Eruptive keratoacanthomas associated with dupilumab therapy

We would like to present the case of eruptive keratoacanthomas associated with dupilumab therapy, which occurred in an 85-year-old woman receiving biologic therapy for the treatment of atopic dermatitis. With the increasing prevalence of Dupilumab usage, this is an important potential complication of which clinicians should be aware.

The lead up to tobacco plain packaging policy in Turkey

Background

Research shows tobacco plain packaging (TPP) is effective in reducing the attractiveness of tobacco products, effectiveness of tobacco packaging and increases the impact of health warnings. Since Australia introduced TPP in 2012, several other countries have adopted similar legislation, and more have begun preparations for introducing it. Turkey first announced its intention to proceed with TPP in 2011, however prior to the eventual passage of legislation in December 2018 there were many false starts and delays. This study (conducted in 2018 before TPP legislation was passed in Turkey) explored the barriers and facilitators to introducing legislation.

Methods

A qualitative study design was employed using a single case study approach. Publicly available documents relevant to TPP in Turkey were analysed and interviews with key informants from academics, bureaucrats in government ministries and non-government organisations (NGOs) were conducted in 2018.

Results

Barriers such as changes to the government, tobacco industry opposition and the economic crisis appeared to contribute most to the delays in introducing TPP. Despite the barriers Turkey had faced, TPP legislation managed to reach the political agenda primarily through the collaborative advocacy efforts of NGOs, academics and the leadership of particular tobacco control advocates.

Conclusions

TPP legislation was approved by the Turkish government on the 5th December 2018 and has been in force since the 5th January 2020. Implications for the wider uptake of TPP include the importance of building effective coalitions and raising public awareness.

Key messages

The tobacco industry opposition can be defeated by tobacco control advocates working together. Turkey’s experience should be considered by other countries who are willing to implement TPP.

Expert clinical management of autoimmune hepatitis in the real world

BACKGROUND

High-quality data on the management of autoimmune hepatitis (AIH) are scarce. Despite published guidelines, management of AIH is still expert based rather than evidence based.

AIM

To survey expert hepatologists, asking each to describe their practices in the management of patients with AIH.

METHODS

A survey questionnaire was distributed to members of the International AIH Group. The questionnaire consisted of four clinical scenarios on different presentations of AIH.

RESULTS

Sixty surveys were sent, out of which 37 were returned. None reported budesonide as a first line induction agent for the acute presentation of AIH. Five (14%) participants reported using thiopurine S-methyltransferase measurements before commencement of thiopurine maintenance therapy. Thirteen (35%) routinely perform liver biopsy at 2 years of biochemical remission. If histological inflammatory activity is absent, four (11%) participants reduced azathioprine, whereas 10 (27%) attempted withdrawal altogether. Regarding the management of difficult-to-treat patients, mycophenolate mofetil is the most widely used second-line agent (n = ~450 in 28 centres), whereas tacrolimus (n = ~115 in 21 centres) and ciclosporin (n = ~112 in 18 centres) are less often reported. One centre reported considerable experience with infliximab, while rescue therapy with rituximab has been tried in seven centres.

CONCLUSIONS

There is a wide variation in the management of patients with autoimmune hepatitis even among the most expert in the field. Although good quality evidence is lacking, there is considerable experience with second-line therapies. Future prospective studies should address these issues, so that we move from an expert- to an evidence- and personalised-based care in autoimmune hepatitis.

The effect of storage conditions on the composition and functional properties of blended bulk tank milk

The objective of this study was to investigate the effects of storage temperature and duration on the composition and functional properties of bulk tank milk when fresh milk was added to the bulk tank twice daily. The bulk tank milk temperature was set at each of 3 temperatures (2, 4, and 6°C) in each of 3 tanks on 2 occasions during two 6-wk periods. Period 1 was undertaken in August and September when all cows were in mid lactation, and period 2 was undertaken in October and November when all cows were in late lactation. Bulk tank milk stored at the 3 temperatures was sampled at 24-h intervals during storage periods of 0 to 96 h. Compositional parameters were measured for all bulk tank milk samples, including gross composition and quantification of nitrogen compounds, casein fractions, free amino acids, and Ca and P contents. The somatic cell count, heat stability, titratable acidity, and rennetability of bulk tank milk samples were also assessed. Almost all parameters differed between mid and late lactation; however, the interaction between lactation, storage temperature, and storage duration was significant for only 3 parameters: protein content and concentrations of free cysteic acid and free glutamic acid. The interaction between storage temperature and storage time was not significant for any parameter measured, and temperature had no effect on any parameter except lysine: lysine content was higher at 6°C than at 2°C. During 96 h of storage, the concentrations of some free amino acids (glutamic acid, lysine, and arginine) increased, which may indicate proteolytic activity during storage. Between 0 and 96 h, minimal deterioration was observed in functional properties (rennet coagulation time, curd firmness, and heat stability), which was most likely due to the dissociation of β-casein from the casein micelle, which can be reversed upon pasteurization. Thus, this study suggests that blended milk can be stored for up to 96 h at temperatures between 2°C and 6°C with little effect on its composition or functional properties.

