A functional psychosis precipitated by quinidine

A 62-year-old man with a syndrome of gradually progressive cognitive deterioration accompanied by paranoid features is described. He had been taking quinidine since 1974 for a recurring supraventricular tachyarrhythmia. Examination revealed a suspicious man with widespread patchy cognitive deficits but no focal neurological signs. An exhaustive range of investigations gave unremarkable results. Within 24 hours of cessation of quinidine there was a dramatic improvement in his mental state and, after a further four days, he had returned essentially to normal with no demonstrable cognitive deficits. Several months later he suffered a recrudescence with prominent paranoid and depressive features which gradually settled after commencement of pimozide and dothiepin. It is likely that these events reflect a recurring functional psychosis which was precipitated or exacerbated in the first instance by quinidine. This represents a significant complication of quinidine therapy which has been largely unrecognized. Therapy with quinidine should be considered as a potential contributing factor in any patient with dementia or a functional psychosis who is also taking this drug.

Involvement of gamma interferon in antibody enhancement by adjuvants

In a previous study the adjuvant action of a monophosphoryl lipid A, a nontoxic derivative of endotoxic lipopolysaccharide (LPS), was found to be negated by a monoclonal anti-gamma interferon (anti-IFN-gamma) antibody. The present investigation centered on three other adjuvants of diverse microbial origins, testing for their capacity to affect the release of IFN-gamma as an explanation for their antibody-enhancing action. The adjuvant action of each of the three, a wild-type LPS, synthetic poly(A)-poly(U) complexes, and a synthetic muramyl dipeptide, n-acetylmuramyl-L-alanyl-D-glutaminyl-n-butyl ester (murabutide), was transferable by adjuvant-stimulated T cells to normal spleen cells on coculture. Supernatant fluids from these T cells contained increased levels of IFN-gamma. Addition of a monoclonal anti-IFN-gamma antibody to adjuvant-stimulated spleen cell cultures reduced the adjuvant action by approximately one-half. Removal of natural killer cells from spleen cell populations prior to culture with antigen had no effect on the enhancement induced by LPS and monophosphoryl lipid A. It was concluded that the enhancement induced by the adjuvants LPS, poly(A)-poly(U), and murabutide is mediated in part by their action on T cells resulting in release of IFN-gamma suggesting activation of a common transmembrane signal.

A study of the cellular and molecular mediators of the adjuvant action of a nontoxic monophosphoryl lipid A

A detoxified endotoxin, termed monophosphoryl lipid A (MPL, Ribi), has been shown to increase antibody forming cell numbers in aging Balb mice both in vivo and in vitro. Separation of splenocytes from aging mice into purified T, B and adherent cell populations and subsequent incubation of each with MPL and admixture with their cellular counterparts and antigen, revealed only the T cell compartment capable of transferring the adjuvant action. Incubation of purified T cells from aging mice with MPL for 2 hr, followed by washing and culture for 48 hr, resulted in a supernatant fluid which enhanced antibody formation in cultures of aging spleen cells. This enhancing action was eliminated by an antiserum containing anti-alpha/beta/gamma interferon, but not by an anti-alpha/beta interferon antiserum. These data, as well as evidence gained by others as discussed, suggests the hypothesis wherein MPL increases antibody formation in aging mice by inducing the helper T cell population to secrete interferon gamma. The latter activates the macrophage to secrete increased levels of interleukin 1, thereby resulting in increased responsiveness throughout the ensuing sequence of cellular and molecular events leading to antibody synthesis.

T cell and interferon-gamma involvement in the adjuvant action of a detoxified endotoxin

The adjuvant activities of a detoxified derivative of endotoxic lipopolysaccharides, isolated from the outer membrane of gram-negative bacteria, were evaluated in aging mice. This monophosphoryl lipid A (MPL) (Ribi) was capable of enhancing antibody production in vitro in splenic cultures from 2-3-month-old male Balb/c mice as well as cultures from 22-24-month-old Balb/c mice. Separation of spleen cells from MPL and phosphate-buffered saline-injected mice into adherent and nonadherent populations and subsequent mixing of populations and culture with antigen implicated an adherent cell as being involved in the enhancement of antibody formation induced by MPL. However, separation of normal spleen cells into purified populations of adherent cells, T-lymphocytes, and B-lymphocytes, followed by in vitro stimulation of the individual populations with MPL and subsequent transfer into cultures of normal spleen cells, revealed only the T cell as capable of transferring the enhancement of antibody formation. In addition, culture filtrates from MPL-stimulated T cells were able to enhance antibody production by spleen cell cultures from aging mice twofold above that of filtrates from unstimulated T cells. The enhancement of antibody formation induced by such filtrates and also by MPL in spleen cell cultures from young and aging mice was inhibited by a monoclonal antibody (MAb) to recombinant interferon-gamma (rIFN-gamma) as well as antiserum against IFN-alpha, -beta, and -gamma, but not by an antiserum to IFN-alpha/beta. Enhancement of antibody formation correlated well with an increase in interleukin-1 (IL-1) but not with an increase in IL-2 production. Addition of anti-asialo-GM1 MAb plus complement to the effective spleen populations did not diminish the adjuvant action.

