Course of Disease in Patients with Microscopic Colitis: A European Prospective Incident Cohort Study

BACKGROUND AND AIMS

The disease course of microscopic colitis [MC] is considered chronic but benign. However, this assumption is based on mainly retrospective studies, reporting on incomplete follow-up of selective cohorts. Systematic, prospective and unbiased data to inform patients and healthcare professionals on the expected course of the disease and real-life response to therapy are warranted.

METHODS

A prospective, pan-European, multi-centre, web-based registry was established. Incident cases of MC were included. Data on patient characteristics, symptoms, treatment and quality of life were systematically registered at baseline and during real-time follow-up. Four disease course phenotypes were discriminated and described.

RESULTS

Among 381 cases with complete 1-year follow-up, 49% had a chronic active or relapsing disease course, 40% achieved sustained remission after treatment and 11% had a quiescent course. In general, symptoms and quality of life improved after 3 months of follow-up. A relapsing or chronic active disease course was associated with significantly more symptoms and impaired quality of life after 1 year.

CONCLUSIONS

A minority of MC patients follow a quiescent disease course with spontaneous clinical improvement, whereas the majority suffer a chronic active or relapsing disease course during the first year after diagnosis, with persisting symptoms accompanied by a significantly impaired quality of life.

European guidelines on microscopic colitis: United European Gastroenterology and European Microscopic Colitis Group statements and recommendations

INTRODUCTION

Microscopic colitis is a chronic inflammatory bowel disease characterised by normal or almost normal endoscopic appearance of the colon, chronic watery, nonbloody diarrhoea and distinct histological abnormalities, which identify three histological subtypes, the collagenous colitis, the lymphocytic colitis and the incomplete microscopic colitis. With ongoing uncertainties and new developments in the clinical management of microscopic colitis, there is a need for evidence-based guidelines to improve the medical care of patients suffering from this disorder.

METHODS

Guidelines were developed by members from the European Microscopic Colitis Group and United European Gastroenterology in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists, pathologists and basic scientists, and voted upon using the Delphi method.

RESULTS

These guidelines provide information on epidemiology and risk factors of microscopic colitis, as well as evidence-based statements and recommendations on diagnostic criteria and treatment options, including oral budesonide, bile acid binders, immunomodulators and biologics. Recommendations on the clinical management of microscopic colitis are provided based on evidence, expert opinion and best clinical practice.

CONCLUSION

These guidelines may support clinicians worldwide to improve the clinical management of patients with microscopic colitis.

Microscopic colitis in Denmark and Sweden: incidence, putative risk factors, histological assessment and endoscopic activity

OBJECTIVE

The significantly higher incidence rates of microscopic colitis (MC) in Denmark compared to Sweden remains unexplained.

METHODS

Consecutive patients with newly diagnosed MC in the neighbouring regions of Skåne in 2011-2015 and Zealand in 2010-2016 were prospectively identified. Data on large bowel endoscopies and biopsies rates were retrieved. Information on putative factors were obtained from registers and literature. Interobserver agreement between pathologists from both regions on 40 blinded hematoxylin and eosin (H&E)-stained colon biopsies (collagenous colitis (CC), lymphocytic colitis (LC), non-specific inflammation and normal) was evaluated using kappa statistics.

RESULTS

The mean annual incidence per 10⁵ inhabitants in Skåne and Zealand 2010-2015 was 5.9 (95% CI 4.6-7.3) versus 16.4 (95% confidence intervals (95% CI) 13.6-19.2) for CC and 2.7 (95% CI 1.0-4.3) versus 11.1 (95% CI 8.8-13.4) for LC, respectively. Number of endoscopies with biopsy per 1000 and the rate of MC per endoscopy with biopsy was higher in Zealand (34-52/1000) than in Skåne (12-21/1000). The kappa value for overall agreement between pathologists was good (0.72; 95% CI 0.64-0.79). Prescription of proton pump inhibitors and selective serotonin reuptake inhibitors was higher in Skåne in the relevant age groups and prescription of non-steroidal anti-inflammatory drugs and smoking rate higher in Zealand. Alcohol consumption was higher in Denmark than in Sweden.

CONCLUSION

The incidence of MC and number of cases per colonic biopsy was higher in Zealand and could not be readily explained by endoscopy or biopsy rates, differences in histological assessment or putative risk factors.

Risk of osteoporosis in microscopic colitis

OBJECTIVES

Patients with microscopic colitis (MC) have several risk factors for osteoporosis. The prevalence of osteopenia and osteoporosis in MC is unknown. The primary purpose of this study was to evaluate bone mineral status in MC.

METHODS

Patients with MC and disease activity within the last 2 years were included. Bone turnover markers were analyzed and bone mineral density (BMD) was measured with Dual Energy X-ray Absorptiometry (DXA) at inclusion and after one year. Medical history, demographics, risk factors for osteoporosis, disease activity and treatment with cumulative budesonide dosage at least 3 years before inclusion was registered. Adrenal function was tested by adrenocortico-tropic hormone (ACTH) and an ACTH stimulation test at inclusion. Results were compared with age and sex-matched controls.

RESULTS

Fifty MC patients (44 women) were included. Median age 67 (range 45-93); median disease duration 28 month (range 2-163); median cumulative budesonide dosage 702 mg (range 0-5400). No difference in number of patients with osteoporosis or osteopenia and BMD was detected between groups. The bone mineral formation marker specific alkaline phosphatase was lower in MC than controls 12 (5-69) µg/l versus 16 (10-35) µg/l (p < 0.005). Patients more often smoked (34% versus 10%, p = 0.001). Disease duration and cumulative budesonide dose was associated with lower BMD and T-score in hip (Spearman's rho; p < 0.05) with a cut of point of 2500 mg budesonide predicting osteopenia. Budesonide treatment did not affect adrenal gland function.

CONCLUSION

The risk of osteoporosis in patients with MC is not increased. However, DXA scan is recommended in MC patients with known risk factors or active disease requiring longstanding budesonide treatment. Supplementation of calcium and vitamin-D in patients treated with budesonide is recommended.

Chenodeoxycholic acid stimulated fibroblast growth factor 19 response - a potential biochemical test for bile acid diarrhoea

BACKGROUND

Bile acid diarrhoea is underdiagnosed and better diagnostic tests are needed. Fasting serum fibroblast growth factor-19 (FGF19) has insufficient diagnostic value, but this may be improved by stimulation.

AIM

To explore if an impaired FGF19 response identifies primary bile acid diarrhoea.

METHODS

Eight patients with primary bile acid diarrhoea and eight healthy volunteers ingested (i) a meal plus 1250 mg chenodeoxycholic acid (CDCA), (ii) 1250 mg CDCA or (iii) the meal. Blood was sampled at fasting and repeatedly after stimulation. We analysed FGF19 by enzyme-linked immunosorbent assay and bile acids including 7α-hydroxy-4-cholesten-3-one by liquid chromatography-tandem mass spectrometry.

RESULTS

Stimulation with the meal plus CDCA increased median FGF19 in healthy volunteers from fasting 62 pg/mL [interquartile range (IQR): 41-138] to 99 pg/mL (IQR: 67-147; P = 0.012) after 90 min and peaked after 150 min at 313 pg/mL (IQR: 54-512). This response was impaired in primary bile acid diarrhoea patients [fasting 56 pg/mL (IQR: 42-79); 90 min: 48 pg/mL [IQR: 37-63); 150 min: 57 pg/mL (48-198)]. Receiver operating characteristics (ROC_AUC ) for fasting FGF19 was 0.55 (P = 0.75) and at 90 min 0.84 (P = 0.02). The difference in FGF19 from fasting to 90 min after the meal plus CDCA separated the groups (ROC_AUC 1.0; P = 0.001). 7α-hydroxy-4-cholesten-3-one was elevated in primary bile acid diarrhoea (P = 0.038) and not significantly affected by stimulation.

CONCLUSIONS

The FGF19 response following chenodeoxycholic acid plus meal is impaired in primary bile acid diarrhoea. This may provide a biochemical diagnostic test.

Implications of Infliximab Treatment Failure and Influence of Personalized Treatment on Patient-reported Health-related Quality of Life and Productivity Outcomes in Crohn's Disease

BACKGROUND

This study assessed the effects of infliximab (IFX) treatment failure on patient-reported outcomes and explored the influence of using personalized treatment in this situation.

