Mortality of hepatitis B positive blood donors in England and Wales

Of 2880 men and 1054 women who were found to be hepatitis B surface antigen positive by the Blood Transfusion Service in England and Wales between 1971 and 1981, more than 92% were traced to the end of 1983. 5 deaths from hepatocellular carcinoma had been reported in men, giving a relative risk compared with the male population of England and Wales as a whole of 42. There had been no deaths from liver cancer in women. In both men and women there was a greater than ten-fold increase in the risk of death from chronic liver disease. Secondary preventive action may be indicated.

Magnetic resonance imaging of the Dandy-Walker malformation

Five cases of the Dandy-Walker malformation are described using the magnetic resonance (MR) scan as a primary imaging technique. The patients' ages ranged from 34 weeks (in utero) to 41 years; their clinical and neuroanatomical characteristics encompassed the entire spectrum of the malformation. Clear visualization of the greatly enlarged posterior fossa, Dandy-Walker cyst, and absence of the inferior vermis established the pathological diagnosis and excluded other structural defects. In 3 patients, MR demonstration of the aqueduct and evidence of pressure on adjacent tissue aided in the surgical planning for ventricular decompression. The MR scan is a significant advancement in the radiological diagnosis of the Dandy-Walker malformation. The major technical advantage of the scan consists in its ability to delineate intracranial morphology in multiple planes.

Pharmacology of propranolol in patients with cirrhosis and portal hypertension

Ten patients with cirrhosis and protal hypertension received an initial 20 mg oral test dose of propranolol and subsequently 160 mg of a slow release preparation, orally, each day for seven days. Protein binding, serial plasma propranolol concentrations and effects on heart rate were studied. Protein binding was slightly reduced (mean 85%, range 78.9-88.1%) compared with four normals (mean 87.9%). In patients with severe liver disease (serum albumin less than 30 g/l) propranolol remained detectable in plasma 24 hours after the single 20 mg dose and high steady state concentrations (mean 266.5 ng/ml, range 84-406) were observed during regular dosing. At steady state there was a significant correlation between log total plasma propranolol concentrations and the percentage fall in heart rate (r = 0.659, p less than 0.05). We suggest that in patients with severe liver chronic disease (serum albumin less than 30 g/l), propranolol therapy should be initiated in hospital. The starting dose should be low (20 mg of the conventional formulation tds or 80 mg of the slow release preparation daily) and that regular monitoring of the heart rate should be carried out.

Efficacy of crystalloid cardioplegic solutions in patients undergoing myocardial revascularization. Effect of infusion route and regional wall motion on preservation of adenine nucleotide stores

The effect of varying the mode of cardioplegic delivery and the presence of regional wall motion abnormalities on myocardial protection by crystalloid cardioplegic solutions was assessed in 68 patients undergoing coronary artery bypass grafting. Serial transmural biopsy specimens from the left ventricular apex were assayed for adenosine triphosphate. All patients had more than 75% stenosis of the left anterior descending coronary artery. They were prospectively randomized into Groups I and II to receive (I) all cardioplegic solution infused via the aortic root or (II) reinfusions of cardioplegic solution given both centrally and through the completed distal left anterior descending anastomosis. Patients were also stratified as to the presence of normal (N) or impaired (Ab) apicoanterior regional wall motion. Inadequate delivery of cardioplegia during ischemia in Group I was manifested by a 41% (p less than 0.01) depletion of adenosine triphosphate stores in abnormally contracting myocardium distal to the left anterior descending stenosis that was not repleted after restoration of coronary flow and a 27% (p less than 0.05) decline in ATP stores during reperfusion in myocardium with normal preoperative wall motion. In contrast, nucleotide stores were preserved at preischemic levels throughout ischemia and reperfusion in Group II regardless of preoperative wall motion. Preservation of ATP did not correlate with duration of ischemia, highest recorded septal temperature, or volume of cardioplegic solution infused. Two patients in each group had a new perioperative infarction. However, 38% of patients in Group IAb required transient inotropic support versus 5% in Group IIAb (p less than 0.05). These data emphasize that reinfusion of cardioplegic solutions distal to coronary obstructions is mandatory for optimal myocardial protection during coronary revascularization.

