Fecal Microbiota Transplantation Controls Progression of Experimental Autoimmune Hepatitis in Mice by Modulating the TFR/TFH Immune Imbalance and Intestinal Microbiota Composition

Intestinal microbiota (IM) dysbiosis contributes to the development of autoimmune hepatitis (AIH). This study aimed to investigate the potential effect of fecal microbiota transplantation (FMT) in a murine model of experimental AIH (EAH), a condition more similar to that of AIH patients. Changes in the enteric microbiome were determined in AIH patients and EAH mice. Moreover, we established an experimental model of secondary EAH mice harboring dysbiosis (ABx) to analyze the effects of therapeutic FMT administration on follicular regulatory T (TFR) and helper T (TFH) cell imbalances and IM composition in vivo. Alterations of the IM composition and bacterial translocation occurred in AIH patients compared to nonalcoholic fatty liver disease patients and healthy controls (HCs). Therapeutic FMT significantly attenuated liver injury and bacterial translocation and improved the imbalance between splenic TFR cells and TFH cells in ABx EAH mice. Furthermore, therapeutic FMT also partially reversed the increasing trend in serum liver enzymes (ALT and AST) of CXCR5-/-EAH mice on the 28th day. Finally, therapeutic FMT could effectively restore antibiotic-induced IM dysbiosis in EAH mice. Taken together, our findings demonstrated that FMT was capable of controlling hepatitis progression in EAH mice, and the associated mechanism might be involved in the regulation of the TFR/TFH immune imbalance and the restoration of IM composition.

A case report of endoscopic resection for the treatment of duodenal Brunner's gland adenoma with upper gastrointestinal bleeding

RATIONALE

Gastrointestinal bleeding as the first sign of Brunner's gland adenoma (BGA) is an extremely rare, and its clinical features and treatment methods have not been well described.

PATIENT CONCERNS

We described a 81-year-old female patient with coronary artery disease and chronic atrial fibrillation presenting with presenting with gastrointestinal bleeding requiring blood transfusion.

DIAGNOSES

The diagnosis of our case mainly refered to radiologic imaging and endoscopic examination. Histological result was compatible with BGA.

INTERVENTIONS

This mass lesion (6 × 7 cm diameter) was successfully totally removed by endoscopic submucosal dissection (ESD) for more than three hours.

OUTCOMES

The patient was followed up for 6 months to date without recurrence.

LESSONS

Endoscopic removal is considered as a safe and low-risk treatment for elderly patients with severe underlying diseases presenting with gastrointestinal bleeding.

Endoscopic submucosal dissection of coexisting early esophageal carcinoma and leiomyoma: a case report and review of the literature

The occurrence of early esophageal cancer located within an area of leiomyoma is extremely rare, and its clinical features and treatment methods have not been well described. We herein report the clinical characteristics, diagnosis, and treatment methods of early esophageal cancer that developed on top of a leiomyoma in the upper third of the esophagus in a 78-year-old woman. All tumor marker concentrations were normal. The leiomyoma was correctly diagnosed as a submucosal tumor by endoscopy and endoscopic ultrasonography. Endoscopic biopsy revealed esophageal squamous cell carcinoma. Both lesions were successfully treated by endoscopic submucosal dissection. The patient was followed up for 6 months without recurrence. Endoscopic submucosal dissection was a successful initial treatment method for esophageal carcinoma coexisting with esophageal leiomyoma in this case.

Dysregulated TFR and TFH cells correlate with B-cell differentiation and antibody production in autoimmune hepatitis

Follicular helper T (TFH) cell provides germinal centre (GC) B cell with critical signals for autoantibody production in the immunopathogenesis and progression of autoimmune hepatitis (AIH). However, the immunoregulatory functions of follicular regulatory T (TFR) cell in AIH are still unclear. The numbers of circulating TFR/TFH cells were measured in AIH patients. Moreover, we established experimental autoimmune hepatitis (EAH) model to examine the function of TFR cells on B‐cell differentiation and autoantibody production in vivo and vitro. AIH patients had significantly increased numbers of TFH cells and decreased numbers of TFR cells as well as imbalanced TFR/TFH‐type cytokines (IL‐10, TGF‐β1 and IL‐21) compared with healthy controls (HCs). In addition, TFR cell numbers negatively correlated with TFH cell numbers. Also, serum hypergammaglobulinaemia (IgG and IgM) concentration negatively correlated the levels of serum IL‐21, but positively correlated with the levels of serum IL‐10 in AIH patients. Furthermore, in comparison with control group, significantly higher frequencies of spleen TFR cells but lower frequencies of spleen TFH cells were detected in the EAH group. Further analysis found that TFR cells simultaneously express the phenotypic characteristics of Treg and TFH cells, but exercise as negative regulators of autoantibody production in vitro culture. Our findings demonstrated that dysregulated between TFR and TFH cells might cause excessive production of autoantibodies and destruction of the immune homeostasis, leading to the immunopathological process in AIH.

A rare case report of fungal esophagitis combined with giant gastric ulcer in an immunocompetent patient

RATIONALE

Fungal infection of gastrointestinal (GI) tract is usually seen in immunocompromised patients, but can rarely occur in immunocompetent people in whom no permissive factor is present.

PATIENT CONCERNS

We describe a 68-year-old male immunocompetent patient presenting with simultaneous fungal esophagitis and giant gastric ulcer.