METHODS

Sixty-nine Crohn's disease patients with IFX treatment failure were randomized to an intensified IFX regimen (n = 36) or personalized treatment defined by IFX and anti-IFX antibodies (n = 33). Health-related quality of life evaluated with the Short Inflammatory Bowel Disease Questionnaire (IBDQ) and productivity evaluated with the Work Productivity and Activity Impairment Questionnaire (WPAI:CD) were assessed at treatment failure and after 4, 8, 12 and 20 weeks.

RESULTS

Median IBDQ score at manifestation of IFX treatment failure was 40 and improved markedly in responders by 11 at weeks 4 and 8 (p < 0.001) and by 13 at weeks 12 and 20 (p < 0.001). Non-responders improved modestly at weeks 12 and 20 (increase of median 4, p < 0.05). Overall activity impairment was high at IFX failure (median 70%) and decreased substantially in responders (40-50%, p < 0.001) and to a lesser extent in non-responders (15-40%, p < 0.05). In employed patients (55%), absenteeism was negligible during the entire study period. However, median presenteeism was 40% at manifestation of IFX failure and decreased only among responders across time (decrease 10-30%, p < 0.05). Although anti-tumour necrosis factor (TNF) therapy was discontinued in most patients handled by personalized treatment, IBDQ and WPAI:CD scores were similar in these patients compared with patients routinely dose-intensified on IFX.

CONCLUSION

Regaining low disease activity after IFX failure is necessary for minimizing patient impairment and indirect disease-related costs. A personalized treatment strategy does not have a negative influence on patient-reported outcomes.

Changes in serum trough levels of infliximab during treatment intensification but not in anti-infliximab antibody detection are associated with clinical outcomes after therapeutic failure in Crohn's disease

BACKGROUND AND AIMS

Intensification of the infliximab (IFX) regimen is recommended if the treatment effect is inadequate. However, the rationale for this is not well defined as the underlying mechanisms vary. The aim of this study was to explore the association between changes in serum IFX and anti-IFX antibodies (Abs) after IFX intensification and clinical outcomes.

METHODS

We performed a post hoc analysis of a randomized clinical trial including 42 Crohn's disease patients with IFX treatment failure, all treated with an intensified IFX regimen (5mg/kg every 4 week) for 12 weeks. Trough serum IFX and anti-IFX Ab concentrations were measured by a homogeneous mobility shift binding assay (HMSA) and a functional cell-based reporter gene assay (RGA) at treatment failure and the end of the trial.

RESULTS

Twenty-one patients (50%) regained clinical response on the intensified IFX regimen. The increase in serum trough levels of IFX during treatment intensification was higher among responders than non-responders (RGA, 8.8 versus 3.0 μg/mL, p = 0.035; HMSA, 9.9 versus 4.7 μg/mL, p = 0.040), and differentiated patients by clinical outcome (RGA, area under receiver operating characteristic curve [AUC] 0.75 [0.53-0.97], p = 0.035; HMSA, AUC 0.74 [0.53-0.95], p = 0.042). All responders exhibited an IFX increase ≥2.6 μg/mL (sensitivity 100%, specificity 50%). Anti-IFX Abs detected by HMSA in 13 patients (32%) were often non-functional and became undetectable during IFX intensification. However, even functional anti-IFX Abs detected by RGA in six patients (15%) became undetectable.

CONCLUSION

Increase in IFX levels following treatment intensification was associated with improved clinical outcomes, indicating insufficient drug levels in a subgroup of patients. Anti-IFX Abs may become undetectable during treatment intensification, suggesting lowered production or the formation of immune complexes.

The use of shared medication record as part of medication reconciliation at hospital admission is feasible

INTRODUCTION

Medication reconciliation improves congruence in cross sectional patient courses. Our regional electronic medical record (EMR) integrates the shared medication record (SMR) which provides full access to current medication and medication prescriptions for all citizens in Denmark. We studied whether our SMR integration could facilitate medication reconciliation.

MATERIAL AND METHODS

Patients admitted to the emergency department for hospitalization were randomised to consultation using EMR with or without the integrated SMR access. Observed time used for medication reconciliation was the primary efficacy parameter.

RESULTS

A total of 62 consecutive patient consultations were randomised including 39 with more than five prescriptions. EMR had data from previous consultations for 46 patients, 59 patients provided information on medication. In all, 18 junior physicians in early postgraduate medical training each participated with a median of three consultations (range 1-9). Time expenditure for medicine reconciliation was 5:27 min.:sec. (range: 2:00-15:37) with access to SMR integration and 4:15 min.:sec. (1:15-12:00) without SMR access. The number of active medicine prescriptions was eight and nine, respectively. Incorporating SMR did not increase the work load. Physicians judged the SMR integration and workflow as being useful. Patients unambiguously sup-ported physicians' use of SMR in this setting.

CONCLUSION

Integration of information on individuals' medication from a national SMR into a hospital EMR was feasible and useful, and it did not increase time expenditure for medication reconciliation.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Azathioprine and mercaptopurine in the management of patients with chronic, active microscopic colitis

BACKGROUND

Microscopic colitis (MC) is a common chronic diarrhoeal disease, and remission can be induced with budesonide. However, diarrhoea relapses frequently when budesonide is tapered and a few patients become budesonide intolerant.

AIM

To examine retrospectively the effect of azathioprine (AZA) and mercaptopurine (MP) in patients with chronic, active MC.

METHODS/PATIENTS

Data on all MC patients who received AZA or MP in the years 1997-2011 at three centres representing three countries were pooled for analysis. The indications for thiopurine therapy were frequent relapses after short-term treatment (N = 26), budesonide dependency on 6 mg (N = 15) and budesonide intolerance (N = 5). The response to thiopurine treatment was defined as clinical remission, intolerance or nonresponse.

RESULTS

Forty-six MC patients (32 CC and 14 LC), 32 female; median age 59 years (range: 36-83) with a median disease duration of 3 years (range: 0.5-18) were included. Thirteen patients (28%) achieved long-term clinical remission on AZA therapy. AZA failed in 31 patients (67%) due to intolerance and in 2 patients (4%) because of nonresponse. Thirteen of 31 AZA-intolerant patients were switched to MP and 6 patients (46%) obtained clinical remission. Thus, the overall response rate to thiopurines was 19/46 (41%). The main side effects were nausea/vomiting and abnormally elevated liver enzymes.

CONCLUSIONS

In this retrospective case series, the majority of chronic, active MC patients were intolerant to AZA leading to cessation of treatment. However, further studies are needed to explore the efficacy, acceptance, tolerance and safety of MP in patients with chronic, active MC refractory to budesonide.

Microscopic colitis: Current status, present and future challenges: statements of the European Microscopic Colitis Group

Microscopic colitis (MC) is an inflammatory bowel disease presenting with chronic, non-bloody watery diarrhoea and few or no endoscopic abnormalities. The histological examination reveals mainly two subtypes of MC, lymphocytic or collagenous colitis. Despite the fact that the incidence in MC has been rising over the last decades, research has been sparse and our knowledge about MC remains limited. Specialists in the field have initiated the European Microscopic Colitis Group (EMCG) with the primary goal to create awareness on MC. The EMCG is furthermore a forum with the intention to promote clinical and basic research. In this article statements and comments are given that all members of the EMCG have considered being of importance for a better understanding of MC. The paper focuses on the newest updates in epidemiology, symptoms and diagnostic criteria, pathophysiology and highlights some unsolved problems. Moreover, a new treatment algorithm is proposed on the basis of new evidence from well-designed, randomized control trials.

Systematic review: are lymphocytic colitis and collagenous colitis two subtypes of the same disease - microscopic colitis?

BACKGROUND

Despite similar clinical symptoms, collagenous colitis (CC) and lymphocytic colitis (LC) are considered two distinct disease entities.

AIM

To compare pathoanatomical findings, clinical presentations, risk factors, course of diseases and response to treatment in CC and LC to establish whether they could be subtypes of the same disease, microscopic colitis (MC).

METHODS

The MEDLINE was searched for CC, LC and MC, and clinical studies of >20 patients were included. Pooled results with 95% confidence intervals were calculated based on the number of patients.