Sex differences in the metabolism of ethanol and acetaldehyde in normal subjects

Blood ethanol and acetaldehyde concentrations were compared in normal young male and female subjects after intravenous infusion of 0.5 g of ethanol/kg body weight. After the infusion was completed, females had significantly higher mean concentrations of blood ethanol than males, but a significantly lower apparent volume of distribution (Vd) of ethanol (0.56 +/- 0.06 1/kg vs 0.68 +/- 0.17 1/kg, P less than 0.05). There were no differences in ethanol elimination rate (EER) (females 1.78 +/- 0.3 mmol h-1kg-1; males 1.87 +/- 0.41 mmol h-1kg-1). The mean value of the areas under the acetaldehyde/time curves (AUC) were significantly greater for males (88.5 +/- 26.4 mumol/1. h) than for females (58.6 +/- 31.5 mumol/1. h, P less than 0.05). Since the ethanol elimination rate was similar in both sexes, the observed differences in AUC for acetaldehyde may reflect the sex differences in metabolism of this substrate by the liver.

Ultrasound survey of gallstones and other hepatobiliary disorders in patients with Crohn's disease

Abdominal ultrasound was performed in conjunction with liver function tests in 38 patients with small bowel Crohn's disease and a similar number of age- and sex-matched healthy controls. Five (13%) patients had had previous cholecystectomies for cholelithiasis, and eight (21%) were found to have gallstones on ultrasound. Thus, a total of 34% of patients as compared with 8% of controls had gallstones (P less than 0.01). Compared with 8% of controls, 53% of patients had evidence of at least one biochemical or ultrasonic hepatobiliary abnormality (P less than 0.001). A bright liver echo pattern may be indicative of portal triaditis. The high prevalence of gallstones in Crohn's disease should be considered in any patient who continues to complain of abdominal pain despite otherwise appearing to be in remission.

Genetics of adeno-associated virus: isolation and preliminary characterization of adeno-associated virus type 2 mutants

We constructed insertion and deletion mutants with mutations within the adeno-associated virus (AAV) sequences of the infectious recombinant plasmid pSM620. Studies of these mutants revealed at least three AAV phenotypes. Mutants with mutations between 11 and 42 map units were partially or completely defective for rescue and replication of the AAV sequences from the recombinant plasmids (rep mutants). The mutants could be complemented by mutants with replication-positive phenotypes. The protein(s) that is affected in rep mutants has not been identified, but the existence of the rep mutants proves that at least one AAV-coded protein is required for viral DNA replication. Also, the fact that one of the rep mutant mutations maps within the AAV intron suggests that the intron sequences code for part of a functional AAV protein. Mutants with mutations between 63 and 91 map units synthesized normal amounts of AAV duplex DNA but could not generate single-stranded virion DNA (cap mutants). The cap phenotype could be complemented by rep mutants and is probably due to a defect in the major AAV capsid protein, VP3. This suggests that a preformed capsid or precursor is required for the accumulation of single-stranded AAV progeny DNA. Mutants with mutations between 48 and 55 map units synthesized normal amounts of AAV single-stranded and duplex DNA but produced substantially lower yields of infectious virus particles than wild-type AAV (lip mutants). The lip phenotype is probably due to a defect in the minor capsid protein, VPI, and suggests the existence of an additional (as yet undiscovered) AAV mRNA. Evidence is also presented for recombination between mutant AAV genomes during lytic growth.

