A rare missense mutation in CHRNA4 associates with smoking behavior and its consequences

Using Icelandic whole-genome sequence data and an imputation approach we searched for rare sequence variants in CHRNA4 and tested them for association with nicotine dependence. We show that carriers of a rare missense variant (allele frequency=0.24%) within CHRNA4, encoding an R336C substitution, have greater risk of nicotine addiction than non-carriers as assessed by the Fagerstrom Test for Nicotine Dependence (P=1.2 × 10(-4)). The variant also confers risk of several serious smoking-related diseases previously shown to be associated with the D398N substitution in CHRNA5. We observed odds ratios (ORs) of 1.7-2.3 for lung cancer (LC; P=4.0 × 10(-4)), chronic obstructive pulmonary disease (COPD; P=9.3 × 10(-4)), peripheral artery disease (PAD; P=0.090) and abdominal aortic aneurysms (AAAs; P=0.12), and the variant associates strongly with the early-onset forms of LC (OR=4.49, P=2.2 × 10(-4)), COPD (OR=3.22, P=2.9 × 10(-4)), PAD (OR=3.47, P=9.2 × 10(-3)) and AAA (OR=6.44, P=6.3 × 10(-3)). Joint analysis of the four smoking-related diseases reveals significant association (P=6.8 × 10(-5)), particularly for early-onset cases (P=2.1 × 10(-7)). Our results are in agreement with functional studies showing that the human α4β2 isoform of the channel containing R336C has less sensitivity for its agonists than the wild-type form following nicotine incubation.

Regaining familiarity with own body after treatment for operable lung cancer - a qualitative longitudinal exploration

Little is known about the experiences of operable lung cancer patients during treatment in a clinical setting based on fast-track surgery. The study aimed to explore (1) the embodied meaning of illness in patients with operable lung cancer during treatment to 4 months after surgery and (2) patterns of change over time that may affect the patients' daily lives. Twenty patients referred for lung cancer surgery were interviewed three times, corresponding to potential critical transition points following surgery: hospitalisation; hospital-to-home transition; and resumption of daily life activities. Data collection, analysis and interpretation followed a phenomenological hermeneutical approach inspired by Ricoeur and the theoretical framework was grounded in Merleau-Ponty's phenomenology of perception. The findings reveal the process patients went through in regaining familiarity with their own body after lung cancer treatment. Through the post-operative trajectory the patients' resumption of daily activities involved adjusting to a new awareness of everyday life, physical restrictions and their perception of themselves. The findings are expressed in four sub-themes: (1) perceptions of embodied alterations; (2) transformation of embodied structures in the transition from hospital to home was unexpectedly challenging; (3) embodied perceptions of the intersubjective world; and (4) transforming embodied disruptions into bodily awareness. Patients experienced a smooth treatment trajectory regarding physical consequences of illness and treatment which might be due to the fast-track surgery. Clinicians should be aware of patients' experiences of illness to facilitate patient reconstitution of own identity.

Impaired postoperative outcome in chronic alcohol abusers after curative resection for lung cancer

OBJECTIVE

It has been demonstrated that chronic alcohol misusers, who drink at least 60 g of ethanol per day, are suffering increased postoperative morbidity after various non-pulmonary surgical procedures. The aim of this study was to evaluate the association between alcohol consumption and postoperative morbidity and mortality after potential curative resection for lung cancer.

METHODS

The records of all patients who underwent curative resection for lung cancer in a single University Centre in Cardiothoracic surgery during 1997 and 1998 were retrospectively reviewed. One hundred and seven patients, 42 women and 65 men, median age of 64 (33-79) years, were included and subdivided with regard to alcohol consumption. There were 26 pneumonectomies, 68 lobectomies and 13 lesser resections. Clinical complications occurring within 30 days after surgery and requiring therapy, were registered and subdivided into major, potentially lethal complications, and minor complications. Mortality within 30 days after surgery was also registered.

RESULTS

Patients drinking at least 5 drinks per day had increased postoperative mortality, 3/13 versus 2/94 (odds ratio (95% confidence limits): 13.80 (2.06-92.68); P=0.007). The rate of major, live threatening complications including septicaemia and cardiopulmonary insufficiency was significantly increased among patients drinking at least 5 drinks per day 6/13 versus 19/94 (odds ratio (95% confidence limits): 3.38 (1.02-11.25); P=0.047) in univariate analysis. However, in multivariate analysis this association was not significant.

CONCLUSION

Postoperative mortality after curative resection for lung cancer was significantly increased among patients drinking at least 5 drinks of alcohol per day.

Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management

BACKGROUND

A study was undertaken to evaluate the clinical impact of endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) in patients with mediastinal masses suspected of malignancy.