RESULTS

An abnormal number of intraepithelial lymphocytes are found in 45% (40-50%) with CC, and an abnormal subepithelial collagen band in 16% (13-20%) with LC suggesting a histological overlap. The incidence of CC and LC has increased in parallel. Mean age (CC 63 years; LC 60 years) and clinical presentation are indistinguishable, and females are predominant in CC (77%; 75-79%) as well as LC (68%; 66-70%). Risk factors such as nonsteroid anti-inflammatory drugs consumption CC 39% (36-42%); LC 32% (29-35%) are similar and prevalence of concomitant autoimmune diseases such as coeliac disease (CC 5%; CI: 4-6% and LC 7%; CI: 6-9%) do not differ. Bile acid diarrhoea is highly prevalent in CC (41%; 37-45%) and LC (29%; 24-34%). The effect of budesonide is identical.

CONCLUSIONS

CC and LC could be considered histological subtypes of the same disease, MC. To facilitate recruitment to clinical trials, all MC patients could be included in future trials and stratified for subtypes.

Microscopic colitis: clinical findings, topography and persistence of histopathological subgroups

BACKGROUND

Uncertainty remains on topography and persistence of histological subgroups of microscopic colitis (MC).

AIM

To assess longitudinal clinical, endoscopic, histological, and therapeutic description of MC subgroups including patients with incomplete findings of MC (MCi).

METHODS

Retrospective review of a consecutive cohort with MC and histological reassessment of MCi.

RESULTS

Clinical characteristics of 168 patients with lymphocytic colitis (LC), 270 with collagenous colitis (CC) and 101 with MCi were similar. At colonoscopy 95% (95% CI: 91-98%) of CC and 98% (93-100%) of LC cases had diagnostic histopathology of MC in both left and right colon. Eight and three patients had characteristics of MC only in the left and right colon, respectively. Histology findings resembling coexistence of the other MC subtype was present in 48% (40-55%) with CC and 24% (18-31%) with LC. A first diagnosis of MC was made in 49 (30%) of 164 patients only at repeat endoscopy. Another 34 of 115 (30%) with MC in the first endoscopy did not fulfil the MC criteria at repeat endoscopy. Only seven cases had a primary endoscopy without histopathological abnormalities. Fifteen percentage of MCi were reclassified as MC. Ileal inflammation was present in 33 of 81 patients. Budesonide was efficacious in all MC subgroups irrespective of bile acid malabsorption.

CONCLUSIONS

Clinical characteristics of microscopic colitis subgroups are indistinguishable. Biopsies from the left colon suffice to exclude microscopic colitis, and the histological diagnosis of microscopic colitis is inconsistent over time. Ileal inflammation is common. The term microscopic colitis should perhaps be considered one clinical entity and include lymphocytic colitis, collagenous colitis, and incomplete findings of microscopic colitis.

Use of biological molecules in the treatment of inflammatory bowel disease

The introduction of biological agents (i.e. antitumour necrosis factor-α and anti-integrin treatments) for the treatment of inflammatory bowel disease (IBD) [i.e. Crohn's disease (CD) and ulcerative colitis] has led to a substantial change in the treatment algorithms and guidelines, especially in CD. However, many questions still remain about the true efficacy and the best treatment regimens. Thus, a need for further treatment options still exists as up to 40% of IBD patients treated with the presently available biologicals do not have positive clinical responses. Better patient selection might maximize the clinical benefit for those in most need of an effective therapy to avoid disabling disease whilst also minimizing the complications associated with therapy. Further, the 'trough-level strategy' may help clinicians to optimize therapy and to avoid loss of response and/or immunogenicity. The idea behind this dosage regimen is that correct dosing must ensure that the patient's lowest level of drug concentration (i.e. the trough level) occurring just before the next drug administration is high enough for the full effect to be seen. Controversy continues regarding the appropriate use of biologicals; therefore, in this review, we focus on considerations that might lead to a more rational strategy for antitumour necrosis factor-α agents in IBD, emphasizing the situations in which the risks may outweigh the benefits. Finally, the need for an appropriate strategy for stopping biological treatment is discussed.

Drug insight: aminosalicylates for the treatment of IBD

Sulfasalazine and mesalazine (also known as mesalamine; 5-aminosalicylic acid) preparations have for many years been used for the treatment of IBD (i.e. ulcerative colitis and Crohn's disease), for both active disease and the control of remission. It has also been suggested that mesalazine is a chemoprophylactic agent that protects against the development of colorectal cancer. This Review focuses on the latest clinical evidence for the use of these aminosalicylates for the treatment of IBD, and concludes that sulfasalazine and mesalazine are useful for the treatment of both active and quiescent ulcerative colitis, whereas they have no clinical effect on either active or inactive Crohn's disease. Furthermore, evidence is lacking that mesalazine per se is a chemoprophylactic agent.

Probiotic treatment of collagenous colitis: a randomized, double-blind, placebo-controlled trial with Lactobacillus acidophilus and Bifidobacterium animalis subsp. Lactis

BACKGROUND

Probiotic treatment may be effective in diseases involving gut microflora and intestinal inflammation. In collagenous colitis (CC), a potential pathogenic role of the gut microflora has been proposed. The effect of probiotic treatment in CC is unknown. Our aim was to investigate the clinical effect of treatment with Lactobacillus acidophilus LA-5 and Bifidobacterium animalis subsp. lactis BB-12 (AB-Cap-10) in patients with CC.

MATERIALS AND METHODS

Patients with CC and diarrhea were in a double-blind placebo-controlled study randomized (2:1) to AB-Cap-10 or placebo for 12 weeks. The primary end point was reduction in bowel frequency per week of >or=50%. Secondary end points were changes in bowel frequencies, stool consistency, stool weight, histopathology, and abdominal bloating and pain.

RESULTS

Twenty-nine patients were randomized: 21 to probiotics and 8 to placebo. Reduction in bowel frequency per week of >or=50% occurred in 6 of 21 (29%) and in 1 of 8 (13%) patients receiving probiotic and placebo, respectively (P = 0.635). No differences between treatments were observed regarding the secondary end points. Post hoc analysis showed a median reduction in bowel frequency per week from 32 (range 18-84) to 23 (range 11-56; P < 0.005), a reduction in number of days with liquid stools per week from 6 days (range 0-7 days) to 1 day (range 0-7 days; P < 0.005), and an increase in number of days with solid stools per week (P < 0.05) in the AB-Cap-10 group.

CONCLUSIONS

AB-Cap-10 had no significant effect on the chosen end points. Post hoc analysis demonstrated amelioration of clinical symptoms in the AB-Cap-10 group, indicating that probiotic treatment may potentially influence the disease course of CC.

H+/amino acid transporter 1 (PAT1) is the imino acid carrier: An intestinal nutrient/drug transporter in human and rat

BACKGROUND AND AIMS

Amino acid (and related drug) absorption across the human small intestinal wall is an essential intestinal function. Despite the revelation of a number of mammalian genomes, the molecular identity of the classic Na(+)-dependent imino acid transporter (identified functionally in the 1960s) remains elusive. The aims of this study were to determine whether the recently isolated complementary DNA hPAT1 (human proton-coupled amino acid transporter 1), or solute carrier SLC36A1, represents the imino acid carrier; the Na(+) -dependent imino acid transport function measured at the brush-border membrane of intact intestinal epithelia results from a close functional relationship between human proton-coupled amino acid transporter-1 and N(+) /H(+) exchanger 3 (NHE3).

METHODS

PAT1 function was measured in isolation ( Xenopus laevis oocytes) and in intact epithelia (Caco-2 cell monolayers and rat small intestine) by measurement of amino acid and/or H(+) influx. Tissue and membrane expression of PAT1 were determined by reverse-transcription polymerase chain reaction and immunohistochemistry.

RESULTS

PAT1-specific immunofluorescence was localized exclusively to the luminal membrane of Caco-2 cells and human and rat small intestine. The substrate specificity of hPAT1 is identical to that of the imino acid carrier. In intact epithelia, PAT1-mediated amino acid influx is reduced under conditions in which NHE3 is inactive.

