Cigarette smoking is not a risk factor in atopic dermatitis

BACKGROUND

In recent years several diseases have been shown to have a relationship with smoking. Psoriasis is largely a disease of smokers, whereas acne appears to be associated with not smoking.

METHODS

One hundred and fifty patients with atopic dermatitis were sent a postal questionnaire on smoking habits and the results were compared with those from matched controls in the local community.

RESULTS

One hundred and twenty-seven patients (85%) completed the questionnaire. There was no apparent difference in the prevalence of current smokers amongst atopic dermatitis patients compared with controls (odds ratio = 1.1, 95% confidence limits 0.65-1.86, P = 0.8).

CONCLUSIONS

There was no significant difference between the smoking prevalence of patients with atopic dermatitis and matched controls.

A new noninvasive method for the estimation of peak dP/dt

BACKGROUND

Peak dP/dt is a good index of ventricular performance that is not influenced by afterload, wall motion abnormalities, or the variations in ventricular anatomy and morphology commonly encountered among patients with congenital heart disease. Unfortunately, the clinical utility of peak dP/dt has been limited by the fact that its measurement generally requires an intraventricular catheter. However, peak dP/dt occurs during isovolumetric contraction, and the pressure rise during isovolumetric contraction is almost linear. Therefore, the mean dP/dt during isovolumetric contraction (mean dP/dtic), ie, the ratio of the rise in pressure during isovolumetric contraction (aortic diastolic pressure minus the systemic ventricular end-diastolic pressure [VEDP]) over the isovolumetric contraction time, should provide a good estimate of peak dP/dt that could be generated noninvasively.

METHODS AND RESULTS

Echo/phonocardiography was used to measure the isovolumetric contraction time and a blood pressure cuff to estimate aortic diastolic pressure of 27 patients (age, 1 day to 77 years) with congenital or acquired heart disease. VEDP was determined by three methods: (1) intraventricular catheter, (2) assumed VEDP of 10 mm Hg, and (3) assignment of a normal or elevated value on the basis of clinical history. The three estimates of mean dP/dtic thus generated were compared with simultaneous measurements of peak dP/dt obtained during cardiac catheterization. Invasively measured peak dP/dt correlated well with the indirect determinations (r = .95, .89, and .92 for methods 1, 2, and 3, respectively; P < .0001).

CONCLUSIONS

Echo/phonocardiography can be used in conjunction with a blood pressure cuff and indirect estimates of VEDP to generate mean dP/dtic, an index of ventricular function that approximates and closely correlates with peak dP/dt. This noninvasive measurement can be obtained in almost any patient and may be useful in the assessment of ventricular performance in a variety of cardiovascular disorders.

Hormone replacement therapy prevents bone loss in patients with inflammatory bowel disease

Patients with inflammatory bowel disease have an increased prevalence of osteoporosis, and suffer high rates of spinal bone loss. Hormone replacement therapy (HRT) is effective in the treatment and prevention of osteoporosis but has not been studied in patients with inflammatory bowel disease. A two year prospective study of HRT in inflammatory bowel disease was performed in 47 postmenopausal women aged 44 to 67 years with ulcerative colitis (25) or Crohn's disease (22). Patients had radial and spinal bone density measured annually by single photon absorptiometry and quantitative computed tomography respectively. The mean (95% confidence intervals) annual change in radial bone density was +1.42%/yr (+0.58 to +2.26; P < 0.005) and for spinal bone +2.60%/yr (+1.06 to +4.15; p < 0.005). There was no significant correlation between rates of change of bone density at the two sites, or between the rates of change and the initial bone density either in the radius or spine. Twelve patients were given prednisolone during the study, and their rates of change for spinal bone density were lower, but values were not statistically significantly different from those who did not receive corticosteroids. Changes in bone density for patients with ulcerative colitis and Crohn's disease were not significantly different. The change in bone density did not correlate with the patients' age or number of years after the menopause. It is concluded that HRT is effective in prevention of bone loss in postmenopausal women with inflammatory bowel disease.

A four-year longitudinal study of bone loss in patients with inflammatory bowel disease

Serial measurements of spinal trabecular and radial cortical bone density were made over 4 years in 70 patients with inflammatory bowel disease. Mean rates of bone loss for the cohort differed little from rates reported in normal populations; however, some patients showed increased rates of loss, including patients whose bone density at entry to the study was already well below normal. There was a significant correlation between the amount of corticosteroid prescribed and spinal trabecular bone loss in males, but no significant correlation with other clinical parameters. Increased rates of bone loss emphasise the need for bone densitometry and prophylactic measures in patients with inflammatory bowel disease.

Hormone replacement therapy in chronic active hepatitis; a case report

There is an increased incidence of osteoporosis in patients with chronic liver disease. Because patients with chronic active hepatitis (CAH) usually require corticosteroids for their liver disease prevention and treatment of bone loss presents a difficult problem. This case report describes a 41 year old female patient with CAH who had a high rate of bone loss. After an early menopause with noticeable menopausal symptoms, she was given transdermal oestrogen replacement therapy. The menopausal symptoms resolved completely, and there was no deterioration in her liver function tests or corticosteroid requirement. In addition, follow up quantitative bone mineral measurements over two years have shown improvement. This case shows the value of measurements of bone density, and oestrogen replacement therapy in CAH, even in the presence of continued corticosteroids.

Smoking and ulcerative colitis: a community study

Smoking habits of patients with ulcerative colitis, diagnosed in the City of Cardiff between the 1st of January 1978 and the 31st of December 1987 were examined. There was a significant deficit of current smokers, an excess of life-long non-smokers and ex-smokers compared with the general population. Men who had previously smoked presented with colitis later than life long non-smokers (mean age difference 16.1 years). The proportion of ex-smokers in this group of patients with colitis was more than twice that expected in the general population. The interval between cessation of smoking and subsequent onset of colitis in ex-smokers was relatively short and in more than half of them occurred within 8 years. There was no significant difference in the frequency of colectomy or the extent of disease among smokers, ex-smokers or life-long non-smokers with ulcerative colitis.