Seasonal trends in milk quality in Ireland between 2007 and 2011

The objectives of this study were to evaluate annual and seasonal trends in bulk tank somatic cell count (SCC), total bacterial count (TBC), and laboratory pasteurization count (LPC) in Ireland between 2007 and 2011 (inclusive), and to compare trends based on herd type and herd size. The unadjusted median SCC and TBC of all records were 266,000 and 17,000 cfu/mL, respectively. Data were transformed to log values and analyzed using a mixed model. Fixed effects included milk processor, year, month, and total monthly milk volume; milk producer was fitted as a random variable. After analysis, means were back transformed for interpretation. Annual SCC increased slightly from 259,000 cells/mL in 2007 to a peak of 272,647 cells/mL in 2009 and then declined slightly thereafter. Although statistically significant changes in annual TBC are probably not biologically relevant, values ranged between 23,922 and 26,290 cfu/mL. Annual LPC peaked in 2008 (265 cfu/mL), declined in 2009, and increased thereafter. Monthly mean SCC of all records increased from April onward, with the greatest increases seen from October to December, when the majority of cows entered late lactation. Monthly mean TBC exhibited a seasonal trend, whereby TBC was greatest at the beginning and end of the year, coinciding with winter housing. Seasonal milk production herds (n=8,002 herds) calve all cows in spring (February to April), whereas split-calving herds (n=1,829 herds) calve cows in the spring and autumn. From February to September, monthly SCC was lower for seasonal herds than for split-calving herds, whereas SCC was lower for split-calving herds for the remaining months. During winter (October to March), split-calving herds had lower monthly TBC than seasonal herds, most likely because of stricter regulations imposed upon them. Herd size was approximated using total annual milk production figures. Across all months, larger herds had lower SCC and TBC compared with smaller herds. No obvious improvements in milk quality were seen between 2007 and 2011. Farmers have the opportunity to improve milk quality by reducing bulk tank SCC in late lactation and by imposing stricter hygiene practices at the beginning and end of the year to overcome the seasonal variation of bulk tank TBC.

Microbialite taphonomy and biogenicity: new insights from NanoSIMS

We here show that nano-scale mapping of elements commonly utilized in biological cycles provides a promising new additional line of evidence when evaluating the extent of the contribution of biology to microbialites. Our case study comes from Lake Clifton in Western Australia, a unique environment where living domical and conical microbialites occur in close proximity to ≤ 4000-year-old fossilized equivalents. The outer margins of a partially lithified, actively growing Lake Clifton microbialite are characterized by abundant filamentous cyanobacteria within a loosely cemented aragonite matrix. Nano-scale chemical maps have been successfully matched to specific morphological features such as trichomes, sheaths and putative extracellular polymeric substances (EPS). A suite of elements (C, O, Mg, N, Si, S) is concentrated within cyanobacterial sheaths, with carbon, magnesium, nitrogen and sulfur also enriched within trichomes and putative EPS. Calcium distribution highlights the sites of aragonite mineralization. In contrast, the fossilized Lake Clifton microbialite contains only rare, extensively degraded cyanobacterial filaments, the mean diameter of which is <50% of the living equivalents. Nevertheless, nano-scale chemical maps can again be matched with morphological features. Here, poorly preserved filamentous microfossils are highlighted by enrichments in nitrogen and sulfur. Magnesium is no longer concentrated within the filaments, instead it co-occurs with calcium and oxygen in the calcite cement. Extension of this study to a ~2720-million-year-old stromatolitic microbialite from the Tumbiana Formation of Western Australia shows that similar nano-scale signals, in particular nitrogen and sulfur enrichments, are characteristic of stromatolite laminations, even when morphological microfossils are absent. The close similarities of nano-scale elemental distributions in organic material from modern and ancient microbialites show that this technique provides a valuable addition to the morphological investigation of such structures, particularly in non-fossiliferous ancient examples.

Effect of pre-milking teat preparation procedures on the microbial count on teats prior to cluster application

A study was carried out to investigate the effect of six pre-milking teat preparation procedures on lowering the staphylococal, streptococcal and coliform microbial count on teat skin prior to cluster application. The teat preparations included 'Iodine', 'Chlorhexidine' teat foam, 'Washing and drying' with paper, 'No preparation', 'Chlorine' teat foam, and disinfectant 'Wipes'. Teat preparations were applied for five days to 10 cows for each treatment during two herd management periods (indoors and outdoors). Teats were swabbed on day four and five before teat preparation and repeated after teat preparation. The swabs were plated on three selective agars: Baird Parker (Staphylococcus spp.), Edwards (Streptococcus spp.), and MacConkey (coliform). Following incubation, microbial counts for each pathogen type were manually counted and assigned to one of six categories depending on the microbial counts measured. The results were analysed by logistic regression using SAS 28. The main analysis was conducted on binary improvement scores for the swabbing outcomes. There were no differences for staphylococcal, streptococcal and coliform bacterial counts between treatments, measured 'before' teat preparation. Treatments containing 'Chlorhexidine' teat foam (OR = 4.46) and 'Wipes' (OR = 4.46) resulted in a significant reduction (P < 0.01) in the staphylococcal count on teats compared to 'Washing and drying' or 'No preparation'. 'Chlorine' teat foam (OR = 3.45) and 'Wipes' (3.45) had the highest probability (P < 0.01) of reducing streptococcal counts compared to 'Washing and drying' or 'No preparation'. There was no statistical difference between any of the disinfectant treatments applied in reducing coliforms. Thus, the use of some disinfectant products for pre-milking teat preparation can have beneficial effects on reducing the levels of staphylococcal and streptococcal pathogens on teat skin.

Cannabinoid receptors in invertebrates

Two cannabinoid receptors, CB1 and CB2, are expressed in mammals, birds, reptiles, and fish. The presence of cannabinoid receptors in invertebrates has been controversial, due to conflicting evidence. We conducted a systematic review of the literature, using expanded search parameters. Evidence presented in the literature varied in validity, ranging from crude in vivo behavioural assays to robust in silico ortholog discovery. No research existed for several clades of invertebrates; we therefore tested for cannabinoid receptors in seven representative species, using tritiated ligand binding assays with [3H]CP55,940 displaced by the CB1-selective antagonist SR141716A. Specific binding of [3H]CP55,940 was found in neural membranes of Ciona intestinalis (Deuterstoma, a positive control), Lumbricusterrestris (Lophotrochozoa), and three ecdysozoans: Peripatoides novae-zealandiae (Onychophora), Jasus edwardi (Crustacea) and Panagrellus redivivus (Nematoda); the potency of displacement by SR141716A was comparable to measurements on rat cerebellum. No specific binding was observed in Actinothoe albocincta (Cnidaria) or Tethya aurantium (Porifera). The phylogenetic distribution of cannabinoid receptors may address taxonomic questions; previous studies suggested that the loss of CB1 was a synapomorphy shared by ecdysozoans. Our discovery of cannabinoid receptors in some nematodes, onychophorans, and crustaceans does not contradict the Ecdysozoa hypothesis, but gives it no support. We hypothesize that cannabinoid receptors evolved in the last common ancestor of bilaterians, with secondary loss occurring in insects and other clades. Conflicting data regarding Cnidarians precludes hypotheses regarding the last common ancestor of eumetazoans. No cannabinoid receptors are expressed in sponges, which probably diverged before the origin of the eumetazoan ancestor.