DIAGNOSES

Repeated endoscopic biopsies were taken from the giant gastric ulcer edge and base and histology demonstrated granulation tissue and pseudohyphal fungal forms.

INTERVENTIONS

The patient was treated with fluconazole and omeprazole for 8 weeks.

OUTCOMES

After antifungal treatment with fluconazole, the patient's clinical symptoms gradually disappeared with the healing of gastric ulcer, which never recurred in this patient until 3 months after follow-up.

LESSONS

Nonhealing gastroesophageal ulcers highlights the importance of repeated endoscopies and biopsies.

A case report of endoscopic therapy for radiation-induced hemorrhagic gastritis in patient with recurrent hepatocellular carcinoma

RATIONALE

Radiation-induced hemorrhagic gastritis is an infrequent cause of upper gastrointestinal bleeding and difficult to manage. The current standard treatment has not been well established.

PATIENT CONCERNS

We described a 32-year-old male patient with hemorrhagic gastritis induced by external radiotherapy for hepatocellular carcinoma recurrence.

DIAGNOSES

The endoscopic examination showed a diffuse area of bleeding in the gastric antrum.

INTERVENTIONS

After failure of conventional hemostasis treatment, we successfully stopped the hemorrhage with repeated endoscopic argon plasma coagulation (APC) combined with low-dose polyglycerol sclerotherapy.

OUTCOMES

The patient was followed up for 6 months to date without recurrence.

LESSONS

Based on this case, we think that endoscopic APC combined with low-dose polidocanol sclerotherapy can be tried as a treatment for potentially life-threatening radiation-induced hemorrhagic gastritis.

[Changes in chemokine receptor 4, interleukin-6, and collagen X expression in the ATDC5 cell line stimulated by cyclic tensile strain and stromal cell-derived factor-1]

OBJECTIVE

This study further explores the stromal cell-derived factor-1 (SDF-1)/chemokine receptor 4 (CXCR4) signaling axis mechanism in temporomandibular joint osteoarthritis (OA) by detecting the changes in CXCR4, interleukin (IL)-6, and collagen X expression in the ATDC5 cell line stimulated by the cyclic tensile strain and SDF-1.

METHODS

Insulin-transferrin-selenium (ITS) was used to induce ATDC5 cells to differentiate into chondrocyte-like cells. After three weeks, the cells were divided into two groups: those with and without cyclic tensile strain. These groups were further divided into the negative control and SDF-1 groups. Strain force of 20% was applied. After 12 h, the total proteins were extracted from cells of the four groups, and Western blot analysis was used to detect the changes in CXCR4, IL-6, and collagen X expression.

RESULTS

SDF-1 could enhance CXCR4, IL-6, and collagen X expressions in the chondrocytes, and 20% tensile strain force could further upregulate the three factors.

CONCLUSION

Under abnormal tensile force, SDF-1 can upregulate its specific receptor CXCR4, thus increasing its-binding efficiency and resulting in the activation of the SDF-1/CXCR4 axis. This condition enhances the expressions of IL-6 and other inflammatory factors and directly damages to cartilage tissue. Such damage directly promotes chondrocyte hypertrophy, which enhances collagen X expression.

Process design and economic analysis of a hypothetical bioethanol production plant using carob pod as feedstock

A process for the production of ethanol from carob (Ceratonia siliqua) pods was designed and an economic analysis was carried out for a hypothetical plant. The plant was assumed to perform an aqueous extraction of sugars from the pods followed by fermentation and distillation to produce ethanol. The total fixed capital investment for a base case process with a capacity to transform 68,000 t/year carob pod was calculated as 39.61 millon euros (€) with a minimum bioethanol production cost of 0.51 €/L and an internal rate of return of 7%. The plant was found to be profitable at carob pod prices lower than 0.188 €/kg. An increase in the transformation capacity of the plant from 33,880 to 135,450 t/year was calculated to result in an increase in the internal rate of return from 5.50% to 13.61%. The obtained results show that carob pod is a promising alternative source for bioethanol production.

Upregulation effect of ginsenosides on glucocorticoid receptor in rat liver

We have demonstrated earlier that ginsenosides (GSS) could partially reverse the dexamethasone (Dex)-induced downregulation of glucocorticoid receptor (GR) and enhance Dex-induced transcription of GR reporter gene in HL 7 702 cells, but whether it can play a similar role IN VIVO has not been studied. Male Sprague-Dawley rats were pretreated with saline (1 ml.d (-1)) or GSS (50 mg kg (-1).d (-1)) for 5 days, and then subjected to GR downregulation induced by polyvinyl alcohol containing hydrocortisone (F-PVA). The rats were killed by decapitation to determine liver GR and plasma corticosterone levels. Pretreatment with GSS resulted in upregulation of GR with respect to binding capacity, cytoplasmic protein expression, and mRNA levels, but did not produce significant effects on GR binding affinity and serum corticosterone levels. Pretreatment with GSS also led to increase in GR translocation and TAT mRNA levels. Data obtained in the present study indicate that GSS may upregulate GR levels IN VIVO and enhance glucocorticoid efficiency.

