[Neuropsychiatric symptoms in vitamin B12 deficiency and microcarcinoidosis. The complications of chronic atrophic gastritis]

HISTORY AND FINDINGS

A 69-year-old woman reported marked restriction of voluntary movements of the hands in the preceding 6 months. She had also experienced loss of motivation, memory and concentration. Her skin was pale yellow, and scratches on her skin indicated marked pruritus.

INVESTIGATIONS

Neurological examination revealed decreased vibratory sense in both legs. Haemoglobin concentration was 8.3 g/dl, mean corpuscular volume 114 fl, vitamin B12 level < 100 ng/l, folic acid level normal. Antibody titre against parietal cells was increased, vitamin B12 resorption diminished. Gastroscopy revealed small raised lesions, made up of hyperplastic cells which stained with chromogranin, indicating a diagnosis of microcarcinoid of the gastric mucosa.

TREATMENT AND COURSE

On administration of cobalamine (1,000 micrograms i.m. daily for 2 weeks, twice weekly for 6 weeks, then once per week for the last 7 months) the blood picture returned to normal, but the microcarcinoids, the psychological symptoms and the apraxia of the hands were unchanged.

Enhanced superoxide anion release of normal neutrophil granulocytes primed with sera of patients with inactive inflammatory bowel disease

During active inflammatory bowel disease (IBD) the respiratory burst of neutrophil granulocytes has been shown to be impaired using isolated circulating neutrophil granulocytes of patients with active disease. Using normal neutrophil granulocytes of healthy volunteers the present study examines the potential priming effect of sera of patients with active and quiescent IBD. The superoxide anion (O2-)-release of normal neutrophil granulocytes in response to N-formyl-methionyl-leucyl-phenylalanine (FMLP) has been investigated after incubation with sera of patients with active and inactive Crohn's disease and ulcerative colitis. O2(-)-release was measured using the superoxide dismutase inhibitable reduction of ferricytochrome c. The O2(-)-release of normal neutrophil granulocytes primed with sera of patients with inactive Crohn's disease (607.1 +/- 218.2 nmol/60 min, n = 10, p = 0.001) or cultured with sera of patients with quiescent ulcerative colitis (497.4 +/- 94.9 nmol/60 min, n = 3, p = 0.005) was significantly enhanced when compared with sera of normal controls (319.8 +/- 86.5 nmol/60 min, n = 10). There was no significant difference between priming with sera of patients with quiescent or active Crohn's disease (481.0 +/- 113.0 nmol/60 min, n = 5). Normal neutrophil granulocytes primed with sera of patients with active ulcerative colitis produce significantly larger amounts of O2- (809.5 +/- 256.9 nmol/60 min, n = 4, p = 0.001) when compared with sera of normal controls. The study shows that sera of patients with quiescent IBD as well as sera of patients with active disease have the potential to prime normal neutrophil granulocytes for an enhanced O2(-)-release in response to FMLP.(ABSTRACT TRUNCATED AT 250 WORDS)

Muscarinic receptors in gastric mucosa are increased in peptic ulcer disease

Muscarinic receptors stimulate the secretion of acid pepsinogen and mucous in gastric mucosa. Whether muscarinic receptors are involved in the pathogenesis of benign gastric disease is unknown. Receptor changes in these conditions were therefore sought. An autoradiographic technique was developed to determine quantitatively muscarinic receptors in microtome sections of biopsy specimens obtained during gastroscopy. Muscarinic receptor density was mean (SEM) 18.4 (1.2) fmol/mg protein in the corpus and 8.9 (0.7) fmol/mg protein in the antrum (n = 53). Neither chronic nor active gastritis was associated with receptor changes in the antrum but chronic gastritis was associated with a receptor loss in the corpus. Patients with acute or recent duodenal or antral ulcers (n = 23) had significantly higher levels of muscarinic receptors in the corpus than controls (n = 25) (22.2 (1.5) v 16.9 (1.7) fmol/mg protein respectively (p < 0.025). These results suggest that muscarinic M3 receptor is overexpressed in duodenal ulcer disease and may play a part in its pathogenesis.

