An Israeli national survey on ischemic colitis induced by pre-colonoscopy bowel preparation (R1)

BACKGROUND AND STUDY AIMS

Ischemic colitis (IC) may occur as a complication of colonoscopy. The aim of this study was to characterize patients with IC that occurred after exposure to bowel preparation laxatives, prior to an elective colonoscopy.

PATIENTS AND METHODS

A survey among Israeli gastroenterologists. Information was collected regarding individual cases.

RESULTS

Eight patients, who developed IC after bisacodyl ingestion that was taken as part of pre-colonoscopy bowel preparation protocol, were reported. In all patients, severe abdominal pain and/or hematochezia started shortly after the ingestion of the first dose of bisacodyl. IC was found in 7 patients during the planned colonoscopy and in 1 patient using computerized tomography. All patients received supportive treatment and recovered.

CONCLUSIONS

IC induced by bisacodyl is a rare phenomenon. Regardless of being rare, we would advise withholding bisacodyl bowel preparation in elderly subjects with risk factors for IC that are scheduled for a colonoscopy.

Severe hepatocytotoxicity linked to denosumab

OBJECTIVE

Denosumab (Prolia, Amgen, Thousand Oaks, CA, USA) is a fully human antibody to the receptor activator of nuclear factor-KB ligand (RANKL). We present a case of submassive hepatic necrosis with evidence implicating cytokine induction resulting from an immune reaction to denosumab.

CASE REPORT

A 72-year-old lady presented with elevated liver enzymes. One month previously, she received a s/c administration of 60 mg of denosumab. Viral hepatitis A, B and C and human herpes viruses 6-7 were negative as were routine autoimmune serology. Transaminases reached more than 50 x ULN, and gamma-glutamyl-transpeptidase (GGT) increased to more than 30 x ULN. Serum bilirubin reached 13.8 mg/dL. The serum albumin level decreased to 2.8 g/L. Prednisone (40 mg) and ursodeoxycholic acid (900 mg) were administered. The Naranjo Adverse Drug Reaction probability score was 6, consistent with a probable adverse drug reaction. A liver biopsy revealed sub-massive hepatic necrosis consistent with drug-induced liver injury (DILI). During steroid tapering, there was a slow decline in the levels of both the transaminases and the GGT, and a concomitant increase in the serum albumin. A month after stopping prednisone and ursodeoxycholic acid, there was an acute increase in the level of the transaminases and a decrease in the serum albumin. Steroid reintroduction resulted in normalization of the liver enzymes and synthetic capacity. A lymphocyte toxicity assay to denosumab was demonstrated a hypersensitivity reaction to denosumab resulting in 31% toxicity. The control patient showed no toxicity to denosumab. Cytokine levels (pg/mL) were as follows: Interleukin (IL)1 was 1193 (normal-24.5), IL8 357 (20-60), RANKL 224 (60-80), RANTES 215 (15-50), TNF-a 850 (25-50), TGF-b 546 (20-40), VEGF 735 (25-30). Serum RANKL was markedly reduced in the presence of denosumab (16 pg/mL). The elevated markers of apoptosis ccK18(M-30)(68-132) 140 IU and K18 apoptosis+ necrosis (M65) (62-213) 322 U/L implicate necrosis.

CONCLUSIONS

We suggest that RANKL inhibition can produce severe hepatic necrosis together with an increase in proinflammatory cytokines.

Oral administration of non-absorbable delayed release 6-mercaptopurine is locally active in the gut, exerts a systemic immune effect and alleviates Crohn's disease with low rate of side effects: results of double blind Phase II clinical trial

Therapy for Crohn's disease (CD) with thiopurines is limited by systemic side effects. A novel formulation of fixed-dose, delayed-release 6-mercaptopurine (DR-6MP) was developed, with local effect on the gut immune system and minimal absorption. The aim of this study was to evaluate the safety and efficacy of DR-6MP in patients with moderately severe CD compared to systemically delivered 6-mercaptopurine (Purinethol). Seventy CD patients were enrolled into a 12-week, double-blind controlled trial. The primary end-point was the percentage of subjects with clinical remission [Crohn's Disease Activity Index (CDAI) < 150] or clinical response (100-point CDAI reduction). Twenty-six (56·5%) and 13 (54·2%) subjects from the DR-6MP and Purinethol cohorts, respectively, completed the study. DR-6MP had similar efficacy to Purinethol following 12 weeks of treatment. However, the time to maximal clinical response was 8 weeks for DR-6MP versus 12 weeks for Purinethol. A higher proportion of patients on DR-6MP showed clinical remission at week 8. A greater improvement in Inflammatory Bowel Disease Questionnaire (IBDQ) score was noted in the DR-6MP group. DR-6MP led to a decrease of CD62(+) expression on T cells, implying a reduction of lymphocyte adhesion to site of inflammation. DR-6MP was safer than Purinethol, with significantly fewer adverse events (AEs). There was no evidence of drug-induced leucopenia in the DR-6MP group; the proportion of subjects who developed hepatotoxicity was lower for the DR-6MP. Non-absorbable DR-6MP is safe and biologically active in the gut. It is clinically effective, exerting a systemic immune response with low systemic bioavailability and a low incidence of side effects.

Metabolic syndrome is associated with increased prevalence of advanced colorectal polyps

OBJECTIVES

To examine the association between metabolic syndrome (MetS) and/or its components and colorectal neoplasms in adult population undergoing screening colonoscopy.

