Detection of hepatitis C virus antibody by first and second generation assays and polymerase chain reaction in patients with autoimmune chronic active hepatitis types I, II, and III

In this study we have attempted to classify a group of North American patients with autoimmune chronic hepatitis into types I, II, and III according to the class of autoantibody present in serum, and determine the prevalence and significance of antibody to hepatitis C virus (anti-HCV). A total of 62 patients (type I, 51; type II, 3; type III, 8) were tested with first-generation enzyme-linked immunosorbent assay (ELISA)-1. Seropositive patients were assessed by second-generation recombinant immunoblot assay (RIBA)-2 and polymerase chain reaction (PCR). Our results demonstrate that 12 (19%) of the 62 patients with autoimmune hepatitis were anti-HCV ELISA-1 positive (type I, 9; type II, 1; type III, 2). Only one patient with type II autoimmune hepatitis was reactive by RIBA-2 and PCR. Eight of the 12 seropositive patients entered remission after corticosteroid therapy and seven of them became seronegative by ELISA-1. The RIBA-2 and PCR reactive patient did not respond to immunosuppressive therapy and remained seropositive. We conclude that there is a low prevalence of anti-HCV antibody in autoimmune hepatitis. Results based only on ELISA-1 anti-HCV testing can be misleading, and second-generation testing is necessary to recognize the presence of HCV infection. The fact that the only RIBA-2 reactive patient had type II autoimmune hepatitis may suggest a role for HCV infection in the pathogenesis of this condition. Nevertheless, corticosteroid therapy remains effective in those patients who are ELISA-1 seropositive, but RIBA-2 and PCR nonreactive.

Patient controlled analgesia--a pharmacy based service

Patient controlled analgesia (PCA) is a proven method of administering analgesics via programmable infusion devices to relieve postoperative pain and pain associated with terminal illnesses. In mid-1989, a pain management service was started in the authors' hospital by the anesthesiology service. Since pharmacists had been previously involved in PCA postoperative pain management, it was decided they would continue in that capacity with the pain management service. Responsibility for procuring, storing, and programming the pumps, as well as drug preparation and patient instruction remains an integral part of the daily operation of our pharmacy. Physician orders written by the anesthesiologists for PCA therapy are processed in the pharmacy computer. The drugs are prepared, and pumps are programmed and primed by the central intravenous (IV) admixture service. The pumps with the drugs and accessory administration set and supplies are sent to satellites where staff pharmacists aid the nurses in starting the pumps and training the patients in their correct use. All subsequent programming including dose changes, rate changes, boluses, bag changes, and problem resolution are the responsibility of the staff pharmacists. Pharmacists are periodically certified in programming skills as part of the department's quality assurance program. In 1990, over 1800 patients received the benefits of this innovative service.

Prevalence of antibodies to hepatitis C virus among patients with cryptogenic chronic hepatitis and cirrhosis

Many cases of chronic hepatitis and cirrhosis cannot be attributed to a known cause and are collectively referred to as cryptogenic chronic liver disease. We have evaluated the role of the hepatitis C virus in the pathogenesis of this condition in a retrospective serum analysis for antibody to hepatitis C virus in 129 patients with cryptogenic liver disease. Other causes of chronic hepatitis and cirrhosis were ruled out by clinical, serum biochemical and serological techniques. All 129 patients were HBcAg negative, but 28 (22%) had antibody to HBcAg. Sera were tested by radioimmunoassays using recombinant peptides for antibodies to nonstructural (C100-3 and C33c) and structural regions (C22) of HCV. Among the 129 patients, 61 (47%) had antibody to C100-3, 76 (59%) had antibody to C33c and 74 (57%) had antibody to C22. Seventy-nine (61%) were reactive with at least one and 76 (59%) were reactive with at least two HCV peptides (this is the criterion used for hepatitis C virus antibody reactivity). A proportion of patients with chronic hepatitis and cirrhosis (55 of 91; 60%) similar to that of patients without cirrhosis (21 of 38; 55%) had hepatitis C virus antibody. No significant clinical, serum biochemical or histological differences were noted between the group of patients with hepatitis C virus antibody and those without this antibody reactivity. Thus more than half the patients with cryptogenic chronic liver disease had hepatitis C virus antibody, suggesting that chronic HCV infection plays a major role in the origin of cryptogenic chronic hepatitis and cirrhosis.