Ultrasound guidance in the placement of a percutaneous endoscopic gastrostomy (PEG): an adjuvant technique in patients with abdominal wall varices?

Malnutrition in patients with liver disease is common. As a result, enteral feeding may be indicated. Percutaneous endoscopic gastrostomy insertion is rarely performed because the presence of varices is considered to be a contraindication. We report a case of percutaneous endoscopic gastrostomy insertion in a patient with both gastric and oesophageal varices. The use of abdominal ultrasound may provide an adjuvant tool for percutaneous endoscopic gastrostomy insertion. This novel technique may minimise the risk of complications in selected patients.

Detection of serum M2 anti-mitochondrial antibodies by enzyme-linked immunosorbent assay is potentially less specific than by immunofluorescence

AIM

To compare the predictive values of enzyme-linked immunosorbent assays (ELISAs) and indirect immunofluorescence (IIF) techniques for the detection of M2 anti-mitochondrial antibodies.

METHODS

Commercial ELISAs are widely available for the detection of anti-mitochondrial antibody subtypes in primary biliary cirrhosis (PBC). We compared the results from two ELISAs (one recombinant, one purified antigen) with those from two IIF methods in a well-defined cohort of PBC patients and in patients with systemic lupus erythematosus, Sjögren's syndrome, sicca syndrome, systemic sclerosis, rheumatoid arthritis and blood donor controls.

RESULTS

There was good correlation between a rodent substrate IIF and ELISA A (r=0.9134), but poor correlation with ELISA B (r=0.5999), which produced many false-positive results in the control population. We show that rodent IIF alone or human epithelial cell (HEp-2000) screening with confirmation by ELISA produce similar predictive values for PBC and require lesser degrees of skilled interpretation of IIF patterns.

CONCLUSIONS

We conclude that the specificities of IIF are greater than the ELISA methods (99% versus 85-97%), although the ELISAs are slightly more sensitive in biopsy-proven PBC. Careful in-house validation of all new ELISA technologies is mandatory for good laboratory practice, but IIF in experienced hands remains an effective and specific assay.

Health and safety in the catering industry

There is evidence that the catering industry has high levels of work-related injury and disease. This study examined the incidence, nature and causes of work-related injury and disease among 315 catering students, at a large school of catering in the west of Ireland, over a 10 month academic year. A high incidence of accidents that caused injury was found. Cuts and lacerations, arising from accidents with knives, were the most common injuries seen, followed by burns and scalds from handling hot liquids. A significant level of work-related dermatitis was also recorded. Trainee chefs were identified as an occupational group with a high risk of occupational injury and disease. This group would benefit from vaccination against tetanus. Work-related injuries and disease generated a significant workload for the student health unit, which in itself is a good reason for catering establishments to make use of occupational health services. Health and safety procedures need to be audited and constantly reviewed at a local level. Further research is necessary to more accurately determine the incidence, nature and leading causes of work-related injury and disease in the catering industry in Ireland. This would help in the planning and implementation of an effective health and safety management system.

The architecture of Mg(II) centres in MAPO-36 solid acid catalysts

The local structure around Mg2+ ions of a Magnesium substituted aluminophosphate, with the ATS structure (MgAPO-36, Mg/P=0.08), in the as-prepared and calcined state has been investigated by Mg K-edge XAS spectroscopy. High quality XAS data were collected using the solid-state fluorescence detector. Mg2+ is found to replace tetrahedrally co-ordinated Al3+ in the as-prepared state and remained intact even after calcination, thus yielding a highly active, solid acid catalyst.

Effect of Si(IV) substitution on the stability of microporous ZnAPSO-44 solid acid catalysts: a combined XAS/XRD study

The combined XAS/XRD technique has been used to investigate the stability of the microporous structure during calcination process for a series of ZnAPSO-44 materials. Incorporation of large amounts of Zn is found to produce materials that are unstable upon removal of the structure directing organic template molecule. However, simultaneous incorporation of Si is found to increase the thermal stability of the materials, yielding catalysts that are well suited for acid catalysed reactions.

Molecular phylogenetics of leafrollers application to DNA diagnostics

Accurate and rapid diagnosis of taxa whether they be welldefined species or biotypes is of crucial importance to quarantine pest management and research Recent developments in DNA technology has resulted in a range of molecular techniques being available for use in such applications We have employed a phylogenetically focussed approach in the development of a diagnostic key to distinguish a range of leafroller species (Lepidoptera Tortricidae) using DNA sequence data derived from a 23 kb region of the mitochondrial genome containing the genes cytochrome oxidase I and II Phylogenetic analysis has revealed clear relationships between taxa although the genus Apoctena does not appear monophyletic The most appropriate diagnostic characters are either those which are phylogenetically informative either synapomorphies or autapomorphies A standardised approach to data collection is advocated for future studies

Low-dose methotrexate is ineffective in primary biliary cirrhosis: long-term results of a placebo-controlled trial

BACKGROUND & AIMS

New treatments for primary biliary cirrhosis (PBC) need to be evaluated. We conducted a single-center double-blind, randomized trial of methotrexate, 7.5 mg/wk (n = 30), vs. placebo (n = 30) for up to 6 years in PBC.

METHODS

Methods included three monthly symptom assessment and liver function tests and liver biopsy and gastroscopy at baseline, after 2 years, and after 4-6 years.