Duodenal bulb acidity and the natural history of duodenal ulceration

Fasting and post-prandial duodenal bulb pH was recorded in 10 subjects with untreated duodenal ulcers (DU), 10 subjects with healed DU, and 15 healthy volunteers. During fasting, pH was less than 4 for a greater percentage of time in healed than in active DU. Ingestion of a solid test meal accentuated this difference: subjects with active DU and controls both showed less bulb acidification than subjects with healed ulcers. Bulb pH was similar in patients with active ulceration and controls. The finding of neutral bulb pH with active ulceration and low bulb pH with healing may explain the typical cycle of spontaneous healing and relapse in duodenal ulcer disease.

Serum phospholipase A2 activity in acute pancreatitis: an early guide to severity

Daily measurements of serum phospholipase A2 activity were carried out on 73 consecutive patients admitted to hospital with acute pancreatitis. During the first 6 days there were significant differences in activity in those patients predicted as severe by multiple prognostic criteria when compared with those with mild disease. Follow-up studies at 6 weeks showed no difference between those graded as mild and those graded as severe at the time of attack. In the patients with elevated activity, nine had this at the time of admission and all were raised within 24 h. Elevated activity correlated well with the clinical outcome and showed good agreement with the multiple prognostic criteria in the prediction of severe disease. It is suggested that measurement of serum phospholipase A2 activity may provide a simple test for the early identification of most patients with severe acute pancreatitis.

The lessons from in vitro lithotripsy for the clinical treatment of gallstones

Fifty-eight gallbladder stones were treated in vitro, using a Wolf Piezolith 2300 lithotripter, to discover whether complete fragmentation (i.e., no particles greater than 2 mm diameter) could be achieved by lithotripsy alone. In 16 stones this was accomplished with up to 6000 shocks being administered. The degree of fragmentation was judged first by eye during the experiment and then by both microscopy and sieving of the debris. Eye judgement proved to be an unreliable indicator with 23 of the 42 stones in the failed lithotripsy group receiving 6000 shocks or less. Cholesterol analysis and high resolution radiography revealed no significant differences between the successfully and unsuccessfully fragmented stones, but X-ray diffractometry did show a higher incidence of inorganic calcium salts in the latter group. This study shows that lithotripsy can successfully fragment gallbladder stones, but that a minimum of 6000 shocks, using the Piezolith 2300, should be given to ensure adequate treatment. Additionally, the presence of radiopaque stones does not necessarily preclude successful treatment by this method.

Short-term effects of extracorporeal shock wave lithotripsy on the human gallbladder

Extracorporeal shock wave lithotripsy (ESWL), whereby shock wave energy is focused upon gallstones causing their disintegration into fragments sufficiently small to be passed via the biliary system, offers a promising non-invasive alternative to surgery for gallstone disease. The tissue effects in humans of ESWL are poorly characterized and no systematic study of the tissue effects of ESWL by piezoelectrically generated shock waves has been published. Sixteen patients for elective cholecystectomy were therefore subjected to ESWL before surgery and detailed histology of the gall-bladders (including scanning electron microscopy of the mucosa) was compared with that from 20 age/sex-matched control cases. The gall-bladders treated by ESWL, in addition to showing the histological changes associated with chronic cholecystitis, showed serosal vasodilatation, mural oedema, and serosal and mucosal petechial haemorrhages focally over the entire surface. Between 10 and 90 per cent epithelial denudation was observed, but all cases showed surviving columnar epithelial cells in the crypts. No case showed vascular thrombosis, tissue necrosis, or acute inflammation. These tissue effects are likely to be reversible and unlikely to present a risk of perforation, although the long-term clinicopathological effects await investigation.

Malignant haemangiopericytoma of the pelvic retroperitoneum

A case of malignant haemangiopericytoma of the pelvic retroperitoneum is described. The patient finally died of the complications of radiotherapy. In the absence of any reported long term benefits of adjuvant radiotherapy to the lesion, the lower morbidity of chemotherapy may make this form of adjuvant therapy worthy of further evaluation.