DESIGN

Cross-sectional study.

SETTING

Institute of Gastroenterology, Kaplan Medical Center, Rehovot, Israel.

PARTICIPANTS

Two hundred ninety nine consecutive outpatients undergoing screening colonoscopy.

MEASUREMENTS

MetS was determined according to the Adult Treatment Panel III of the National Cholesterol Education Program (ATP III) criteria. Blood test results and other clinical data were retrieved from the electronic medical records.

RESULTS

In 94 patients (31.8%) polyps were detected. Thirty two (34%) of the polyps were advanced. Eighty one percent of patients with an advanced polyp met the criteria for MetS. About the same MetS prevalence (84%) was found in men, but not in women. An advanced polyp was detected in 14% of patients with MetS, compared to 5% of patients without MetS. Odds ratio for having an advanced polyp in a patient with MetS compared to a patient without MetS was 10.64.

CONCLUSION

MetS was found to be a risk factor for advanced polyps. This association is suggestive of the need that patients with MetS should be urged to have a screening colonoscopy.

Combining physostigmine with meperidine for sedation and analgesia during colonoscopy

BACKGROUND AND STUDY AIM

Opiate or benzodiazepine drugs are often used during colonoscopy, but they are associated with respiratory depression and prolonged recovery. Physostigmine, a tertiary anticholinesterase agent, is known to enhance analgesia and to reverse the central nervous system depressant effects of these drugs. This study compared the effect of giving meperidine alone with the effect of giving meperidine in combination with physostigmine in patients who were undergoing complete colonoscopy.

PATIENTS AND METHODS

A total of 44 outpatients undergoing elective colonoscopy were randomly assigned to receive analgesia with either meperidine 0.5 mg/kg intravenously (group 1, n=24) or physostigmine 10 micrograms/kg intravenously, followed 5 minutes later by meperidine 0.5 mg/kg intravenously (group 2; n=20). The patients were assessed with regard to oxygen saturation, hemodynamic changes, pain perception and sedation scores, readiness to go home, and adverse effects.

RESULTS

The group 1 patients' oxygen saturations consistently fell, both during the procedure and in the recovery period; in group 2, oxygen saturations remained stable throughout the procedure and recovery period (95.88%+/-0.99 vs. 98.15+/-0.99, P<0.001). Patients in group 2 reported lower pain perception scores during the procedure (measured using a visual analog scale) than patients in group 1 (1.46+/-0.31 vs. 1.75+/-0.41; F1,42=6.484, P<0.015) and were less sedated during recovery (F1,41=6.56, P<0.015). No significant differences were found between the two groups with regard to heart rate or arterial blood pressure. All patients in group 2 were ready to go home after 25 minutes in the recovery area; three patients in group 1 were not ready to leave at 25 minutes and left the facility after 60 minutes. Four patients suffered from minor side effects of physostigmine (sweating and nausea).

CONCLUSIONS

Combining physostigmine with meperidine as preparatory treatment for patients undergoing colonoscopy prevents respiratory depression, improves analgesia, and shortens recovery time, with only mild side effects.

Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study

BACKGROUND AND STUDY AIMS

Outcomes following early colonoscopy in patients with acute diverticulitis have not previously been studied. The present study describes the effects of early colonoscopy in patients with acute diverticulitis.

PATIENTS AND METHODS

Consecutive patients hospitalized for acute diverticulitis were included in the study. In the first phase, patients with adjacent peridiverticular air or fluid on computed tomography (CT) were excluded. In the second phase of the study, only patients with free intraperitoneal air were excluded.

RESULTS

The study population consisted of 107 patients. During the first phase of the study, 49 patients were included; 10 were excluded because of peridiverticular air or fluid. The remaining 39 patients underwent uneventful colonoscopy. During the second phase of the study, 58 patients were included; four were excluded because of free air in the peritoneum. The remaining 54 patients underwent colonoscopy, and perforation of the sigmoid colon occurred in one patient with peridiverticular air. Complete colonoscopy to the cecum or to the obstructing tumor was achieved in 76 patients (81.7 %). A second colonoscopy performed 6 weeks later in 16 of the remaining 17 patients was successfully completed. Findings during the first colonoscopy were polyps in nine cases, polyp with infiltrating adenocarcinoma in one, obstructing adenocarcinoma in one, and a bone trapped in a diverticulum in another one. The latter two patients had a more protracted course and were clearly the ones who benefited most from the colonoscopy.

CONCLUSIONS

Early colonoscopy in patients with acute diverticulitis may alter the working diagnosis and be of therapeutic value. The rate of cecal intubation is lower and the perforation rate appears to be higher. A clear-cut indication therefore has to be evident clinically.

Role of circulating soluble CD40 as an apoptotic marker in liver disease

OBJECTIVES

To measure levels of soluble CD40, a laboratory marker of apoptosis in patients with liver disease, determine its origin, and correlate the findings with disease activity and histology.

DESIGN

Laboratory research study with comparison group.

SETTING

Liver Institute, Laboratory of HLA Typing and Histopathology Department, Rabin Medical Center, Israel.

SUBJECTS

One hundred ten patients with liver disease and 20 healthy controls.

METHODS

Serum samples were collected from all patients; in addition, paired hepatic and portal vein samples were collected from 23 patients, and bile samples from 5 patients. Soluble CD40 was measured with an enzyme-linked immunosorbent assay. Apoptotic cells in liver tissue were identified by morphological criteria and quantified with the TUNEL assay.