RESULTS

Patients randomized to methotrexate had, compared with patients randomized to placebo, (1) significantly lower on-treatment serum alkaline phosphatase, gamma-glutamyltransferase, immunoglobulin (Ig) M, IgG, and (after 24 months) aspartate aminotransferase and alanine aminotransferase levels (P < 0.02-0.001 by analysis of covariance to adjust for baseline differences); (2) a nonsignificant trend toward lower on-treatment pruritus scores; (3) similar on-treatment Knodell inflammatory scores but nonsignificant trends toward lower Knodell fibrosis score and less ductopenia; (4) a trend toward greater increases in serum bilirubin level and Mayo score with time (both significant after 5 years of follow-up); and (5) a 2.9-fold (95% confidence interval, 0.85-10.25-fold) increase the rate of death or liver transplantation as a result of liver disease during or after the trial (P = 0.09) in a Cox multivariate regression analysis compared with patients randomized to placebo.

CONCLUSIONS

These results do not support the clinical use of low-dose methotrexate in PBC.

Primary biliary cirrhosis shows association with genetic polymorphism of tumour necrosis factor alpha promoter region

BACKGROUND/AIMS

Primary biliary cirrhosis is an autoimmune disease in which increased prevalence in first-degree relatives and an association with HLA DR8 suggest a genetic background. TNFalpha is a mediator of inflammation and immunity, and is implicated in the pathogenesis of primary biliary cirrhosis, ex vivo studies having shown reduced production of TNFalpha by lymphocytes from patients. Our group has previously described a biallelic promoter-region polymorphism of the TNFA gene at position -308, and demonstrated that the rare allele, TNF*2, has increased promoter function compared with the common allele, TNF*1. A further biallelic base change has been described in the TNFA gene at -238. We conducted a case-control study to assess association of these gene polymorphisms with primary biliary cirrhosis.

METHODS

Ninety-one patients and 213 controls were genotyped for both TNFA loci using restriction fragment length polymorphism analysis of PCR products.

RESULTS

The high production TNFA-308*2 allele was significantly under-represented among subjects with primary biliary cirrhosis (27.5% PBC, 41.6% controls, p=0.02, pc=0.04, OR for carriage of TNF*1/*1 genotype=1.89, CI=1.10-3.32). No association was shown with the TNFA -238 polymorphism.

CONCLUSION

Primary biliary cirrhosis is associated with reduced carriage of TNF*2. This is in keeping with a protective role of TNFalpha against the disease.

Effect of acute bile acid pool depletion on total and ionized calcium concentrations in human bile

Although calcium salts are important components of gallstones, there are few data on the total and ionized calcium content of human bile. Therefore, in 14 fasting T-tube patients studied 7-11 days after cholecystectomy, we measured bile flow, bile acid [BA], total [CaTOT] and free ionized [Ca++] calcium concentrations, in 20-30 min bile collections during acute BA pool depletion induced by 6-8 h of continuous bile drainage. During washout of the BA pool there were parallel falls in bile flow, BA output and total calcium output (correlation coefficients ranging from 0.59 to 0.99; P < 0.02-0.001). In 12 of the 14 patients, [CaTOT] also fell (from 1.84 +/- 0.29 to 1.32 +/- 0.34 mmol L-1) in parallel with [BA] (from 34.0 +/- 14.0 to 8.2 +/- 8.0 mmol L-1; r = 0.75-0.98; P < 0.005). In contrast, biliary [Ca++] remained virtually unchanged. These data suggest that the BAs are linked to the bound, rather than to the free, ionized, fraction of biliary calcium, which is consistent with in vivo calcium binding by BAs. A model is proposed in which BA-induced biliary calcium secretion results from (i) bile acid-induced water flow via solvent drag; and (ii) calcium binding in the bile canaliculus by bile acids, which induces paracellular diffusion of Ca++, thereby maintaining [Ca++] independent of [BA].

Changes in serum calcium levels influence biliary calcium levels in humans

BACKGROUND/AIMS

There are few data on the influence of serum calcium on biliary total and ionized calcium levels in humans. The aims of the study were to increase serum calcium levels short-term by intravenous calcium infusion and study the resultant changes in total and ionized calcium concentrations ([CaTOT] and [Ca2+]) in T-tube bile.

METHODS

Serum and biliary total and ionized calcium concentrations were measured over an 8-hour period in 7 postcholecystectomy patients with T tubes before, during, and after a 4-hour intravenous infusion of 10% calcium gluconate.

RESULTS

During the infusion, serum [CaTOT] increased from 2.08 +/- 0.14 mmol/L (mean +/- SD) to 3.18 +/- 0.33 mmol/L, and serum [Ca2+] increased from 1.13 +/- 0.13 mmol/L to 1.68 +/- 0.13 mmol/L. After a 20-40-minute time lag, there were corresponding increases in biliary [CaTOT] from 1.90 +/- 0.45 mmol/L to 2.80 +/- 0.52 mmol/L and in biliary [Ca2+] from 0.70 +/- 0.11 mmol/L to 1.19 +/- 0.16 mmol/L. When the data were pooled, serum [Ca2+] showed significant correlations with both biliary [CaTOT] (n = 128; r = 0.56; P < 0.001) and biliary [Ca2+] (n = 128; r = 0.64; P < 0.001).

CONCLUSIONS

These results support the hypothesis that the biliary tree is freely permeable to calcium ions and that serum calcium level is one determinant of biliary calcium concentration. Our data may also explain the observation that patients with hypercalcemia are reported to have a greater than normal prevalence of calcified gallstones.