METHODS

From April 1993 to December 1999, 84 patients were referred for EUS-FNA. In all patients CT scanning had shown a lesion of the mediastinum suspected of malignancy located adjacent to the oesophagus. In order to evaluate the clinical impact of EUS-FNA, the history of each patient up to referral for EUS-FNA was reviewed. A board of thoracic specialists was asked to decide the further course of the patient if EUS-FNA had not been available, and this diagnostic strategy was compared with the actual clinical course after EUS-FNA.

RESULTS

For the 79 patients in whom sufficient verification was obtained, EUS-FNA had a sensitivity of 92%, specificity of 100%, PPV of 100%, NPV of 80%, and an accuracy of 94% for cancer of the mediastinum. In 18 of 37 patients (49%) a thoracotomy/thoracoscopy was avoided as a result of EUS-FNA, and in 28 of 41 patients (68%) a mediastinoscopy was avoided. The direct result of the cytological diagnosis obtained by EUS-FNA was that a final diagnosis of small cell lung cancer was made in eight patients resulting in referral for chemotherapy, and in another three patients with benign disease specific treatment could be initiated (sarcoidosis, mediastinal abscess, and leiomyoma of the oesophagus).

CONCLUSIONS

EUS-FNA is a safe and sensitive minimally invasive method for evaluating patients with a solid lesion of the mediastinum suspected by CT scanning. EUS-FNA has a significant impact on patient management and should be considered for diagnosing the spread of cancer to the mediastinum in patients with lung cancer considered for surgery, as well as for the primary diagnosis of solid lesions located in the mediastinum adjacent to the oesophagus.

[Accelerated course in hip arthroplasty]

INTRODUCTION

The aim of the study was to assess the results of a well-defined rehabilitation programme after hip arthroplasty.

METHODS

The effects of a revised, optimised, perioperative care programme with continuous epidural analgesia, oral nutrition, and physiotherapy were assessed in 60 patients before intervention and 60 patients after intervention.

RESULTS

The hospital stay was reduced from nine to six days (p < 0.01), there were fewer complications and less need for rehabilitation after discharge (p < 0.05) in the intervention group.

CONCLUSION

A clinical programme focusing on pain relief, oral nutrition, and rehabilitation may reduce the stay in hospital and improve recovery after hip arthroplasty.

Lung cancer screening by low-dose spiral computed tomography

The poor prognosis of lung cancer has barely changed in the last decades, but the prognosis is better when the disease is detected earlier. Lung cancer screening by chest radiography did not lead to a decrease in lung cancer mortality, presumably because the chest radiograph is a poor screening tool with low sensitivity. With the advent of the low-dose spiral computed tomography (CT) scan it has become feasible to detect early invasive stage I lung cancer in 8-90% of cases. This technique could possibly decrease lung cancer mortality, but the extent of this effect is as yet unknown, and whether lung cancer screening will be cost-effective is yet to be determined. These questions can only be resolved in a randomized controlled trial with lung cancer mortality as an unbiased end-point. In this review, the initiatives to evaluate low dose spiral CT screening for lung cancer in Japan, USA and Europe are presented. In the USA and Japan, evaluation is in one-armed studies, whereas in many European countries randomized trials are now being planned and several one-armed studies have been initiated. A formal collaboration among these countries has now been set up. It is strongly recommended that lung cancer screening be evaluated in randomized trials in order to allow evidence-based health policy decisions to be made on this subject.

Comparative kinetics of polymerisation of three fibrin sealants and influence on timing of tissue adhesion

The clinical performance of fibrin sealants may be influenced by physical properties such as elasticity, tensile strength, and ability to adhere to human tissue. These properties are related to the internal structure of the fibrin sealant that builds as it polymerises. Analysis of the minimum polymerisation time to achieve a functional fibrin clot is clinically important. Instant tissue-fibrin sealant adhesion is desirable to ensure that the fibrin sealant functions on contact and remains at the site of application without being washed away by blood or displaced by movement of the target tissue (e.g., the heart or lungs). The physical characteristics of fibrin sealants are related to the extent of fibrin cross-linking. Determination of the polymerisation rate allows calculation of the minimum time required to produce a functional clot. The adhesion characteristics to vital human tissue and kinetics of polymerisation between 20 and 300 seconds postapplication of Vivostat system patient-derived sealant have been analysed and compared to those obtained for two conventional fibrin sealants, Tissucol and Beriplast. Mathematical analysis of the experimental data revealed that polymerisation of Vivostat sealant followed first-order kinetics, whereas that of Beriplast and Tissucol followed second-order kinetics. This study demonstrates that Vivostat sealant polymerises faster than these other conventional fibrin sealants.