RESULTS

Soluble CD40 concentration was significantly higher in patients with liver disease than controls (mean 112.9 +/- 197.2 pg/ml vs. 24.2 +/- 9.1 pg/ml, p = 0.0001), with highest levels in the chronic viral hepatitis group (mean 131.7 +/- 137.5 pg/ml, p = 0.0001). Levels of sCD40 were correlated with serum creatinine, alkaline phosphatase, alpha-feto protein, and the apoptotic index. In the 23 paired samples, CD40 level was higher in the hepatic vein (mean 74.9 +/- 114.5 pg/ml) than the portal vein (mean 51.6 +/- 67.9 pg/ml); it was highly detectable in bile (mean 115.6 +/- 119.6 pg/ml, p = 0.0123). Untreated patients with chronic viral hepatitis (B and C) had higher levels (mean 106.2 +/- 76.5 pg/ml) than treated patients (mean 59.3 +/- 68.6 pg/ml, p = 0.049).

CONCLUSIONS

Levels of soluble CD40 increase in different types of liver disease. It probably derives from the liver and is secreted into the bile. Levels correlate with the apoptotic index and are affected by antiviral treatment. Soluble CD40 may serve as a serum marker of apoptosis in liver disease.

Oral signs and symptoms in relation to disease activity and site of involvement in patients with inflammatory bowel disease

OBJECTIVE

An assessment of oral symptoms and signs in patients with inflammatory bowel disease (IBD).

METHODS

Fifty-four patients with IBD, 34 with Crohn's disease (CD) and 20 with ulcerative colitis (UC) participated in the study. Forty-two patients without gastrointestinal disease or complaints attending the orthopedic clinic served as controls. Each patient completed a written questionnaire and was subjected to an oral examination.

RESULTS

The main findings of this study were the higher prevalence of halitosis (50% vs 10% P < 0.0008), nausea (30% vs 7%, P < 0.017) and reflux (regurgitation) (45% vs 17%, P < 0.017) in patients with UC, and nausea (50% vs 7%, P < 0.026), dry mouth and halitosis (29% vs 10%, P < 0.026) and vomiting (41% vs 5%, P = 0.01) in patients with CD, compared with controls. Patients with active CD had a higher prevalence of dry mouth, nausea and vomiting compared with controls (46, 69 and 54% vs 10, 7 and 5%, respectively, P < 0.001) and of reflux compared with non-active CD (46% vs 5%, P < 0.001). Patients with active UC had a higher prevalence of halitosis and regurgitation (50 and 60% vs 10 and 17%, P < 0.001) compared with controls.

CONCLUSIONS

The present study demonstrates increased frequency of oral signs and symptoms in patients with IBD. Patients with active CD had more oral signs compared with non-active CD patients. Manifestations such as nausea, vomiting, regurgitation and dry mouth may have detrimental effects on teeth and soft tissues of the oral cavity. Communication between gastroenterologists and dentists is imperative for success of the overall treatment of their patients.

Lung involvement and enzyme replacement therapy in Gaucher's disease

Symptomatic lung involvement in Gaucher's disease is relatively rare, being restricted to patients with other severe manifestations. We describe our experience in eight of 411 patients in our referral clinic, who presented with prominent pulmonary signs or symptoms. There were four adults and four children; all have been successfully treated with enzyme replacement therapy. Routine means of monitoring pulmonary status including clinical assessment, chest X-ray, pulmonary function tests, and high-resolution CT (HRCT) were used. Enzyme treatment resulted in decreased hepatosplenomegaly, improved haematological parameters, and increased well-being; There was decreased clubbing and decreased dyspnoea in some of the patients, although on radiology, lung pathology had not normalized. All four children showed improved respiratory compliance, with significant improvement of the radiological findings in one and unchanged disease in the others. Two adults showed improvement in oxygen saturation but worsening of pulmonary hypertension. On chest X-ray, both had increased interstitial markings; one had gradual progression of pulmonary artery accentuation and fine interstitial stable pattern on HRCT. The other two adults had no change in lung function or on chest X-ray, but on HRCT there was apparent improvement in one patient. There is great heterogeneity in presentation and response to enzyme therapy in patients with Gaucher's disease and symptomatic lung involvement. Clinically, some benefited significantly from enzyme therapy, but in contrast to the dramatic reduction in organomegaly, there was no normalization in pulmonary function or lung architecture.

Triazolo- and tetrazolopyridazine derivatives and their hypotension and heart rate activity

6-Chloro-, 6-morpholino- and 6-N-methylpiperazino-1,2,4-triazolo[4,3-b]- or 1,2,3,4-tetrazolo[1,5-b]pyridazines [II-VII] were synthesized from 3-chloro-6-hydrazinopyridazine [I]. Positive effect of a series of tetra- and triazolopyridazines for lowering blood-pressure without affecting the heart rate was found in tests on rats. Their lipophilicity and other properties are discussed.

The effect of culture results for Helicobacter pylori on the choice of treatment following failure of initial eradication

BACKGROUND

Current treatment for the eradication of Helicobacter pylori in patients with peptic disease is based on the combination of antibiotic and anti-acid regimens. Multiple combinations have been investigated, however no consensus has been reached regarding the optimal duration and medications.

OBJECTIVES

To assess the efficacy of two treatment regimens in patients with peptic ulcer disease and non-ulcer dyspepsia, and to determine the need for gastric mucosal culture in patients failing previous treatment.

