Inhibition of rat renal 11 beta-hydroxysteroid dehydrogenase by steroidal compounds and triterpenoids; structure/function relationship

Various compounds with steroidal structure were tested for inhibitory effects on enzymatic activity of 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) from rat renal microsomes. Most substances exerting inhibitory potency on both the oxidative as well as the reductive activity can be classified into two main groups: pentacyclic triterpenoids of the oleane type and steroidal detergents of the CHAPS-series. Inhibition is competitive, as was shown for one compound of each group. The IC50 values of the various inhibitors range over five orders of magnitude. In all cases, oxidative activity was inhibited more effectively than reductive activity. An attempt has been made to correlate structural properties and inhibitory potency. In brief, inhibition seems to be enhanced by a C11-oxygen function, which is present in all endogenous glucocorticosteroids and a C7-OH function. Inhibition is reduced by a large and polar substituent at C3 in the A-ring. A large D-ring substituent, such as a bisgluconamidopropyl side chain or even an additional E-ring, does not prevent binding to the enzyme, although inhibition seems to be influenced by its steric conformation. The cardiac glycosides and steroidal antibiotics tested exert no inhibitory effect on 11 beta-HSD. Cholesterol and pentacyclic triterpenoids of the lupane type exhibit a very poor inhibition, probably caused by the localization of planar structures in the ring systems, which differs from that of the effective oleane type inhibitors.

[Colonic polyps: clinical and practical implications]

Among colorectal polyps, various forms of neoplastic or non-neoplastic lesions are distinguished by histology. Most accumulated knowledge suggests that the majority of cancer of the colon arise in pre-existing benign neoplastic polyps (adenoma-carcinoma sequence). Because of the risk of cancer being already present, all adenomatous polyps must be removed in toto. The carcinoma may occupy only a small area of the polyp, and therefore, forceps biopsies are inappropriate due to the sampling error. Since patients with polyps detected by rectosigmoidoscopy often have further polyps in the remaining part of the colon, complete examination of the whole colon is required. Follow-up examinations are indicated, because the risk of developing new polyps is high. Studies of the life history of the adenoma-carcinoma sequence suggest that interval of complete large-bowel follow-up may be about 5 years. The policy of polypectomy and follow-up examinations should be possible to prevent the development of colorectal cancer.

Bile acids and their amidates inhibit 11 beta-hydroxysteroid dehydrogenase obtained from rat kidney

Recently it has been demonstrated that interaction of corticosteroids with extraadrenal target cells can effectively be modulated by metabolic transformation of the steroid hormone. As far as 11-hydroxylated glucocorticoids are concerned 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) is the most important enzyme charged with target cell metabolism. Inhibition of 11 beta-HSD function either by genetically transmitted deficiency or by exogenous enzyme inhibitors causes severe pathophysiological derangements, which result in a syndrome of "apparent mineralocorticoid excess". In the present paper we have tested whether or not endogenous inhibitors of this enzyme system might exist. The effects of the main naturally occurring mono-, di-, and trihydroxylated bile acids in man on 11 beta-HSD have been studied in in vitro experiments. Using rat renal microsomes it could be demonstrated that unconjugated bile acids of all three classes as well as the corresponding glycine and taurine amidates effectively inhibit oxidative as well as reductive activity of 11 beta-HSD, with lithocholic acid and chenodeoxycholic acid being the most potent compounds. It is concluded that bile acids are potent endogenous inhibitors of 11 beta-HSD and, therefore, could participate in abnormalities of cortisol metabolism observed in liver cirrhosis and extrahepatic biliary obstruction and, possibly, after ingestion of bile acids.