Comparison of bismuth citrate and 5-aminosalicylic acid enemas in distal ulcerative colitis: a controlled trial

An enema that contained a complex of bismuth citrate and polyacrylate was compared with 5-aminosalicylic acid (5-ASA) enemas for treatment of distal ulcerative colitis. The multicentre trial involving 63 patients was randomised and double blind with enemas given over four weeks; clinical, sigmoidoscopic, and histological assessments were made. Improvements were seen in both treatment groups. Clinical remission was seen in 18 of 32 patients treated with 5-ASA and 12 of 31 patients treated with bismuth citrate-carbomer (chi 2 1.94; p = 0.16). Sigmoidoscopic remission occurred in 20 of 32 patients in the 5-ASA group and 15 of 31 patients given bismuth (chi 2 1.27; p = 0.26). Improvement of rectal biopsy histology by at least one grade was seen in 16 of 32 patients in the 5-ASA group and 14 of 31 patients with bismuth (chi 2 0.15; p = 0.70). Analysis of covariance gave no significant difference between groups, although there was a trend favouring 5-ASA. There was no evidence of bismuth accumulation during the trial. Bismuth enemas may offer a new therapeutic option in distal ulcerative colitis.

Effect of hemodialysis on left ventricular contractility in pediatric patients with end-stage renal disease

Assessment of the effect of hemodialysis on myocardial contractility is complicated by variations in loading conditions that can occur during hemodialysis and by the prevalence of coronary artery disease among patients with chronic renal failure. Therefore, we used a load-independent index of left ventricular contractility, derived from analyses of the rate corrected velocity of circumferential fiber shortening (Vcfc)-end systolic wall stress (ESWS) relationship, to study the acute effects of hemodialysis on left ventricular function in the cases of 15 pediatric patients with end-stage renal disease. Prior to dialysis, Vcfc was appropriate for ESWS (102% +/- 16% of predicted) and did not differ significantly from values obtained from a group of nine normal control subjects of similar ages (103% +/- 9% of predicted), indicating that the patients' left ventricles were functioning in a normal inotropic state. After dialysis, Vcfc increased to levels beyond those expected for ESWS (118% +/- 20% of predicted, P < .05 versus control; P < .001 versus predialysis levels), indicating that dialysis was associated with enhancement of the left ventricle's inotropic state. A statistically significant increase in plasma norepinephrine levels was also observed. However, the increase in the percentage of the predicted Vcfc did not correlate with observed changes in this inotropic agent or with dialysis-induced variations in body weight or levels of electrolytes, urea nitrogen, or creatinine, and firm conclusions regarding the identity of the factors responsible for the positive inotropic effect of hemodialysis could not be drawn.

Comparison of antigen presentation of influenza A nucleoprotein expressed in attenuated AroA- Salmonella typhimurium with that of live virus

Rationally attenuated strains of Salmonella expressing foreign proteins represent a potentially important vaccine delivery system. The characteristics of Ag presentation of influenza nucleoprotein expressed in an AroA- strain of Salmonella typhimurium (SL3262-pNP-2) have therefore been compared with those of soluble purified nucleoprotein (NP) and infectious influenza virus. This represents three distinct modes of internalization of the same protein into APC. Human monocytes and the monocytic leukemia cell line THP-1 infected with SL3261-pNP-2 were found to present several different epitopes from NP to human CD4+ class II-restricted T lymphocytes. Ag presentation to these T cell clones was enhanced by pretreatment of THP-1 cells with IFN-gamma but not TNF-alpha. Bacterial phagocytosis and Ag presentation of NP were increased after opsonization of Salmonella with immune serum. Macrophages infected with SL3261-pNP-2 were unable to present NP to class I-restricted T cells. In contrast, cells infected with live influenza virus, although recognized by NP-specific class I-restricted CTL, were inefficiently recognized by NP-specific class II-restricted T cells. Ag presentation to CD4+ T cell clones by monocytes of SL3261-pNP-2, purified recombinant NP, and live influenza virus, but not the synthetic peptide 206-229, was inhibited by chloroquine and the protease inhibitors pepstatin A and leupeptin, suggesting that the major route of processing in each case was via the exogenous pathway. T cell recognition of NP via all of these Ag delivery systems was also abrogated by cycloheximide and brefeldin A treatment, indicating a requirement for recently synthesized MHC class II molecules in presentation of whole NP after processing but not for the corresponding synthetic peptide.

Comparison of antigen presentation of influenza A nucleoprotein expressed in attenuated AroA- Salmonella typhimurium with that of live virus

Rationally attenuated strains of Salmonella expressing foreign proteins represent a potentially important vaccine delivery system. The characteristics of Ag presentation of influenza nucleoprotein expressed in an AroA- strain of Salmonella typhimurium (SL3262-pNP-2) have therefore been compared with those of soluble purified nucleoprotein (NP) and infectious influenza virus. This represents three distinct modes of internalization of the same protein into APC. Human monocytes and the monocytic leukemia cell line THP-1 infected with SL3261-pNP-2 were found to present several different epitopes from NP to human CD4+ class II-restricted T lymphocytes. Ag presentation to these T cell clones was enhanced by pretreatment of THP-1 cells with IFN-gamma but not TNF-alpha. Bacterial phagocytosis and Ag presentation of NP were increased after opsonization of Salmonella with immune serum. Macrophages infected with SL3261-pNP-2 were unable to present NP to class I-restricted T cells. In contrast, cells infected with live influenza virus, although recognized by NP-specific class I-restricted CTL, were inefficiently recognized by NP-specific class II-restricted T cells. Ag presentation to CD4+ T cell clones by monocytes of SL3261-pNP-2, purified recombinant NP, and live influenza virus, but not the synthetic peptide 206-229, was inhibited by chloroquine and the protease inhibitors pepstatin A and leupeptin, suggesting that the major route of processing in each case was via the exogenous pathway. T cell recognition of NP via all of these Ag delivery systems was also abrogated by cycloheximide and brefeldin A treatment, indicating a requirement for recently synthesized MHC class II molecules in presentation of whole NP after processing but not for the corresponding synthetic peptide.