[Rheumatoid disorders in Crohn disease and ulcerative colitis. Dominance of non-inflammatory factors]

82 consecutive outpatients with Crohn's disease (n = 52) and ulcerative colitis (n = 30) were examined ambulatory. Rheumatic complaints, objective results and diagnosis were correlated to the activity of the underlying illness and the extent of the bowel affected. 61% of the examined patients complaint about rheumatic pains. In two thirds this could be attributed to noninflammatory causes (30% insertion tendinitis. 16% degenerative arthritis, 16% wrong carriage), which appeared to be independent of the activity and severity of the underlying disease. One fourth of the rheumatic complaints was caused by inflammation (21% arthritis, 5% sacroileitis). In these cases a dependency on the disease activity and the extent of the colon involvement could be found. No cause was found for 12% of the rheumatic complaints. In patients with ulcerative colitis suffering from arthritis a significant increase of disease activity (Rachmilewitz index) could be shown as compared to ulcerative colitis patients without arthritis (p < 0.02). For patients with Crohn's disease no significant correlation between arthritis and disease activity could be established. In these cases the occurrence of arthritis was associated with the colon involvement (Chi2 = 8.48). The data indicate the high frequency of rheumatic complaints in inflammatory bowel diseases due to noninflammatory causes.

Neurotoxicity, haemostatic disturbances and haemolytic anaemia after a bite by a Tunisian saw-scaled or carpet viper (Echis 'pyramidum'-complex): failure of antivenom treatment

A young man in Germany was bitten by a large captive saw-scaled viper (Echis 'pyramidum'-complex) of Tunisian origin. During the first few hours after the bite he developed evidence of disseminated intravascular coagulation and fibrinolysis, and bled spontaneously. Despite being given a total of 310 ml of three different Echis-specific antivenoms (together with large amounts of fresh frozen plasma and concentrated clotting factors), venom antigenaemia (measured by enzyme immunoassay) and coagulopathy persisted for more than 10 days, and he developed a haemolytic anaemia and mild renal dysfunction. Transient bilateral ptosis was attributed to envenoming. The venom of the snake responsible for the bite was immunologically distinct from that of Nigerian E. ocellatus and was clearly not neutralised by the three monospecific antivenoms which had been administered. This case is another illustration of the geographical variation in snake venoms and the need for pooling venoms from snakes from different parts of the geographical range in the preparation of antivenoms. Envenoming by North African Echis species may not be reversible by available antivenoms.

[Osteopenia in chronic inflammatory bowel diseases. Results of a cross-sectional study using quantitative computerized tomography]

53 unselected patients with Crohn's disease (CD) (35 female, 18 men; mean age: 32.3 +/- 12.5 y.; mean duration of CD: 78.6 +/- 65.7 months) and 23 patients with ulcerative colitis (UC) (8 female, 15 men; mean age: 43.7 +/- 17.9 y.; mean duration of UC: 100.7 +/- 86.0 months) were examined by quantitative computertomography (lumbar spine 1-3). Incipient (manifest) osteopenia (OP) was defined as a reduced axial bone mineral density from -1 standard deviations (SD) to -2 (SD) (< -2SD) as compared to a control Group. Reduced bone mineral density was found in 30.2% (16/53) of patients with CD and 9% (2/23) with UC (p < 0.05). In particular 12/53 pts. (22.6%) with CD and 1/23 pts. (4.35%) with UC showed incipient OP, whereas 4/53 pts. (7.5%) with CD and 1/23 pts. (4.35%) with UC showed manifest OP. With respect to the location of CD the mean relative bone density (SD) was found to be significantly lower in patients with ileal involvement of CD (-0.88 +/- 0.8 SD; n = 39) as compared to patients with colonic involvement (-0.09 +/- 0.86 SD; n = 14) and UC (-0.09 +/- 0.55 SD; n = 23) (p < 0.05). No significant correlation to the duration of the disease was found. Previous therapy with steroids led to lower mineral bone density as compared to untreated patients. As a trend duration of steroid treatment and bone density were shown to be correlated inversely.(ABSTRACT TRUNCATED AT 250 WORDS)

[Manometric studies of the esophagus in healthy subjects of different age groups]