CONCLUSIONS

The identification in intact epithelia of a cooperative functional relationship between PAT1 (H(+) /amino acid symport) and NHE3 (N(+) /H(+) exchange) explains the apparent Na + dependence of the imino acid carrier in studies with mammalian intestine. hPAT1 is the high-capacity imino acid carrier localized at the small intestinal luminal membrane that transports nutrients (imino/amino acids) and orally active neuromodulatory agents (used to treat affective disorders).

Randomized controlled azathioprine withdrawal after more than two years treatment in Crohn's disease: increased relapse rate the following year

INTRODUCTION

Azathioprine is effective for maintenance of remission in Crohn's disease, however, duration of efficacy and the dose response relationship has not been fully evaluated.

AIMS

To investigate whether patients kept in remission by azathioprine treatment for >2 years benefit from further treatment, and to explore dose-response relationship.

PATIENTS AND METHODS

In an open 12-month trial, patients with inactive Crohn's disease after >2 years (median 37 months) of azathioprine treatment were randomized to azathioprine withdrawal or continued treatment. Primary end point was relapse defined as: (i) Crohn's disease activity index rise >/= 75, and Crohn's disease activity index >150 or (ii) disease activity requiring intervention.

RESULTS

Of 29 patients, 28 completed the observation period or relapsed. Eleven of 13 patients (85%) continuing azathioprine remained in remission compared with seven of 15 (47%) observed without azathioprine (P = 0.043). In patients who had been treated with azathioprine >1.60 mg/kg/day the difference was even more pronounced, eight of nine (89%) vs. four of 12 (33%) respectively (P = 0.017).

CONCLUSIONS

Patients with Crohn's disease in remission after >2 years of continuous azathioprine treatment will benefit from further continued treatment. Further controlled studies with azathioprine doses <2.0 mg/kg/day are needed.

Congruence on medication between patients and physicians involved in patient course

OBJECTIVE

To analyse congruence on medication throughout patient courses, including an acute admission to a medical department.

DESIGN

A prospective, observational study. Data were collected from patient records in primary health care, hospital departments, from the Health Insurance database and through patient interviews.

SETTING

Departments of internal medicine, general practice and patients' homes.

MAIN OUTCOME MEASURES

Number, type and character of discrepancies between paired sources of information on patient medication at predefined time points throughout the complete patient course. Assessment of likelihood and severity of potential untoward effects of discrepancies.

RESULTS

Data were obtained for 75 of 99 consecutive patients included. Patients stated use of four drugs (median, range 0-17) at admission, five (0-16) at discharge and four (0-15) 1 month after discharge. At admission, 11 patients used no drugs. A median of one (0-20) to three (0-16) discrepancies per patient were identified in seven paired source comparisons with no improvement along patient course. Full agreement throughout the course was found in six patients (8%; 95% confidence interval: 3-17%). No association was found among source discrepancies and number of drugs and age. Of discrepancies, 4-13% were considered serious and likely to cause untoward effects. Discrepancies due to synonymous and analogous drugs accounted for 2-7% of the discrepancies.

CONCLUSION

Congruence between sources of information on medication throughout patient courses cannot be obtained with separate medication charts. Discrepancies among patient, general practitioner and hospital give rise to a definitive risk of serious untoward effects.

Incomplete remission with short-term prednisolone treatment in collagenous colitis: a randomized study

BACKGROUND

Microscopic colitis is a disease of unknown aetiology characterized by chronic watery diarrhoea and diarrhoea can be eliminated by budesonide but frequently recurs when budesonide is stopped. We studied whether prednisolone could induce remission in patients with disabling, chronic diarrhoea due to microscopic colitis.

METHODS

A double-blind, randomized (3:1) trial of oral prednisolone 50 mg daily or placebo for 2 weeks. Remission was defined as stool weight < or = 200 g/day or frequency < or = 2/day; effect was defined as > 50% reduction of either stool frequency or weight. Six centres screened 31 consecutive patients and included 11 with collagenous colitis and 1 with lymphocytic colitis. Median duration of diarrhoea was 9 months. Patients had a normal colonoscopy, and no evidence of coeliac disease, bile acid or lactose malabsorption. Patients with gastrointestinal infection, previous gastrointestinal surgery, abnormal biochemical screening or recent treatment with immunosuppressive agents were excluded.

RESULTS

Stool weight (grams) declined in 7 of 9 patients given prednisolone and in 1 of 3 receiving placebo; changes in median weight were from 430 to 278 and from 825 to 489, respectively. Stool frequency (per day) declined from 6 to 3 and from 8 to 5. Remission was obtained in 2 and 0, and effect in 5 and 0, respectively (NS; Fisher exact test).

CONCLUSIONS

Prednisolone 50 mg daily for 2 weeks induces incomplete remission in patients with chronic diarrhoea due to collagenous colitis.

Incomplete remission with short-term prednisolone treatment in collagenous colitis: a randomized study

BACKGROUND

Microscopic colitis is a disease of unknown aetiology characterized by chronic watery diarrhoea and diarrhoea can be eliminated by budesonide but frequently recurs when budesonide is stopped. We studied whether prednisolone could induce remission in patients with disabling, chronic diarrhoea due to microscopic colitis.

METHODS

A double-blind, randomized (3:1) trial of oral prednisolone 50 mg daily or placebo for 2 weeks. Remission was defined as stool weight < or = 200 g/day or frequency < or = 2/day; effect was defined as > 50% reduction of either stool frequency or weight. Six centres screened 31 consecutive patients and included 11 with collagenous colitis and 1 with lymphocytic colitis. Median duration of diarrhoea was 9 months. Patients had a normal colonoscopy, and no evidence of coeliac disease, bile acid or lactose malabsorption. Patients with gastrointestinal infection, previous gastrointestinal surgery, abnormal biochemical screening or recent treatment with immunosuppressive agents were excluded.

RESULTS

Stool weight (grams) declined in 7 of 9 patients given prednisolone and in 1 of 3 receiving placebo; changes in median weight were from 430 to 278 and from 825 to 489, respectively. Stool frequency (per day) declined from 6 to 3 and from 8 to 5. Remission was obtained in 2 and 0, and effect in 5 and 0, respectively (NS; Fisher exact test).

CONCLUSIONS

Prednisolone 50 mg daily for 2 weeks induces incomplete remission in patients with chronic diarrhoea due to collagenous colitis.

[Joint charts in drug handling. Toward increased drug safety]

INTRODUCTION

Medication errors contribute to 8% of all hospital admissions. Minimalization of the number of information transferrals and improvement in communication may increase the quality of drug treatment.

MATERIAL AND METHODS

The effect of introducing joint charts for prescription and administration on the quality of drug handling in a hospital setting is reported.

RESULTS

When separate charts were used the prescriptions in the case records and the nurses' charts for administration did not tally for any of 20 patients. One year after introducing the joint charts, prescriptions for the regular medication and medication on demand were correct and signed for 88% and 48%, respectively, on a patient basis. Ninety-five per cent of the regular administrations were correct and signed. Potential interactions were identified in 15% of the prescriptions. Discharge medication was stated in 65% of the discharge letters to the family doctors. Complete agreement on admission medication between the patient and family doctor was found in 39%.

DISCUSSION

Joint charts for prescription and administration represent a significant step towards safe and rational medical treatment. It is more time-consuming. Improvement in communication between all parties involved in the treatment of the same patient represents an important potential for further improving the quality of care, including drug treatment.

Transport of neutral, cationic and anionic amino acids by systems B, b(o,+), X(AG), and ASC in swine small intestine

Amino acid influx across the brush border membrane of the intact pig ileal epithelium was studied. It was examine whether in addition to system B, systems ASC and b(o,+) were involved in transport of bipolar amino acids. The kinetics of interactions between lysine and leucine demonstrates that system b(o,+) is present and accessible also to L-glutamine. D-aspartate (K(1/2) 0.3 mM) and L-glutamate (K(i) 0.5 mM) share a high affinity transporter with a maximum rate of 1.3 micromol cm(-2) h(-1), while only L-glutamate with a K(1/2) of 14.4 mM uses a low affinity transporter with a maximum rate of 2. 7 micromol cm(-2) h(-1), system ASC, against which serine has a K(i) of 1.6 mM. In the presence of 100 mM lysine, L-glutamine (A), leucine (B), and methionine (C) fulfilled the criteria of the ABC test for transport by one and the same transporter. However, serine inhibits not only transport of L-glutamate but also of glutamine (K(i) 0.5 mM), and L-glutamate inhibits part of the transport of glutamine. The test does, therefore, only indicate that the three bipolar amino acids have similar affinities for transport by systems B and ASC. Further study of the function of system B must be carried out under full inhibition by lysine and glutamate.