Ventilatory work and oxygen consumption during exercise and hyperventilation

The work of breathing (WB), and thus the energy requirement of the respiratory muscles, is increased any time minute ventilation (VE) is elevated, by either exercise or voluntary hyperventilation. Respiratory muscle O2 consumption (VRMO2) in humans has generally been estimated by having subjects breathe at a level comparable to that during exercise while the change in O2 consumption (VO2) is measured. The difference between VO2 at rest and during hyperventilation is attributed to the respiratory muscles and is assumed to be similar to VRMO2 during exercise at the same VE. However, it has been suggested that WB differs between exercise and hyperventilation and that WB during exercise is lower than during hyperventilation at the same VE. In this study we measured WB during exercise and hyperventilation and from these measurements estimated VRMO2. WB, VE, and VO2 were measured in five male subjects during rest and during exercise or hyperventilation at levels of VE ranging from 30 to 130 l/min. VE/WB relationship was determined for both hyperventilation and exercise. Multiple regression analysis showed that the shape of the two curves was different (P < 0.0001), with WB at high levels of VE being < or = 25% higher in hyperventilation than in exercise. In a second study in which frequency, tidal volume, and duty cycle were controlled as well as VE, there was no difference in WB between exercise and hyperventilation. VO2 was significantly correlated with WB, and the estimated VRMO2 did not increase as a fraction of total VO2 as exercise intensity rose.(ABSTRACT TRUNCATED AT 250 WORDS)

Longitudinal study of cortical bone loss in patients with inflammatory bowel disease

Bone mineral density of the radius was measured by single-photon absorptiometry in 50 patients with inflammatory bowel disease. Thirty-three had Crohn's disease and 17 ulcerative colitis; 25 were women. The mean age was 45 years (range, 18-70 years). Measurements were repeated in 39 of them after a mean follow-up period of 7.9 years (range, 7.1-8.2 years). In female patients the mean (95% confidence interval) annual change in radial bone mineral density was -0.74% (-1.34% to -0.14%) (P = 0.022), the greatest bone loss occurring in postmenopausal women (mean, -1.16% (-2.01% to -0.30%)). In male patients the mean annual rate of bone loss was -0.07% (-0.41% to 0.28%) (P = NS). Patients with abnormally low values at the first measurement remained osteopenic at the second measurement, whilst some others with normal values initially showed increased rates of bone loss and had a subnormal bone mineral density after the follow-up period. These results show increased rates of cortical bone loss in some patients with inflammatory bowel disease and emphasize the need to monitor bone mass in these patients so that prophylactic measures can be instituted.

A comparison of upper gastrointestinal mucosal damage by standard and delayed-release indomethacin

Forty-five patients taking long-term indomethacin and with endoscopic erosions or superficial ulcers in the oesophagus, stomach or duodenal bulb were randomized in a double-blind study to continue with standard indomethacin or receive a 'delayed-release' formulation. This consisted of microgranules of indomethacin coated with an acrylic resin, Eudragit L, which releases drug in the small intestine. Endoscopy was repeated after 8 weeks and biopsies taken on both occasions. Changes in endoscopic lesions and histological appearances were similar in both groups, although mucosal erythema was less in those given Eudragit L indomethacin. Systemic, rather than topical, effects of indomethacin may therefore be responsible for persistence of gastro-duodenal mucosal lesions in these patients. There is reason to question the clinical practice of using expensive, delayed-release preparations.

Total parenteral nutrition-induced changes in gut mucosal function: atrophy alone is not the issue

BACKGROUND

Total parenteral nutrition (TPN) has been implicated in gut atrophy and breakdown of barrier function leading to bacterial translocation (BT) in animals. BT during TPN, however, is not found consistently, and it has therefore been suggested that macromolecular permeability may occur independently of BT during TPN.

METHODS

Male Sprague-Dawley rats were administered isocaloric standard TPN enterally, parenterally, or split equally between the two routes or allowed food ad lib. A second group of rats was administered isocaloric TPN with and without 4% lipids, and changes in gut barrier function were assessed by measuring lactulose permeability.

RESULTS

Rats receiving TPN both enterally and parenterally maintained histologic intestinal structure to the same degree as rats fed enterally and those allowed food. Although parenteral feeding led to significant gut atrophy and cecal bacterial overgrowth, BT was not increased. Gut permeability to lactulose, however, was increased significantly in the TPN groups. Lipid content did not affect outcome.

CONCLUSIONS

These results suggest that gut atrophy, BT, and permeability to macromolecules are not necessarily related. Gut-origin septic states during TPN or trauma may be caused by an increased escape of macromolecules from the gut, and BT may be an end result rather than a primary cause of such septic episodes.

Smoking habits in psoriasis: a case control study

We have examined smoking habits in 108 patients with psoriasis, including some with palmoplantar distribution, and compared the results with matched controls from the community. There was a significant association between psoriasis, current smoking status (OR = 2.7, 95% CI 1.44-5.42, P less than 0.01) and smoking habits prior to the onset of disease (OR = 3.75, 95% CI 1.68-9.47, P less than 0.001). There was also a marked dose-response relationship; the relative risk of psoriasis in those currently smoking more than 20 cigarettes/day was significantly elevated (OR = 5.3, 95% CI 2.1-13.0, P less than 0.001). Separate analysis of patients without palmoplantar distribution of psoriasis showed a significant association with smoking prior to onset of psoriasis (OR = 3.6, 95% CI 1.5-9.8, P less than 0.001). Smoking may play a role in the aetiology of this common skin disorder.