Acid-base transport systems in a polarized human intestinal cell monolayer: Caco-2

Acid-base transport systems have been incompletely characterized in intact intestinal epithelial cells. We therefore studied the human cell line Caco-2, cultured on Teflon membranes to form confluent monolayers with apical microvilli on transmission electron microscopy and progressive enrichment in microvillar hydrolases. Monolayers (16- to 25-day-old), loaded with the pH-sensitive dye BCECF-AM (2',7'-bis (carboxyethyl)-5-carboxyfluorescein), were mounted in a spectrofluorometer cuvette to allow selective superfusion of apical and basolateral surfaces with Hepes- or HCO(3-)-buffered media. Intracellular pH (pHi) was measured by dual-excitation spectrofluorimetry; calibration was with standards containing nigericin and 110 mM K+ corresponding to measured intracellular [K+] in Caco-2 cell monolayers. In HCO(3-)-free (Hepes-buffered) media, bilateral superfusion with 1 mM amiloride or with Na(+)-free media reversibly inhibited pHi recovery from an intracellular acid load (NH4Cl pulse) by 86 and 98% respectively. Selective readdition of Na+ to the apical or basolateral superfusate also induced a pHi recovery, which was inhibited by ipsilateral but not by contralateral amiloride (1 mM). The pHi recovery induced by apical Na+ readdition had a Michaelis constant (Km) for Na+ of 30 mM and a relatively high inhibitor constant (Ki) for amiloride of 45.5 microM. Initial pHi in HCO(3-)-buffered media was lower than in the absence of HCO3- (7.35 vs. 7.80). pHi recovery from an acid load in HCO3- was Na- dependent but was inhibited only 18% by 1 mM amiloride. The amiloride-independent pHi recovery was inhibited 49% by pre-incubation of cells in 5 mM DIDS (4,4'-diisothiocyanatostilbene-2,2'-disulphonic acid). These data suggest that Caco-2 cells possess: (a) both apical and basolateral membrane Na(+)-H+ exchange mechanisms, the apical exchanger being relatively resistant to amiloride, similar to apical Na(+)-H+ exchangers in several normal epithelia; and (b) a Na(-)-dependent HCO3- transport system, either Na(+)-HCO3- cotransport or Na(-)-dependent Cl(-)-HCO3- exchange.

Hepatitis C virus in autoimmune liver disease in the UK: aetiological agent or artefact?

Hepatitis C virus antibody titres (anti-HCV) were measured in serum from 122 patients with autoimmune liver disease (96 with primary biliary cirrhosis and 26 with autoimmune chronic active hepatitis using three generations of enzyme immunoassay (EIA): first generation--Ortho, EIA1; second generation--Abbott, EIA2; and third generation--Murex, EIA3. Anti-HCV was below the positive cut-off level in all 26 autoimmune chronic active hepatitis patients for all tests, while seropositivity values in primary biliary cirrhosis were 31% (EIA1), 14% (EIA2), and 0% (EIA3). In primary biliary cirrhosis, anti-HCV values as measured by all three tests correlated positively with serum IgG concentrations, serum storage time, and a number of other indices of hepatic dysfunction. Multiple regression analysis showed that anti-HCV values were independently affected by both serum IgG and the length of storage time, although the magnitude of the effects varied between tests. When all three multiple regression models were applied to an extreme clinical example, however, EIA3 was least likely to give a false-positive result. The difference in test performance was emphasised further by examination of anti-HCV values in nine primary biliary cirrhosis patients (confirmed negative by recombinant immunoblot assay 2) in whom serial samples were tested (seven to 14 per patient, stored for one to 138 months). Apparent anti-HCV values (EIA1 and EIA2) increased with increasing serum storage time, but were unchanged when measured by EIA3. A similar pattern was evident in a limited study of five autoimmune chronic active hepatitis patients. As the second generation EIA is in widespread use and confirmatory testing is not always available, the effect of serum storage in addition to hyperglobulinaemia should be considered in the interpretation of positive results in auto immune and in other types of chronic liver disease.

Gall stone recurrence and its prevention: the British/Belgian Gall Stone Study Group's post-dissolution trial

The British/Belgian Gall Stone Study Group (BBGSG) post-dissolution trial was a prospective, multicentre, randomised, double blind trial of: (i) low dose ursodeoxycholic acid, (ii) placebo, and (iii) a high fibre, low refined carbohydrate diet in the prevention of gall stone recurrence in patients with complete gall stone dissolution. Further aims included establishing the timing and frequency of recurrence and its association with biliary symptoms, a comparison of the sensitivity of ultrasonography v oral cholecystectography in detecting recurrent stones, and a search for risk factors predicting recurrence. Ninety three patients entered the study, and 82 were followed up for up to five years (mean (SEM) 28 (1.5) months) with six monthly ultrasonography and yearly oral cholecystectography. There were 21 recurrences (26 by oral cholecystectography or ultrasonography, or both), only two of which were symptomatic, which were detected between 12 and 42 months after trial entry. This corresponded to an actuarial recurrence rate of 33.9 (7.0%) by lifetable analysis at 42 months and subsequently. There were four recurrences in the ursodeoxycholic acid, six in the placebo, and 11 in the diet groups, corresponding to 21.9 (9.9)%, 27.4 (10.1)%, and 45.8 (12.4)% respectively at 42 months by lifetable analysis (NS). Variables including age, obesity, menopausal state, pregnancy, and oestrogen containing drugs were not shown to affect recurrence rate. Men had more frequent recurrence than women (NS). Patients who had had multiple stones experienced more recurrences than did those with single stones (NS). Recurrence did not occur in patients who took non-steroidal anti-inflammatory drugs (NSAIDs) (p < 0.02). The stone free interval between stone dissolution and trial entry proved to be important--those stone free > nine months had a recurrence rate of only 12.7 (6.0)% at 42 months compared with 55.4 (12.5)% in those stone free < nine months (p < 0.01). There was imbalance between the ursodeoxycholic acid and placebo groups for this factor, and after applying a statistical correction, the adjusted recurrence rate in the ursodeoxycholic acid group was 15% compared with 30% in both placebo and diet groups (NS). These data suggest that after medical dissolution, the risk of gall stone recurrence is not reduced by a high fibre, low refined carbohydrate diet: it may be lowered, but not abolished, by low dose ursodeoxycholic acid.