A 2-year follow-up study of cigarette smoking and risk of dementia

The report focused on investigating the relationship between cigarette smoking and dementia in elderly people through prospective studies. We did a 2-year follow-up study of elderly people. A total of 2820 participants aged 60 years old and over from six communities of Chongqing agreed to take part. Dementia was diagnosed with MMSE (Mini-Mental State Examination) and DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders). Participants were classified as never smokers, past smokers, and current smokers. During follow-up, we recorded incident cases of dementia. The association of smoking and dementia was investigated using proportional hazards regression analysis. A total of 121 incident cases of dementia were detected, of which 84 (69%) were Alzheimer's disease, 17 (14%) were vascular dementia, and 21(17%) were other dementia. Compared with never smokers, current smokers had an increased risk of Alzheimer's disease (RR = 2.72; 95% CI = 1.63-5.42) and vascular dementia (RR = 1.98; 95% CI = 1.53-3.12) adjusting for age, sex, education, blood pressure, and alcohol intake. Compared with light smokers, the adjusted risk of Alzheimer's disease was significantly increased among smokers with a medium level of exposure (RR = 2.56; 95% CI = 1.65-5.52), with an even higher risk of Alzheimer's disease in the heavy smoking group (RR = 3.03; 95% CI = 1.25-4.02). Smoking was associated with the risk of dementia. This study suggests that both smoking status and amount is associated with dementia.

A neural network approach to evaluate fold recognition results

Fold recognition techniques assist the exploration of protein structures, and web-based servers are part of the standard set of tools used in the analysis of biochemical problems. Despite their success, current methods are only able to predict the correct fold in a relatively small number of cases. We propose an approach that improves the selection of correct folds from among the results of two methods implemented as web servers (SAMT99 and 3DPSSM). Our approach is based on the training of a system of neural networks with models generated by the servers and a set of associated characteristics such as the quality of the sequence-structure alignment, distribution of sequence features (sequence-conserved positions and apolar residues), and compactness of the resulting models. Our results show that it is possible to detect adequate folds to model 80% of the sequences with a high level of confidence. The improvements achieved by taking into account sequence characteristics open the door to future improvements by directly including such factors in the step of model generation. This approach has been implemented as an automatic system LIBELLULA, available as a public web server at http://www.pdg.cnb.uam.es/servers/libellula.html.

Oesophageal transit, disintegration and gastric emptying of a film-coated risedronate placebo tablet in gastro-oesophageal reflux disease and normal control subjects

BACKGROUND

Risedronate sodium is a pyridinyl bisphosphonate, proven effective for the treatment and prevention of postmenopausal osteoporosis and glucocorticoid-induced osteoporosis and Paget's disease of the bone.

AIM

To compare the oesophageal transit, disintegration and gastric emptying of the commercial film-coated risedronate tablet in subjects with gastro-oesophageal reflux disease (GERD) and normal control subjects.

METHODS

A total of 30 subjects, 15 patients with GERD and 15 age- and sex-matched, normal control subjects, participated in a single-centre, open-label, comparative gamma scintigraphy study. The GERD subjects had active erosive oesophagitis within 4 weeks prior to dosing.

RESULTS

The mean oesophageal transit (GERD, 4.4 s; controls, 3.1 s), mean disintegration (GERD, 21.8 min; controls, 19.2 min) and mean gastric emptying (GERD, 15.9 min; controls, 15.0 min) were similar in the two subject groups. The oesophageal transit is rapid and given the rapid disintegration and gastric emptying, oesophageal contact occurring via reflux of risedronate was unlikely since most, if not all, of the dosage form exited from the stomach within 30 min.

CONCLUSIONS

The oval shape and film-coating on the commercial risedronate tablet promotes rapid oesophageal transit and minimizes oesophageal contact, even in the high-risk GERD population.

Prenatal diagnosis of Fukuyama type congenital muscular dystrophy in eight Japanese families by haplotype analysis using new markers closest to the gene

We conducted prenatal diagnosis by haplotype analysis, using newly developed microsatellite markers, in eight Fukuyama type congenital muscular dystrophy (FCMD) families. In addition to six new families, two previously reported families were reexamined by haplotype analysis including detection of an ancestral founder haplotype (138-183-301) for 3 microsatellite markers closest to the FCMD gene, designated D9S2105-D9S2107-D9S172, the distances of which from the FCMD gene are presumed to be approximately 140, approximately 20, and approximately 280 kb, respectively. Five fetuses from five families were diagnosed as nonaffected, and were subsequently confirmed to be healthy. Three fetuses of the other three families were diagnosed as having a high probability of being affected by FCMD. In the prenatal diagnosis conducted for these eight families, the ancestral founder allele was observed in 13 of 16 (81%) FCMD-bearing chromosomes. Detection of the ancestral haplotype facilitated achieving accurate prenatal diagnosis of FCMD. The brains of all three fetuses prenatally diagnosed as FCMD-affected showed the initial stage of cortical dysplasia, strong evidence of FCMD.

Effects of estazolam and flurazepam on cardiopulmonary function in patients with chronic obstructive pulmonary disease

Benzodiazepine drugs have been shown to suppress respiratory function in patients with chronic obstructive pulmonary disease (COPD). We designed a placebo-controlled crossover study to compare the effects of a new benzodiazepine, estazolam ('ProSom'), with those of flurazepam ('Dalmane') on cardiopulmonary function in COPD patients. 29 patients completed all treatment phases (estazolam 2 mg, flurazepam 30 mg or placebo). Respiratory and cardiovascular function were assessed in awake patients on days 1 and 5 (acute and cumulative effects). Eight patients were also assessed during sleep in each period. The effects of estazolam and flurazepam on ventilatory response to CO2 and mouth occlusion pressure were no different from those of placebo. However, acute administration of flurazepam lowered tidal volume and increased inspiratory flow. Although no clinical signs of respiratory depression were observed with any long term treatment, flurazepam decreased oxygen saturation and inspiratory time and increased respiratory frequency. Neither drug altered breathing control during sleep. Our results indicate that estazolam 2 mg is equally as safe a hypnotic agent as flurazepam for patients with mild COPD.