Prevention of air leakage by spraying vivostat fibrin sealant after lung resection in pigs

STUDY OBJECTIVES

To evaluate Vivostat fibrin sealant in the prevention of air leakage after experimental lung resection in pigs.

DESIGN

Randomized study.

SETTING

University laboratory.

METHODS

Six Landrace pigs were operated on in both lungs through a median sternotomy. Five different resection sites were created in each lung.

INTERVENTION

Randomization was performed to either application of Vivostat fibrin sealant (ConvaTec; Skillman NJ) or human albumin 20% (control) at the resection sites. The lung parenchyma was occluded with a soft clamp for either 1, 2, 5, or 10 min in the treatment group and 10 min in the control group. After removal of the clamp, the lung was ventilated with an increasing intrabronchial pressure of 20, 30, and 45 cm H(2)O for 2 min at each step.

RESULTS

At inspiratory pressures of 20 and 30 cm H(2)O air leaks were found in the control group but not in the Vivostat group (p < 0.001). At an inspiratory pressure of 45 cm H(2)O, there were two small air leaks in the Vivostat group at each clamping time (four at 5 min), compared with five small and seven large leaks in the control group. Analysis of the data after 10 min of clamping showed that the Vivostat group was superior to the human albumin group (p = 0.002).

CONCLUSIONS

This randomized study shows that Vivostat fibrin sealant is effective in preventing air leakage after small lung resections in pigs, even at high inspiratory pressures.

A prospective study of combined phacoemulsification-trabeculectomy versus conventional phacoemulsification in cataract patients with coexisting open angle glaucoma

This prospective study compares combined phacoemulsification and trabeculectomy (phaco-trab) to conventional phacoemulsification (phaco) in patients with coexisting cataract and open angle glaucoma. Twenty eyes were randomly assigned to either phaco-trab or phaco and followed for 12 months. Postoperatively, IOP decreased significantly in both groups, but patients with the combined procedure had fewer early IOP-elevations and significantly less medication. Visual acuity improved equally in the two groups.

Effect of fructose on the capacity of urea-N synthesis in rats

We studied the effect of fructose on hepatic conversion of amino-N to urea-N as quantified by the Capacity of Urea-N Synthesis (CUNS) determined in rats during alanine loading. There were 2 control groups, one without and one with infusion of somatostatin, in order to control the effects of insulin and glucagon. Somatostatin reduced CUNS from 8.5 +/- 0.5 mumol/(min x 100 g BW) to 6.3 +/- 0.3 mumol/(min x 100 g BW) (mean +/- SEM) (p < 0.01) and reduced glucagon concentrations by 75% (p<0.05). Insulin and glucose concentrations did not change. Fructose, at blood concentrations of about 1 mmol/l further reduced CUNS to 3.6 +/- 0.3 mumol/(min x 100 g BW) (p < 0.01). Insulin increased slightly (p < 0.05), but neither glucose nor glucagon changed. At increasing fructose concentrations up to 2 mmol/l there was no further effect on CUNS. Fructose in concentrations as used for parenteral nutrition and independent of glucoregulatory hormones, decreased hepatic amino acid catabolism.

Clinical comparison of two low-dose oral contraceptives, Minulet and Mercilon, in women over 30 years of age

A comparative study of two low-dose oral contraceptives, gestodene (GES) 75 mcg/ethinyl oestradiol (EE) 30 mcg and desogestrel (DES) 150 mcg/EE 20 mcg, was conducted in women over 30 years of age. This randomised, open-label study was organised in Denmark, Italy, New Zealand and United Kingdom. A total of 505 women received GES/EE and 501 received DES/EE for 6 consecutive menstrual cycles. The two groups were comparable in terms of demographic and gynaecologic characteristics at baseline. However, the menstrual flow length was slightly longer in the GES/EE group before the start of the treatment. The mean age (+/- SD) was 35 +/- 4 years in the GES/EE group and 35 +/- 5 years in the DES/EE group. The subjects in the GES/EE group contributed data for a total of 2800 cycles and those in the DES/EE group, data for 2796 cycles. There were no pregnancies on medication with either preparation. The results showed that there were significantly more normal cycles in the GES/EE group for cycles 1 to 6. Irregular bleeding between withdrawal bleeds occurred in 10% of GES/EE and 18.5% of DES/EE cycles. Absence of all bleeding was reported in 29 (1%) and 63 (2%) cycles, respectively. The incidence of missed pills was low in both groups (11% of cycles). No significant differences were observed in cycle length or withdrawal bleeding episode length. Withdrawal bleeding mean intensity was statistically significantly greater with GES/EE. However, for both preparations, the mean intensity was close to light bleeding. No clinically significant differences were noted in weight, blood pressure, Papanicolaou smears or laboratory data. Sixty-eight (13.5%) subjects in the GES/EE group and 64 (12.8%) in the DES/EE group discontinued before the end of the study. Among them, 37 (7%) and 40 (8%) in the respective groups withdrew because of adverse reactions. There was no difference between groups in terms of primary reasons for withdrawal. The most frequently reported complaints that led to discontinuation in both groups were headache, nausea and metrorrhagia. Breast tenderness led to the discontinuation of 1 subject in the GES/EE group and 3 in the DES/EE group. These results show excellent cycle control, efficacy and very low rate of side effects with both GES/EE and DES/EE. These low-dose oral contraceptives could be well suited to healthy nonsmoking women requiring contraception up to the age of menopause.