Effects of pH changes on systems ASC and B in rabbit ileum

Influx of D-aspartate (D-Asp), L-glutamate (L-Glu), and serine (Ser) across the brush-border membrane of the intact mucosa from rabbit ileum has been examined. L-Glu influx is chloride independent and completely sodium dependent. D-Asp and L-Glu share a transport system with a maximum transport rate of 1 micromol. cm-2. h-1 and an apparent affinity constant (K1/2) of approximately 0.3 mM. The function of this transport system is pH insensitive between pH 5.65 and 8.2, and bipolar amino acids do not affect the way in which the transport system handles D-Asp and L-Glu. The characteristics of this transport system match those of system X-AG. L-Glu and Ser share a transporter for which the inhibitor constant (Ki) of L-Glu against Ser decreases from 54 to 10 mM when pH is reduced from 7.2 to 5.65, while the maximum rate of transport remains unaffected at approximately 10 micromol. cm-2. h-1. The Ki values (5 mM) of Ser against L-Glu influx and the L-Glu-sensitive contribution to Ser influx (0.8 micromol. cm-2. h-1 at 1 mM Ser) are the same at both pH values. The L-Glu-sensitive transport of Ser together with the contribution of system bo,+ account for approximately 50% of Ser influx at pH 7.2. The remaining 50% can be ascribed to system B. Transport of Ser by system B is reduced by >95% at pH 5.65. At pH 7. 2 Ki of Ser against transport of leucine (Leu) by system B is 18 mM and Ki of Leu against transport of Ser is 1.7 mM. The low-affinity transport of L-Glu and the L-Glu-sensitive transport of Ser are performed by an equivalent of system ASC. Supplementary experiments using the jejunum confirm the validity of these results for a major portion of the rabbit small intestine.

Comparative aspects of chloride-dependent amino acid transport across the brush-border membrane of mammalian small intestine

Chloride-dependent amino acid transport has been described in several tissues. This article briefly reviews the evidence of cotransport of chloride and amino acids across the brush-border membrane of rabbit distal ileum. On the basis of amino acid carriers described in the rabbit and the surveys of chloride-dependence reported, a comparison of amino acid carriers in the mammalian small intestine is performed. Additional characteristics of the carriers in the different species are included in the discussion when necessary. From this comparison the rabbit distal ileum and the pig small intestine emerge as the best models of amino acid transport in the human small intestine.

Regional differences in the effect of mucosal glucose and amino acids on ion transport in normal and cholera toxin-stimulated porcine small intestine

BACKGROUND

This study explores regional differences in the response to mucosal D-glucose and L-amino acids in both normal intestine and intestine stimulated with cholera toxin.

METHODS

Proximal, mid and distal small intestines from 6- to 8-week-old pigs were bathed in Ussing chambers with a buffer containing 15 mM serosal glucose, and the effect of adding a cocktail giving luminal chamber concentrations of 15 mM D-glucose and 20 mM of each L-alanine, L-proline, L-lysine, L-phenylalanine, and L-glutamine on transmucosal Na+ and Cl- transport was measured.

RESULTS

In all segments of both normal and cholera toxin-treated intestine, electrogenic Na+ and electroneutral NaCl absorption were promoted. No significant differences in the net increase of Na+ and Cl- absorption between normal and cholera toxin-stimulated intestine were present. Under both conditions no segmental differences were present in the stimulated Cl- absorption, describing identical capacity for stimulated electroneutral NaCl absorption. In contrast the electrogenic Na+ absorption was, compared to the proximal part, doubled in the mid and distal parts under both conditions.

CONCLUSIONS

We conclude that mucosal D-glucose and L-amino acids stimulate electroneutral NaCl and electrogenic Na+ absorption to the same degree in normal and cholera toxin-treated small intestine. There is no segmental difference in stimulated electroneutral NaCl absorption, while electrogenic Na+ absorption is highest in mid and distal parts.

Na+-independent transport of bipolar and cationic amino acids across the luminal membrane of the small intestine

The role of sodium in transport of bipolar and cationic amino acids and their interactions were examined in vitro by measuring unidirectional influx across the brush-border membrane of intact rat jejunal and rabbit ileal epithelia. The chloride-dependent and beta-alanine inhibitable B(0,+) present in rabbit ileum was blocked by combining inhibition by beta-alanine with Na(+)- or Cl(-)-free conditions. Under these conditions, lysine influx across the brush-border membrane is Na+ independent. All Na+-independent influx of cationic and bipolar amino acids is by a system b(0,+) equivalent in the brush-border membrane of both species, where a system y+ is not present. System b(0,+) is shown to be a potent exchanger of intracellular leucine for extracellular lysine and of intracellular lysine for extracellular leucine. The model used to explain leucine stimulation of mucosa to serosa lysine transport can explain Na+ dependence of net lysine absorption. On the assumption that b(0,+) in situ, like the transporter induced by retroperitoneal brown adipose tissue in Xenopus laevi oocytes, acts as an obligatory exchanger, this model can also explain the effects of lysine on short-circuit current and net transport of sodium and the effect on transport capacity by preincubation at Na+-free conditions.

beta-Amino acid transport in pig small intestine in vitro by a high-affinity, chloride-dependent carrier

This study describes unidirectional influx of amino acids and D-glucose across the small intestinal brush-border membrane of fully weaned eight week old pigs. Influx is minimal in the duodenum and maximal in the distal and/or mid small intestine. Influx of beta-alanine, taurine and N-methyl-aminoisobutyric acid is chloride-dependent. The activation stoichiometry for taurine influx is 1.0 +/- 0.2 chloride/2.4 +/- 0.3 sodium/1 taurine. Influx of D-glucose, lysine, glycine and glutamate is chloride-independent. An ABC test demonstrates a common beta-amino acid carrier: (a) the apparent affinity constant K1/2Taurine is 44 +/- 13 microM (means +/- S.D.) and the inhibitory constant (KiTaurine) against beta-alanine influx is 41 +/- 5 microM (means +/- S.E.). (b) K1/2beta-alanine is 97 +/- 23 microM and Kibeta-alanine against taurine influx is 160 +/- 22 microM. (c) KiHypotaurine against taurine and beta-alanine influx is 43 +/- 4 (n = 7) and 22 +/- 5 microM (n = 7), respectively. In conclusion, a high affinity, low capacity, sodium- and chloride-dependent carrier of beta-amino acids is present in pig small intestine.

Chloride-dependent amino acid transport in the small intestine: occurrence and significance

The unidirectional influx of amino acids, D-glucose and ions across the brush-border membrane of the small intestine of different species has been measured in vitro with emphasis on characterization of topographic and species differences and on chloride dependence. The regional differences in transport along the small intestine are outlined and shown to be caused by variation in transport capacity, while the apparent affinity constants are unchanged. Rabbit small intestine is unique by exhibiting maximal rates of transport in the distal ileum and a very steep decline in the oral direction from where tissues are normally harvested for preparation of brush-border membrane vesicles. Transport in the guinea pig and rat is much more constant throughout the small intestine. Since the capacity of nutrient carriers is regulated by their substrates it is possible that bacterial breakdown of peptides and proteins in rabbit distal ileum increases the concentration of amino acids leading to an upregulation of the carriers. Chloride dependence is a characteristics of the carrier rather than the transported amino acid, and is used to improve the classification of amino acid carriers in rabbit small intestine. In this species the imino acid carrier, the beta-amino acid carrier, and the beta-alanine carrier, which should be renamed the B0,+ carrier, are chloride-dependent. The steady-state mucosal uptake of classical substrates for these carriers in biopsies from the human duodenum is also chloride-dependent. The carrier of beta-amino acids emerges as ubiquitous and chloride-dependent, and evidence of cotransport with both sodium and chloride is reviewed. A sodium:chloride:2-methyl-aminoisobutyric acid coupling stoichiometry of approx. 2:1:1 is suggested by ion activation studies. Direct measurements of coupled ion fluxes in rabbit distal ileum confirm that sodium, chloride and 2-methyl-aminoisobutyric acid are cotransported on the imino acid carrier with an identical influx stoichiometry. Control experiments and reference to the literature on the electrophysiology of the small intestine exclude alterations of the membrane potential as a feasible explanation of the chloride dependence. Thus, it is concluded that chloride is cotransported with both sodium and 2-methyl-aminoisobutyric acid across the brush-border membrane of rabbit distal ileum.