Unaltered drug metabolizing enzyme systems in type II diabetes mellitus before and during glyburide therapy

Diabetes mellitus is associated with alterations in hepatic drug metabolizing enzyme activities in experimental animals. To determine whether Type II diabetes or glyburide affect hepatic drug metabolism, the authors used 13C-labeled aminopyrine and caffeine breath tests as in vivo probes of the hepatic cytochrome P450 and P(1)450 enzyme activities respectively in six subjects with Type II diabetes (4 women, 2 men). These subjects had been treated previously with diet, had an age range of 41-63 years, had a body mass index range of 24.1-43.3 kg/m2 and had a mean fasting plasma glucose of 14.6 +/- 1.2 mM and a mean hemoglobin A1c of 12.2 +/- 0.7%. These subjects did not drink alcohol or take drugs known to affect hepatic drug metabolism. The caffeine and aminopyrine breath tests (CBT, ABT) were performed sequentially while fasting before the start of glyburide treatment (5 mg daily) and at weekly intervals for 4 weeks. ABT and CBT values are expressed as cumulative percentage of dose exhaled through 2 hours. Before beginning glyburide, the mean ABT and CBT results were 10.2 +/- 0.7% and 4.2 +/- 0.7% respectively, well within the normal ranges for these tests (ABT 6.5-15%; CBT 2.5-10%). The ABT and CBT values remained unaltered during 4 weeks of glyburide therapy. However, FBS decreased to 10.2 +/- 1.1 mM and HbA1C to 10.1 +/- 0.8% by the end of drug treatment. Type II diabetes that is poorly controlled by diet alone is not associated with alterations of the hepatic drug metabolizing enzymes as judged by the caffeine and aminopyrine breath tests. Furthermore, glyburide does not induce or inhibit the drug metabolizing enzyme systems in the liver, thereby precluding drug-drug interactions of this type.

Ventilatory response to single, high dose estazolam in healthy humans

The purpose of this study was to determine the effect of oral estazolam at two and three times the usually recommended dosage (2 mg) on ventilation and respiratory drive during wakefulness. Sixty healthy subjects were randomized to receive a single oral dose of either: 1) estazolam 4 mg; 2) estazolam 6 mg; 3) placebo; or 4) morphine 0.15 mg/kg. Predrug and postdrug measurements were obtained for ventilation, respiratory cycle timing, metabolic rate, temperature, and ventilatory and mouth occlusion pressure (P0.1) responses to exogenous CO2. No difference between placebo and the study drugs was noted during eupneic breathing. During administration of exogenous CO2, morphine caused a decrease in the slope of the ventilatory (-0.4 +/- 0.1 L/min/mm Hg, P = .008) and P0.1 (-0.22 +/- 0.06 cm H2O/mm Hg, P = .015) responses. Estazolam (4 and 6 mg) had no effect on the ventilatory response to exogenous CO2. However, estazolam (6 mg) caused the P0.1 at a PCO2 of 57 mm Hg to decrease (-0.67 +/- 0.30 cm H2O, P = .005). The preservation of ventilation with the highest dose of estazolam, despite the decrease in P0.1, indicates that a compensatory strategy independent of respiratory center drive may have been activated. Sedation was a common side effect of estazolam reported in 13% and 53% of subjects at the 4 mg and 6 mg doses, respectively. We conclude that a single, high dose of estazolam does not cause ventilatory depression during wakefulness in healthy subjects.

Impairment of theophylline clearance by a hypocaloric low-protein diet in chronic obstructive pulmonary disease

The effect of a hypocaloric, low protein diet on theophylline kinetics was studied in a 70-year-old man with chronic obstructive pulmonary disease who lost 6.2 kg of weight. Total systemic clearance, unbound clearance, and intrinsic hepatic clearance fell dramatically. Theophylline elimination half-life rose from 8.4 to 17.1 h. Therefore, a diet deficient in both calories and protein can significantly impair theophylline clearance and prolong theophylline elimination half-life.

Effects of a low calorie, low protein diet on nutritional parameters, and routine laboratory values in nonobese young and elderly subjects

The effect of a low calorie (1100 kcal), low protein (35 g) intake for 9 days on nutritional and laboratory parameters was studied in six young and six elderly healthy subjects. All subjects lost weight on the test diet (an average of 2.0 kg in the young and 2.1 kg in the elderly). Basal serum albumin, serum transferrin, creatinine height index, and creatinine clearance in the elderly subjects were lower than in the young (p less than 0.05). Serum albumin remained unchanged at the end of diet in both groups. There was, however, a significant decrease in the transferrin level in the younger subjects (p less than 0.01). The decrease in creatinine height index was not significant in either group. Baseline nitrogen balance of the elderly was -1.1 g/day compared to +0.5 g/day (p less than 0.01) in the young subjects. The test diet caused a negative nitrogen balance of about -5 g/day in both groups (p less than 0.005). Blood urea nitrogen was significantly lower at the end of the test diet and was related to the intake of protein in both groups. At the end of the diet the serum potassium and GGT were significantly lower in the young (p less than 0.01); serum creatinine was unchanged but creatinine clearance was significantly lower in both groups. From this study it appears that significant changes occur in nutritional and laboratory parameters within 9 days on a diet deficient in calories and protein in normal healthy subjects. These changes need to be recognized as having nutritional basis and should not be attributed to illness or drug therapy.