Hormone and metabolite profiles in alcoholic liver disease

Circulating hormone and metabolite profiles have been studied in ten patients with alcoholic cirrhosis, five patients with alcoholic hepatitis and/or fatty liver, and nine normal controls over a 12-h period of meals and activity. Blood glucose was elevated throughout the day in both cirrhotic and non-cirrhotic alcoholics (mean 12-h glucose; controls 5.38 +/- 0.16 (SEM) mmol/l; cirrhotics 6.98 +/- 0.30 mmol/l, P less than 0.001; non-cirrhotics 7.18 +/- 0.26 mmol/l, P less than 0.001). Non-cirrhotic alcoholics had an exaggerated insulin response to meals, whereas cirrhotic patients had hyperinsulinaemia throughout the day (mean 12-h insulin; controls 16.3 +/- 2.3 mU/l; cirrhotics 35.8 +/- 6.6 mU/l, P less than 0.02). Growth hormone levels were elevated only in patients with cirrhosis (mean 12-h growth hormone, 7.06 +/- 1.35 v. 0.85 +/- 0.17 micrograms/l, P less than 0.001). Serum cortisol was persistently elevated in cirrhotics but only in the evening in non-cirrhotic alcoholics. Lactate and pyruvate responses to meals were exaggerated in non-cirrhotic patients whereas in cirrhotics, levels were persistently raised. Blood glycerol was elevated in all alcoholic patients whereas ketone body levels were normal. Hypertriglyceridaemia was observed only in non-cirrhotic patients. No relationship between the endocrine and metabolic state was observed in either cirrhotic or non-cirrhotic patients.

Gastric mucosal lymphocyte subpopulations in pernicious anemia and in normal stomach

Gastric mucosal lymphocyte subpopulations were determined by an indirect immunoperoxidase method applied to cryostat sections of gastric biopsies obtained from 12 patients with pernicious anemia (PA group) and from 12 patients whose stomachs were endoscopically and histologically normal (comparison group). T-Cell populations were identified by means of monoclonal antibodies directed against all T cells (UCHT1), T suppressor cells (anti-Leu-2a), and T helper cells (anti-Leu-3a). Non-T cell numbers were estimated indirectly. Concentrations of all T cells, T suppressor cells, T helper cells, and non-T cells were all significantly greater in the PA than in the comparison group. The most striking difference was in non-T cell numbers, which showed an approximately sixfold increase in the PA group. Mean T/non-T cell ratios in PA and comparison groups were significantly different (0.49 and 1.50, respectively). T suppressor/T helper cell ratios were similar in the two groups. There were highly significant positive correlations between numbers of non-T and T helper cells, and non-T and T suppressor cells in PA, but not in comparison groups. If, as seems likely, the majority of non-T cells in these gastritic stomachs were in fact cells of B lineage, these results would be consistent with the hypothesis that gastric mucosal damage in pernicious anemia is mediated primarily by a humoral mechanism, which may involve cytotoxic autoantibodies.

Dupuytren's contracture, chronic liver disease and IgA immune complexes

Contrary to previous reports, Dupuytren's contracture was found to be equally common in patients with alcoholic and non-alcoholic biopsy-proven liver disease (25% v 28%). Furthermore, in 69 patients with Dupuytren's contracture referred for surgical correction, there was no significant increase in either history of alcohol abuse or abnormality of liver function compared to a matched control group. Patients with Dupuytren's contracture were found to have increased levels of circulating IgA immune complexes compared to those without (p less than 0.05 for those with liver disease; p less than 0.001 for those awaiting surgical correction). Circulating immunoglobulins and immune complexes of other classes were similar between the groups with and without Dupuytren's contracture. These results suggest that the importance of alcohol has previously been exaggerated but that IgA immune complexes may be involved in the pathogenesis of the condition.