METHODS

Ninety patients with established peptic ulcer and NUD (with previously proven ulcer) were randomly assigned to receive either bismuth-subcitrate, amoxycillin and metrnidazole (BAM) or lansoprasole, clarithromycine and metronidazole (LCM) for 7 days. Patients with active peptic disease were treated with ranitidine 300 mg/day for an additional month.

RESULTS

Eradication failed in 8 of the 42 patients in the BAM group and in 2 of the 43 patients in the LCM group, as determined by the 13C urea breath test or rapid urease test (19% vs. 5%, respectively, P = 0.05). Five of these 10 patients were randomly assigned to treatment with lansoprazole, amoxycillin and clarithromycin (LAC) regardless of the culture obtained, and the other 5 patients were assigned to treatment with lansoprazole and two antibacterial agents chosen according to a susceptibility test. Eradication of H. pylori was confirmed by the 13C urea breath test. The same protocol (LAC) was used in all patients in the first group and in four of the five patients in the second group. The culture results did not influence the treatment protocol employed.

CONCLUSIONS

Combination therapy based on proton pump inhibitor and two antibiotics is superior to bismuth-based therapy for one week. Gastric-mucosal culture testing for sensitivity of H. pylori to antibiotics is probably unnecessary before the initiation of therapy for patients with eradication failure.

The natural course of upper gastrointestinal submucosal tumors: an endoscopic ultrasound survey

BACKGROUND

Differentiating between benign and malignant submucosal tumors is difficult. Moreover, the natural course of benign-appearing SMTs is not clearly elucidated.

OBJECTIVES

To evaluate the natural course of upper gastrointestinal SMTs by endoscopic endosonography.

METHODS

We followed 25 consecutive patients with small (< 40 mm) SMTs for a mean period of 19 months. Evaluation included maximal tumor diameter, internal echo pattern, and outer margin of lesions.

RESULTS

Follow-up revealed no change in echo features in 24 of 25 patients (96%). In only one patient a homogenous hypoechoic smooth margin lesion converted to a non-homogenous tumor with an irregular outer margin. This lesion also increased in size from 30 to 38 mm. On surgical removal this tumor was found to be a stromal tumor with high malignant potential.

CONCLUSIONS

Most small SMTs do not change during a period of 19 months and a conservative policy of surveillance is warranted.

Detection of pancreatic carcinoma: diagnostic value of K-ras mutations in circulating DNA from serum

Somatic activating mutations at codon 12 of the K-ras gene are present in the majority of exocrine pancreatic cancers and occur early in tumorgenesis. The aim of this study was to test the feasibility of using a mutated K-ras gene from the serum as a potential tumor marker for detection of exocrine pancreatic carcinoma. Codon 12 K-ras mutations were examined in DNA extracted from the sera of 20 patients with pancreatic carcinomas, six patients with chronic pancreatitis, and five healthy individuals. K-ras gene mutations at codon 12 were detected in the sera of 14 of 20 patients with pancreatic carcinoma and in none of the six patients with chronic pancreatitis, or in the five healthy controls. Elevation of either CA19-9 or K-ras mutation was detected in 19/20 patients. These results suggest that K-ras abnormalities in serum could be used as a potential tumor marker in patients with a pancreatic lesion. The absence of K-ras mutations in serum and presence of CA19-9 in the normal range make the diagnosis of pancreatic cancer unlikely.

Colonoscopic resection of large colonic polyps--a prospective study

Forty-five patients who were referred for surgical resection of large colonic polyps after index colonoscopy were considered for endoscopic polypectomy. Eighteen of these patients were ultimately referred for surgery. Twenty-five patients with 25 large polyps underwent endoscopic polypectomy; there were 9 females and 16 males with a mean age of 69 years. Among the polypectomy patients, polyp size was 3.0-6.0 cm, found mostly in the left colon. There were 21 pedunculated and 4 sessile polyps. Follow-up was carried out for a mean of 48 months (range, 12-171 months). Polypectomy was possible on a single attempt in 12 (48%) cases and in 13 (52%) cases by a piecemeal technique. Pathological examination revealed malignancy in 11 (44%), adenomatous polyp in 11 (44%), and inflammatory, hyperplastic and harmartoma in 1 patient each. Complications included bleeding in 3 (12%) patients and diarrhea and fever in 1 (4%). All complications were successfully treated conservatively without sequellae. Two patients were referred for surgery, 1 with invasion of the base of the polyp and 1 because of a synchronous malignant polyp. During follow-up, 8 metachronous polyps were detected. In 1 of these, a carcinoma was found and treated with endoscopic polypectomy. In conclusion, endoscopic polypectomy of large polyps is safe and can defer surgical treatment. Regular follow-up is required. Endoscopic polypectomy of large polyps should be considered before referral for surgical treatment.