[Surgical treatment methods in furcation involvement and their long-term prognosis]

Multi-rooted teeth showing severe furcation defects can be treated by either of the following techniques: Tunnel preparation, hemisection and root resection. The aim of these approaches is to reestablish the anatomical features making it possible to carry out proper homecare in the future. In hemisection and root resection this is achieved by separating and/or removal of roots. An assessment of prognosis is made on the basic of long-term follow-ups. After ten years an average bone loss of 9.5% was recorded. When bridgework was correctly designed loading did not have a detrimental influence on further bone loss. Roots restored by using gold dowels showed the same technical durability as roots restored with root screws/composite cores. The total failure rate after ten years varied between 32 and 38%. Nonperiodontal failures were predominating. This leads to the conclusion that prognosis may not be judged on the basis of periodontal aspects alone.

[Hepatitis C antibodies in acute Non-A, Non-B hepatitis]

Stored serum samples of 20 patients with clinically and bioptically proven non-A, non-B hepatitis (NANBH) in the acute stage were tested for the presence of antibodies to hepatitis C virus (anti-HCV) by means of the Ortho ELISA system. After a mean period of 8 weeks from onset of the disease, 8 of 20 patients (40%) had anti-HCV. Our follow-up study included 14 patients. Of 9 primarily anti-HCV-negative patients, 2 became positive after 2 and 7 months respectively, whereas 7 patients remained anti-HCV-negative up to 52 months (range 1-128) after the onset of hepatitis. The prevalence of anti-HCV was 71% in 7 patients with parenteral hepatitis related to transfusions (n = 2) or drug abuse (n = 5), and 38% in 13 patients with sporadic NANBH. Of the 8 anti-HCV-negative patients with sporadic NANBH, 5 had stayed in one of the countries where enterically transmitted NANBH is endemic 3 to 6 weeks before the onset of their disease. Our results show that at present the anti-HCV-test supplies an etiologic basis for approximately half of all cases of NANBH in acute stage. Nevertheless, in most cases the acute NANBH remains a diagnosis of exclusion.

[Non-A, Non-B hepatitis: advances in diagnosis and therapy]

The characterization of the hepatitis C virus (HCV) and the development of an anti-HCV antibody test have closed a further gap in the etiological diagnosis of viral hepatitis, but at the same time new questions have been raised. It has been shown that HCV is by far the most frequent source of the parenterally transmitted form of non-A, non-B hepatitis (NANBH). The anti-HCV test is reactive in the majority of cases with chronic NANBH. However, seroconversion is delayed by weeks or even months and therefore the test is inappropriate for confirmation of acute NANBH. Most patients with autoimmune hepatitis and some with alcoholic liver injury were shown to be anti-HCV reactive, giving rise to a debate on the specificity of the anti-HCV test. The significance of these findings has not yet been explained, since a confirmation test is currently lacking. Alpha-interferon has been shown to be the first promising drug for treatment of chronic viral hepatitis. In a high percentage of patients with chronic NANBH, treatment with interferon induces biochemical and histological remission. Nevertheless, about half of the patients had relapses under the treatment regimens currently used. The aim of ongoing studies is to improve results by optimizing the dosage and duration of interferon treatment.

Limited proteolysis of lactate dehydrogenase from porcine heart with trypsin: characterization and reactivation of the fragments

The ternary complex formed by native lactate dehydrogenase (LDH) from porcine heart, NAD+ and sulfite, was digested with trypsin over a period of 12-16 h3. After removal of the ligands and residual native lactate dehydrogenase by ion exchange chromatography dimers were obtained which were almost inactive. The dimers were lacking a hexapeptide at the N-terminus; however, the secondary structure was the same as that of native lactate dehydrogenase. The circular dichroism spectra showed a dependence on temperature which suggested an equilibrium of two different structural states. The reaction of antibodies against native porcine heart LDH with the dimers restored the catalytic activity, and subsequently the dimers behaved similarly to the native enzyme. Addition of 1 M phosphate or NAD-sulfite to the dimers restored 80-90% of the catalytic activity. It could be demonstrated that the behavior of the reactivated dimers, in contrast to that of the inactive dimers, was similar to the behavior of native lactate dehydrogenase. For instance, ultracentrifugal analysis showed that dimers reactivated with NAD-SO3- were associated to give tetramers. The reaction of antibodies against native LDH with the dimers reactivated with NAD-SO3- demonstrated that the native LDH and the dimers have the same surface determinants.