Protocol for genetic testing in Huntington disease: three years of experience in Minnesota

Molecular genetic testing for Huntington disease (HD) by linkage analysis of DNA markers close to the HD gene has been possible since the mid-1980s. Because of ethical and practical concerns about this kind of testing, most groups performing the test in the past have operated under lengthy research protocols designed to assess the psychological morbidity of the presymptomatic diagnosis of a fatal disease. Our approach to HD testing is service-oriented, and our testing process has been designed to be flexible, to meet the varying needs of our patients. Between 1988 and 1990, 87 inquiries about the test have been received; 22 inquiries had family structures which were unsuitable for linkage analysis. Eleven of the 37 individuals who entered the testing program have not completed it. Of 19 patients who have received DNA results, seven received an increased risk of carrying the HD gene, and ten, a decreased risk. For two additional individuals, nonpaternity resulted in a negligible risk for HD. Several of those consulted, or their spouses, have had continuing outpatient counseling since completing the test; none have required hospitalization. Our short-term results indicate that molecular genetic testing for HD can be performed safely in a clinical setting using our protocol. As molecular genetic testing for HD and other diseases moves out of research centers and into clinics, clinicians must devise practical strategies for providing the medical, genetic, and psychological services needed for the growing number of individuals who will seek such testing.

Hepatitis C-associated hepatocellular carcinoma

In the United States, a large percentage of patients with hepatocellular carcinoma are serologically negative for hepatitis B. We conducted a retrospective study to determine the prevalence of hepatitis C antibody in the sera of 59 patients with hepatocellular carcinoma who were HBsAg-negative and had no evidence of alcoholic liver disease, primary biliary cirrhosis, autoimmune hepatitis, hemochromatosis or alpha 1-antitrypsin deficiency. Twenty patients (34%) were hepatitis C antibody-positive and hepatitis B core antibody-negative. All twenty patients had underlying cirrhosis, and seven (35%) had histories of transfusions. Eleven (19%) additional patients were also hepatitis C antibody-positive but were hepatitis B core antibody-positive as well. Twenty-one (36%) patients were both hepatitis C antibody- and hepatitis B core antibody-negative and seven (12%) were hepatitis C antibody-negative but hepatitis B core antibody-positive. The prevalence of hepatitis C antibody was also determined among three other population groups serving as controls and found to be 14% in 28 HbsAg-positive patients with hepatocellular carcinoma, 44% in 76 patients with cryptogenic cirrhosis and 0.5% in 200 consecutive volunteer blood donors. We conclude that hepatitis C antibody is prevalent among patients with hepatocellular carcinoma and may therefore be a common causative agent of this disease. A significant number of patients with and without cirrhosis, negative for hepatitis C antibody and hepatitis B core antibody, remain without a discernible cause for this malignancy. Perhaps a second- or third-generation test will detect hepatitis C antibody in some of these patients.

Sexual expression of mentally retarded people: educational and legal implications

Issues of legal consent and competency, in addition to the relevant psychological literature, were reviewed in relation to institutional policy for sexual management of mentally retarded individuals. The significance of comprehensive sex education was also discussed. Finally, suggestions were provided that minimize prejudicial treatment of mentally retarded people, without eliminating their opportunities for sexual expression.

Small bowel edema: mosaic pattern

We report an unusual radiographic appearance of small bowel submucosal edema produced by obstruction from metastatic colorectal carcinoma. The distinctive muscosal pattern of raised polygonal plaques is the same mosaic pattern described in the colon and referred to as "urticaria." This mosaic pattern in the small bowel has not previously been reported.

Thyroid radiation absorbed dose from diagnostic procedures in U.S. population

According to a 1981 survey of thyroid imaging methods in the United States, radionuclide thyroid scans and uptake studies increased 250%-300% between 1966 and 1981, while the U.S. population increased only 17%. Collective absorbed dose decreased from 18 X 10(6) rad (18 X 10(4) Gy) in 1966 to 13.9 X 10(6) rad (13.9 X 10(4) Gy) in 1981. The decrease was due to the use of iodine 123 and technetium 99m pertechnetate rather than iodine 131 (I-131 was used for 100% of scans and uptake studies in 1966 and 10% and 54%, respectively, in 1981) and also to fewer free-standing thyroid uptake studies (150,000 in 1966 and 33,000 in 1981). Even with reduced usage, I-131 still accounted for 93% of the collective absorbed dose in 1981. If I-131 were eliminated from diagnostic procedures, the annual absorbed dose would decrease to 1.4 X 10(6) rad (1.4 X 10(4) Gy). The number of radiation-induced cancer cases would also be reduced.