In vitro cytostatic activity of 1,2,4-triazolo- and 1,2,3,4-tetrazolo pyridazines

Out of a series of fourteen 1,2,4-triazolo(4,3-b)-, and 1,2,3,4-tetrazolo-(1,5-b)pyridazine derivatives, 4 compounds have been found to reveal high cytostatic activity in KB and HeLa human cancer cell lines in vitro with ED50 activity values ranging from 0.25 to 3.0 micrograms/cm3 (0.009-0.158 x 10(-4) mole/l), and according to DR and D, NCI, NIH Bethesda criterion were qualified for further in vivo screening investigation. 6-Chloro-8-(N,N-dimethylaminosulfonylmethyl)-1,2,3,4-tetrazolo+ ++-(1,5-b)- pyridazine exhibited the strongest in vitro cytostatic activity (ED50 = 0.009 x 10(-4) mole/l), comparable with the best standards, and higher in comparison with a standard cytosine arabinoside (ED50 = 0.03-0.04 x 10(-4) mole/l). The presence of chlorine atom at C-6 position in the pyridazine ring determines the cytotoxic activity of tetrazolopyridazines as the primary factor and C-8 substituents, which influence their better solubility seems to be a secondary one, as confirmed by the results of the structure-activity and solubility-activity relationship analysis. However, for the exhibition of the triazolopyridazine activities the presence of two chlorine atoms at C-6 and C-3 position was essential.

Assessment of the esophageal wall by endoscopic ultrasonography in patients with nutcracker esophagus

BACKGROUND

The correlation between the width of muscularis propria and esophageal pressure in patients with the nutcracker esophagus is unknown. We examined by endoscopic ultrasonography the width of the muscularis propria in patients with nutcracker esophagus.

METHODS

The width of muscularis propria was measured at the gastroesophageal junction and at the lower, middle, and upper esophagus in 18 patients and 10 control subjects.

RESULTS

Mean muscularis propria diameter in patients was 1.8 +/- 1.4, 1.5 +/- 1.2, 1.5 +/- 0.8, and 1.2 +/- 0.4 mm at the gastroesophageal junction, lower, middle, and upper esophagus. In the control group, the mean width was 1.2 +/- 0.3, 1.2 +/- 0.3, 1.1 +/- 0.3, and 0.9 +/- 0.1 mm, respectively. The difference was significant at the gastroesophageal junction and upper esophagus. The muscularis propria was wider than 3 mm in 30% of patients. There was no correlation between the site of the wide muscularis propria and the esophageal segment where high pressure was recorded. Length of disease, frequency of symptoms, and length of each symptomatic period did not correlate with the width of muscularis propria.

CONCLUSION

The muscularis propria is thickened in one third of patients with nutcracker esophagus. The extent and magnitude of this thickening do not correspond to the location and the magnitude of the manometric abnormality or clinical presentation.

Preoperative assessment of blood vessel involvement in patients with pancreatic cancer

The major prerequisite for resection of a pancreatic tumor is non-involvement of large blood vessels. Preoperative assessment of blood vessel infiltration may prevent unnecessary surgery. The aim of our study was to investigate the accuracy of endoscopic ultrasonography (EUS) in diagnosis of pancreatic cancer and in preoperative staging. Thirteen patients (7 females, 6 males; mean age 64 years) with a pancreatic tumor, but no evidence of distant metastases, underwent EUS and computerized tomography (CT) in order to assess blood vessel involvement by the tumor. The results were compared with intraoperative findings in 12 patients and with postmortem findings in 1 patient. A tumor was demonstrated by EUS in 12 patients and was confirmed at surgery in all 12 patients. In one patient no tumor was demonstrated by EUS, although a tumor was visible by CT; no tumor was found at surgery. In two patients CT failed to demonstrate a pancreatic tumor that was demonstrated by EUS; at surgery a tumor was detected in both patients. EUS detected blood vessel involvement in seven patients, which was confirmed at surgery in six of them. In the other six patients surgery confirmed the EUS finding of no blood vessel involvement. CT detected blood vessel involvement in two patients only. The overall accuracy of EUS and CT for detecting the tumor was 100% and 77% respectively, and for blood vessel involvement 92% and 61% respectively. In conclusion, EUS is an accurate procedure for preoperative assessment of blood vessel involvement in patients with pancreatic cancer. This procedure may enable the selection of those patients who may benefit from surgery, and should be part of the evaluation of patients with pancreatic cancer who are candidates for curative surgery.

Pulmonary function abnormalities in type I Gaucher disease

The purpose of this study was to determine the prevalence of pulmonary function and radiographic abnormalities among patients with type I Gaucher's disease, and to analyse the relationship between the pulmonary involvement and genotype and clinical severity score. All patients attending the Gaucher clinic at the Shaare Zedek Medical Center, Jerusalem, Israel, during the years 1992-1993 were prospectively evaluated. Each patient had pulmonary function tests, chest radiography, clinical assessment in terms of degree of organ involvement, and genotype analysis. Of the 95 patients included in the study (mean +/- SD age 29 +/- 15 yrs), 68% had some pulmonary function abnormalities, most commonly a reduced FRC and transfer coefficient for carbon monoxide (Kco), found in 45% and in 42% of the patients respectively. Total lung capacity (TLC) was reduced in 22% of the patients and forced expiratory flows in approximately one third of the patients. Signs of airtrapping (elevated residual volume (RV) or RV/TLC) were seen in 18% of the patients. Males had a higher incidence of reduced expiratory flow than females, (forced expiratory volume in one second (FEV1) was reduced in 36% of males vs 5% of females). Chest radiographic abnormalities were found in 17% of the patients, although only 4% had severe changes. Patients with abnormal pulmonary function had a significantly higher severity score index than those with normal pulmonary function tests. There was no association between abnormal pulmonary function and genotype or age. In conclusion, abnormal pulmonary function is common among type I Gaucher patients. Pulmonary function tests show airways obstruction, with reduced expiratory flows, reduction in lung volumes and alveolar-capillary diffusion abnormality. The rate of progression and the clinical significance need to be determined.