Transport of glycine and lysine on the chloride-dependent beta-alanine (B0,+) carrier in rabbit small intestine

Transport of glycine, lysine and beta-alanine in rabbit, guinea pig and rat small intestine has been examined by measurements of the unidirectional influx across the brush border membrane of the intact epithelium. In rabbit distal ileum the chloride-dependent fraction of glycine transport, and all sodium- and chloride-dependent lysine transport is carried on the beta-alanine carrier. Lysine eliminates all saturable, sodium-independent transport of glycine. The saturable, sodium-dependent, and lysine resistant influx of glycine is characterized by a K1/2Gly of 60 mM. Glycine transport in the mid intestine of the guinea pig is chloride-independent and in the rat only a minute fraction may be chloride-dependent. These species do not possess an equivalent of the rabbit beta-alanine carrier. In conclusion, glycine transport in rabbit distal ileum is by the sodium-dependent carrier of neutral amino acids, by the sodium-independent lysine carrier, and by the sodium- and chloride-dependent beta-alanine carrier which closely resembles the B0,+ carrier described in mouse blastocysts. All sodium dependent lysine transport in rabbit distal ileum is by the chloride- and sodium-dependent beta-alanine carrier. It is proposed that the beta-alanine carrier in rabbit distal ileum be renamed the B0,+ carrier.

Chloride dependent amino acid transport in the human small intestine

Carriers of beta amino acids and imino acids in the small intestine of rabbits and guinea pigs are chloride dependent, and a cotransport of chloride, sodium, and 2-methyl-aminoisobutyric acid has been shown. This study examines the chloride dependence of amino acid transport in the human small intestine. The steady state tissue uptake of amino acids, given as the ratio between substrate concentration in intracellular and extracellular water after 35 minutes incubation at 37 degrees C, was determined in mucosal biopsy specimens from the duodenum of patients undergoing diagnostic upper endoscopy and compared using one way analysis of variance. Uptake of leucine and alpha-methyl-D-glucoside in the duodenum and the distal ileum did not differ. The accumulation of all substrates was sodium dependent. In the absence of mucosal chloride the uptake of taurine, glycine, and 2-methyl-aminoisobutyric acid was significantly reduced while that of leucine and alpha-methyl-D-glucoside was unaffected and the reduction of beta alanine uptake not statistically significant. Uptake of 2-methyl-aminoisobutyric acid and proline showed mutual inhibition. Leucine did not reduce uptake of the beta amino acids. In conclusion, chloride dependent transport processes for 2-methyl-amino-isobutyric acid, taurine, and glycine are present in the human small intestine.

[High mortality from both natural and unnatural causes. A 10-year follow-up of patients admitted to a center for poisoning treatment after attempted suicide]

While it is well known that suicide rates for suicide attempters are high, mortality rates for all causes needed to be more thoroughly investigated. A Danish 10-year follow-up study of patients who in 1980 were admitted to a poisoning treatment centre after attempted suicide was carried out with the purpose of describing mortality by suicide and other causes of death, and to identify predictive factors. A total of 974 patients aged 15 and over referred to a poisoning treatment centre after deliberate self-poisoning were included in the study. Death by different causes registered in the Danish Death Cause Register was the outcome measure. Over a 10-year follow-up period 306 patients had died; 103 by suicide, 131 from natural causes, 31 by accidents, five were murdered and in 36 cases the cause of death was uncertain. The Standard Mortality Rate (SMR) was 550. The cause-specific SMRs were for suicide 2960, for natural causes 236, for accidents 1256 and for uncertain causes 5459. In Cox-regression analysis high-risk factors for later suicide were more than one previous suicide attempt (relative risk (RR) 2.25), living alone (RR 2.28) and age (RR 1.03 per year). Predictors of death by natural causes were pension (RR 1.69), drug abuse (RR 2.72), more than one previous suicide attempt (RR 2.25), age (RR 1.06 per year) and male sex (RR 2.49). The group of patients fulfilling at least one high-risk criteria for later suicide differed significantly from the rest of the patient group regarding frequency of suicide, but both sensitivity and specificity remain low.(ABSTRACT TRUNCATED AT 250 WORDS)

Phenylalanine transport in rabbit small intestine

1. The proposal that rabbit small intestine possesses a separate, sodium-dependent carrier of phenylalanine has been examined by measurements of the unidirectional influx of amino acids across the brush-border membrane of the intact epithelium of the rabbit small intestine. 2. We demonstrate that, like alanine, glycine and leucine, phenylalanine shares sodium-dependent as well as sodium-independent transport with lysine. 3. Using the distal ileum we applied the A (phenylalanine)-B (leucine)-C (alanine) test on the sodium-dependent, lysine-resistant transport of phenylalanine. For phenylalanine, K1/2 (concentration required for half-maximal transport) was 3.1 +/- 0.2 mM (n = 7) and Ki (inhibitor constant) against leucine transport was 3.1 +/- 0.2 mM (n = 4). For leucine, K1/2 was 1.1 +/- 0.1 mM (n = 4) and Ki against transport of phenylalanine was 1.1 +/- 0.1 mM (n = 4). For alanine, K1/2 was 12.6 +/- 1.1 mM (n = 3), Ki against phenylalanine was 13.1 +/- 1.8 mM (n = 4) and Ki against leucine was 11.0 +/- 0.4 mM (n = 4). 4. Using the jejunum we applied the A (phenylalanine)-B (alanine)-C (methionine) test on the lysine-resistant, sodium-dependent transport of phenylalanine. For phenylalanine, K1/2 was 4.7 +/- 0.2 mM (n = 7) and Ki against alanine was 4.8 +/- 0.2 mM (n = 4). For alanine, K1/2 was 15.6 +/- 0.8 mM (n = 7) and Ki against phenylalanine was 18.1 +/- 0.9 mM (n = 5).(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of tropisetron to inhibit jejunal water and electrolyte secretion induced by 5-hydroxytryptamine in healthy volunteers

The effects of the 5-hydroxytryptamine (5-HT3) receptor antagonist, ICS 205-930 (tropisetron), on basal and 5-HT induced jejunal secretion of water and electrolytes were examined using a double blind, randomised crossover design. In seven healthy volunteers steady state perfusions of the proximal jejunum were performed twice with the Loc-I-Gut tube after 5+5 mg ICS 205-930 or placebo capsules were given. After equilibration for 60 minutes and completion of a 120 minute basal period 5-HT (10 micrograms/kg x min intravenously) was infused for 120 minutes. Net water absorption (mean (SEM)) in the basal period was 0.55 (0.84) ml/cm x h and 0.74 (0.72) ml/cm x h after placebo and ICS 205-930, respectively (p > 0.05). Infusion of 5-HT caused significant net secretion of water after placebo (2.05 (0.58) ml/cm x h; p < 0.02) as well as ICS 205-930 (2.60 (0.89) ml/cm x h; p < 0.05). As ICS 205-930 excerted no effects on either basal or 5-HT induced water and electrolyte transport in the intact human jejunum the compound is probably not efficacious as an anti-secretory drug in patients with 5-HT induced diarrhoea.

Specificity of the imino acid carrier in rat small intestine

The rat intestinal imino acid carrier is chloride independent, while in guinea pig and rabbit intestine it is chloride dependent. While non-alpha-amino acids do not significantly interact with guinea pig and rabbit imino acid carriers, inhibition studies had indicated that in rat small intestine beta-alanine, gamma-aminobutyric acid (GABA), and probably taurine might be transported by the imino acid carrier. The present study of rat jejunum demonstrates that the half-maximal activation concentration of beta-alanine (K1/2 beta-Ala) is identical to its inhibition constant (Ki beta-Ala) against GABA, that K1/2GABA is identical to KiGABA against beta-alanine, that proline and sarcosine have identical values of Ki against beta-alanine and GABA, and that Ki of beta-alanine and proline against sarcosine are equal to their K1/2 values. Taurine inhibits the transport of beta-alanine, and 300 mM proline and beta-alanine reduce the transport of taurine measured at 80 mM taurine to the level expected for the diffusive contribution, corresponding to Ki values equal to those against sarcosine. Thus the rat imino acid carrier is the principal carrier of taurine and the only carrier of beta-alanine and GABA. It is also demonstrated that alpha-amino-monocarboxylic acids with side chains in excess of one methyl group do not significantly interact with the imino acid carrier, and the lack of stereospecificity is confirmed.