Oesophageal manometry was performed under standardized conditions in 100 healthy persons of different ages (54 males, 46 females; mean age 43.1 [18-84] years). They were grouped by age in decades (< or = 29 years: n = 23; 30-39 years: n = 18; 40-49 years: n = 19; 50-59 years; n = 20; and > or = 60 years: n = 20). The mean resting pressures at the lower oesophageal sphincter ranged among the different age groups from 18-22 mm Hg (total group 19 +/- 7 mm Hg), the mean contraction force at the distal tubular oesophagus ranged from 77-100 mm Hg (84 +/- 35 mm Hg), in the proximal tubular oesophagus from 53-58 mm Hg (56 +/- 22 mm Hg), and the resting pressures at the upper oesophageal sphincter from 34-45 mm Hg (37 +/- 17 mm Hg). There was no statistically significant difference between the various age groups for any of the motility parameters. It is concluded that age does not influence the findings in comparative studies of healthy persons and patients of differing ages.

[Acute effect of metoclopramide on esophagus motility in diabetes mellitus]

The acute effect of metoclopramide on oesophageal motility was investigated prospectively in 33 consecutive patients (20 men and 13 women; mean age 60.5 +/- 12.6 years) with type I (n = 8) or type II (n = 25) diabetes. 15 patients had a peripheral sensory-motor polyneuropathy only and three just an autonomic cardial neuropathy. Both lesions were present in ten, none in five. No patient had oesophago-gastroduodenal lesions. Sphincter pressure, relaxation time, contraction amplitude and propulsion velocity of bolus-induced oesophageal peristalsis were measured manometrically after intravenous administration of 10 mg metoclopramide. Resting pressure in the lower oesophageal sphincter rose significantly by 26.7%, contraction amplitude in the tubular portion of the oesophagus by more than 30%, and propulsion velocity by more than 20% (P for each < 0.05). At the same time the amount of segmental and aperistaltic oesophageal contractions regressed significantly. The effect of metoclopramide was demonstrated regardless of the type of diabetes, duration of diabetes and any manifestation of autonomic cardial or peripheral sensory-motor neuropathy.

A tobacco gene family for flower cell wall proteins with a proline-rich domain and a cysteine-rich domain

Flowering is known to be associated with the induction of many cell wall proteins. We report here five members of a tobacco gene family (CELP, Cys-rich extensin-like protein) whose mRNAs are found predominantly in flowers and encode extensin-like Pro-rich proteins. CELP mRNAs accumulate most abundantly in vascular and epidermal tissues of floral organs. In the pistil, CELP mRNAs also accumulate in a thin layer of cells between the transmitting tissue and the cortex of the style and in a surface layer of cells of the placenta in the ovary. This unique accumulation pattern of CELP mRNAs in the pistil suggests a possible role in pollination and fertilization processes. CELP genes encode a class of plant extracellular matrix proteins that have several distinct structural features: a Pro-rich extensin-like domain with Xaa-Pro3-7 motifs and Xaa-Pro doublets, a Cys-rich region, and a highly charged C terminus. The extensin-like domains in these proteins differ significantly in their length and these differences appear to be results of both long and short deletions within the coding regions of their genes. Furthermore, the number of charged amino acid residues in the C-terminal region varies among the CELPs. These structural differences may contribute to functional versatility in the CELPs. On the other hand, the Cys-rich domain is highly conserved among CELPs and the positions of the Cys residues are conserved, suggesting that this region may have a common functional role. The presence of a Pro-rich domain and a Cys-rich domain in these CELPs is reminiscent of a class of hydroxyproline-rich glycoproteins, solanaceous lectins, that are believed to be important in cell-cell recognition. The structure of these CELPs indicates that they may be multifunctional and that their genes may have arisen from recombinational events.