Omeprazole has no effect on acetaminophen kinetics in the rat

We investigated in the rat the effect of the H+/H(+)-ATPase inhibitor, omeprazole, on the kinetics of acetaminophen. Two groups of rats were treated with either omeprazole 50 mg/kg/day or the vehicle for 7 days. On day seven, the pharmacokinetic parameters of acetaminophen clearance were determined in the conscious rat. Elimination rate constant, elimination half life time, clearance and volume of distribution of acetaminophen were not disturbed by omeprazole. It is concluded that in the rat, omeprazole does not affect acetaminophen kinetics and, therefore, will not increase susceptibility to acetaminophen toxicity.

Accuracy of endoscopic ultrasonography for preoperative staging of esophageal malignancy

Surgery for esophageal cancer carries a high mortality rate and a low rate of resectability for cure. Accurate preoperative staging is therefore of utmost importance. Staging is based on computerized tomography (CT), and recently, the use of endoscopic ultrasonography (EUS). We performed EUS and CT on 10 patients with esophageal cancer. Tumors were staged according to the TNM classification. According to the CT results, seven patients had a T3 tumor, one T1-2 and two T0. All patients were diagnosed as T3 by EUS. One patient, who was treated by combined modality treatment with chemotherapy and radiotherapy, converted to T0. Six patients were operated on, and in five, pathological findings were of an invasive tumor. The T stage was predicted correctly in five patients by CT and in all six patients by EUS. N stage was correctly diagnosed in two patients by CT and in five by EUS. It is concluded that EUS is superior to CT for preoperative staging of esophageal tumors. EUS should be undertaken as a routine procedure prior to surgery for esophageal cancer.

Famotidine has no effect on cardiac performance and liver blood flow in the rat

Conflicting results have been reported on the effect of famotidine on cardiac performance and visceral hemodynamics, studied by non-invasive techniques. It is for that reason that we used the radioactive microsphere technique to study the effect of famotidine on cardiac performance in the rat. Hepatic blood flow (HBF) and portal blood flow (PBF) were measured during the same experiment. Rats were either given famotidine (2.0 mg/kg per day) or drinking water for 7 days through an orogastric tube. Administration of famotidine had no effect on cardiac output (CO), HBF, PBF, or liver blood flow (LBF), which is the sum of HBF and PBF. In both groups, LBF consisted of a similar fraction of CO, 14.5 +/- 3.9% and 15.7 +/- 4.38%, in the control and the famotidine groups, respectively. Pulse rate, systolic pressure and left ventricular contractility were not affected by famotidine. It is concluded that in the rat, administration of famotidine for 7 days has no effect on systemic, hepatic or portal hemodynamics.

A multicenter, double-blind, randomized controlled study of omeprazole versus ranitidine in the treatment of duodenal ulcer in Israel

A multicenter, double-blind, randomized, controlled study of 203 Israeli patients with endoscopically proven duodenal ulcer is described. The study compares the efficacy (i.e., ulcer healing and relief of symptoms) and safety of 20 mg omeprazole once daily in the morning, with those of 300 mg ranitidine once daily at night. The omeprazole group had significantly higher cumulative healing rates than the ranitidine group both at day 15 (71% vs. 55%, P < 0.03) and day 29 (94% vs. 86%, P < 0.05). The efficacy was unaffected by known risk factors such as smoking. The omeprazole group had significantly fewer days with pain than the ranitidine group (median 1 vs. 3.5 days) (P < 0.03). There were no differences in ulcer size, symptoms or healing rates between Ashkenazi and Sephardic patients who were born in Israel, or who had immigrated to Israel. In summary, the present study confirms the efficacy and safety of omeprazole in the treatment of duodenal ulcer. Omeprazole provides more rapid relief of the symptoms and heals a greater proportion of duodenal ulcers, within 2-4 weeks, than ranitidine.

Vanadate has no effect on insulin-extraction by the rat liver

The mechanism(s) responsible for the insulin-like effects of vanadate are still unclear, although several possible explanations have been raised. However, the possibility that vanadate induces inhibition of insulin degradation in the liver was not examined yet. Therefore, in the present study we examined the effect of vanadate on the extraction of insulin by the perfused rat liver using an open, non-recycling system. Baseline insulin extraction (44 +/- 2% and 37 +/- 3%) was not affected by the administration of 1 and 5 microM vanadate (decreased to 42 +/- 2% and 36 +/- 1, respectively, p = NS). Vanadate had no adverse effects on liver viability, and the bile flow remained stable during and after vanadate administration (0.87 +/- 0.08 microliter/min/g liver prior to Vs. 0.084 +/- 0.11 microliter/min/g liver following vanadate administration). This study shows that vanadate does not inhibit insulin extraction by the perfused liver, and that does of vanadate that effectively inhibit hepatic glucose production possess no adverse effects on liver viability.