Anorectal varices, haemorrhoids, and portal hypertension

In a prospective study of 100 consecutive patients with cirrhosis, 44% had anorectal varices. The prevalence of anorectal varices rose with progression of portal hypertension; it was 19% in cirrhotic patients without portal hypertension compared with 59% in those who had bled from oesophageal varices. There was no evidence that endoscopic sclerotherapy directly increased the prevalence of anorectal varices. Haemorrhoids occurred independently of anorectal varices and their presence was unrelated to the degree of portal hypertension. These data provide further evidence that haemorrhoids and anorectal varices are separate and distinct entities. However, both can bleed and careful examination is essential to prevent misdiagnosis and inappropriate treatment.

Phospholipase A2 activity in taurocholate-induced acute pancreatitis in the rat model

The activity of phospholipase A2 (PA2) was measured in the plasma of rats after the induction of acute pancreatitis. Buffered sodium taurocholate (3.75% w/v), injected into the pancreatico-biliary duct, was used to induce acute pancreatitis. Blood was taken at 1-h intervals for the measurement of phospholipase A2, glucose, lipase, and arterial gases. Plasma lipase was markedly elevated in the test groups, indicating acute pancreatitis, but no significant difference in PA2 activity was seen between the controls and the test group. However, in four animals the PA2 activity was elevated and in all cases this was accompanied by a low arterial pO2. This supports the theoretical role of PA2 in the pathogenesis of the respiratory complications observed in severe acute pancreatitis.

Management of bleeding varices in the elderly

In 207 consecutive patients the outcome of bleeding varices was compared in those aged under 65 (n = 146) and those aged over 65 (n = 61). All patients were seen during seven years and were treated by active initial and maintenance sclerotherapy. Alcoholic cirrhosis was commoner in younger patients (68 (47%) v 12 (20%] and cryptogenic cirrhosis commoner in older patients (21 (34%) v 19 (13%]. Mortality due to the first bleed was dependent on the severity of liver disease and was unrelated to age. Survival corrected for age (life table analysis) was 65% at one year and 60% at two years for both groups of patients. It is concluded that patients should not be denied active treatment for bleeding varices on the basis of age alone. In order to obtain optimum results early endoscopy and sclerotherapy is essential.

The effects of cisapride on antroduodenal co-ordination and gastric emptying

Five studies have shown that cisapride increased the antral motility index in the interdigestive and digestive states and three of these studies showed a stimulation of duodenal motility index and increased antroduodenal coordination. In normal volunteers and in patients with dyspepsia (223 subjects), both solid and liquid emptying is speeded by cisapride compared with placebo, and cisapride was as good as, or better than, metoclopramide at the same dosage. In studies in 37 diabetics with gastroparesis, both solid and liquid emptying were speeded and returned to normal, and cisapride was superior to metoclopramide. Solid emptying was speeded in patients with anorexia nervosa, chronic pseudo-obstruction and systemic sclerosis and the delay in gastric emptying induced by both morphine and dopamine was reversed. The effect of cisapride on bile reflux is still uncertain. Eight different methods of measuring gastric emptying were employed in these studies and they all gave similar results; the doses ranged from 2.5-10 mg i.v., and up to 20 mg orally.

Evaluation of applied potential tomography as a new non-invasive gastric secretion test

Applied potential tomography (APT) is a new, non-invasive technique that can yield sequential images of changes in the resistivity of gastric contents. Studies were performed to investigate the application of APT to measure gastric acid secretion. Experiments in 20 normal volunteers showed that changes in gastric resistivity were closely correlated with changes in the volume (r = 0.80), the acidity (r = 0.83) and the total conductivity of gastric contents (r = 0.87). Studies in 13 patients referred for a pentagastrin test showed that changes in gastric resistivity before pentagastrin were closely correlated with basal acid output measured on a separate occasion (r = 0.85, p less than 0.001), while changes in gastric resistivity after pentagastrin were correlated with maximal acid output (r = 0.58, p less than 0.05). Ingestion of alcohol by six normal subjects decreased gastric resistivity markedly, probably due to alcohol induced gastric acid secretion as it was prevented by cimetidine. Applied potential tomography is a safe non-invasive method of measuring gastric acid secretion. The equipment is simple to use, and the test is comfortable and acceptable to patients.

Effect of composition of gastric contents on resistance to emptying of liquids from stomach in humans

Experiments were conducted in normal healthy volunteers to investigate whether factors other than the intragastric pressure induced by tonic contraction of the gastric fundus could regulate the gastric emptying of liquids. The emptying of solutions of different osmolality and composition from the stomach was measured, while maintaining the intragastric pressure constant with a barostat system that employed an external reservoir. Preliminary experiments showed a linear relationship between intragastric pressure and emptying rate, but indicated that a normal intragastric pressure of 7 cm water would be insufficient by itself to maintain normal emptying. When intragastric pressure was maintained at 20 cm water, an isotonic solution of 30 mM glucose in saline (278 mosm/kg) emptied at a rate of 49.9 +/- 0.5 ml/min (mean +/- SEM, N = 11). Milk (284 mosm/kg) and a hyperosmolar solution of 30 mM glucose in saline (586 mosm/kg) significantly reduced the emptying rate. These results suggest that factors other than the intragastric pressure induced by fundic contraction regulate the rate at which liquids empty from the stomach and that the slower emptying of hyperosmotic solutions or solutions containing fat could be brought about in part either by an increased resistance of the pylorus and possibly the duodenum or a reduction in the effectiveness of an antroduodenal pump.

