fibrosa, demonstrated the efficiency of 25 to 200 mug/day of 25-(OH)D3 and the lack of therapeutic action of 345 to 685 mug/day of vitamin D2. In nine subjects with normal roentgenograms or minimal skeletal alterations, the first biopsy taken at the beginning of intermittent hemodialysis showed evidence of defective mineralization and/or lesions of resorption. Four of these children were treated with 25-(OH)D3 (25 to 50 mug/day) and calcium supplementation orally (0.5 to 1.5 g/day); five children received calcium orally (0.5 to 0.75 g/day) alone. Aggravation of bone lesions during intermittent hemodialysis was observed in patients treated with calcium supplements alone. In subjects who were given 25-(OH)D3, mineralization improved and marrow fibrosis disappeared. However, as the two groups of patients were different in composition and in the manner in which they were treated, it is difficult to state whether the beneficial effects observed were solely attributable to 25-(OH)D3 administration. 25-(OH)D3 therapy induced severe intoxication in two patients. A rise in plasma calcium concentration to 11.0 to 11.5 mg/100 ml was observed in two other patients. It is concluded that: a) pharmacologic doses of 25-(OH)D3 are highly effective in healing bone lesions of children with terminal renal failure; b) such treatment requires strict clinical surveillance as 25-(OH)D3 intoxication may occur even in anephric patients.