Alpha interferon has no effect on lidocaine metabolism in the rat

Interferons (IFN) inhibit activity of many isoenzymes of the hepatic microsomal cytochrome P-450 system. This inhibition is species specific. Lidocaine is metabolized by cytochrome P-450 III A 4. We investigated in the rat the effect of rat alpha-IFN on lidocaine elimination and on its extraction by the isolated perfused rat liver. To determine elimination, the femoral artery and vein were cannulated. 24 h later, the conscious rat was given lidocaine through the venous catheter and blood was drawn from the arterial catheter for lidocaine determination every 3 min for 20 min. 7 rats were pre-treated with intramuscular rat alpha-IFN 7.5 x 10(5) U, 24 h prior to the experiment and another 4 rats were given saline i.m. The lidocaine elimination rate constant was unchanged, 0.065 min-1 and 0.063 min-1 for the control and IFN groups, respectively. To investigate lidocaine extraction, the isolated perfused rat liver was used. Perfusate samples from the portal and hepatic veins were drawn at 2 min intervals for 20 min, and lidocaine extraction determined. Extraction was determined in two groups of 6 rats each. The first group served as control and these rats were injected with saline only, while in the second group, the rats were pre-treated with rat alpha-IFN 7.5 x 10(5) U. Lidocaine extraction by the isolated perfused rat liver remained unchanged, 97.0 +/- 0.7% and 94.0 +/- 2.4% in the control and IFN treated groups, respectively. It is concluded that the rat alpha-IFN affects neither the elimination nor the extraction of lidocaine.

Complications of rubber band ligation of symptomatic internal hemorrhoids

In a prospective study, 512 patients undergoing hemorrhoidal band ligation over a seven-year period were followed up to focus on complications. Thirteen patients (2.5 percent) were hospitalized: six with delayed massive rectal bleeding, three with urinary retention, pain, and fever (one developed perianal abscess), and three others with severe pain due to prolapsed thrombotic hemorrhoids (one developed difficulty in urination). One patient developed perianal abscess and perianal fistula two months after ligation. Twenty-four patients (4.6 percent) suffered from minor complications: 11 patients had painful thrombosed hemorrhoids; five experienced slippage of bands; three had mild bleeding; two developed band-related mucosal ulcer; one experienced each time, after two subsequent ligations, priapism lasting several hours; and difficulty in urination and tender induration above the dentate line occurred in two other patients. Rubber band ligation is, in effect, a miniature hemorrhoidectomy and has been considered, until recent reports of fatalities associated with this procedure, as an effective, safe, and efficient method of treating symptomatic second-degree and third-degree hemorrhoids. We conclude that the ability to handle complications that occur secondary to the rubber band ligation and, thereby, prevent sepsis and the low rate of major complications in our study justify reliance on this method of treating symptomatic hemorrhoids.

Recovery of pressor response to norepinephrine following relief of the obstructed common bile duct in the rat

Jaundice caused by common bile duct (CBD) obstruction is associated with a blunted pressor response to norepinephrine (NE). We studied the rate and extent of recovery of the pressor response in the rat following relief of the obstruction. Three groups of male Wistar rats underwent CBD ligation. In the first and second group blood pressure measurements were obtained at 72 and 144 h after CBD ligation, respectively. In the third group pressure measurements were recorded 72 h after the relief of a 72-h obstruction. A fourth group served as control, and measurements were obtained 72 h after a sham operation. In all four groups measurements included basal blood pressure and pressure change following escalating doses of NE, ranging from 0.5 to 10 micrograms/kg. Basal blood pressure was similar in all four groups. In the control group the change of blood pressure was 23.4% +/- 6.7% in response to the lowest dose of NE, and 83.5% +/- 24.9% in response to the highest dose. A blunted pressor response to NE was recorded in all three groups with CBD obstruction. The duration of CBD ligation (72 or 144 h) did not affect this blunded response. Re-establishment of bile flow for 72 h made only a slight improvement in the response to NE. Obstruction of the CBD was associated with hyperbilirubinemia which disappeared following the re-anastomosis of the CBD to the duodenum. This most significant decrease in serum bilirubin was not associated with a similar improvement in pressor response to NE. We conclude that in the rat CBD obstruction is associated with a blunted pressor response to NE, that relief of CBD obstruction for 72 h is insufficient to abolish this response, and that there is no full correlation between serum bilirubin and pressor response.

Recovery of hepatic clearance and extraction following a release of common bile duct obstruction in the rat

The rate of recovery for hepatic clearance and extraction following release of common-duct obstruction was investigated in the rat. Male Wistar rats underwent ligation of a cannulated common bile duct. Two weeks later, the cannula was opened and implanted into the duodenum, thus re-establishing enterohepatic circulation. Hepatic extraction and indocyanine green clearance were determined in three groups of six rats each, which differed by the time elapsed from the re-establishment of communication between the common bile duct and duodenum, i.e., 1, 48 and 168 h, respectively. A fourth group, in which a sham operation was performed, served as a control. Clearance was reduced from 16.9 +/- 2.5 ml/min per kg in the control group to 2.9 +/- 0.8, 5.4 +/- 2.4, and 8.5 +/- 3.3 ml/min per kg 1, 48, and 168 h, respectively, after release of common-bile-duct obstruction. Extraction rate was reduced from 37.3 +/- 5.9% to 17.5 +/- 2.7% in the 1st hour and recovered completely at 1 week. Thus, in the rat, release of a 2-week common-bile-duct obstruction is associated with complete recovery of the extraction capacity of the liver within a week, but only incomplete recovery of clearance. This decrease in clearance seems to be due to a decrease in effective hepatic blood flow, mostly probably due to the development of porto-systemic shunts.