Phrenic nerve paresis associated with the use of iced slush and the cooling jacket for topical hypothermia

Phrenic nerve injury has been reported with the use of iced slush for topical cardiac hypothermia. To study this problem in both valve and coronary procedures, we tried to detect phrenic nerve injury in five groups of patients undergoing cardiac operations in which different techniques of topical hypothermia were used. The results indicate a 24% incidence of left phrenic nerve paresis in patients undergoing coronary bypass with iced slush used for topical hypothermia, 12.5% in patients in whom the cardiac cooling jacket was used in association with cold saline, and 22.9% in patients in whom both the cardiac cooling jacket and iced slush were used in the pericardial sac. There was no phrenic nerve injury when saline alone was used. Phrenic paresis is transient and of no clinical significance except when bilateral. Avoidance of contact of either the cooling jacket or iced slush with the phrenic nerve could avoid this complication.

Value of screening for markers of hepatitis in dialysis units

The value of monitoring the serum activity of SGOT, as well as markers of hepatitis B virus and hepatitis A virus infections, in the patients and staff of two dialysis units has been assessed retrospectively. Sera were checked each month for SGOT and HBsAg on 406 patients and 170 staff members over a 4-year period. Anti-HBc, anti-HBs, and anti-hepatitis A antibodies were assayed on the stored sera. Only 30% of the patients had normal SGOT values (less than 65 units per ml) on all occasions. Most of the abnormal values were less than 100 units per ml and could not be explained. Viral hepatitis was a reasonable explanation for only half of those instances where the SGOT value was greater than 100 units per ml. Hepatitis A virus contributed nothing to the problem of dialysis-associated liver disease. Testing for HBsAg alone missed approximately 40% of the hepatitis B events acquired in the unit. Only two of these episodes were of epidemiologic importance, however, because the rest were recognized only after there was serologic resolution of the infection. There was a high frequency of potentially "false positive" reactions with all the antibodies tested. It is not cost-effective to monitor dialysis patients and staff regularly with anti-HBc, anti-HBs, or antibodies against hepatitis A. Initial screening with anti-HBc and anti-HBs on entry to the unit is of value but weak positive results must be interpreted with caution since approximately half of such results will prove to be nonspecific.

Further validation of the plasma isotope ratio method for measurement of cholesterol absorption in man

Recently we evaluated an isotope ratio method (IRM) for measurement of cholesterol absorption in 14 patients (15 experiments) hospitalized in the metabolic ward by comparing it to simultaneous measurements with a fecal radioactivity method (FRM) and found good to excellent agreement between two procedures (Samuel, P., J. R. Crouse, and E. H. Ahrens, Jr. 1978 J. Lipid Res. 19: 82-93). This comparison has now been extended to additional studies carried out in eight hospitalized patients (19 experiments). Of the 34 comparisons between the IRM and the FRM in our hands, 29 were technically acceptable (chromic oxide fecal recovery >/=80%): percent cholesterol absorption was 43.1 +/- 12% by the FRM and 46.0 +/- 11% by the IRM, exhibiting an accuracy within 3.5% at the 95% and 4.7% at the 99% confidence levels. In addition, various procedural modifications of the IRM were studied in out-patients. The measurement of isotope ratios in a single blood sample (analyzed in sextuplicate) on the third day (or later) following the tests gave identical results to those obtained from six to eight daily blood samplings. Blood samples drawn at any time during the day gave cholesterol absorption values similar to those obtained from samples drawn following an overnight fast. Absorption tests carried out before and 1 hr after breakfast, lunch, or dinner, or giving the oral isotope in three divided daily doses all yielded identical results with tests carried out in the am in the fasting state. Cholesterol absorption was markedly reduced when the oral radiolabeled cholesterol was administered in orange juice vs. liquid formula, milk or a solution of glucose and amino acids, consistent with the well-known fact that gallbladder contraction is a critical requirement of cholesterol absorption. A meal high in cholesterol consumed on the day of the test did not influence the results of the absorption measurements. Furthermore, addition of three eggs per day (~750mg cholesterol) for 3 weeks to a low-cholesterol poly-unsaturated fat diet caused no significant change in percent cholesterol absorption in any of eight patients. We conclude that the isotope ratio method accurately and precisely measures cholesterol absorption in man, and that it is suitable not only for in- but also for out-patient studies.-Samuel, P., D. J. McNamara, E. H. Ahrens, Jr., J. R. Crouse, and T. Parker. Further validation of the plasma isotope ratio method for measurement of cholesterol absorption in man.