Calcium and carbonate ion concentrations in gallbladder and hepatic bile

Calcium carbonate is a major component of gallstones, but there are few data on calcium and carbonate (CO3(2-)) concentrations in human bile. Therefore, in patients undergoing cholecystectomy for gallstones, total [CaTOT] and free ionized [Ca2+] calcium concentrations, pH, PCO2, and total [CO2] were measured and [CO3(2-)] was derived in gallbladder and hepatic bile (aspirated anaerobically at surgery or from T tubes). Gallbladder bile had lower pH (6.96 vs. 7.30) and total [CO2] (14.1 vs. 21.6 mmol/L), higher PCO2 (53.8 vs. 40.2 mm Hg), lower [CO3(2-)] (2.52 vs. 6.11 x 10(5) mol/L) and lower [Ca2+] x [CO3(2-)] ion product (1.88 vs. 4.74 x 10(-8) mol/L) than did hepatic bile. Gallbladder bile pH correlated positively with total [CO2], [CO3(2-)], and [Ca2+] x [CO3(2-)] but negatively with PCO2. Patients with surface gallstone calcification had similar gallbladder bile [CaTOT] and [Ca2+] but higher gallbladder bile pH (7.30 vs. 6.90), lower PCO2 (42.9 vs. 57.2 mm Hg), higher [CO3(2-)] (7.29 vs. 1.84 x 10(-5) mol/L), and higher [Ca2+] x [CO3(2-)] ion product [4.73 vs. 1.45 x 10(-8) (mol/L)2] than those with radiolucent gallstones. There were no differences in these parameters between patients with cholesterol stones and those with pigment stones. These data suggest that the human gallbladder acidifies bile by secreting hydrogen ion and that impairment of this secretion is one cause of calcified gallstone formation in humans.

Combination therapy with oral ursodeoxycholic and chenodeoxycholic acids: pretreatment computed tomography of the gall bladder improves gall stone dissolution efficacy

In a five year study, 55 patients with radiolucent gall stones were treated with the combination of 7.5 mg chenodeoxycholic acid (CDCA) and 5.0 mg ursodeoxycholic acid (UDCA)/kg/day--that is, half the monotherapeutic doses. Side effects were few but four patients could not tolerate the prescribed bile acids because of diarrhoea or nausea. Analysis of fasting duodenal bile confirmed that CDCA+UDCA converted supersaturated into unsaturated bile but the saturation indices did not predict the dissolution response. By actuarial analysis, the confirmed (by ultrasound x2) complete gall stone dissolution rates in all 55 patients were mean (SEM) 29 (7)% at 12 and 44 (8)% at 24 months. The advent of routine computed tomography before treatment enabled comparison of dissolution efficacy in those screened by computed tomography (n = 24), whose maximum gall stone attenuation was less than 100 Hounsfield units, with that in those not screened (n = 29). Although stone size and number were comparable, patients screened by computed tomography had significantly better dissolution rates (p less than 0.025) than those not screened in this way. At 12 months, partial or complete gall stone dissolution rates were 93 (7)% in the screened and 55 (11)% in the non-screened patients. At 18 months, complete dissolution rates were 64 (12%) and 20 (9)% respectively. Computed tomography before treatment is cost effective in selecting those patients likely to achieve gall stone dissolution on treatment with UDCA+CDCA.

Androgen associated hepatocellular carcinoma with an aggressive course

The hepatocellular carcinomas that develop in patients treated with androgens have previously been associated with a benign clinical outcome. We describe a man who developed a hepatocellular carcinoma after 24 years of androgen treatment, whose tumour initially showed partial regression after withdrawal of androgens but subsequently pursued an aggressive and fatal course.

Final outcome of ursodeoxycholic acid treatment in 126 patients with radiolucent gallstones

One hundred and twenty-six patients with radiolucent gallstones in 'functioning' gallbladders were treated with 8-10 mg ursodeoxycholic acid (UDCA) kg/day and followed to a treatment conclusion. Complete or partial gallstone dissolution was achieved in 74 (59 per cent). However, only 22 achieved complete gallstone dissolution, as judged by two normal oral cholecystograms; ultrasonograms were performed in 16 of these patients, and all were normal. UDCA was stopped in 76 patients: because of cystic duct obstruction (n = 12), severe biliary pain (n = 13), non-response (n = 25) or partial stone dissolution with arrested progress (n = 26). Life-table analysis showed that complete gallstone dissolution rates at four years were 25-30 per cent (two normal oral cholecystograms) and 17-19 per cent (two normal oral cholecystograms plus one ultrasonogram). All patients with complete gallstone dissolution had shown partial stone dissolution at 6-12 months; of those with partial stone dissolution at six months, only 25 per cent went on to complete gallstone dissolution, and then always within two years. Efficacy correlated inversely with stone size but not with age, sex, obesity or on-treatment saturation indices. Acquired surface gallstone calcification developed in 13 patients (life-table analysis 22 +/- 7 per cent at four years); none of these patients achieved complete gallstone dissolution and only five achieved partial stone dissolution. Thus, despite relatively high partial gallstone dissolution rates, the ultimate efficacy of UDCA in achieving complete gallstone dissolution is low.

Calcium binding by bile acids: in vitro studies using a calcium ion electrode

In this study, we compared in vitro calcium binding by the taurine and glycine conjugates of the major bile acids in human bile: cholic (CA), chenodeoxycholic (CDCA) and deoxycholic (DCA) acids, together with the cholelitholytic bile acids ursodeoxycholic (UDCA) and ursocholic (UCA) acids. At physiological total calcium (CaTOT) (1-15 mM) and bile acid (BA) (10-50 mM) concentrations, all the bile acids caused concentration-dependent falls in [Ca2+], suggesting calcium binding. Except for glycine-conjugated CDCA, all the other calcium-bile acid complexes were soluble in 150 mM NaCl. The calcium binding affinities followed the pattern: dihydroxy (CDCA, UDCA and DCA) greater than trihydroxy (CA and UCA) bile acids, and glycine conjugates greater than taurine conjugates. The glycine conjugate of UDCA, which increases during UDCA treatment, had the highest calcium binding affinity. Ten-20 mM phospholipid modestly increased calcium binding by CA conjugates, but not by CDCA, UDCA, and DCA conjugates. Phospholipid also prevented the precipitation of glyco-CDCA in the presence of calcium. Bile acid-calcium biding was pH-independent over the range 6.5-8.5. The different calcium binding affinities of the major biliary bile acids may partly explain their varying effects on biliary calcium secretion. The results also suggest that neither precipitation of calcium-bile acid complexes nor impaired calcium binding by bile acids is important in the pathogenesis of human calcium gallstone formation.