Chloride-dependent intestinal transport of imino and beta-amino acids in the guinea pig and rat

The present study extends the observations of chloride-dependent intestinal amino acid carriers to the guinea pig and the rat using the technique of in vitro influx across the brush-border membrane of intact epithelium. Transport rates of D-glucose and L-amino acids are lowest in guinea pig proximal small intestine and are constant from midjejunum through distal ileum, except for leucine. The guinea pig possesses a sodium- and chloride-dependent, high-affinity, very low-capacity carrier of beta-amino acids for which taurine and beta-alanine compete and for which the Na(+)-taurine activation stoichiometry is 2.1 +/- 0.3:1. The imino acid carrier of the guinea pig is also chloride dependent with a Na(+)-Cl(-)-2-methylamino-isobutyric acid activation stoichiometry of 1.8 +/- 0.1:0.7 +/- 0.3:1. In contrast, the rat imino acid carrier is chloride independent and transport rates vary insignificantly along the small intestine. The rat taurine carrier has its maximal transport rate in midjejunum. It is chloride dependent but does not transport beta-alanine.

Cotransport of 2-methyl-aminoisobutyric acid and chloride in rabbit small intestine

This article examines the nature of the Cl- dependence of the rabbit intestinal imino acid carrier using 2-methyl-aminoisobutyric acid (MeAIB) as substrate for measuring influx across the luminal membrane of rabbit distal ileum. Reduction of mucosal Cl- concentration from 140 to 6 mM successively increased the concentration at which MeAIB influx is half-maximal from 3.6 +/- 0.2 (SD) to 21.0 +/- 3.7 mM. Maximal influx of MeAIB was unchanged. Measured at 70 mM Cl-, MeAIB induced a Cl- influx across the brush-border membrane (delta JClmc) of 5.01 +/- 0.65 mumol.cm-2 x h-1 (SE, n = 16; 45%), and an identical Cl(-)-independent influx of leucine induced a delta JClmc of 1.82 +/- 0.52 mumol.cm-2 x h-1 (SE, n = 12; 16%) (P < 0.001). At 24 mM Cl-, delta JClmc induced by leucine did not differ significantly from zero, whereas the effect of MeAIB was maintained. The ratio between Na+ influx across brush-border membrane (delta JNamc) and the Na(+)-dependent flux measured at 140 mM Cl- was 2.4 +/- 0.7 (n = 8) for MeAIB, 1.4 +/- 0.4 (n = 10) for leucine, and 1.1 +/- 0.2 (n = 13) for D-glucose. The Hill coefficient of Na+ activation (+/- SD) in distal ileum was 0.82 +/- 0.19 for leucine and 1.14 +/- 0.03 for D-glucose. A Hill coefficient of 1.60 +/- 0.05 was obtained for D-glucose in the jejunum. Concentrations of MeAIB and D-glucose, chosen to given equal delta JNamc, induced a 40 and 21% increment of JClmc (P < 0.05), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

High mortality by natural and unnatural causes: a 10 year follow up study of patients admitted to a poisoning treatment centre after suicide attempts

OBJECTIVE

To describe mortality by suicide and other causes of death in a group of patients who attempted suicide, and to identify predictive factors.

DESIGN

10 year follow up study based on records of suicide attempters in 1980.

SETTING

Poisoning treatment centre at a general hospital.

SUBJECTS

974 patients aged 15 and over referred to the poisoning treatment centre after deliberate self poisoning.

MAIN OUTCOME MEASURES

Death by different causes registered in the Danish death cause register.

RESULTS

In 10 years of follow up 306 patients died: 103 by suicide, 131 from natural causes, and 31 by accident; five were murdered, and in 36 cases the cause of death was uncertain. The standard mortality ratio was 550. Cause specific standardised mortality rates were 2960 for suicide, 236 for natural causes, 1256 for accidents, and 5459 for uncertain causes. In a Cox regression analysis, high risk factors for subsequent suicide were: more than one previous suicide attempt (relative risk 2.25), living alone (2.28), and age (1.03 per year). Predictors of death by natural causes were receiving a pension (1.69), drug misuse (2.72), more than one previous suicide attempt (2.25), age (1.06 per year), and male sex (2.49). The group of patients fulfilling at least one high risk criterion for later suicide differed significantly from the rest of the patient group in incidence of suicide, but both sensitivity and specificity were low.

CONCLUSIONS

Most patients who attempted suicide were at high risk of succeeding because the risk factors, though significant, are not very specific. A strategy to prevent suicide must be directed toward the majority of those who attempt suicide.

Baclofen (beta-p-chlorophenyl-gamma-aminobutyric acid) transport across rat jejunum

Intestinal transport of baclofen (beta-(p-chlorophenyl)-gamma-aminobutyric acid) in the rat has been examined in vitro. Influx of baclofen across the brush-border membrane (JmcBacl) and steady-state accumulation by everted segments of the intestine were measured. JmcBacl could be accounted for as the sum of a saturable process with a maximum rate of approx. 10-20 nmol cm-2 h-1 and a K1/2Bacl of approx. 0.3 mM and a diffusive contribution with a permeability of 0.073 cm h-1. JmcBacl was Na(+)- and Cl(-)-independent. The steady state distribution ratio between the intracellular space of the everted segments and incubation fluid was 1.0 +/- 0.1 (n = 12). Inhibition tests demonstrated that the Na(+)- and Cl(-)-independent, passive, but saturable fraction of baclofen transport can not be mediated by any of the known amino acid carriers of the rat small intestine. Preliminary results suggests that qualitatively baclofen transport in guinea-pig and rabbit is also by facilitated transport.

Variation in amino acid transport along the rabbit small intestine. Mutual jejunal carriers of leucine and lysine

The jejuno-ileal variation of amino and imino acid transport across the brush-border membrane of intact rabbit small intestine was studied. For the amino acids tested--beta-alanine, leucine, lysine, MeAIB, proline--and for D-glucose, the rates of transport at constant concentrations increase from very low values in the proximal jejunum to maximum values in the most distal 30 cm of the ileum. The apparent affinity constant for jejunal taurine transport is identical to that of the distal ileum, while the jejunal transport capacity is less than half. In the jejunum, as in the distal ileum, leucine and lysine share both sodium-dependent and sodium-independent carriers. Approx. 50% of the quantitative difference in transport capacity is accounted for by the absence of the beta-alanine carrier in the jejunum. These data indicate that the gradients of transport along the small intestine reflect gradients of transport capacities rather than affinities. In comparison with hamster, man and rat, the rabbit seems unique with respect to the location of transport maximum and the steepness of the gradient along the intestine.

The rabbit jejunal 'imino carrier' and the ileal 'imino acid carrier' describe the same epithelial function

For rabbit jejunal brush border vesicles an 'imino carrier' has been defined as a sodium-dependent, alanine-resistant transporter of cyclic imino acids, while for intact rabbit jejunal and ileal epithelia an 'imino acid carrier' has been defined as a sodium-dependent transporter of both aliphatic and cyclic imino acids. This study on intact rabbit intestine examines whether these two terms describe the same epithelial function. The KPro1/2 and the KProi against JMeAIBmc are identical and so are KMeAIB1/2 and KMeAIBi against JPromc. Likewise, KLeui is the same against the transport of both proline and MeAIB. It is, therefore, concluded that the terms 'imino carrier' and 'imino acid carrier' describe the same epithelial function: A sodium-dependent, relatively high afinity, saturable transporter of both aliphatic and cyclic imino acids. Estimates of the apparent affinity and inhibitory constants for MeAIB, proline and leucine confirm that the jejuno-ileal variation of amino acid transport along the rabbit small intestine is a variation of maximal transport capacity.