[Captopril-induced toxic hepatitis]

Captopril, the competitive inhibitor of angiotensin-converting enzyme, has proved efficient in the treatment of arterial hypertension and heart failure. Its use is generally associated with low incidence of adverse reactions and hepatic injury has not been emphasized as an important adverse reaction in Denmark. However worldwide, several cases of hepatic injury have been reported. We report one case of Captopril-induced hepatic injury. Despite discontinuation of Captopril a hepatorenal syndrome developed and the patient died five weeks after admission. This report emphasizes the need to be aware of the possibility of hepatic injury in patients receiving Captopril.

Distribution of neurotensin-like immunoreactivities in porcine and human gut

The distribution of neurotensin-like immunoreactivity (NTLI) in porcine and human intestine was studied by extraction of mucosal and muscular layers of esophagus, stomach, duodenum, jejunum, ileum, and colon. NTLI was quantitated and characterized by radioimmunoassays and gel filtration chromatography. Porcine tissue was obtained in anesthetized animals (n = 6) and human tissue during surgery (n = 28). Concentrations of NTLI increased gradually from the distal esophagus to the ileum. Highest concentrations were found in 2.0 M acetic acid extracts of proximal ileal mucosa (150 (131-223) and 525 (500-729) pmol/g wet tissue, respectively (medians and interquartile range]. After acid extraction, concentrations of intact NT and COOH-terminal and NH2-terminal NTLI were similar, but in water concentrations of NH2-terminal NTLI were high and intact NT and COOH-terminal NTLI low. The distribution of NTLI was similar in the two species. Gel chromatography of ileal, jejunal, and duodenal mucosa indicated that in these tissues NTLI consisted primarily of intact NT. In antral mucosa COOH-terminal immunoreactivity different from NT was detected. The chemical identity is unknown, but it may represent precursor forms of NT.

Pharmacokinetics and metabolism of neurotensin in man

We studied the pharmacokinetics, arteriovenous extraction, and degradation sites of neurotensin (NT) in man during iv infusions of synthetic intact NT [NT-(1-13)] and the NH2-terminal metabolite NT-(1-8) during lipid ingestion and by catheterization of various vascular beds in normal subjects and patients with hepatic disease. NT-like immunoreactivities in plasma were quantitated using 2 sequence-specific RIAs and gel filtration chromatography. During iv infusion of NT-(1-13) in 6 normal subjects, the median t1/2 was 1.7 min (interquartile range, 0.7-2.8), the MCR was 36 mL/kg.min (range, 21-54), and distribution space was 78.8 mL/kg (range, 56-91). The results were similar at infusion rates of 72, 144, and 288 pmol/kg.h (n = 6). During infusion of NT-(1-8) in 7 normal subjects, the median t1/2 was 8.3 min (range, 4.7-13.8), the MCR was 11.0 mL/kg.min (range, 6.7-21.7), and the distribution space was 142.6 mL/kg (range, 45.3-281.0). Significant peripheral arteriovenous extraction of NT-(1-13) was found at infusion rates of 144 and 288 pmol/kg.h. Extraction of NH2-terminal immunoreactivity was not significant. Intact NT was identified by gel chromatography in arterial plasma after lipid ingestion and iv infusion of NT-(1-13), but postprandially in only low concentrations. In 17 patients with various nonhepatic diseases, plasma intact NT levels were not different in blood sampled from the renal vein, inferior vena cava, brachial artery, or hepatic vein. In contrast, NH2-terminal immunoreactivity was significantly higher in hepatic venous than in systemic plasma. In 6 patients with hepatic disease, systemic plasma intact NT levels were increased, but even more so in hepatic venous plasma. These results demonstrate that metabolism of intact NT is rapid, and a significant peripheral arterio-venous extraction is present. Further studies are necessary to establish if the liver is a site of degradation of intact NT in man.

Central embolization of needle fragment following intravenous drug abuse

A case of migration of a broken needle from the right femoral vein to the heart leading to severe pericarditis in a heroin addict is described.