Galactose oxidation in the design of immunogenic vaccines

Potent immunological adjuvants are urgently required to complement recombinant and synthetic vaccines. However, it has not been possible to derive new principles for the design of vaccine adjuvants from knowledge of the mechanism of immunogenicity. Carbonyl-amino condensations, which are essential to the inductive interaction between antigen-presenting cells and T helper cells, were tested as a target for the enhancement of immune responses. Enzymic oxidation of cell-surface galactose to increase aminereactive carbonyl groups on murine lymphocytes and antigen-presenting cells provided a potent, noninflammatory method of enhancing the immunogenicity of viral, bacterial, and protozoal subunit vaccines in mice.

A pharmacokinetic study of sulphasalazine and two new formulations of mesalazine

We have examined the pharmacokinetics of enteric coated sulphasalazine compared with two new formulations of mesalazine. These consisted of microgranules of mesalazine coated with Eudragit S in a concentration of either 20 or 25% dry lacquer substance; these in turn were enclosed in capsules coated with Eudragit L. In-vitro dissolution studies of coated microgranules showed that drug release was pH dependent. Studies in 7 normal volunteers showed median peak concentrations of 5-amino-salicylic acid and N-acetyl-5-amino-salicylic acid occurred at about 6 hours with both microgranular preparations, compared with sulphasalazine at 15 h. The microgranule formulation coated with 20% Eudragit S gave serum levels and overall systemic absorption similar to values with sulphasalazine. This new formulation may be of value for delivering mesalazine and other therapeutic agents to the colon.

Inhibition of specific T-cell activation by monosaccharides is through their reactivity as aldehydes

The effect of monosaccharides on the inductive interaction between antigen-presenting cells and T cells was investigated in a human system. Some monosaccharides, but not others, were found to inhibit antigen-specific T-cell activation. Responses to mitogen were unaffected. In order for inhibition to occur, a high concentration (approximately 50 mM) of monosaccharide was necessary. The role of monosaccharide aldehyde groups in inhibition was investigated using the alpha-methyl pyranoside and the alditol forms of inhibitory monosaccharides. Unlike the native monosaccharides, these molecular configurations possess the ring structure and the open chain structure respectively but do not contain aldehydes. Together they represent all the molecular characteristics of both forms of the monosaccharide except the possession of aldehyde groups. These two molecular species produced no significant inhibition. Modified forms of the sugar moiety of ribofuranosidoadenine (adenosine) were also tested. The periodate oxidized form of the molecule in which the ribose bears two aldehyde groups, was a potent inhibitor of antigen-induced T-cell activation whereas periodate-oxidized, borohydride-reduced ribofuranosidoadenine, in which the ribose aldehydes are converted to alcohols, produced no inhibition. The former was shown to form Schiff bases with ligands on peripheral blood mononuclear cells (PBMC) as predicted whereas the latter did not. Periodate oxidized dextran, but not native dextran, was also inhibitory. Together these data show that inhibition of T-cell activation by sugars requires reactive aldehydes and this is consistent with the Schiff base model of specific antigen-presenting cell (APC)-T cell inductive interaction in which exogenous aldehydes and other carbonyl donors prevent the necessary formation of Schiff bases between cellular ligands.

Perceived discrimination in education and employment by people with Crohn's disease: a case control study of educational achievement and employment

Eighty three patients in whom the diagnosis of Crohn's disease had been made before the age of 40 years and who had been resident in the city of Cardiff were asked to complete a detailed questionnaire about their educational and employment experiences. Responses were obtained from 58 patients (response rate = 70%), 23 buddy controls, and 27 community controls. The mean (SD) age of patients at the time of the survey was 31 (5) years. Twenty four of the patients were diagnosed before leaving secondary education, at a mean age of 17 years. They had lost significantly more days' schooling than controls (chi 2 = 14.3 p less than 0.001) but had achieved similar academic success as measured by examination passes and attendance at tertiary institutes of education. Similar numbers of patients and controls were employed at the time of the survey, although significantly more patients had experienced long term unemployment (z = 2.6 p less than 0.01). As a result of their experiences up to 30% actively concealed their illness from employers.

Incidence of ulcerative colitis in Cardiff over 20 years: 1968-87

The annual incidence of ulcerative colitis in the city of Cardiff was examined over a 20 year period. In the decade 1968-77, the mean annual incidence was 6.4 per 10(5) of the population compared with 6.3 for the period 1978-87. There was no difference in the distribution or extent of the disease between decades or between sexes. This contrasts with the increased incidence of Crohn's disease during the same period. The study included a survey of family practitioners which identified a further 19 patients (11% of the total).

Sexual dysfunction amongst women with Crohn's disease: a hidden problem

The sexual problems of 50 women with Crohn's disease, of whom 45 had a stable relationship, were investigated by structured interview and compared with age-matched controls. Twenty-four percent patients had either infrequent or no intercourse compared with 4% of controls (chi 2 = 8.3, p < 0.005). However, amongst patients and controls who were sexually active, the frequency of intercourse was similar. Reasons for sexual inactivity included abdominal pain (24%), diarrhoea (20%) and fear of faecal incontinence (14%). Dyspareunia was common in patients (chi 2 = 6.5, p < 0.01) and this was irrespective of the site of disease (large vs. small bowel chi 2 = 0.85, NS). Women with perianal disease and fistulae were more likely to have dyspareunia than women with neither (chi 2 = 4.2, p < 0.05), although this was not so for less extensive involvement with only perianal disease (chi 2 = 2.8, NS) or fistulae (chi 2 = 0.8, NS). Vaginal candidiasis was more common in patients (chi 2 = 5.8, p < 0.02), and on occasions this may have contributed to dyspareunia. Women with Crohn's disease experience sexual problems much more than healthy controls and they need support, sympathetic investigation and management.