Pharmacokinetics of N-acetylprocainamide in patients profiled with a stable isotope method

N-Acetylprocainamide (NAPA) absorption and disposition were profiled in five patients with ventricular arrhythmias by the simultaneous intravenous administration of NAPA-13C and oral administration of a 500 mg NAPA hydrochloride tablet. NAPA distribution was modeled with a three compartment mammillary system. The central compartment volume of 14.1 +/- 2.6 L (mean +/- SD) was similar to expected intravascular space, corrected for NAPA partitioning between erythrocytes and plasma. Other compartment volumes, intercompartmental and nonrenal clearances, and the steady-state distribution volume of 1.45 +/- 0.09 L/kg were similar to normal subject values. The least-squares estimate of 1.67 for the NAPA renal clearance/creatinine clearance ratio was similar to the value of 1.68 previously reported for functionally anephric patients and showed the expected age-associated decrease. The oral NAPA dose was 78.0% +/- 11.7% absorbed and interindividual variation in NAPA absorption was correlated with fast intercompartmental clearance (r = 0.89, p = 0.045). Because fast intercompartmental clearance partly reflects splanchnic blood flow, hemodynamic changes may affect NAPA bioavailability, as has been found for procainamide.

Theophylline pharmacokinetics in normal elderly subjects

The effect of age on theophylline kinetics was examined in six normal young men and six elderly men. There were no age-associated differences in theophylline volume of distribution, total clearance, or t1/2. The unbound fraction of theophylline was significantly raised in the elderly (mean 77.7% vs. 62.3%, p less than 0.001) and was correlated with the serum albumin level (r = -0.7, p less than 0.01). Theophylline nonrenal clearance was not changed, but the total unbound clearance was significantly reduced in the elderly subjects as compared with the young ones (mean 0.744 vs. 1.085 ml/min/kg, p less than 0.05). Creatinine clearance was reduced in the elderly and was significantly correlated with unbound renal clearance (r = 0.6, p less than 0.04). There were no age-related differences in the urinary excretion of theophylline, 1-methyluric acid, 3-methylxanthine, or 1,3-dimethyluric acid. However, significant reduction in unbound renal theophylline clearance (p less than 0.002) as well as the unbound metabolic clearance of 1,3-dimethyluric acid (p less than 0.03), 3-methylxanthine (p less than 0.04), and 1-methyluric acid (p less than 0.02) were observed in the elderly subjects. These observations indicate that both renal and metabolic elimination processes for theophylline are less active in the normal elderly.

Diet-induced changes in trough theophylline concentrations in an elderly asthmatic patient

A 66-year old obese man with asthma was given a hypocaloric (1100 Kcal) and low protein (35 g) diet for nine days. While receiving theophylline (Theodur), 200 mg bid, his morning trough theophylline concentrations rose from 3.40 micrograms/ml to 12.7 micrograms/ml by day 9 of this diet. Following discontinuation, his theophylline concentration fell to 5.95 micrograms/ml by day 6 on home diet. The patient lost 3.67 kg during the nine-day study. Thus, a brief exposure to a hypocaloric, low protein diet in this elderly patient with asthma caused a dramatic rise in trough theophylline concentrations.

Effects of dietary protein on theophylline pharmacokinetics and caffeine and aminopyrine breath tests

The effects of low- and high-protein diets on theophylline kinetics and the time course of changes in 13C-labeled caffeine and aminopyrine CO2 breath tests were examined in six young men. With a low-protein diet, mean theophylline clearance fell 21% (P less than 0.04) and the t1/2 rose from 8.0 to 10.6 hours (P less than 0.02). With a high-protein diet, mean theophylline clearance rose 26% (P less than 0.004) and the t1/2 shortened to 7.4 hours (P less than 0.03). Theophylline volume of distribution and protein binding did not change. Renal clearance of theophylline was lowered during the low-protein diet. Theophylline clearance correlated with caffeine breath test values during the low- (r = 0.73) and high- (r = 0.70) protein diets. Theophylline clearance correlated less well with the aminopyrine breath test values during the low- (r = 0.47) and high- (r = 0.55) protein diets. Thus dietary protein significantly influenced theophylline clearance, but the caffeine and aminopyrine breath tests showed a differential response to this important environmental factor.

Case report of vasopressin-responsive diabetes insipidus associated with chronic myelogenous leukemia

A sixth case in the world literature is reported of a 59-year-old male with diabetes insipidus (DI) associated with chronic myelogenous leukemia (CML). The patient is unique in that his CML was diagnosed 10 years before he presented with vasopressin-responsive DI. Radiation to the central nervous system failed to reduce the daily requirement of his need for vasopressin.