[The long-term effect of molsidomine on frequency of hemorrhage, portal and cardiac hemodynamics in patients with liver cirrhosis--a pilot study]

The aim of the study was to examine the effects of maintenance molsidomine therapy on portal and cardiac haemodynamics in patients with confirmed alcoholic or nonalcoholic liver cirrhosis and portal hypertension. Molsidomine is a selective reducer of preload without development of tolerance. 16 patients with portally decompensated cirrhosis of the liver following an initial or recurrent episode of bleeding form oesophageal/fundal varices were on long-term treatment (4-24 months) with 2 or 3 x 8 mg molsidomine/day (Corvaton retard). They were followed up after 3-6 months. 6 of the 16 had been treated previously with propranolol for haemorrhage prophylaxis over 11 +/- 15 months. In a total of 70 treatment months with propranolol, 10 recurrent bleeds had occurred. During 166 treatment months with propranolol, 10 recurrent bleeds had occurrences of bleeding. This long-term treatment showed reductions in hepatic venous pressure gradient of 24.8% (n = 8) (p < 0.05), variceal pressure of 28.7% (n = 7) (p < 0.05) and size of varices of 17% (n = 8). This occurred without any clinically relevant impairment of systemic cardiovascular regulation. Therefore long-term therapy with molsidomine may be suitable for prophylaxis of haemorrhage of oesophageal varices.

Transfected cGMP-dependent protein kinase suppresses calcium transients by inhibition of inositol 1,4,5-trisphosphate production

cGMP is a key regulatory molecule in visual transduction, integration of neuronal response to excitatory neurotransmitters, relaxation of smooth muscle, intestinal secretion of water and salt, and reabsorption of sodium and water in the distal tubules of the nephron. Some of these cellular functions are associated with the activation of cGMP kinase and a decrease in cytosolic calcium levels ([Ca2+]i). The mechanism by which cGMP kinase lowers [Ca2+]i is controversial. We have used CHO cells stably transfected with cGMP kinase to test several of the proposed [Ca2+]i-lowering mechanisms. Thrombin induces a calcium transient in wild-type and cGMP kinase-expressing CHO cells by releasing calcium from intracellular stores. Preincubation of wild-type cells with 8-bromo-cGMP had no effect on the calcium transient, whereas 8-bromo-cGMP prevented the thrombin-stimulated calcium transient in cGMP kinase-expressing CHO cells. In both cell types 8-bromo-cGMP had no effect on [Ca2+]i transients induced by replacing extracellular sodium by tetramethylammonium, ruling out an effect of cGMP kinase on Ca(2+)-ATPases. However, cGMP kinase activation effectively suppressed thrombin-induced stimulation of inositol 1,4,5-trisphosphate production. These results show that cGMP kinase lowers [Ca2+]i by interfering with the inositol 1,4,5-trisphosphate synthesis.

[The anterior sonographic-guided celiac plexus blockade. Review and personal observations]

The coeliac plexus block is an approved method for the relief of upper abdominal pain due to cancer of the upper intra-abdominal viscera or to chronic pancreatitis. While there are many reports concerning the posterior approach to the coeliac plexus block, little attention has been given the anterior approach. There are two ways of implementing the anterior approach to the coeliac plexus: CT-guided and the ultrasound guided approach. METHODS. The ultrasonic-guided anterior approach to the coeliac plexus block is used with the patient in the supine position. The aorta and discharge of the truncus coeliacus or the a. lienalis respectively, are ultrasonographically presented at two levels. After setting local cutaneous and subcutaneous anaesthesia, a 15-cm-long 25 G-needle is introduced into the epigastrium. The point of the needle is--ultrasonographically guided--inserted into the pre-aortic area near the discharge of the truncus coeliacus. The position of the needle point is ultrasonographically controlled on two levels. For the enforcement of a diagnostic coeliac plexus block after careful aspiration on two levels, 10 ml of bupivacaine 0.5% is injected. The spread of the solution is evaluated by ultrasound. If the needle position is correct; a few minutes later the patient has a feeling of warmth in the upper abdominal region. For the enforcement of a neurolytic coeliac plexus block 10 ml ethanol 96% and 10 ml prilocaine 1% can be administered. The two solutions are applied as small volumes in permanent succession. Thus the burning pain, which is often observed after the injection of alcohol, is avoided. RESULTS. In the literature there are only a few reports, about the results and side-effects after use of the anterior approach in the coeliac plexus block. The results of these investigations and our own show total pain relief or at least good pain reduction by at best 85%. The reduction in pain achieved continues in as many as 60% of the treated patients. There is the possibility to stop or at least reduce the analgesic premedication. These results are comparable with those after using the posterior approach to the coeliac plexus block. When carrying out the anterior approach in the coeliac plexus block, most of the patients showed increased intestinal motility. Therefore, about 60% of all patients had transitory diarrhoea. In 12-25% of the patients orthostatic hypotension was observed. This side-effect is avoided by an appropriate infusion before enforcement of the block. In a frequency of 4-100% the occurrence of burning pain was reported during injection of the alcohol. No serious side-effects were observed. CONCLUSIONS. The results concerning total pain relief or at least pain reduction are comparable to the posterior approach for the block. Nevertheless, there are some advantages to the ultrasound-guided anterior approach. There is less risk using this technique. No methodological complications have been observed so far. There is no risk of neurological complications such as paraplegia. Because the patients remain in the supine position, the anterior approach to the coeliac plexus block is suitable for terminally ill patients, who are not able to tolerate the prone position and need careful supervision and good ventilation. Also, no contrast medium is necessary. Only a small volume of local anaesthetics or alcohol is required. We prefer the anterior approach of the coeliac plexus block as a fast, safe and cost-effective method, which should receive increasing attention during the next few years.