Risk of ulceration with long-term indomethacin: endoscopic and histological changes in upper gastro-intestinal mucosa

Twenty patients taking long-term indomethacin were chosen for the study because all had a normal endoscopic examination; biopsies, however, from the oesophagus, gastric antrum and duodenal bulb revealed histological inflammation in all patients in at least one site. After 8 weeks during which indomethacin therapy was continued, a further endoscopy revealed lesions in 5 patients--peptic ulcer in 3 and erosions in 2--but only 1 of these had any change in gastro-intestinal symptoms. Irrespective of whether mucosal lesions are seen on endoscopy in patients established on non-steroidal anti-inflammatory drug therapy, they remain in danger of developing both ulcers and erosions which are likely to be asymptomatic. At no time can one justifiably feel this patient group is not at risk of peptic ulceration.

Hemodynamic correlates of exercise function in patients with primary pulmonary hypertension

The purpose of this investigation was to study the hemodynamic correlates of exercise function in patients with primary pulmonary hypertension and to further define the role of exercise testing in the evaluation of these individuals. Data from the progressive exercise tests and subsequent cardiac catheterization in 16 consecutive patients, aged 16.9 +/- 10.4 years (range 6 to 35), with primary pulmonary hypertension were prospectively collected and analyzed. Exercise capacity averaged 40 +/- 36% (range 0 to 117%) of that predicted for age, height and gender. Statistically significant correlations existed between exercise capacity and 10 invasively measured hemodynamic variables. Mean right atrial pressure, a variable previously noted to be one of the best predictors of survival in patients with primary pulmonary hypertension, correlated best with exercise capacity (r = -0.83, p less than 0.0001). Exercise capacity greater than 75% of the predicted value identified the two patients who had a positive response to acute pulmonary vasodilator drug testing. Poor exercise capacity (less than 10% of the predicted value) identified the three patients who died during or soon after cardiac catheterization. The ability of exercise testing to identify patients at high risk for cardiac catheterization was superior to that of other noninvasive variables. Results of exercise testing may help guide decisions regarding the optimal timing of heart-lung or single lung transplantation.

A long-term clinical review of patients with oesophageal pain

Oesophageal and cardiac chest pain are often difficult to distinguish on clinical grounds. The clinical course of 32 patients with recurrent chest pain due to oesophageal dysmotility has recently been assessed by questionnaire 9 years after diagnosis. Twenty-six of the 27 who replied continued to have pain, but despite this there was a significant reduction in the number of hospital admissions associated with chest pain. Repeat oesophageal manometry in nine showed that the disturbance in motility persisted. Three had died, one of them from a myocardial infarction; two patients could not be traced.

A survey of the monosodium glutamate content of foods and an estimation of the dietary intake of monosodium glutamate

The MSG contents of a wide range of manufactured foods (over 200 samples) were measured using the AOAC Procedure (ion-exchange chromatography followed by formol potentiometric titration). The results obtained were used, in conjunction with published data on UK food consumption, to calculate tentative estimates of the dietary intake of MSG for specific groups of the UK population.

Smoking, humoral immunity, and ulcerative colitis

Since ulcerative colitis predominantly affects non-smokers and ex-smokers we have examined the possibility that smoking modifies the humoral immune response to an antigenic challenge from the gut lumen. Gut lavage was used in healthy subjects and patients with ulcerative colitis, including both smokers and non-smokers. Antibodies in the intestinal fluid to Escherichia coli (five pooled serotypes), Candida albicans, gliadin, ovalbumin, and beta lactoglobulin were measured by ELISA to determine specific antibody concentrations of IgG, IgA, and IgM classes. Total IgG, IgA, and IgM were also measured in intestinal secretions and serum. In addition, circulating antibody concentrations of IgG, IgA, and IgM to three gut commensals - E coli (five pooled serotypes) C albicans, and Poroteus mirabilis were measured. There was a significant reduction in the IgA concentration in intestinal fluid of smokers with ulcerative colitis compared with healthy non-smoking controls. No other significant differences were found between the groups. Overall, these data are not consistent with the idea that smoking suppresses immune responses in the gut and suggest that the effect of smoking in colitis is mediated by another mechanism.

Human T cell recognition of influenza A nucleoprotein. Specificity and genetic restriction of immunodominant T helper cell epitopes

The characterization of human T cell antigenic sites on influenza A nucleoprotein (NP) is important for subunit vaccine development for either antibody boosting during infection or to stimulate T cell-mediated immunity. To identify such sites, 31 synthetic peptides that cover more than 95% of the amino acid sequence from NP of influenza A/NT/60/68 virus were tested for their ability to stimulate PBL from 42 adult donors. The most frequently recognized region was covered by a peptide corresponding to residues 206-229 of NP, with 20/42 (48%) of responders. In many individuals this was also one of the peptides that stimulated the strongest T cell responses. Other regions that were also frequently recognized were 341-362 by 13/42 (30%), 297-318 by 10/42 (23%), and 182-205 by 9/42 (21%) of individuals. These peptides covered highly conserved regions in NP of influenza A viruses, suggesting that they could be useful in boosting cross-reactive immunity against the known type A virus strains. In order to define the class II restriction molecules used to present particular T cell epitopes, 22 persons from the donor panel were HLA-typed. The majority of persons who expressed DR2, and proliferated to NP also responded to the major immunodominant region 206-229. In addition, this peptide was also immunodominant in the one person expressing DRw13. The observation that recognition of this peptide is associated with DR2 was confirmed by using short term T cell lines and APC from a panel of typed donors. Further results with virus-specific T cell lines and clones and transfected L cells expressing DR molecules showed that DR1 could also present this peptide. Therefore the results suggest that recognition of 206-229 is associated with at least three different DR haplotypes and this may explain the high frequency with which this peptide is recognized in the population. The fine specificity of the response to peptide 206-229 was distinct when presented by DR1- or DR2-expressing APC. The DR1 response was dependent on the N terminus, and the DR2 response was directed to the C terminus of the peptide.