Neurotensin-like immunoreactivity after intestinal resection in the rat

Neurotensin is a tridecapeptide located mainly in the distal small intestine. The present study was carried out in order to investigate the neurotensin response after proximal small intestinal resection in the rat. After resection, the median plasma concentration of neurotensin like immunoreactivity (NTLI) was unchanged compared with sham operated rats. Intragastric instillation of fat increased the plasma concentration of NTLI from 45 pmol/l (34-63) in sham operated rats to 92 pmol/l (46-121) in resected rats. No significant increase in the plasma concentration of NTLI was found after intragastric instillation of amino acids or glucose. The tissue concentration of NTLI increased significantly in the jejunum and ileum after proximal small intestinal resection, while the number of immunoreactive neurotensin cells was unchanged. This study shows that the adaptive responses in the distal small intestine after proximal small intestinal resection also involve the neurotensin producing cells.

Occurrence of VIP and peptide HM in human pancreas and their influence on pancreatic endocrine secretion in man

By immunohistochemistry it was found that VIP- and peptide HI/peptide HM (PHI/PHM)-like immunoreactivity occurred in autonomic neurons in the human pancreas. Antisera against both VIP and PHI/PHM reacted with neuronal cells in local ganglia and these ganglia also contained PHI/PHM- and VIP-immunoreactive fibre plexuses. VIP- and PHI/PHM-positive fibres were also seen close to the Langerhans' islets. In addition, PHI/PHM- but not VIP-like immunoreactivity was observed in the endocrine cells often located in the periphery of the islets. The nature of these PHI/PHM-positive cells remains to be established. I.v. infusion of VIP at constant rates of 300 and 900 pmol/kg X h for 30 min in 6 healthy volunteers resulted in plateau values of 102 +/- 26 and 291 +/- 25 pM, respectively. These levels of VIP which are above those found in the circulation under physiological conditions stimulated secretion of insulin, C-peptide and pancreatic glucagon dose-dependently. On the contrary prolonged (60 min) infusion of PHM in doses resulting in plasma levels up to 1340 +/- 405 pM had no effect on pancreatic hormone secretion. These findings suggest that VIP is a likely neurotransmitter in the control of endocrine pancreatic secretion while PHM has a less prominent role, if any.

Fasting and meal-stimulated plasma levels of neurotensin in obese patients after jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio

The functional role of the jejunum and ileum with regard to peripheral plasma levels of intact neurotensin and NH2-terminal immunoreactivity of neurotensin was studied by using jejunoileal bypass as a model. Plasma levels were measured by radioimmunoassay before and after jejunoileal bypass randomized to different jejunoileal ratios. Seven patients were studied before bypass surgery and 28 were examined after end-to-side jejunoileal bypass with 50 cm intestine in continuity and a 3:1 or 1:3 ratio between the length of the jejunal and ileal segments. Fasting levels of intact neurotensin were unchanged by surgery, whereas levels of NH2-terminal immunoreactivity were higher in bypass patients with a long ileal segment (37.5 cm) than in unoperated patients and in those with a short ileal segment (12.5 cm). Meal-stimulated levels of intact neurotensin were higher after 1:3 than 3:1 jejunoileal bypass. The levels of NH2-terminal immunoreactivity in patients with a short ileal segment and in controls were lower than in patients with a long ileal segment. The results show that postprandial levels of both intact neurotensin and NH2-terminal immunoreactivity are related to the length of the functioning ileum and that even a difference in length of 25 cm is reflected in the circulating levels of neurotensin.

Effect of ganglionic blockade on endogenous circulating pancreatic polypeptide, vasoactive intestinal polypeptide, substance P, neurotensin and noradrenaline in healthy controls and long-term insulin-dependent diabetic patients

Plasma pancreatic polypeptide (PP), vasoactive intestinal polypeptide (VIP), substance P (SP), neurotensin (NT) and noradrenaline (NA) were measured in eight healthy subjects and 12 long-term insulin-dependent diabetic patients with and without autonomic neuropathy, before and after intravenous infusion of the ganglionic blocking agent trimethaphan camsylate, in order to determine the influence of the autonomic nervous system on the baseline values of the substances. The basal levels of the measured substances were not significantly different in healthy subjects and patients with or without diabetic autonomic neuropathy. In healthy subjects, the ganglionic blockade induced a significant decrease in PP (80%) (P less than 0.02), NA (58%) (P less than 0.05), NT (27%) (P less than 0.05) and a significant increase in SP (30%) (P less than 0.05), while the VIP concentration remained unchanged. The diabetic patients had nearly the same significant decrease in PP (68%) (P less than 0.01), NA (50%) (P less than 0.01), NT (22%) (P less than 0.02), VIP (21%) (P less than 0.05) and increase in SP (73%) (P less than 0.01). No relationship was found between the autonomic neuropathy and changes of the substances during ganglionic blockade. The results indicate that the postganglionic part of the autonomic nervous system participates in the maintenance of a normal baseline level of PP, NT and NA, but not of VIP. The regulation of VIP may be disturbed in long-term diabetic subjects.