Oral phosphate load unmasks underlying renal phosphate leak in symptomatic and asymptomatic members of family with idiopathic hypercalciuria

The effects of a 2 Gm oral phosphorus load in a family with idiopathic hypercalciuria (IH) consisting of 3 symptomatic (DT, CS, DS) and 2 asymptomatic (MS, PD) members were compared with 12 normal control subjects. Biochemical parameters measured included: total and ionized calcium, phosphorus, intact and carboxyl-terminal parathyroid hormone, urinary calcium, phosphorus, and sodium. Water loading had no effect on these parameters. After the phosphorus load, serum phosphorus rose 1.60 mg/dl in the control subjects but only 1.34 mg/dl in the IH family at the end of one hour. Basal tubular reabsorption of phosphate (TRP) were comparable in the control subjects and the IH family. After the phosphorus load, the TRP in the control subjects fell (average 9.2%) accompanied by a significant (P less than 0.02) rise in the carboxyl-terminal parathyroid hormone. Except for DT who had been taking hydrochlorothiazide, the TRP fell dramatically in the rest of the IH family (DS 25%, CS 12%, PD 26%, MS 50%) in the absence of any perturbations in either the intact or carboxyl-terminal parathyroid hormone. A hypocalciuric effect was observed in the IH family but not in the control subjects after phosphorus loading. The oral phosphorus challenge unmasked a parathyroid hormone independent renal phosphate leak in both symptomatic and asymptomatic members in a family with idiopathic hypercalciuria.

Altered responses in serum calcium phosphorus and parathyroid hormone to oral calcium load in symptomatic and asymptomatic members of family with idiopathic hypercalcemia

A family of idiopathic hypercalciuria (IH), 3 symptomatic and 2 asymptomatic, plus 3 normal subjects were given the 1 Gm oral calcium challenge. Biochemical parameters measured included: serum and urinary calcium and phosphate, urinary cyclic AMP, and serum intact and carboxyl-terminal parathyroid hormone. Major differences between the normal control and the family with IH include: (1) higher calcemic response in the family with IH (0.9 vs 0.4 mg/dl); (2) a fall in carboxyl-terminal PTH and urinary cyclic AMP in the IH family in contrast to control subjects in whom there were no changes; (3) a rise in serum phosphorus in the IH family (0.8 vs 0.2 mg/dl, p less than 0.05). Urinary excretion of calcium, phosphorus, and sodium after the calcium challenge was minimal. The oral calcium challenge is a simple and useful test in demonstrating increased calcium absorption even in asymptomatic relatives of patients with idiopathic hypercalciuria.

Cation-dependent vitamin D activation of human renal cortical guanylate cyclase

The objective of this investigation was to determine whether physiological levels of vitamin D and its metabolites have part of their mechanisms of action through stimulation of guanylate cyclase (EC 4.6.1.2). These sterols enhanced both soluble and particulate guanylate cyclase activities as well as cGMP levels two- to threefold in human and rat tissues. At a concentration of 1 nM, 1,25(OH)2D3 greater than 25(OH)D3 greater than vitamin D3 greater than 24,25(OH)2D3 = 25,26(OH)2D3 = vitamin D2. Dose-response curves revealed that maximal stimulation of guanylate cyclase by these sterols was at 1 nM and that there was no augmented guanylate cyclase activity at 0.01 nM. The precursors of vitamin D, cholesterol and 7-dehydrocholesterol, had no effect on guanylate cyclase activity. The activation of guanylate cyclase activity by the vitamin D sterols required the presence of manganese ion. Calcium was not as efficient as manganese in optimizing basal or hormone-stimulated guanylate cyclase activity. Vitamin D and its metabolites failed to stimulate adenylate cyclase (EC 4.6.1.1) activity. The data in this investigation suggest that guanylate cyclase may play a role in the mechanism of action of vitamin D at the cellular level.

Diagnostic utility of carboxyl-terminal and intact parathyroid hormone immunoassays in hospitalized patients

In a university-affiliated community hospital, medical records of 58 patients on whom the intact parathyroid hormone immunoassay (I-PTH) and 29 patients on whom both the carboxyl terminal PTH(C-PTH) and I-PTH ordered by physicians were reviewed to determine the reasons for requesting these tests. Reasons for ordering the PTH tests include (1) the evaluation of hypercalcemic patients (25/58 I-PTH); (2) the evaluation of hypocalcemic patients (2/58 I-PTH); (3) to rule out primary hyperparathyroidism in normocalcemic stone formers (4/58 I-PTH, 4/29 C-PTH) and in those with abnormal skeletal x-ray (3/48 I-PTH 1/29 C-PTH); (4) to follow patients with chronic renal failure on dialysis (11/58 I-PTH, 9/29 C-PTH); (5) to rule out ectopic hyperparathyroidism in patients with cancer (2/58 I-PTH, 3/29 C-PTH); (6) to satisfy physicians' intellectual curiosity of patients with diabetes mellitus (3/58 I-PTH, 3/29 C-PTH) and obesity (5/58 I-PTH; 6/29 C-PTH); (7) to evaluate acute renal failure (1/29 C-PTH). In 3/58 patients on whom I-PTH tests were ordered, reason(s) could not be determined. The C-PTH was elevated in 9/9 patients with chronic renal failure, 4/6 obese patients, 2/3 patients with cancer, 1/3 diabetic patients, 1/4 stone formers, 2/2 patients with primary hyperparathyroidism. Patients with chronic renal failure had the highest C-PTH. Based on well established indications for ordering the PTH immunoassays, 25 out of 58 (43%) of I-PTH and 9 out of 29 (31%) of C-PTH ordered are inappropriate.