Human T cell recognition of influenza A nucleoprotein. Specificity and genetic restriction of immunodominant T helper cell epitopes

The characterization of human T cell antigenic sites on influenza A nucleoprotein (NP) is important for subunit vaccine development for either antibody boosting during infection or to stimulate T cell-mediated immunity. To identify such sites, 31 synthetic peptides that cover more than 95% of the amino acid sequence from NP of influenza A/NT/60/68 virus were tested for their ability to stimulate PBL from 42 adult donors. The most frequently recognized region was covered by a peptide corresponding to residues 206-229 of NP, with 20/42 (48%) of responders. In many individuals this was also one of the peptides that stimulated the strongest T cell responses. Other regions that were also frequently recognized were 341-362 by 13/42 (30%), 297-318 by 10/42 (23%), and 182-205 by 9/42 (21%) of individuals. These peptides covered highly conserved regions in NP of influenza A viruses, suggesting that they could be useful in boosting cross-reactive immunity against the known type A virus strains. In order to define the class II restriction molecules used to present particular T cell epitopes, 22 persons from the donor panel were HLA-typed. The majority of persons who expressed DR2, and proliferated to NP also responded to the major immunodominant region 206-229. In addition, this peptide was also immunodominant in the one person expressing DRw13. The observation that recognition of this peptide is associated with DR2 was confirmed by using short term T cell lines and APC from a panel of typed donors. Further results with virus-specific T cell lines and clones and transfected L cells expressing DR molecules showed that DR1 could also present this peptide. Therefore the results suggest that recognition of 206-229 is associated with at least three different DR haplotypes and this may explain the high frequency with which this peptide is recognized in the population. The fine specificity of the response to peptide 206-229 was distinct when presented by DR1- or DR2-expressing APC. The DR1 response was dependent on the N terminus, and the DR2 response was directed to the C terminus of the peptide.

Protection from gastrointestinal side-effects by azapropazone by its incorporation into a glucose-sodium acid citrate formulation

Addition of glucose and sodium citrate to azapropazone, in proportions of 1:1:1 by weight reduced gastric mucosal damage in rats and there was a trend towards reduction in radiolabelled faecal red cell loss in human volunteers compared with that with azapropazone alone. The glucose and citrate did not affect the pharmacokinetics of azapropazone, or its therapeutic efficacy. While no difference was observed in endoscopic injury and in symptomatic gastrointestinal complaints in a multicentre comparison in rheumatic patients, a striking reduction in symptoms was observed in those patients with a history of severe gastrointestinal intolerance to non-steroidal anti-inflammatory drugs.

Total body calcium in patients with inflammatory bowel disease: a longitudinal study

1. Serial measurements of total body calcium have been made by prompt gamma-neutron activation analysis in 13 patients with inflammatory bowel disease over a mean period of 23 months. Changes in spinal trabecular bone mineral density and radial shaft bone mineral content were also assessed by using quantitative computed tomography and single photon absorptiometry, respectively. 2. The mean annual decreases (95% confidence intervals) were: total body calcium, 7.8% (-12.0 to -3.7%; P less than 0.001); spinal trabecular bone mineral density, 2.5% (-5.0 to +0.1%; 0.05 less than P less than 0.1), radial bone mineral content, 2.1% (-3.4 to -0.8%; P less than 0.01). 3. No significant correlations were found between rates of change of the three variables. However, there were significant positive correlations between the baseline values for total body calcium and radial bone mineral content (r = 0.638, P less than 0.05), spinal bone mineral density and radial bone mineral content (r = 0.854, P less than 0.01), and total body calcium and spinal bone mineral density (r = 0.876, P less than 0.001). 4. These results demonstrate rapid decreases in total body calcium in patients with inflammatory bowel disease which, in conjunction with the significant decrease in radial shaft bone mineral content, indicate increased rates of cortical bone loss. Whilst values for bone mass at different skeletal sites showed positive correlations within individuals, no relationship was found between the rates of change in bone mass at these sites. 5. The rapid bone loss observed in some subjects emphasizes the importance of early detection of osteoporosis by bone densitometry and the need for effective prophylactic measures to be established in this group of patients.

Sensitivity and tolerance to nicotine in smokers and nonsmokers

We studied the responses of smokers and lifelong non-smokers to transdermal nicotine patches over 24 h in three groups of subjects: non-smokers on a 15 mg patch (n = 8), non-smokers on a 30 mg patch (n = 8) and smokers on a 30 mg patch (n = 8). Unexpectedly, the non-smokers appeared to absorb nicotine more rapidly. The increase in blood nicotine concentrations of non-smokers over the first 2 h of patch use was double that of the smokers, with mean increases of 4.5 (SD = 3.7), 10.9 (SD = 4.2) and 4.1 (SD = 2.7) ng/ml in the three groups, respectively (P less than 0.005). The smokers had no pleasant or unpleasant effects from the 30 mg patch (X Cmax 13.9 ng/ml, SD = 4.9; Tmax 8.75 h) but all eight non-smokers experienced mild nausea and lightheadedness (P less than 0.01) within the first hour, and seven dropped out (P less than 0.01) at 3-8 h due mainly to severe nausea, vomiting or headache (X Cmax 18.4 ng/ml, SD = 4.9; Tmax 5.25 h). Only one non-smoker dropped out on the 15 mg patch, but five had transient nausea in the first hour (X Cmax 7.9 ng/ml, SD = 3.0; Tmax 8.0). Our study provides evidence of chronic pharmacodynamic nicotine tolerance in smokers, but does not address whether this is acquired or innate. The higher rate of transdermal nicotine absorption in non-smokers is unexplained and requires replication.