Cosecretion of peptide histidine methionine (PHM) and vasoactive intestinal peptide (VIP) in patients with VIP-producing tumors

Regional specific antibodies and chromatography were used to analyze the concentration and molecular forms of vasoactive intestinal peptide (VIP) and peptide histidine methionine (PHM) in plasma from 39 patients with VIP-producing tumors. Plasma VIP concentrations ranged from 29 to 2550 pmol/l and the corresponding PHM immunoreactive values measured with C-terminally directed antibody were 42 to 2100 pmol/l which correlated closely with the VIP concentrations. N-terminal PHM concentrations were significantly higher than the C-terminal values ranging from 92 to 5850 pmol/l and correlated poorly with the corresponding VIP concentrations. Infusion experiments with PHM disclosed that the higher levels of N-terminal immunoreactivity could not be explained by slower metabolic clearance or by degradation to smaller N-terminal immunoreactive forms. N-terminally directed PHM antibody revealed, in addition to intact PHM, a larger immunoreactive form in patient plasma which constituted the major proportion of the total immunoreactivity. In conclusion, VIP and PHM are cosecreted from VIPomas and measurement of PHM, especially N-terminal immunoreactivity, may be useful in this condition.

Effect of neurotensin in the dumping syndrome

The possibility that the gut peptide, neurotensin, may contribute to the dumping syndrome was investigated in 17 patients with a long history of dumping after a Billroth II gastrectomy for duodenal ulcer. After a test meal plasma levels of neurotensin were higher than in normal subjects, but no correlation to the severity of symptoms was found. In eight of the patients with meal-provoked dumping symptoms, intravenous infusion of neurotensin in relevant doses produced neither symptoms nor changes in blood glucose, blood pressure, or pulse rate. The apparent plasma half-life of neurotensin (t1/2 = 2.3 min) did not differ from that previously found in normal subjects. The results indicate that it is unlikely that neurotensin alone has a pathogenetic role in the dumping syndrome in gastrectomized patients.

Comparison of ultrasonography and transhepatic cholangiography in the evaluation of obstructive jaundice

The diagnostic value of ultrasonography and percutaneous cholangiography was compared in 114 consecutive patients with obstructive jaundice. The final diagnosis was obtained by surgery or autopsy. Transhepatic cholangiography diagnosed obstruction and its level in all patients, whereas ultrasonography failed to find obstruction in 3 patients and was unable to determine the level in 11 patients. The cause of obstruction was correctly assessed in 106 patients by transhepatic cholangiography and in 74 by ultrasonography. In 15 patients with obstruction caused by common duct calculi ultrasonography only diagnosed the five, and in 9 patients malignant obstruction was diagnosed as calculi. Ultrasonography is a reliable tool for diagnosis of obstructive jaundice and in most cases for localisation of the level of the obstruction. However, diagnosis of the cause of obstruction and of its precise topography requires direct cholangiography.

Plasma levels of neurotensin in gastroplasty for morbid obesity

Fasting and postprandial plasma levels of the tridecapeptide neurotensin were determined in ten women before and three months after gastroplasty for morbid obesity. Measurements were by radioimmunoassay in unextracted plasma with two antisera recognizing intact neurotensin (NT1-13) or intact neurotensin together with small C-terminal fragments, which may circulate as metabolites of neurotensin. Levels of both intact neurotensin and C-terminal immunoreactivity in obese women were in the same order of magnitude as those found previously in lean persons. Fasting levels measured with both antisera were significantly reduced following gastroplasty (P less than 0.01). Meal-stimulated levels and increments were unchanged. The cause of this prolonged reduction is at present unknown, but may be a reduced luminal stimulation of the small intestine or an altered vagal tonus following gastroplasty.