[Coronal repositioning of root fragment by root elongation with a titanium endodontic implant]

Teeth with deep transverse or oblique root fractures can nowadays be preserved by intra-alveolar transplantation. This method, however, has its limitation: The apical root fragment must not be too short in proportion to the crown length. This report describes a method to retain even very short roots. 14 roots have been carefully extracted. Then, the following treatment has been performed extraorally: Apectomy, lengthening of the root with a common titanium root screw and replantation of the root in an extruded position which allowed to carry out correct root filling and crown reconstruction. After an average observation period of 19 months 11 cases out of 14, i.e. 79%, were successful according to the criteria stated by Kristersson and Kvint. If the long-term results turn out as promising as the short-term findings, the concept might well be extended to other indications. One example is to stimulate the growth of a genuine periodontal "re-attachment" in intrabony pockets by extruding viable periodontal membrane areas to a more coronal level.

[Endoscopic treatment of bile duct stones and their complications]

Endoscopic treatment of bile duct stones has reached a high degree of perfection by the introduction of adjuvant therapies raising the rate of success while at the same time reducing risk. Large stones are fragmented mechanically or by means of extracorporal shock wave lithotripsy thus permitting to avoid a long and risky papillotomy. Drainage of the bile is assured with a nasobiliary drain in case of primary failure reducing the risk for cholangitis. Endoscopic treatment is the choice for residual or recurring stones after cholecystectomy and for severe purulent cholangitis in which surgical treatment is still charged with a high mortality. Endoscopic stone removal is further indicated when an operation per se carries a high risk. Long-term studies have demonstrated that even patients in which the gall bladder is preserved stay free of recurrence. In patients with severe biliary pancreatitis early papillotomy reduces complication-rate and mortality. The question remains unsettled whether patients at normal risk with simultaneous cholecysto- and choledocholithiasis should undergo direct cholecystectomy and bile duct revision or if they could profit from endoscopic removal of stones prior to cholecystectomy.

[Ultrasonically-guided sclerosing of kidney and liver cysts using polidocanol]

First experiences are reported with percutaneous sclerosing therapy of cysts with polidocanol (aethoxysklerol 1%) using ultrasound for needle guidance. They cover two patients with symptomatic cysts of the liver and a patient with polyglobulinemia and an erythropoietin-producing renal cyst. These experiences are compared to previously reported ones.

[Measurement of intestinal permeability in Crohn's disease, ulcerative colitis, sprue and idiopathic hyperamylasemia using polyethyleneglycol-400]

We investigated intestinal permeability in healthy adult volunteers, and in patients with Crohn's disease, ulcerative colitis, idiopathic sprue and idiopathic hyperamylasemia by oral administration of 10 g low molecular weight polyethylene glycol (PEG-400) and quantitation of its renal excretion over the subsequent 6 hours by high performance liquid chromatography (gel permeation HPLC). The mean amount of PEG-400 excreted during the first 6 hours by the 12 patients with Crohn's disease (3.1 +/- 0.3 g, mean +/- SE) and the 8 patients with ulcerative colitis (2.6 +/- 0.3 g) was not significantly different from the amount excreted by the 24 healthy volunteers (2.9 +/- 0.1 g). The 3 patients with idiopathic sprue excreted significantly less (1.4 +/- 0.3 g, p less than 0.05) and the 3 patients with idiopathic hyperamylasemia significantly more (4.0 +/- 0.4 g, p less than 0.05) than the healthy controls. In conclusion, no alteration of intestinal permeability could be demonstrated in patients with Crohn's disease or ulcerative colitis. However, intestinal permeability was decreased in patients with idiopathic sprue and increased in those with idiopathic hyperamylasemia.