Stress management for irritable bowel syndrome: a controlled trial

Thirty-five patients with irritable bowel syndrome were randomized to receive treatment in a stress management programme or conventional therapy which included the antispasmodic Colpermin. The stress management programme involved a median of six 40-min sessions with a physiotherapist during which patients were helped to understand the nature of their symptoms, their relationship to stress and were taught relaxation exercises. Two thirds of those in the stress management programme found the programme effective in relieving symptoms and experienced fewer attacks of less severity. This benefit was maintained for at least 12 months. Few of those given conventional management had any benefit. A stress management programme would appear to be of value for patients with irritable bowel syndrome.

Tripotassium dicitrato bismuthate enemas in the treatment of ulcerative proctitis

Eleven patients with active proctitis or proctosigmoiditis completed one month's treatment with tripotassium dicitrato bismuthate enemas administered at night. Symptoms, sigmoidoscopic appearances, and the histological grade of acute inflammation were assessed at the commencement of therapy and after one month. An overall score of these features showed improvement in 9 of 11 patients, which encourages further investigation of bismuth in controlled trials for patients with inflammatory bowel disease.

Squamous carcinoma in the liver

Squamous carcinoma of the liver has only rarely been reported. We present a case which highlights not only the difficulties in diagnosis but also how it can closely mimic sclerosing cholangitis.

Effect of ulcerative colitis and smoking on rectal blood flow

Rectal blood flow was measured by laser doppler flowmetry over 60 minutes in eight patients with colitis in remission and eight healthy male non-smokers. Ten smokers were also examined on two occasions, one of which included smoking a cigarette. Plasma nicotine concentrations were measured in smokers. All subjects showed a pronounced fall in rectal blood flow in the first 30 minutes and patients with colitis had significantly higher values compared with smokers (p less than 0.002; p less than 0.04) and non-smokers (p less than 0.007; p less than 0.002) during the first and second 30 minutes respectively. Values in smokers and non-smokers were similar, but smoking a cigarette was associated with a significant fall in blood flow (p less than 0.04) and this change was inversely related to the rise in plasma nicotine concentration (r = -0.63; p less than 0.05). The findings may be relevant to the association between colitis and the smoking history.

Erythrocyte rosettes provide an analogue for Schiff base formation in specific T cell activation

Human T cells spontaneously bind sheep E and this reflects physiologic interactions between specific adhesion molecules, principally T cell CD2, and the sheep equivalent of LFA-3. This interaction is important in T cell adhesion and in transmission of accessory activational signals. In this respect, E rosettes provide a partial analogue for T cell:accessory cell interaction and rosetting induces functional alterations in T cells. In studies of Ag-dependent T cell activation, we have obtained evidence that the formation of covalent Schiff bases between ligands on APC and T cell is an essential element. In our study, the specific chemical criteria defining Schiff base formation were applied to T cell E rosettes formed at room temperature, as follows: 1) Prior formation of Schiff bases on T cell epsilon-amino groups by glutaraldehyde inhibited E rosette formation. 2) Rosette formation was inhibited in the presence of exogenous lysine. 3) Reduction of constitutive T cell aldehydes by NaBH4 inhibited subsequent E rosette formation. In response to these chemical modifications of cellular ligands, T cell E rosette formation and T cell inductive interaction with APC were affected in the same way. 4) Oxidation of NaBH4-treated T cells by NaIO4 or galactose oxidase to regenerate cell-surface aldehydes on N-acetylneuraminic acid or galactose residues respectively, consistently restored E rosette formation. 5) Conversion of reversible Schiff bases to irreversible secondary amines by NaCNBH3 stabilized E rosettes against mechanical disruption. Together, these data demonstrate that E rosettes provide an analogue for the Schiff base-forming reactions that are essential in specific T cell activation.

Erythrocyte rosettes provide an analogue for Schiff base formation in specific T cell activation

Human T cells spontaneously bind sheep E and this reflects physiologic interactions between specific adhesion molecules, principally T cell CD2, and the sheep equivalent of LFA-3. This interaction is important in T cell adhesion and in transmission of accessory activational signals. In this respect, E rosettes provide a partial analogue for T cell:accessory cell interaction and rosetting induces functional alterations in T cells. In studies of Ag-dependent T cell activation, we have obtained evidence that the formation of covalent Schiff bases between ligands on APC and T cell is an essential element. In our study, the specific chemical criteria defining Schiff base formation were applied to T cell E rosettes formed at room temperature, as follows: 1) Prior formation of Schiff bases on T cell epsilon-amino groups by glutaraldehyde inhibited E rosette formation. 2) Rosette formation was inhibited in the presence of exogenous lysine. 3) Reduction of constitutive T cell aldehydes by NaBH4 inhibited subsequent E rosette formation. In response to these chemical modifications of cellular ligands, T cell E rosette formation and T cell inductive interaction with APC were affected in the same way. 4) Oxidation of NaBH4-treated T cells by NaIO4 or galactose oxidase to regenerate cell-surface aldehydes on N-acetylneuraminic acid or galactose residues respectively, consistently restored E rosette formation. 5) Conversion of reversible Schiff bases to irreversible secondary amines by NaCNBH3 stabilized E rosettes against mechanical disruption. Together, these data demonstrate that E rosettes provide an analogue for the Schiff base-forming reactions that are essential in specific T cell activation.

Coarse mucosal folds in the duodenum: a twenty-year follow-up

In a 20-year follow-up of 40 patients with coarse duodenal folds, details were obtained about 34 patients of whom 11 had died. Clinical details were reviewed from the remaining 23 patients, and recent barium meal examinations were reviewed from eight patients. Ten of the 23 surviving patients continued to have recurrent dyspepsia, and the radiological appearance in three of the eight recent barium meals showed that coarse mucosal folds persisted. The clinical course of those with coarse duodenal folds is similar to that of peptic ulcer, with recurrent symptoms in some patients continuing for many years, and in others complicated by development of peptic ulcer. Coarse mucosal folds in the duodenum are usually associated with a high acid secretion and treatment to reduce acid secretion is appropriate in view of the severity of symptoms and risk of ulceration.