Effects of osmotic stresses on isolated rat hepatocytes. I. Ionic mechanisms of cell volume regulation

Isolated hepatocyte suspensions were exposed to hypotonic and hypertonic stresses and serial cell volume measurements were made with an electronic particle size analyzer. With the exposure to hypotonic (160 mosM) buffer, hepatocytes swelled within 30-60 s as osomometers [relative volume (RV) = 1.44 +/- 0.08] and subsequently underwent regulatory volume decrease (RVD) back toward the resting (isotonic) level (1.16 +/- 0.05). This volume recovery was blocked by 65 mM extracellular K+ concentration and inhibited by barium (1 mM) and quinine (0.5 mM) but not by bumetanide (0.1 mM). Chloride depletion inhibited RVD by approximately 40% while 0.5 mM 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid (DIDS) blocked the recovery by almost 90%. Calcium deprivation had no effect on RVD, nor did ouabain, amiloride, or sodium replacement. When exposed to buffer made hypertonic by addition of 200 mM sucrose, cells shrunk as osmometers (RV = 0.74 +/- 0.02) but did not exhibit regulatory volume increase (RVI). However, when cells that had first undergone RVD were reexposed to isotonic medium (relative hypertonic stress) RVI could be demonstrated from RV 0.77 +/- 0.17 to 0.91 +/- 0.20. This response was dependent on sodium, partially dependent on bicarbonate and chloride, and inhibited by the Na(+)-H+ exchange inhibitor amiloride (1 mM) but not by DIDS. Our findings suggest that RVD in rat hepatocytes is mediated by quinine- and barium-sensitive K+ conductance and DIDS-sensitive anion conductance, which is partly accounted for by Cl-; RVI is mediated by activation of Na(+)-H+ exchange coupled with a bicarbonate- and chloride-dependent but DIDS-insensitive process.

Effects of osmotic stresses on isolated rat hepatocytes. II. Modulation of intracellular pH

To assess the roles of acid-base transport systems in cell volume regulation in rat hepatocytes, intracellular pH (pHi) was measured in subconfluent monolayers loaded with 2'-7'-bis(carboxyethyl)-5,6-carboxyfluorescein (BCECF) after exposure to hypotonic and relative hypertonic media, interventions that stimulate regulatory volume decrease (RVD) and increase (RVI), respectively. During RVD, pHi decreased from 6.98 +/- 0.11 to 6.85 +/- 0.08 in the absence of HCO3- and from 7.26 +/- 0.10 to 7.19 +/- 0.06 in its presence. Omission of Na+ or addition of 1 mM amiloride prevented the decline in pHi. Acute withdrawal or replacement of Na+ in hypotonic medium resulted in a slower rate of fall or recovery in pHi, respectively, than when the same maneuvers were carried out in isotonic medium. In contrast, during RVI, pHi increased from 6.86 +/- 0.11 to 7.15 +/- 0.15 in the absence of HCO3-, a rise in pHi that was also completely abolished by Na+ removal or by 1 mM amiloride. In the presence of HCO3-, the rise in pHi was less marked than in its absence, although net acid efflux was greater because of a greater intracellular buffering capacity. Cl- removal in the presence of HCO3- had no effect on the change in pHi during either RVD or RVI. Perfusion with 0.5 mM 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid (DIDS) during RVD lowered pHi further and accentuated the subsequent pHi rise seen after the return to isotonic medium. These data suggest that Na(+)-H+ exchange in rat hepatocytes is downregulated during RVD and activated during RVI. Cl(-)-HCO3- exchange does not appear to be involved in hepatocyte volume regulation.

Bicarbonate-dependent and -independent intracellular pH regulatory mechanisms in rat hepatocytes. Evidence for Na+-HCO3- cotransport

Using the pH-sensitive dye 2,7-bis(carboxyethyl)-5(6)-carboxy-fluorescein and a continuously perfused subconfluent hepatocyte monolayer cell culture system, we studied rat hepatocyte intracellular pH (pHi) regulation in the presence (+HCO3-) and absence (-HCO3-) of bicarbonate. Baseline pHi was higher (7.28 +/- 09) in +HCO3- than in -HCO3- (7.16 +/- 0.14). Blocking Na+/H+ exchange with amiloride had no effect on pHi in +HCO3- but caused reversible 0.1-0.2-U acidification in -HCO3- or in +HCO3- after preincubation in the anion transport inhibitor 4,4'-diisothiocyano-2,2'-disulfonic acid stilbene (DIDS). Acute Na+ replacement in +HCO3- alos caused acidification which was amiloride independent but DIDS inhibitible. The recovery of pHi from an intracellular acid load (maximum H+ efflux rate) was 50% higher in +HCO3- than in -HCO3-. Amiloride inhibited H+ effluxmax by 75% in -HCO3- but by only 27% in +HCO3-. The amiloride-independent pHi recovery in +HCO3- was inhibited 50-63% by DIDS and 79% by Na+ replacement but was unaffected by depletion of intracellular Cl-, suggesting that Cl-/HCO3- exchange is not involved. Depolarization of hepatocytes (raising external K+ from 5 to 25 mM) caused reversible 0.05-0.1-U alkalinization, which, however, was neither Na+ nor HCO3- dependent, nor DIDS inhibitible, findings consistent with electroneutral HCO3- transport. We conclude that Na+-HCO3- cotransport, in addition to Na+/H+ exchange, is an important regulator of pHi in rat hepatocytes.