The role of vagotomy in pancreaticoduodenectomy

In a series of 41 pancreatoduodenectomies the Whipple procedure was done in 27 patients and total pancreatoduodenectomy in 14 others with two postoperative deaths. Among 39 survivors, seven developed evidence of stomal ulcer 20 days to six years after operation; details of their courses are summarized. Proven stomal ulcer occurred in five of 14 patients who did not have concomitant vagotomy with pancreatoduodenectomy (36%). Each of these required vagotomy secondarily in management. When two patients with hematemesis in whom stomal ulcer was suspected but not proven are included, the incidence of stomal ulcer in nonvagotomized patients with pancreatoduodenectomy (7/14) is 50%. There were no stomal ulcers in patients with pancreatoduodenectomy who had concomitant vagotomy (0/25). It is logical to add the protective effects of vagotomy to pancreatoduodenectomy, especially when the disease process favors prolonged survival.

Urea synthesis by perfused rat liver in experimental uremia

Urea synthesis was examined in experimental uremia using the isolated perfused rat liver in order to assure strict control of substrate (NH4Cl) presented to the liver. Acute uremia was created in female Sprague-Dawley rats by bilateral nephrectomy (n = 7) 48 h prior to studies. Chronic uremia (8--14 weeks) was produced by right nephrectomy and segmental infarction of the left kidney in 7 rats. At infusion rates of NH4Cl (8.3 mumol/min) which resulted in prehepatic perfusate ammonia levels approximately twice the previously described Km value, livers of chronically uremic rats had slightly higher rates of urea production than controls (controls: 0.41 +/- 0.03; chronic uremia: 0.54 +/- 0.04 mumol/min/g of wet liver weight; p less than 0.02). In acute uremia, urea production was higher (0.66 +/- 0.05 mumol/min/g) than in sham-operated rats (0.59 +/- 0.05 mumol/min/g) but the differences did not achieve statistical significance. Simultaneously performed taurocholate transport studies did not reveal significant functional differences between the livers of uremic and control animals. The data suggest that urea production by livers of uremic rats is increased when compared to that of control animals.

Prostaglandins V (1). Synthesis and pharmacology of (+/-)-11-deoxy-10-hydroxyprostaglandin E1 methyl ester

(+/-)-Deoxy-10-hydroxy-PGE1 methyl ester (Va) has been synthesised via conjugate addition of the cuprate (III) to the 5-tetrahydropyranyloxycyclopentenone (IId). Va was found to be 0.1 times as active as PGE1 as a uterine stimulant in the anaesthetized pregnant rat, 0.25 times as active as PGE1 in causing vasodepression in the anaesthetized cat, and approximately equiactive to PGE1 in inducing bronchoconstriction.

The ultrastructure of mouse testicular interstitial tissue containing plutonium-239 and its significance in explaining the observed distribution of plutonium in the testis

The technique of autoradiography with Araldite-embedded sections was used to study the distribution of 239Pu in mouse testis at various times post-injection. Adjacent sections were examined with both the light microscope and electron microscope. The autoradiographs showed that from 1 week to 3 months postinjection, most 239Pu in located in interstitial tissue. The major change in distribution observed was that the early diffuse deposit in interstitial tissue is concentrated in macrophages with increasing time post-injection. This is a real change of distribution as the amount of 239Pu in mouse testis remains constant from 1 week to 3 months post-injection. Study of the ultrastructure of interstitial tissue indicated that the accumulation of 239Pu in macrophages may be brought about in two ways. First, there may be phagocytosis of dead cells containing 239Pu. Second, 239Pu may follow the transfer of waste products of hormone synthesis from Leydig cells into macrophages. The significance of these observations is discussed with regard to the deposition of 239Pu in human testis.