Comparison of three colon cleansing methods: evaluation of a randomized clinical trial with 300 ambulatory patients

In a prospective randomized clinical trial, three colon cleansing methods for colonoscopy were compared with regard to a) side effects, b) patient acceptance, c) residual liquid and stool during colonoscopy, and d) quality of the examination. The patients were randomly assigned to one of the following three groups for colon preparation: Group 1 (n = 100) 4 liters of Golytely, group 2 (n = 102) 2 liters of Golytely combined with Cascara-Salax, and group 3 (n = 98) X-Prep (a Senna preparation) combined with an enema. X-Prep (group 3) caused significantly more abdominal cramps than 4 liters of Golytely (group 1) or 2 liters of Golytely with Cascara-Salax (group 2) (p less than 0.001). Vomiting was most frequent in group 1 (p less than 0.05 vs. group 3). The patients therefore preferred X-Prep to 4 liters of Golytely (p less than 0.01). The cleanest colon was obtained with 4 liters of Golytely, while 2 liters of Golytely with Cascara-Salax was least efficacious. The quality of the examination was equal in groups 1 and 3, and clearly better than in group 2 (p less than 0.01). We thus conclude that while 4 liters of Golytely and X-Prep plus enema have equivalent cleansing efficacy for colonoscopy, patients judged X-Prep to be less unpleasant.

Evaluation of root-resected teeth. Results after 10 years

There are only a few long-term investigations on root-resected teeth in the literature. This article is a 10-year review of 28 root-resection cases, which mainly had been used as bridge abutments. The periodontal, prosthetic, and endodontic problems were evaluated. After 10 years a total failure rate of 32% was observed. The analysis of the failure causes revealed that endodontic--not periodontal--complications were predominating. The study also includes a comparison of root-resected teeth restored with root screws and composite cores versus those which had been restored with cast gold dowels, showing that both types of reconstruction had the same durability concerning the risk of root fractures or loss of retention.

[Extracorporeal shock wave lithotripsy (ESWL) in the treatment of bile duct stones]

Ten patients with common bile duct stones not removable by endoscopic measures after sphincterotomy were treated by extracorporeally generated shock waves. In 9 patients stones up to 30 mm in diameter were disintegrated. Two patients became free of stone fragments spontaneously within one day and in 7 patients the stone fragments were extracted endoscopically. No complications occurred. Extracorporal shock wave treatment represents a promising alternative to surgery in cases where common bile duct stones cannot be extracted endoscopically.

[Adenocarcinoma of the cervix in Peutz-Jeghers syndrome. Case report and review of the literature]

The incidental finding of "adenoma malignum" or minimal deviation adenocarcinoma (MDA) of the cervix in a 38-year-old woman with Peutz-Jeghers syndrome (PJS) is reported and the literature is discussed. This highly differentiated form of adenocarcinoma is extremely rare but, like some other rare neoplasms, may occur more frequently in patients with PJS syndrome. Since the prognosis of MDA is considered poor and the histological diagnosis is often missed on biopsy, the importance of closely correlating clinical and pathological findings is emphasized.

[Changes in the serum pancreas enzyme following i.v. stimulation with secretin in subjects with a normal pancreas]

The diagnostic value of serum enzyme provocative tests (SEP) is disputed. In particular, the specificity of the test has not been adequately investigated. New interest in the test has arisen with the introduction of pancreas-specific serum enzyme tests. It has been shown that a poststimulatory increase of serum enzymes is found in chronic pancreatitis with well preserved exocrine function, but also in healthy individuals and particularly cigarette smokers. Recently it has been postulated that the lack of a poststimulatory enzyme response is typical of advanced chronic pancreatitis. We investigated the effect of secretin (1 CU/kg i.v.) on serum levels of amylase, pancreasisoamylase, lipase and trypsin for 30 minutes in 48 volunteers without pancreatic disease (19 non-smokers, 19 smokers and 10 patients with hypoxemia). Mean values of all enzymes were significantly higher after stimulation. Enzyme response of trypsin and lipase was more pronounced than that of amylase or pancreasisoamylase. However, depending on the enzyme studied, no significant increase of serum values was found in 47.4% to 89.5% of smokers, 26.3 to 68.4% of non-smokers and 10 to 50% of patients with hypoxemia. The marked variability of enzyme response in controls demonstrates the low specificity of this test. Therefore, SEP are of no diagnostic value in pancreatic disease.

