Tetrahydroisoquinolines as MCH-R1 antagonists

A series of potent and selective inhibitors of h-MCH-R1 has been developed based on the piperidine glycineamide compounds I and II. These structurally more rigid tetrahydroisoquinolines (III and IV) showed better pharmacokinetics. The highly potent compounds 12d and 12g displayed excellent rat pk.

Hydrazides of clozapine: a new class of D1 dopamine receptor subtype selective antagonists

Acylated and aroylated hydrazinoclozapines are highly potent dopamine D(1) antagonists that show remarkable selectivity over other dopamine receptors. The most potent compound in this series is the 2,6-dimethoxybenzhydrazide 33 with a D(1)K(i) of 1.6 nM and 212-fold selectivity over D(2) receptor.

An enzymatic synthesis of glucuronides of azetidinone-based cholesterol absorption inhibitors

Two derivatives, 1 and 3, of a novel cholesterol absorption inhibitor, Sch 58235, were glucuronidated with the help of glucuronyl transferases derived from bovine and dog liver microsomes. An efficient procedure for the iodination of 4 was developed on an analytical scale to be used for the preparation of a 125I-labeled radioactive glucuronide 5.

Structure-activity relationships of pyrroloquinazolines as thrombin receptor antagonists

A series of pyrroloquinazolines has been discovered that represent novel small molecule inhibitors of the intramolecular ligand of the thrombin receptor. Analogs were prepared to study the structure-activity relationships of substitution at the N 1, N3, and N7 positions of the heterocycle. Compounds 4e and 4f have been identified with IC50's of 56 and 52 nM, respectively.

Do shorter-acting neuromuscular blocking drugs or opioids associate with reduced intensive care unit or hospital lengths of stay after coronary artery bypass grafting? CABG Clinical Benchmarking Data Base Participants

BACKGROUND

The authors hypothesized that shorter-acting opioid and neuromuscular blocking drugs would be associated with reductions in duration of intubation, length of stay (LOS) in the intensive care unit (ICU) after tracheal extubation, or postoperative (exclusive of ICU) LOS, and that shorter durations of intubation would be associated with reduced ICU LOS after extubation and postoperative (exclusive of ICU) LOS.

METHODS

One-thousand ninety-four patients undergoing primary coronary artery bypass graft surgery at 40 academic health centers were studied. Multiple patient-related factors were included in multivariate models for hypothesis testing.

RESULTS

The duration of tracheal intubation, ICU LOS after extubation, and postoperative (exclusive of ICU) LOS all varied significantly by site. There was no difference between vecuronium and pancuronium in duration of intubation, ICU LOS after extubation, or postoperative (exclusive of ICU) LOS. Use of sufentanil rather than fentanyl was associated with a significant (P=0.045) reduction of 1.9 h (95% CI, 0.04 to 4.1 h) in duration of tracheal intubation but had no significant effect on ICU LOS after extubation, total ICU LOS, postoperative (exclusive of ICU) LOS, or total postoperative LOS. The authors' best model predicts a complex association between increasing duration of intubation and both ICU LOS after tracheal extubation and postoperative (exclusive of ICU) LOS, which was associated with an increase in those measures when duration of intubation exceeded 7.3 or 3 h, respectively.

CONCLUSIONS

The LOS measures varied considerably among the institutions. Use of shorter-acting opioid and neuromuscular blocking drugs had no association with ICU LOS after tracheal extubation or with postoperative (exclusive of ICU) LOS. Only when the duration of intubation exceeded threshold values was it associated with increased LOS measures.

Discovery of 1-(4-fluorophenyl)-(3R)-[3-(4-fluorophenyl)-(3S)-hydroxypropyl]-(4S)-(4 -hydroxyphenyl)-2-azetidinone (SCH 58235): a designed, potent, orally active inhibitor of cholesterol absorption