Development and validation of a specific radioimmunoassay for PHI in plasma

A sensitive and specific radioimmunoassay for the recently isolated neuropeptide with N-terminal histidine and C-terminal isoleucine amide (PHI) has been developed which can detect 3.0 pmol/l of the peptide in plasma. The routine antiserum produced in rabbit had a titre of 1:800 000 and recognized the sequence 3-8 of the 27 amino acid peptide. Labelling of PHI with 125I was performed by the chloramine T method, and labelled PHI was separated from unlabelled on an octadecylsilyl (ODC)-silica column. Non-specific interference in the assay was excluded by extraction of plasma with ethanol to a mean recovery of 82.4%. Plasma samples diluted parallel to the standard curve and behaved as PHI on ODC-silica column. The intra-assay and inter-assay coefficient of variation (CV) values at a level of 24.0 pmol/l were 6.3% and 13.1%, respectively. In 75 normal adults, the fasting PHI concentration ranged from 3.5-30.0 pmol/l with a mean of 14.2 pmol/l. In 235 children, the PHI concentration varied with age. Ingestion of a meal caused a rapid and short-lived increase in the PHI concentration.

Neurotensin induced inhibition of gastric acid secretion in duodenal ulcer patients before and after parietal cell vagotomy

The influence of the vagal nerve on the inhibitory effect of neurotensin on pentagastrin stimulated gastric acid secretion was investigated in seven duodenal ulcer patients before and after parietal cell vagotomy without drainage. Preoperatively, neurotensin inhibited gastric acid secretion, whereas no effect was found postoperatively. Plasma concentration of neurotensin was identical pre-and postoperatively. This study shows that the inhibitory effect of neurotensin on gastric acid secretion is dependent on an intact vagal innervation of the parietal cell area.

Circulating glucagon after total pancreatectomy in man

In five totally pancreatectomized human subjects the secretion of gut-derived glucagons was stimulated by ingestion of a meal rich in fat and carbohydrates. Glucagon-like immunoreactivity in plasma, measured with an antiserum against the 6-15 sequence, increased fivefold in response to the meal. Glucagon like immunoreactivity measured with a antiserum against the C-terminal sequence was initially normal (12-13 pmol/l), increased slightly (to 20 pmol/l), and then decreased (to approximately 6 pmol/l). The chromatographic profile of glucagon-like immunoreactivity in plasma at maximum stimulation was studied after concentration by affinity chromatography. Both assay systems identified two peaks (at Kd-values of 0.30 and 0.60-0.65, and 0.30 and 0.70, respectively). The position at Kd 0.70 corresponds to that of glucagon 1-29. The same components may be identified in plasma from normal subjects. It is concluded that the human intestine is capable of generating all of the molecular forms of glucagon which normally are present in plasma.

Preparation of 125I-(Tyr 3)- and 125I-(Tyr 11)- neurotensin for radioimmunoassay

The chloramine-T method for radioiodination of neurotensin for radioimmunoassay was studied. As conventional procedures produced heterogeneous preparations, labelling was performed with a low amount of chloramine-T (1.8 nmol) in the presence of excess of peptide (6 nmol). Purification and complete separation of labelled from unlabelled peptide was obtained by ion-exchange chromatography on SP Sephadex C-25. Four labelled components were identified by isoelectric focusing, enzymatic cleavage and studies of immunoreactivity. The two components representing monoiodinated preparations labelled at Tyr 3 or Tyr 11 could be isolated. Depending on the binding site of the particular antiserum the appropriate tracer could be selected for use in the radioimmunoassay. The specific radioactivities were high (2303 (2137-2407) microCi/nmol and 1927 (1608-2307) microCi/nmol (median and range] and the stability of the label and the reproducibility of the procedure was good.

Relief of metastatic obstruction in porta hepatis by endoprosthesis

Percutaneous insertion of an internal endoprosthesis was attempted in 22 patients with obstructive jaundice due to metastatic lesions in the porta hepatis. The primary tumors were located outside the pancreas and the biliary tract. Insertion was successful in 16 patients. The endoprosthesis normalized the plasma bilirubin in 10 patients and improved the general condition in 12. The median survival was short when hepatic metastases were present. Insertion of an endoprosthesis is an attractive alternative to other palliative procedures.

Two oral contraceptives, efficacy, serum proteins, and lipid metabolism. A comparative multicentre study on a triphasic and a fixed dose combination

A triphasic, combined oral contraceptive containing 30 - 40 - 30 micrograms ethinyloestradiol (EE), and 50 - 75 - 125 micrograms levonorgestrel was compared with a fixed dose combination containing 30 micrograms EE and 150 micrograms desogestrel in a randomized multicentre trial in 193/199 women and 1 063/1 073 cycles, respectively. The duration of the trial was six months. Eleven centres in Denmark, Sweden, and Norway participated. Contraceptive reliability, bleeding control and side effects were evaluated. Influence on serum sex hormone binding globulin (SHBG) and transcortin was assayed as well as lipid metabolism. Three pregnancies occurred in the group using the triphasic regimen but none in the fixed dose regimen. Two of the three pregnancies were considered drug failures and the third a possible interaction. Possible reasons for the triphasic contraceptive failure are discussed with special reference to a British report on eight pregnancies. Bleeding control appeared to be equally good for the two preparations. However, the number of cycles with spotting, breakthrough bleeding and missed withdrawal bleeding were above the levels reported earlier on the triphasic regimen. About 80 per cent of the women completed the planned six months on either combination. Side effects were generally mild and in accordance with earlier reports on low dose oral contraceptives. Metabolically the triphasic levonorgestrel combination increased SHBG 100 per cent versus 200 per cent for the fixed desogestrel combination. Transcortin rose about 98 and 110 per cent, respectively. Both preparations induced similar changes in the levels of lipids and lipoproteins with the exception of a significant increase in the arachidonic content of cholesterol during treatment with the desogestrel-containing preparation.