The influence of endotoxin in vitro on hepatic macrophage lysosomal enzyme release in different rat models of hepatic injury

Since bacterial endotoxin is known to be involved in the pathogenesis of hepatic injury, the influence of endotoxin on lysosomal enzyme production by hepatic macrophages has been investigated. Macrophages have been isolated from the livers of normal rats, from the livers of rats given stilboestrol subcutaneously 4 days previously and from the livers of rats given Corynebacterium parvum intravenously 6 days previously. Following isolation and overnight culture, the macrophages have been maintained in in vitro culture for a further 24 h and the production of N-acetyl-beta-glucosaminidase (NAG) has been measured. Histological assessment has shown that in stilboestrol model an approximate doubling of sinusoidal cell numbers occurs and in the C. parvum model a heavy mononuclear cell infiltrate is present, together with granuloma formation. These changes are reflected in the numbers of macrophages isolated from the respective models. Levels of NAG production by resident macrophages from normal livers are low (0.25 +/- 0.05 nmol substrate hydrolysed/microgram cell protein/h) and unchanged following endotoxin exposure (0.25 +/- 0.05 units). Macrophages isolated from the stilboestrol model show levels of NAG production similar to normal (0.34 +/- 0.06 units), but this increases significantly following exposure to endotoxin (0.42 +/- 0.07 units). Macrophages from the C. parvum model demonstrate markedly enhanced production (0.61 +/- 0.09 units), but this does not increase significantly following endotoxin exposure (0.65 +/- 0.09 units). In contrast to macrophages from normal rat livers, macrophages recently recruited in the stilboestrol model demonstrate enhanced lysosomal enzyme production following endotoxin exposure. It is suggested that endotoxin, as well as other mediators of macrophage activation, may promote hepatic damage through this influence on newly recruited macrophages.

The dexamethasone suppression test in depressed outpatients and normal control subjects

In contrast to a recently published report by Amsterdam and associates, the authors noted a higher frequency of abnormal dexamethasone suppression test results in 88 outpatients with primary depression (particularly the endogenous subtype) than in 49 normal controls.

Different aetiology of chronic active hepatitis in U.K. and Iraq

We have compared the clinical, biochemical and immunological features of patients with biopsy-proven chronic active hepatitis from Iraq and from the United Kingdom. Clear-cut differences emerge, which can mostly be attributed to the HBV status, as 91% of patients from Iraq were HBsAg-positive compared to only 6% from the U.K. Most patients from Iraq presented insidiously with established cirrhosis, while those from the U.K. presented more acutely and systemic symptoms were more common. Autoantibodies and associated autoimmune conditions were common in U.K. patients but extremely rare in Iraqis.

Delay in diagnosis of adult coeliac disease

The delay in diagnosis of 106 patients with adult coeliac disease, diagnosed between 1976 and 1980, was studied. Overall, delay in diagnosis was 11 +/- 10.6 years, being considerably greater in females (12.8 +/- 7.8 years) than in males (3.5 +/- 9.8 years). Most of this delay occurred prior to hospital referral, although that following referral to hospital clinics was still significant (1.8 +/- 4.8 years). The most common presenting complaints were lassitude (75%) anaemia (65%) and flatulence (50%). Typical gastro-intestinal symptoms were relatively uncommon and mild, but when present led to a more speedy diagnosis. It is concluded that, despite advances in modern diagnostic procedures, little progress has been made in hastening the diagnosis of coeliac disease.

Hepatitis B among Indochinese refugees in Great Britain

Six hundred and thirty-two blood samples from 879 consecutive admissions to one resettlement camp for Indochinese refugees in Great Britain were screened for markers of hepatitis B (HB) virus infection. The overall prevalence of HB surface antigen (HBsAg) was 15%, being 16% in those aged 40 years or less, and falling to 8% in those older than 40 (P less than 0.05). No significant difference in prevalence was found between males and females. HBe antigen was detected in 56% of those with HBsAg and was demonstrable in 55-76% of those under 30 years of age. HBe antibody was found in 21% of HBsAg-positive refugees. In those under 40 years old, HB core (HBc) antibody was commoner in males (P less than 0.01). HBc antibody prevalence increased significantly with age in females (P less than 0.01) but not in males. There was no definite evidence that vertical transmission of hepatitis B was present in the group studied.