Effect of right ventricular anatomy on the cardiopulmonary response to exercise. Implications for the Fontan procedure

Incorporation of the right ventricle (RV) into the pulmonary circulation of patients with tricuspid atresia undergoing a Fontan procedure has been advocated. The consequences of this approach on the exercise function of these patients was studied by examining the effects of progressive and steady-state bicycle exercise tests performed by 11 patients with right atrial (RA)-RV Fontan anastomoses, seven patients with RA-pulmonary artery (PA) Fontan anastomoses, 13 patients after repair of tetralogy of Fallot, and 34 normal control patients. All patients were in New York Heart Association class I. The exercise function of the patients undergoing RA-RV and RA-PA Fontan procedures were similar. The achieved peak work loads 60% and 67% of control and peak oxygen consumptions 60% and 64% of control, respectively. Both groups also displayed excessive ventilation, elevated dead space/tidal volume ratios, and depressed cardiac output during steady-state exercise. In contrast, tetralogy of Fallot patients achieved peak work loads and oxygen consumptions 83% of control and maintained normal cardiac outputs and dead space/tidal volume ratios during steady-state exercise. These results suggest that the presence of an RV within the pulmonary circulation of the Fontan patient does not result in improved exercise function. This may be due to the development of obstructive gradients across the RA-RV conduits during exercise or to the RV's negative effect on left ventricular compliance. Moreover, in contrast with the postoperative tetralogy of Fallot patient, the hypoplastic RV of tricuspid atresia may not have sufficient myocardium to assume the active pumping function required by exercise.

An essential role for constitutive Schiff base-forming ligands in antigen presentation to murine T cell clones

The role of cell-surface Schiff base-forming ligands in the inductive interaction between class II+ APC and murine T cells was investigated. Schiff bases are produced by the condensation of an amine with the carbonyl group of an aldehyde or ketone in a reversible covalent reaction. Treatment of APC with low concentrations of glutaraldehyde to form Schiff bases on a small proportion of epsilon-amino groups consistently inhibited Ag presentation to primary T cells and T cell clones. Schiff base formation by glutaraldehyde was quantitated by specific reduction with the weak, selective reducing agent sodium cyanoborohydride. Aldehyde inhibition of presentation was observed with allo-, protein, and small peptide Ag, and T cell clones of Th1 and Th2 subtypes were equally susceptible. Large increases in the concentration of glutaraldehyde in brief pretreatments of APC resulted in substantial restoration of Ag-presenting function. Oxidation of T cell sialic acid to produce cell-surface aldehydes resulted in a vigorous proliferative response to class II-positive syngeneic accessory cells. This response was inhibited by preformation of Schiff bases on epsilon-amino groups of the accessory cells by glutaraldehyde. Dose response curves for inhibition of aldehyde-induced and Ag-induced T cell proliferation by glutaraldehyde treatment of accessory cells were similar. Reduction of constitutive aldehydes on cloned T cells by sodium borohydride resulted in inhibition of Ag-specific responses. This took the form of a substantial delay in the time-course of the response consistent with the eventual regeneration of cell-surface aldehydes. Only the presentation of Ag was inhibited. Ongoing established proliferative responses remained unaffected. Together, these data indicate that constitutive Schiff base-forming ligands on APC and T cells are essential in Ag presentation to murine T cells and are consistent with a model of Ag presentation in which reciprocal Schiff base formation is an essential element.

An essential role for constitutive Schiff base-forming ligands in antigen presentation to murine T cell clones

The role of cell-surface Schiff base-forming ligands in the inductive interaction between class II+ APC and murine T cells was investigated. Schiff bases are produced by the condensation of an amine with the carbonyl group of an aldehyde or ketone in a reversible covalent reaction. Treatment of APC with low concentrations of glutaraldehyde to form Schiff bases on a small proportion of epsilon-amino groups consistently inhibited Ag presentation to primary T cells and T cell clones. Schiff base formation by glutaraldehyde was quantitated by specific reduction with the weak, selective reducing agent sodium cyanoborohydride. Aldehyde inhibition of presentation was observed with allo-, protein, and small peptide Ag, and T cell clones of Th1 and Th2 subtypes were equally susceptible. Large increases in the concentration of glutaraldehyde in brief pretreatments of APC resulted in substantial restoration of Ag-presenting function. Oxidation of T cell sialic acid to produce cell-surface aldehydes resulted in a vigorous proliferative response to class II-positive syngeneic accessory cells. This response was inhibited by preformation of Schiff bases on epsilon-amino groups of the accessory cells by glutaraldehyde. Dose response curves for inhibition of aldehyde-induced and Ag-induced T cell proliferation by glutaraldehyde treatment of accessory cells were similar. Reduction of constitutive aldehydes on cloned T cells by sodium borohydride resulted in inhibition of Ag-specific responses. This took the form of a substantial delay in the time-course of the response consistent with the eventual regeneration of cell-surface aldehydes. Only the presentation of Ag was inhibited. Ongoing established proliferative responses remained unaffected. Together, these data indicate that constitutive Schiff base-forming ligands on APC and T cells are essential in Ag presentation to murine T cells and are consistent with a model of Ag presentation in which reciprocal Schiff base formation is an essential element.

Smoking, eicosanoids and ulcerative colitis

In this study, which is the first of its kind using normal tissue samples that are very difficult to obtain, we have investigated the hypothesis that smoking protects against ulcerative colitis by altering the colonic mucosal formation of prostaglandins and related substances. Colonic mucosa biopsied from healthy young men produced prostaglandin E, 6-keto-PGF1 alpha (formed from PGI2), leukotriene B4 and leukotriene C4/D4/E4 as determined by radioimmunoassay. With each substance, the median yield was lower in the group of smokers who smoked 3 cigarettes in the 2 h before biopsy, than in the non-smokers. However, with each eicosanoid the statistical probability approached only the 10% level, but the fact that the trend was the same for all eicosanoids somewhat strengthens the possibility of a real difference between the groups.