Ultrasonic localization of the porta hepatis prior to percutaneous transhepatic cholangiography

Sixtyfour jaundiced patients were randomly allocated to have fine needle PTC performed with or without prior ultrasonographical localization of the porta hepatis. The general success rate was 97% and complications occurred in two patients (3%). Ultrasonography prior to PTC did not significantly reduce the number of needle passes in the liver parenchyma, the failure rate or the number of complications. Ultrasonic scanning, however, should precede PTC to disclose patients with obstructive jaundice and reveal hepatic and perihepatic abnormalities.

Ultrasonography, 99mTc-DIDA cholescintigraphy, and infusion tomography in the diagnosis of acute cholecystitis

Ultrasonography, 99mTc-DIDA cholescintigraphy, and infusion tomography of the gallbladder were compared in a prospective study comprising 45 consecutive patients clinically suspected of having acute cholecystitis. The diagnosis of acute cholecystitis was established or excluded by operation in 35 patients, by oral cholecystography in 5, and by intravenous cholangiography in 5. The predictive values of a positive and a negative test were 100% and 83%, respectively, by ultrasonography and 98% and 88% by cholescintigraphy. Corresponding values for infusion tomography were 87% and 33%. The results suggest that in patients suspected of having acute cholecystitis, 99mTc-DIDA cholescintigraphy and ultrasonography provide a rapid and reliable diagnosis.

Nonsurgical internal biliary drainage by endoprosthesis

Insertion of an endoprostheses for internal biliary drainage was attempted upon 150 patients with obstructive jaundice. It was successful in 123 patients, and 99 patients had permanent drainage with the endoprosthesis. The plasma bilirubin level became normal in 64 of the patients. The effect upon jaundice was equal to that in 43 patients who underwent operation with palliative surgical bypass. The median survival time was not different from that for the patients with surgical anastomoses. Twenty-eight patients died in the first month after insertion, mostly of advanced malignant disease. Fifteen of the patients in the group with surgical anastomoses died within the first month. The insertion of an endoprosthesis for bile duct obstruction is relatively easy and seems to have little risk. Most complications are caused by the transhepatic cholangiography procedure. The method may be used for temporary drainage before operation, in transient benign obstructions or as permanent drainage in unresectable lesions. In patients with dislodgement or insufficient function, additional endoprosthesis may be inserted. Thus, sufficient palliation of jaundice is achieved with a low frequency of cholangitis. Internal biliary drainage by insertion of an endoprosthesis is a valuable alternative to surgical bypass in patients with unresectable lesions.

Dynamic sonography in the evaluation of jaundice

The value of dynamic sonography as a screening procedure in 84 jaundiced patients was examined and compared with the clinical evaluation of a blind prospective study. The predictive value of the sonographic diagnosis of obstruction was 97% and 84% in nonobstruction. The corresponding values of the clinical distinction were 87% and 92% respectively. The level of obstruction was demonstrated in 95% and the cause of obstruction was diagnosed in 68%. When the cause of jaundice is uncertain or obstruction is suspected clinically, dynamic sonography can offer high diagnostic accuracy and guidance for invasive investigations.

Internal endoprosthesis as treatment of obstructive jaundice in pancreatitis

In five patients with pancreatitis, obstructive jaundice was relieved by internal drainage of the biliary tract with an endoprosthesis inserted by percutaneous transhepatic technique. The average duration of treatment was 3.5 months. The endoprosthesis were removed by means of a duodenoscope, and jaundice did not recur.

Therapeutic effect and side effects in patients with endogenous depression treated with oral nortriptyline once a day

Out of 24 patients with endogenous depression, 21 completed the treatment with nortriptyline 150 mg as once-a-day dosage. The therapeutic effect was good and at any rate not inferior to that of dosages several times a day. Side effects were only little pronounced and at any rate not more marked than after dosages several times a day. Out of regard for the administrative and psychological advantages of the once-a-day dosage this form should be preferred, not least in the out-patient treatment with nortriptyline of endogenous depression.