Hyperactivity in a group of children referred to a Scottish Child Guidance Service: a significant problem

This study tested the hypothesis that if the same measure of hyperactivity was used a similar proportion of children in Britain referred for child guidance advice would be found to be hyperactive as in North America. Conners' Teacher Rating Scale for hyperactivity was completed for 89 of the first 100 primary school children referred in one school year to a schools' psychological service. The rating scale was also completed for a matched control group. A significant difference was found between the hyperactivity ratings of the two groups. Of the referred children 42.7 per cent were rated as hyperactive, similar to the reported incidence in North America.

Ursocholic acid: bile acid and bile lipid dose response and clinical studies in patients with gall stones

The biliary bile acid and bile lipid responses to six weeks treatment with approximately 5, 10, and 15 mg/kg/day of ursocholic acid (UCA) were studied in 11 gall stone patients. Maximum enrichment of bile with UCA (24 (SE) 4.9%) occurred with 15 mg UCA/kg/day. The maximum reduction in biliary cholesterol saturation was seen with the 10 mg/kg/day dose when the moles % cholesterol fell from 14 (2.4)% before treatment to 5.6 (0.83)% (p less than 0.02) and the saturation index fell from 1.4 (0.23) to 0.77 (0.13) (p less than 0.05). Clinical studies of the safety and efficacy of UCA in dissolving gall stones were carried out in 13 patients treated for up to two years with a dose of approximately 10 mg/kg/day. Diarrhoea caused withdrawal of treatment in three patients. There were no significant changes in liver function or haematology tests but fasting serum cholesterol tended to rise during treatment. Of nine patients treated for greater than 6 months, only one showed complete gall stone dissolution. As UCA may cause diarrhoea and hypercholesterolaemia, has only a modest effect on biliary cholesterol saturation and low gall stone dissolution efficacy, it is unlikely to replace existing forms of gall stone dissolution therapy.

Prevention of gallstone recurrence by non-steroidal anti-inflammatory drugs

In laboratory animals, non-steroidal anti-inflammatory drugs (NSAIDs) are reported to inhibit diet-induced gallstone formation. To see if these drugs had a similar effect in man, 82 patients who had taken part in a comparison of ursodeoxycholic acid, placebo, and diet for prevention of gallstone recurrence were sent questionnaires about their use of NSAIDs during the period of the trial. 75 replied. After a mean follow-up of 33 (SEM 4) months none of the 12 regular users of NSAIDs had had gallstone recurrences, compared with 20 of the 63 who never or rarely used these drugs (p less than 0.02).

Discrepancies between cholecystography and ultrasonography in the detection of recurrent gallstones

As part of the British Gallstone Study Group's multi-centre post-dissolution trial of different treatment regimes designed to prevent recurrence after complete gallstone dissolution, the frequency of concordance and discordance between oral cholecystography (OCG) and ultrasonography (U/S), and between repeat U/S studies, in diagnosing recurrent stones was recorded. Before entering the trial, all patients had had complete gallstone dissolution, confirmed by 2 normal OCGs 3 months apart during continued bile acid treatment; and all but three had also had at least 1 normal U/S examination of the gallbladder. During 6-24 months follow-up, from a total of 129 U/S examinations, gallstone recurrence was detected on 25 occasions (19 definite and 6 probable) in 14 patients, and from a total of 71 OCGs, recurrent stones were detected on 11 occasions in 10 patients. All the presumed recurrences developed in the absence of symptoms. On 67 occasions, the OCG and U/S studies were performed within 8 weeks of each other and of these, there was discordance in 15 (22%). On 11 occasions (6 patients), ultrasound suggested recurrent stones despite a normal OCG whilst on 4 occasions (4 patients) stones diagnosed on OCG were not confirmed by ultrasound. Of the 25 instances of U/S recurrence, a further U/S examination was performed on 17 occasions in 11 patients which failed to confirm the initial findings on 8 occasions (7 patients). After 1 year's follow-up, the predicted recurrence rates (pooled data from all 3 treatment groups), as calculated by life table analysis, were 29.3 +/- 7.1%, when the diagnosis was based on 1 U/S; 15.4 +/- 5.8% on 1 OCG; 14.9 +/- 5.6% on 2 successive U/S studies, and 8.1 +/- 4.5% on 1 U/S plus 1 OCG. At 24 months, the corresponding values were 37.2 +/- 8.3, 31.5 +/- 8.6, 18.3 +/- 6.3, and 22.4 +/- 8.6%. These results show that following complete gallstone dissolution by bile acid treatment, there is both intra- and inter-technique variation in the detection of recurrent stones.

A prospective randomised controlled trial of diazepam (valium) vs emulsified diazepam (diazemuls) as a premedication for upper gastrointestinal endoscopy

Two hundred and forty four patients were randomised to receive either diazepam or emulsified diazepam (diazemuls) intravenously prior to routine upper gastrointestinal endoscopy. The groups were comparable with regard to age, sex, medical condition, vein size, and amount of drug administered. A quantitative assessment of symptoms at the injection site during the ensuing week was made by analysing questionnaires on pain and tenderness, which the patients graded each day, on a scale 0-3. Twenty-one out of 82 patients who received diazepam (25.6%) and 22 out of 84 who received diazemuls (26.2%) had local symptoms. Although the mean symptom scores over 7 days for the two groups were not different (5.95 +/- 5.19 and 7.27 +/- 6.30 respectively), more patients who received diazepam reported induration (P = 0.033). In 112 patients, signs of thrombosis in the injected veins were looked for 3-7 weeks later without knowledge of the preparation given. Thrombosis was present in 13 (25%) patients who had received diazepam and two (3.6%) who had received diazemuls (P less than 0.002). Only eight (53%) patients with thrombosed veins had symptoms. Thrombosis after intravenous injection of diazepam or diazemuls may be symptomless, and is significantly less likely following diazemuls.