[Toxic alcohol-induced, acute intrahepatic cholestasis with reversible increase of the CA 19-9 tumor marker in chronic alcoholic hepatitis]

The case report on an acute intrahepatic cholestasis caused by alcoholic intoxication in a 52-year-old medical laboratory assistant is given. In addition to extreme pathologic cholestasis parameters the increase of the tumor marker CA 19-9 was remarkable. By means of laparoscopy and histology, chronic fatty liver hepatitis due to alcoholic intoxication was found. The tumor marker CA 19-9 returned to normal following abstinence from alcohol parallel to the deline of the cholestasis parameters, which means the diagnostic importance of tumor markers in diseases with intrahepatic cholestasis is to be seen in relative terms.

[Cholestasis in imipenem/cilastatin treatment]

The case report on a 22-year-old female patient shows how the treatment with Imipenan/Cilastatin resulted in a severe intrahepatic cholestasis. The serum-bilirubin rapidly decreased after discontinuation of the antibiotic. The laboratory findings were no longer conspicuous four weeks after discharge from hospital.

[Crigler-Najjar syndrome type II in a 17-year-old girl]

The Crigler-Najjar-Syndrome type II is characterised by the decreased activity of the bilirubin-UDP-glucuronyltransferase. This fact leads to an increase of the indirect bilirubin to 6-10 mg/dl. The mode of hereditary transmission is autosomal dominant with variable penetrance. The age of manifestation varies from the first year to the second decade of life. The Crigler-Najjar-Syndrome type II of a 17-year-old girl is reported. The diagnosis was made on the basis of the pattern of laboratory parameters in combination with an uneventful morphology of the liver. Under treatment with Chlofibrat the decrease of the serum total bilirubin from 10.4 mg/dl to 2 mg/dl was achieved.

Characterization of cDNAs for stylar transmitting tissue-specific proline-rich proteins in tobacco

The pistil of flowers is a specialized organ which contains the female gametophytes and provides the structures necessary for pollination and fertilization. Pollen deposited on the stigmatic surface of a compatible plant germinates a pollen tube which penetrates the stigmatic papillae and grows intercellularly through the style towards the ovules in the ovary. Pollen tube growth is largely restricted to the transmitting tissue in the style. Therefore the stylar transmitting tissue is extremely important for the migration of the pollen cell towards the ovary. We have isolated two related cDNAs, transmitting tissue-specific (TTS)-1 and TTS-2, derived from two proline-rich protein (PRP)-encoding mRNAs that accumulate specifically in the transmitting tissue of tobacco. The deduced PRP sequences share similarities with proline-rich cell wall glycoproteins found in a variety of plants. TTS-1 and TTS-2 mRNAs are induced in very young floral buds, accumulate most abundantly during the later stages of flower development when style elongation is the most rapid, and remain at relatively high levels at anthesis. These mRNAs become undetectable in maturing green fruits. In situ hybridization shows that TTS-1 and TTS-2 mRNA accumulation is restricted to the transmitting tissue of the style. The possible roles that these transmitting tissue-specific PRPs may play in maintaining the structural integrity of the style or in the function of this organ is discussed.