Pharmacological constriction of the lower oesophageal sphincter: a simple method of arresting variceal haemorrhage

The effect of pharmacological constriction of the lower oesophageal sphincter (LOS) on oesophageal varices was investigated in an experimental study followed by a controlled clinical trial. In the experimental study intravariceal pressure was measured just above the LOS in 11 patients before and after constricting the LOS by intravenous pentagastrin. Intravariceal pressure fell from a mean of 23 (range 12-36) mmHg to 4 (range 0-7) mmHg (p less than 0.001). This marked pressure drop indicated the considerable compression of varices that occurred within the LOS. A prospective controlled clinical trial examined whether LOS constriction (effected by the longer acting metoclopramide) would compress varices sufficiently to arrest active variceal bleeding originating from the lowest 2 cm oesophagus--the area encircled by the LOS. Of 11 patients who received metoclopramide, 10 stopped bleeding compared with four of the 11 who received placebo (p less than 0.01). Pharmacological constriction of the LOS appears to offer a new and effective approach for arresting active bleeding from oesophageal varices.

Comparison of applied potential tomography and impedance epigastrography as methods of measuring gastric emptying

Two new non-invasive methods of measuring gastric emptying, impedance epigastrography (IE) and applied potential tomography (APT) have been compared. Measurements in vitro showed that there is a good correlation between the square of the radius of a glass rod placed in the centre of a tank and values obtained by IE or APT. However, if the rod is moved anteriorly in the tank IE values increase markedly, whereas APT values are unchanged. Both APT and IE can be used to follow gastric emptying of liquid meals; however, the results obtained using APT are more reproducible and have a better correlation with those obtained simultaneously by scintigraphy. Neither method was able accurately to follow gastric emptying unless gastric acid secretion was inhibited by cimetidine.

Bleeding anorectal varices--a misunderstood condition

The management of 13 patients who had bleeding anorectal varices is described and compared with the 20 cases reported to date. The diagnostic procedure of choice is anorectoscopy. Treatment by an under-running suture achieved primary control of bleeding in all patients, and during a median follow-up of 7 months (range, 1 to 36), two early and one late episodes of rebleeding occurred. As all patients had varices in the anal canal with only occasional extension into the rectum, the term "anorectal varices" is to be preferred.

Isolation of a nonendotoxic antitumor preparation from Serratia marcescens

White-type polysaccharide preparation (WPS) obtained from Serratia marcescens bacteria by hot 0.2 N acetic acid extraction was shown to have antitumor effects. These were manifested by enhanced resistance to the take of TA3 transplantable murine adenocarcinoma and by the induction of regression of Meth A sarcoma in mice. Optimal conditions for the liberation and isolation of these substances were sought to achieve the highest antitumor activity and the lowest endotoxin (ET) content. Simultaneously, the activities of the WPS preparations were tested in various tests which are frequently used as in vitro correlates of in vivo antitumor effects, such as the activation of macrophage cytotoxicity, activation of natural killer (NK) cells, and tumor necrosis factor (TNF) generation. We found that the enhanced resistance to the take of TA3 tumor correlated with ET content of the WPS preparations. Preparations with reduced or no ET content showed diminishing activity in this assay or were without any measurable effect. The induction of TNF production and NK activation did not show such close relationship with the ET content. This was particularly evident if testing WPS samples obtained after 60 or 120 min hydrolysis at 90 degrees C. The greatest discrepancy was found between ET content and the Meth A regression induction. Samples with no detectable ET content and no activity in the macrophage, NK, or TNF tests were potent inducers of Meth A regression. Partial purification of such WPS samples could be achieved and a preparation was obtained with high Meth A regression capacity. Preliminary chemical analysis of this preparation showed 25.5% amino acid, 53.7% neutral carbohydrate, less than 0.4% KDO, 0.8% hexosamine, less than 0.1% phosphorous, and less 1.0% long-chain carboxylic acid content. The above chemical analytical data are not consistent with designating such preparations as ET or ET derivatives, such as Lipid A or its split products. This conclusion was confirmed by the lack of endotoxic properties as determined by biological assays on this preparation.