Aspartic-acid synthesis in C3 plants

In a previous study (Melzer and O'Leary, 1987, Plant Physiol. 84, 58-60), we used isotopic methods to show that a substantial fraction of protein-bound aspartic acid in tobacco is derived from anaplerotic synthesis via phosphoenolpyruvate (PEP) carboxylase. Similar studies in soybean (Glycine max L.) and spinach (Spinacia oleracea L.) showed a similar pattern, and this pattern persists with age because of slow protein turnover. A more quantitative analysis indicates that about 40% of protein-bound aspartate is derived in this manner. Analyses of free aspartic and malic acids show that contribution of PEP carboxylase to the synthesis of these acids decreases with increasing age. The C4 plant Zea mays L. did not show this pattern.

Double-blind controlled trial of flumazenil in patients who underwent upper gastrointestinal endoscopy

The antisedative effect of flumazenil, a benzodiazepine antagonist, was studied in a double-blind placebo controlled trial in 61 patients who underwent upper gastrointestinal endoscopy and sedation with benzodiazepines. The efficacy of flumazenil in reversing the effect of both benzodiazepines, diazepam and midazolam, was significantly higher than placebo (p less than 0.0001). The effect of flumazenil was prompt and was clearly noticed at the first assessment, 5 min after its administration. In none of the patients was a relapse of the sedative effect of the benzodiazepines noticed. The administration of flumazenil was free of major side effects. Flumazenil administration permits an earlier discharge of patients following endoscopy. Its availability in the endoscopy suite may improve the outcome of serious but rare side effects related to benzodiazepines.

Oxygen isotope effects on the ribulosebisphosphate oxygenase reaction

The oxygen isotope effect at the substrate O2 on the oxygenase reaction of ribulose bisphosphate carboxylase/oxygenase from spinach is pH and metal dependent. The pH dependence between pH 7.4 and 8.9 is different with Mg2+ (steady decrease in this isotope effect from 1.036 to 1.030) and Mn2+ (minimum isotope effect of 1.028 at pH 8.0). Deuteration of the substrate ([3-2H]ribulose bisphosphate) has no influence on the isotope effect. The results are interpreted as a direct participation of the metal ion in the oxygen-sensitive step, i.e. carbon-oxygen bond formation and the stabilization of the intermediates. In the overall reaction oxygen addition is a major rate-limiting step, and the observed isotope effect is probably close to the intrinsic oxygen isotope effect of the reaction. The basic mechanisms for carboxylation and oxygenation of ribulose bisphosphate appear to be the same.

The effect of PGE2 on hepatic blood flow and bile indocyanin green in the rat

The effect of Prostaglandin E2 (PGE2) on hepatic blood flow and bile excretion has been only partially investigated. We studied in the rat the effect of PGE2 on indocyanine green (ICG) clearance, bile flow and ICG recovery in the bile. PGE2 administered to rats at a rate of 2 micrograms/kg/min had no effect on ICG clearance as compared to vehicle-treated rats (14.6 +/- 2.5 Vs, 16.9 +/- 2.5 ml/min/kg) and on bile flow (1.23 +/- 0.15 Vs. 1.24 +/- 0.11 microliters/min/gm liver). However, ICG excretion in bile was significantly increased as compared to a vehicle-treated group, 0.48 +/- 0.09 and 0.25 +/- 0.02 micrograms/microliters bile, respectively (P less than 0.005). This effect of PGE2 on ICG recovery in bile was found to be dose-dependent, and when PGE2 was administered at a rate of 1 microgram/kg/min, bile ICG decreased to 0.33 +/- 0.10 microgram/microliter bile. The effect of PGE2 on bile ICG is not due to an increased extraction of ICG by the liver since using the isolated perfused rat liver, the mean ICG extraction rate over a 20 minute period, with and without PGE2 infusion, was very similar, 33 +/- 3.5 and 37 +/- 6.2 percent, respectively. The lack of effect of PGE2 on ICG clearance and extraction and on bile flow, with an increase in biliary excretion of ICG, suggests a decreased hepatic storage of ICG induced by PGE2 possibly due to an accelerated rate of ICG excretion from the hepatocytes to the bile canaliculi.

Carbon isotope effects on the decarboxylation of carboxylic acids. Comparison of the lactate oxidase reaction and the degradation of pyruvate by H2O2

The isotope effect at C-1 on the H2O2-catalysed decarboxylation of pyruvate (used as a model reaction for the enzymic reaction) increases between pH 3 and 10 from 1.0007 +/- 0.0004 to 1.0283 +/- 0.0014 (25 degrees C). This result indicates a change in the rate-determining step from formation of the tetrahedral intermediate to decarboxylation of this intermediate. Practically no isotope fractionation at C-1 (1.0011 +/- 0.0002, pH 6.0, 25 degrees C) is found in the lactate oxidase-catalysed decarboxylation of lactate, which is indicative for the existence of an irreversible O2-dependent step prior to the enzyme-catalysed decarboxylation. In addition, the result provides further evidence that dissociation of pyruvate and H2O2 from the enzyme can be excluded. The isotope effect at C-2 of lactate in the enzymic reaction (1.0048 +/- 0.0004) is attributed to the hydrogen transfer step from lactate to the coenzyme.

Pulmonary manifestations of temporal arteritis

Temporal arteritis is a well-recognized multi-systemic disease. Pulmonary manifestations, however, are extremely rare. In two patients with biopsy-proven temporal arteritis, lung involvement was observed. One patient presented with multinodular pulmonary lesions, while the second had a diffuse interstitial pattern. Both patients responded well to corticosteroid treatment. In a review of the literature, only four additional cases associating lung involvement with temporal arteritis were found. The possibility of primary pulmonary vasculitis should be considered in elderly patients with temporal arteritis.