(3R)-(3-Phenylpropyl)-1,(4S)-bis(4-methoxyphenyl)-2-azetidinone (2, SCH 48461), a novel inhibitor of intestinal cholesterol absorption, has recently been described by Burnett et al. and has been demonstrated to lower total plasma cholesterol in man. The potential sites of metabolism of 2 were considered, and the most probable metabolites were prepared. The oral cholesterol-lowering efficacy of the putative metabolites was evaluated in a 7-day cholesterol-fed hamster model for the reduction of serum total cholesterol and liver cholesteryl esters versus control. On the basis of our analysis of the putative metabolite structure-activity relationship (SAR), SCH 58235 (1, 1-(4-fluorophenyl)-(3R)-[3-(4-fluorophenyl)-(3S)-hydroxypropyl]-(4S)- (4-hydroxyphenyl)-2-azetidinone) was designed to exploit activity enhancing oxidation and to block sites of potential detrimental metabolic oxidation. Additionally, a series of congeners of 2 were prepared incorporating strategically placed hydroxyl groups and fluorine atoms to further probe the SAR of 2-azetidinone cholesterol absorption inhibitors. Through the SAR analysis of a series of putative metabolites of 2, compound 1 was targeted and found to exhibit remarkable efficacy with an ED50 of 0.04 mg/kg/day for the reduction of liver cholesteryl esters in a 7-day cholesterol-fed hamster model.

The rigors and rewards of clinical evaluation in an alliance of academic health systems

The University HealthSystem Consortium (UHC), a 70-member alliance of academic health centers, was established in 1984 to help its members improve clinical practice and to strengthen their competitive position in the health care market. This article describes the programs of the UHC's Clinical Practice Advancement Center and its progress to date in promoting strategies to control cost, demonstrate value, and improve health care quality.

2-Azetidinone cholesterol absorption inhibitors: structure-activity relationships on the heterocyclic nucleus

A series of azetidinone cholesterol absorption inhibitors related to SCH 48461 ((-)-6) has been prepared, and compounds were evaluated for their ability to inhibit hepatic cholesteryl ester formation in a cholesterol-fed hamster model. Although originally designed as acyl CoA: cholesterol acyltransferase (ACAT) inhibitors, comparison of in vivo potency with in vitro activity in a microsomal ACAT assay indicates no correlation between activity in these two models. The molecular mechanism by which these compounds inhibit cholesterol absorption is unknown. Despite this limitation, examination of the in vivo activity of a range of compounds has revealed clear structure-activity relationships consistent with a well-defined molecular target. The details of these structure-activity relationships and their implications on the nature of the putative pharmacophore are discussed.

Albumin and nonprotein colloid solution use in US academic health centers

BACKGROUND

Crystalloids, nonprotein colloids (NPCs), and albumin are used for many indications. The use of the least costly agent in situations where these products are clinically interchangeable can reduce health care costs.

OBJECTIVES

To characterize the prescribing of albumin and NPC. To evaluate the appropriateness and cost implications of their use.

METHODS

An observational study conducted in 15 academic health centers from April 11 through May 6, 1994, to assess the appropriateness of albumin and NPC use, based on "model" consensus-derived indication guidelines.

RESULTS

A total of 969 case report forms were evaluated. Albumin and NPCs were administered in 83% and 17% of the cases, respectively. Albumin and NPCs were administered mostly in the intensive care (50%) or operating room (31%) settings. The most common prescribers of these products were surgeons (45%) and anesthesiologists (20%). In 87% of cases, albumin or NPC was administered to reach a defined end point (eg, to achieve a target physiological state or to resolve a pathophysiological condition). Only one albumin recipient experienced an adverse event; no adverse events were noted with NPC administration. Approximately $203,000 was spent on albumin and NPC therapy for the 969 cases; $49,702 (24%) was spent on appropriate administrations, $124,939 (62%) on inappropriate administrations, and $28,014 (14%) on unevaluated indications.

CONCLUSIONS

Evaluated against model guidelines, most of the albumin and NPC use in the study was found to be inappropriate. The need for institutions to define and implement guidelines that focus on the cost-efficient use of these agents is recommended in an increasingly cost-conscious health care environment.

Recommendations for off-label use of intravenously administered immunoglobulin preparations. University Hospital Consortium Expert Panel for Off-Label Use of Polyvalent Intravenously Administered Immunoglobulin Preparations

OBJECTIVE

To summarize consensus recommendations for off-label uses of standard intravenous immunoglobulin (IVIG), as developed by a University Hospital Consortium (UHC) Expert Panel. These findings are intended to help guide clinicians in the appropriate and efficient use of IVIG.