[Chronic pancreatitis as a possible result of analgesic abuse]

Abuse of analgesics (AA) is a well known cause of chronic interstitial nephritis. Recently a noxious effect of AA on the pancreas has been suggested based upon case observations, and first evidence for association of AA with chronic pancreatitis was presented. In the present prospective clinical study 95 patients with chronic renal insufficiency, in 53 of them associated with AA, were investigated for evidence of chronic pancreatitis (e.g. history of pancreatitis, pancreatic calcifications, diabetes and exocrine function). The patients were divided into two groups: group A consisted of 53 patients with chronic nephropathy associated with AA, and control group B consisted of 42 patients with chronic nephropathy of other etiology. Pancreatic calcifications were observed in 5 cases of group A (10%), but in none of the patients of group B. Exocrine insufficiency was found in 2 of the 5 cases with pancreatic calcifications. Only one of the 5 patients had a history of pancreatitis in association with exocrine and endocrine insufficiency. Thus pancreatic calcifications, which are virtually pathognomonic for chronic pancreatitis, were found exclusively in the group with chronic nephropathy due to analgesic abuse. Chronic pancreatitis in this group of patients is likely to be overlooked because of the lack of clinical and laboratory evidence. The present data support our previous observations that AA may be an etiological factor in chronic calcifying pancreatitis. This first evidence for a drug-induced form of chronic pancreatitis is presented.

Treatment of distal ulcerative colitis with beclomethasone enemas: high therapeutic efficacy without endocrine side effects. A prospective, randomized, double-blind trial

Sixteen patients with 18 attacks of distal ulcerative colitis were treated randomly with either 0.5 mg topically administered beclomethasone dipropionate (BDP) or 5 mg betamethasone phosphate (BMT). The effect of the steroid enemas on adrenocortical function was examined by ACTH tests, which were performed before and 20 days after treatment. At completion of the trial, a marked suppression of the adrenocortical function was found in seven of eight patients treated for nine attacks with BMT but not in any patients in the BDP group (P less than 0.01). The mean posttreatment basal and stimulated plasma cortisol levels in the BMT group were significantly lower as compared with the BDP group. The overall therapeutic response assessed by score systems was comparable in the two treatment groups. It is concluded that, in the topical treatment of ulcerative colitis, BDP is preferable to BMT because it exerts an equal anti-inflammatory action without affecting adrenocortical function.

Comparative diagnostic value of the calcium-pentagastrin test versus the tolbutamide test in a patient with a somatostatinoma

We describe a patient with a small somatostatinoma of the papilla of Vater without clinical evidence for diabetes mellitus, diarrhea, steatorrhea, or cholelithiasis, showing normal plasma basal levels for somatostatinlike immunoreactivity. The diagnosis was based on histologic and immunohistochemical analysis of tumor tissue and hypersomatostatinemia induced by the calcium-pentagastrin test. Before removal of the tumor both diagnostic tests recommended for the detection of a somatostatinoma, a tolbutamide test and a calcium-pentagastrin test, were performed. Whereas the calcium-pentagastrin test provoked a markedly elevated plasma somatostatin level in association with a depressed plasma neurotensin level, the tolbutamide test surprisingly did not. After removal of the tumor the calcium-pentagastrin test no longer induced hypersomatostatinemia. Further studies are needed to determine whether the calcium-pentagastrin test is a more reliable diagnostic test than the tolbutamide test in somatostatinomas with normal plasma basal levels.