Distinction between chloride-dependent transport systems for taurine and beta-alanine in rabbit ileum

This study describes the influx of taurine and beta-alanine across the brush-border membrane of rabbit distal ileum. The kinetics of JmcTau [concentration at which half-maximal activation occurs (K1/2) = 41 microM and Jmax = 24 nmol.cm-2.h-1] are consistent with the kinetics of taurine uptake by jejunal brush-border vesicles. The taurine carrier differs from the beta-alanine carrier by being insensitive to leucine inhibition and by the jejunoileal variation of influx along the small intestine. The K1/2 for sodium and chloride activation of the beta-alanine carrier (48 and 8 mM, respectively) differ markedly from the values reported for the taurine carrier. In addition, taurine is not transported by the beta-alanine carrier. Thus the study demonstrates that the taurine and beta-alanine carriers are separate entities, and it adds to the imino and the taurine carriers the beta-alanine carrier as a third chloride-dependent intestinal transporter of amino acids.

A natural flavonoid, IdB 1027, increases gastric luminal release of prostaglandin E2 in healthy subjects

IdB 1027 is an anthocyanidin pigment occurring in bilberries. In laboratory animals this compound shows gastric protective effects without influencing acid secretion. To study how IdB 1027 would affect gastric luminal release of prostaglandin (PG) E2 and basal fluid and acid secretion, we have carried out 'steady state' perfusions of the stomach in 10 healthy males before and after oral administration of IdB 1027 (600 mg b.i.d.) for 10 days. Two subjects were excluded from the study due to a low recovery of perfusates. Gastric fluid secretion, acidity, and acid output were unaffected during IdB 1027 administration, while a significant rise in luminal concentration (403 (124-910) vs 216 (49-506) pg/ml: median and range; p less than 0.05; n = 8 and luminal release 6.5 (2.2-14.6) vs 1.9 (1.0-8.1) ng/15 min; p less than 0.02; n = 8) of PGE2 occurred. The marked increase in gastric mucosal release of PGE2 may explain the antiulcer and gastroprotective effects of IdB 1027 observed in animal experiments.

Chloride-dependence of amino acid transport in rabbit ileum

Chloride-dependence of influx across the brush-border membrane of distal rabbit ileum was examined for beta-alanine, 2-methylaminoisobutyric acid (MeAIB), leucine, lysine, proline and D-glucose. Influx of leucine at 2 mM and of D-glucose at 0.5 mM was chloride-independent indicating that substitution of isethionate for chloride has no unspecific effect on sodium gradient driven transport processes. In contrast influx of beta-alanine and MeAIB was totally dependent on the presence of chloride ions. In the absence of chloride, proline transport was reduced to 20% of its control level. This remaining transport can be accounted for by the function of the carrier of alpha-amino-monocarboxylic acids. Transport of leucine at 0.1 mM was reduced by absence of chloride. This is in accordance with the observation of leucine transport by the beta-alanine carrier. The kinetics of chloride and sodium activation of transport of MeAIB were examined at 1 mM MeAIB. Chloride activation was characterized by a Hill coefficient of 1 and a K1/2 of 23.5 mM, and sodium activation by a Hill coefficient of 2 and a K1/2 of 51 mM. Thus cotransport of chloride with an imino acid would be compatible with the known rheogenic nature of this transport. This study adds the imino acid carrier and the beta-alanine carrier to the group of chloride-dependent, epithelial amino acid transport systems.

Codeine in analgesic doses does not depress respiration in patients with severe chronic obstructive lung disease

Nineteen normocapnic patients with chronic obstructive lung disease participated in an open single dose safety study (part one) followed by a randomized double-blind cross-over study comparing two seven-days treatment periods of 1 g of paracetamol t.i.d. with 60 mg of codeine plus 1 g of paracetamol t.i.d., respectively (part two). In part one, continuous monitoring after a single dose of 2 g of paracetamol and 120 mg of codeine revealed no deterioration in the respiration and gas tensions. In part two, respiratory parameters and arterial gas tensions were recorded one hour after the last morning dose. PaCO2 increased insignificantly (0.05 less than P less than 0.10) by a median of 0.38 kPa during treatment with codeine and paracetamol compared to treatment with paracetamol alone. PaO2 decreased by 0.12 kPa (P greater than 0.10). There was no correlation between changes in PaCO2 and changes in PaO2. FVC, FEV1 and dyspnoea at rest were unchanged. Gastrointestinal side effects were reported significantly (P less than 0.02) more often during treatment with codeine plus paracetamol. There was no correlation between the plasma concentration of codeine or morphine and changes in respiratory parameters or adverse effects. The limitation for the short time clinical use of codeine as an analgesic to normocapnic patients with severe chronic obstructive lung disease in stable phase seem to be gastrointestinal side effects.

In vitro studies of theophylline-induced changes in Na, K and Cl transport in hen (Gallus domesticus) colon suggesting bidirectional, basolateral NaK2Cl cotransport

1. In isolated mucosa from a NaCl-loaded hen theophylline stimulates both unidirectional chloride fluxes (JmsCl and JsmCl). Conductive and electroneutral exchange processes, besides a bumetanide-sensitive, rheogenic process contribute. 2. The bumetanide-sensitive fraction of the theophylline-induced delta JcmCl is sodium-dependent. 3. Incubation in nominally K(+)-free solutions reduces the bumetanide-sensitive fraction delta JsmCl more than treatment with ouabain. 4. With respect to chloride the bumetanide-sensitive fraction of delta JsmCl has a Hill coefficient of 1.93 +/- 0.03, a Jmax of 12.9 +/- 0.2 mumol/cm2.hr and a K 1/2 of 73 +/- 1 mmol/l. 5. After ouabain treatment delta JmsCl and delta JsmCl are equally sensitive to bumetanide, while delta JmsCl is bumetanide insensitive without ouabain treatment.

Intestinal transport of potassium. Effects of changing apical and basolateral influx of sodium in the isolated mucosa of the hen (Gallus domesticus) colon

1. Net potassium secretion (JKnet) by the sodium-depleted hen's colon (low sodium colon) is 0.17 +/- 0.07 mumol/cm2.hr. Amiloride or ouabain eliminates short circuit currents (Isc) of 16-20 mumol/cm2.hr without affecting JKsm. 2. In the NaCl-loaded hen's colon (high sodium colon) stimulating Isc by (a) glucose, (b) amino acids, and inhibiting with (c) ouabain changes JKnet from 0.08 +/- 0.04 to (a) 0.42 +/- 0.07, to (b) 0.60 +/- 0.07 to (c) 0.13 +/- 0.13 mumol/cm2.hr. 3. In both colonic types theophylline increases and bumetanide decreases JKnet by 1 mumol/cm2.hr. 4.

CONCLUSION

Apical membranes of sodium-absorbing and chloride-secreting cells of the high sodium colon are potassium permeable. In the low sodium colon sodium-absorbing cells have potassium-impermeable apical membranes.

Prostaglandin E2 is a mediator of 5-hydroxytryptamine induced water and electrolyte secretion in the human jejunum

Studies in the rat jejunum in vivo have shown that 5-hydroxytryptamine (5-HT) causes secretion of fluid and luminal release of prostaglandin (PG) E2. These effects can be blocked by indomethacin and ketanserin, which suggests that PGE2 may be an important intermediate in the transduction mechanism leading to 5-HT induced fluid secretion. To test this hypothesis in man 'steady state' perfusions (9 ml/min) were done in eight healthy volunteers using the triple lumen technique. The proximal jejunum was perfused with Ringer's solution which contained 51Cr-EDTA as a non-absorbable marker. Before and after the administration of indomethacin (1.0 mg/kg iv) the effects of exogenous 5-HT (10 micrograms/kg/min iv) on jejunal net transport of fluid and electrolytes and jejunal flow rate (JFR) of PGE2 were measured in 15-min periods for 2 x 60 minutes after a 60 minute control period. 5-HT reversed fluid and electrolyte absorption into profuse secretion (p less than 0.01, Duncan's multiple range test) and significantly increased JFR of PGE2 (p less than 0.01). Indomethacin partly restored fluid and electrolyte absorption (p less than 0.01) and inhibited JFR of PGE2 (p less than 0.05). These results provide further evidence in favour of the theory that PGs are involved in 5-HT induced intestinal fluid secretion.