Pharmacologic agents in the management of pheochromocytoma

Medical management of pheochromocytoma involves the use of many therapeutic agents. Phenoxybenzamine HCl (Dibenzyline), an alpha-adrenergic blocking agent, at 40 to 80 mg per day can control the disease in most patients. Use of this drug up to the time of operation is controversial. Beta-adrenergic receptor blockade with propranolol is indicated only after adequate alpha-adrenergic blockade in patients with tachycardia and catecholamine-induced arrhythmias. Alpha-methylparatyrosine (Metyrosine), which decreases catecholamine synthesis, is a new drug recently released for the treatment of pheochromocytoma when surgery is contraindicated or in cases of malignant pheochromocytoma. The use of a combination of anesthetic agents, such as nitrous oxide, thiopental, narcotics, and enflurane, ensures smooth induction of anesthesia in most cases. Careful and prompt control of hypertensive crises with sodium nitroprusside and of arrhythmias with propranolol and lidocaine are critical to the success of surgery.

Pheochromocytoma: clinical manifestations and diagnostic tests

Pheochromocytoma accounts for about 0.1 per cent of patients with diastolic hyperstension. It mimics many diseases varying from anxiety psychoneurosis to intracranial tumors. Cardinal symptoms include sevre headache (72 to 92 per cent), sweating (60 tp 70 per cent), palpitations (51 to 73 per cent), and hypertension (> 90 per cent) of which 50 per cent is sustained, 50 per cent paroxysmal. Many drugs (phenothiazines, Saralasin, antiemetics, steroids, etc.) have been reported as precipitating factors. Patients who should be screened for pheochromocytoma include: (1) all symptomatic patients with sustained or paroxysmal hyperstension; (2) asymptomatic hypertension; (3) all patients with MEA 2a,b (hyperparathyroidism, medullary carcinoma of the thyroid, neurocutaneous lesions) and their first degree relatives, even if the latter are asymptomatic and normotensive; (4) hypertension plus diabetes mellitis or hypermetabolism; (5) hypertensive episode during induction of anesthesia or radiologic procedure; and (6) hypertensive response during histamine administration, i.e., gastric analysis. Urinary metanephrine is the single best screening test. Plasma catecholamine determination is particularly helpful when collected before and immediately after an attack. Provacative agents (histamine, glucagon, tyramine) are needed rarely. Preoperative localization of the tumor can be done with nephrotomography IVP, computerized axial tomography, ultrasound, 131-I-19-iodocholesterol scan, arteriography, venography.

Vitamin D metabolism: update for the clinician

Vitamin D3 must undergo two hydroxylation steps before it becomes fully active: 25-hydroxylation in the liver and 1- or 24-hydroxylation in the kidney. Parathyroid hormone, serum phosphate, and serum calcium are important in regulation of renal production of 1,25-dihydroxy vitamin D3 (1,25-[OH]2D3) and 24,25-dihydroxy vitamin D3. An enzyme involved in renal hydroxylation is deficient or defective in patients with chronic renal failure, the Fanconi syndrome, vitamin D-dependent rickets, hypoparathyroidism, and pseudohypoparathyroidism. Altered vitamin D metabolism also occurs in various hepatic diseases, postmenopausal osteoporosis, and anticonvulsant osteomalacia. Recently, 1,25-(OH)2D3 was approved for treatment of renal osteodystrophy. In physiologic doses, it predictably corrects many of the clinical and biochemical abnormalities associated with this disorder.

Hypocalcemia. Differential diagnosis and mechanisms

There is much individual variability in the clinical manifestations of hypocalcemia. The rapidly of the development of hypocalcemia will determine whether or not symptoms will be present. Signs and symptoms of hypocalcemia consisted of tetany (Chvostek's and Trousseau's signs), seizures, diminshed to absent deep tendon reflexes, papilledema, mental changes (weakness, fatigue, irritability, memory loss, confusion, delusion, hallucination), and skin changes. Etiologic factors for hypocalcemia in man include (1) decreased calcium absorption or increased loss from the gastrointestinal tract; (2) parathyroid hormone deficiency; (3) skeletal resistance to parathyroid hormone; (4) ineffective parathyroid hormone; (5) decreased production or increased degradation of 25-hydroxycholecalciferol or 1,25-dihydroxycholecalciferol; (6) increased complex formation with calcium; (7) increased skeletal uptake of calcium; (8) hypomagnesemic state; and (9) direct inhibition of bone resorption. Measurement of total and ionic calcium, magnesium, parathyroid hormone, vitamin D metabolites (25-hydroxycholecalciferol, 1,25-dihydroxycholecalciferol), and nephrogenous cyclic adenosine monophosphate are especially helpful in the laboratory evaluation of the hypocalcemic patient.

Differential diagnosis of hypercalcemia: a mechanistic approach

Malignant disease and primary hyperparathyroidism are the most common causes of hypercalcemia, but there are many minor causes. Mechanical or humoral factors, or both, may underlie the increase in bone resorption. Parathyroid hormone (PTH) is a major mediator of bone resorption, but many other humoral agents have the same effect, eg, prostaglandin, osteoclast-activating factor, and thyroid hormone. Serial determination of total calcium concentration is the most important laboratory test in hypercalcemia. Other useful tests include the determination of serum and urinary phosphorus concentration, chloride/phosphate ratio, urinary cyclic adenosine 3',5'-monophosphate (cAMP) level; carboxyl-terminal PTH assay; corticosteroid challenge; and appropriate radiologic studies. Nephrogenous cAMP and urinary prostaglandin determinations are research tools that hold great promise in the future. Differentiation between PTH- and non-PTH-mediated hypercalcemia determines subsequent steps in diagnosis and treatment.

Hypophosphatemia in hospitalized patients

Hypophosphatemia is common in hospitalized patients and occurs under a variety of circumstances other than parathyroid hormone excess. Charts of 100 inpatients with hypophosphatemia were reviewed and the patients divided into five groups on the basis of serum phosphate level: 18, 2.1 to 2.4 mg/dL; 49, 1.6 to 2.0 mg/dL; 20, 1.1 to 1.5 mg/dL; 12, 0.6 to 1.0 mg/dL; 1, 0.1 to 0.5 mg/dL. The effect of glucose ingestion on serum phosphate level was shown in one normal patient. Whenever carbohydrate was administered intravenously (45 cases), this was considered the primary cause of the hypophosphatemia. Other causes were as follows: diuretics, hyperalimentation, alcoholism, respiratory alkalosis, dialysis, insulin, corticosteroids, diabetic ketoacidosis, vomiting, phosphate-binding antacid, Gram-negative sepsis, primary hyperparathyroidism, saline, epinephrine, gastrointestinal malabsorption, and unknown. Hypophosphatemia in hospitalized patients may have multiple causes.

The regulation of 24,25-dihydroxyvitamin D3 production in cultures of monkey kidney cells

Primary kidney cell cultures from normal rhesus monkeys were used to study the regulation of 24,25-dihydroxyvitamin D3 production. Kidney cells were grown to confluency in the modified National Cancer Institute Medium NCTC 135 with 2% fetal calf serum and then maintained in a serum-free medium (2% bovine serum albumin) for five additional days prior to a study of regulation. Morphologically, 80% of the cultured cells were epithelial in nautre. These cells produced 24,25-dihydroxy-[3H]vitamin D3 from 25-hydroxy-[3H]-vitamin D3. The identity of the 24,25-dihydroxy-[3H]vitamin D3 was established by Sephadex LH-20 chromatography, by co-chromatography with authentic 24,25-dihydroxyvitamin D3 on high pressure liquid columns, and by periodate sensitivity. Bovine parathyroid hormone at a level of 3 U/ml or human 1-34 parathyroid hormone at 0.05 U/ml for five days suppressed 24,25-dihydroxyvitamin D3 production. Nonradioactive 1,25-dihydroxyvitamin D3 (13 pmol/ml) added once every two days for eight days led to a 2-fold increase in production of 24,25-dihydroxyvitamin D3. Exposure of renal cells to 3 mM instead of 1 mM calcium led to a marked increase in 24,25-dihydroxyvitamin D3 production. These results suggest that renal cell cultures may be an important new approach to a study of regulation of the vitamin D renal hydroxylases.

Absorption of inorganic phosphate in the human jejunum and its inhibition by salmon calcitonin

The jejunal absorption of inorganic phosphate (P) was studied under basal conditions and during the intravenous infusion of synthetic salmon calcitonin (SCT) in normal subjects. Net P absorption increased as the intraluminal P concentration was raised. At intraluminal P concentrations equal to or above the plasma P level P absorption manifested first order kinetics. At intraluminal P concentrations below the plasma P level, net P absorption was non-linear presumably due to the movement of P from plasma to the lumen down a chemical gradient. A net secretion of water and electrolytes occurred in six normal subjects given SCT (250 ng/kg/hr) while saline infusion instead of SCT had no effect on jejunal absorption. Along with the secretory effect SCT reduced calcium and P absorption by 58% and 62% respectively, without any significant fall in the serum levels of calcium or P. The jejunal response to SCT was reproduced twice in a hypoparathyroid subject showing that endogenous parathyroid hormone was not involved in this effect. Calcium and P absorption were positively correlated with water movement suggesting that the observed changes in calcium and P absorption are due primarily to SCT-induced secretion of water. It is concluded that SCT induces a net secretion of water and ions while simultaneously reducing calcium and P absorption.

Ion transport changes during calcitonin-induced intestinal secretion in man

Previous studies have shown that synthetic salmon calcitonin (SCT) infused intravenously causes secretion of water and electrolytes in the jejunum of normal human subjects. The present experiments were carried out to learn more about the nature of this intestinal secretory process. During SCT- or synthetic human calcitonin (HCT)-induced intestinal secretion, the following observations were made: (1) There was no change in potential difference; (2) Cl was secreted against an electrochemical gradient; (3) unidirectional Na flux out of the lumen was decreased while the opposite flux was normal; (4) luminal pCO2 fell; (5) addition of glucose to the jejunal contents stimulated Na abdsorption, and this in turn counteracted the secretory effect of calcitonin. These findings suggest that calcitonin induces active Cl secretion and inhibits active Na absorption, and that HCO3 absorption is reduced by virtue of OH secretion; furthermore, jejunal glucose absorption and glucose-stimulated Na absorption are intact during calcitonin-induced secretion. Intravenous infusion of HCT caused intestinal secretion only when blood levels were much higher than occur physiologically; therefore, calcitonin is probably not a mediator of spontaneous variations of intestinal transport in normal people. However, because calcitonin induces secretion in the ileum as well as in the jejunum, hypercalcitonemia (within the range commonly found in patients with medullary carcinoma of the thyroid) could be a cause of severe secretory diarrhea.

Salmon calcitonin and water and electrolyte transport in rabbit ileum

The administration of SCT, natural and synthetic, has no apparent effect on the ileal water and electrolyte transport in the rabbit. The failure of SCT to influence ileal transport of water and electrolytes in the rabbit, as it does in man, may be due to differences in the rabbit intestinal response to a foreign peptide hormone.