PARTICIPANTS

The UHC-sponsored panel included eight physicians (board certified in critical care, hematology, immunology, neurology, oncology, pediatrics, or rheumatology) and two hospital pharmacists.

EVIDENCE

MEDLINE and EMBASE were searched to identify all English-language review articles (n = 201) and original reports (n = 1904) on IVIG (human use only, excluding editorials, letters, and comments) published between January 1982 and March 1994. Relevant original reports (250) and review articles (87) were evaluated by the first author (T.A.R.). Extracted data included laboratory and clinical findings, objective measures, or clinical impressions. The evidence quality was graded by study design according to the US Preventive Services Task Force.

CONSENSUS PROCESS

Before the panel meeting, a draft literature review and recommendations were produced by one of the authors (T.A.R.). The recommendations herein represent consensus (100% agreement) based on the published evidence.

CONCLUSIONS

The UHC Expert Panel made specific recommendations for 53 off-label indications and the following general recommendations: (1) Usually IVIG is indicated only if standard approaches have failed, become intolerable, or are contraindicated; (2) IVIG products should be considered therapeutically equivalent and interchangeable; (3) interproduct pharmaceutical differences should be considered with the patient's clinical and physiological status when selecting an IVIG product; and (4) currently, IVIG manufacturers cannot guarantee freedom from viral contamination in the finished product.

Hypocholesterolemic activity of a novel inhibitor of cholesterol absorption, SCH 48461

The amount of cholesterol that circulates in the plasma as lipoproteins can be affected by the balance of cholesterol metabolism within and between the intestines and liver. In the present report, we describe a novel hypocholesterolemic agent and document its pharmacological effects in animal models of hypercholesterolemia. The oral administration of (3R,4S)-1,4-bis-(4-methoxyphenyl)-3-(3-phenylpropyl)-2-azetidinone (SCH 48461) reduced plasma cholesterol concentrations in cholesterol-fed hamsters, rats and rhesus monkeys with ED50s of 1, 2 and 0.2 mg/kg per day, respectively, SCH 48461 was also highly effective in reducing hepatic cholesteryl ester accumulation in cholesterol-fed hamsters and rats after 7 days of treatment. In one 3 week study, rhesus monkeys were fed a 0.25% cholesterol/22% saturated fat diet with or without SCH 48461. At the end of the 3 week period the control group's VLDL + LDL-cholesterol increased to 180 Mg/dl from a baseline of approximately 65 mg/dl while plasma apolipoprotein B levels had doubled. Animals treated daily with 1 mg/kg SCH 48461 maintained their baseline levels of VLDL + LDL-cholesterol, HDL-cholesterol, and plasma apolipoproteins B and A-I. After 3 weeks the diets of the two groups were switched. Within 1 week SCH 48461 (1 mg/kg per day) rapidly reversed the elevated VLDL + LDL-cholesterol levels of the previous control group to near baseline values. SCH 48461 exerted its hypocholesterolemic effect through the inhibition of cholesterol absorption. A dose of 10 mg/kg per day inhibited cholesterol absorption in cholesterol-fed hamsters by 68% while a similar reduction was achieved in chow-fed monkeys with 3 mg/kg per day. This latter dose inhibited cholesterol absorption in cholesterol-fed monkeys by 95%. Treatment of cholesterol-fed monkeys with 10 mg/kg per day SCH 48461 significantly increased fecal neutral sterol excretion (52 vs. 32 mg/kg) but had no effect on acidic sterol excretion. Using a 2-h absorption model in cholesterol-fed hamsters, SCH 48461 caused a 46% inhibition of unesterified [14C]cholesterol accumulation in the intestinal wall and a 90% inhibition of cholesteryl ester formation at a dose of 10 mg/kg. Similar data were observed when the plasma radioactivity was assessed, indicating inhibition of both free (61%) and esterified (85%) cholesterol appearance. In contrast, CI-976, a potent acyl-CoA:cholesterol acyltransferase (ACAT) inhibitor, did not affect the uptake of free cholesterol into the intestines while inhibiting cholesterol esterification (98% inhibition).(ABSTRACT TRUNCATED AT 400 WORDS)

Surveillance of colony-stimulating factor use in US academic health centers

OBJECTIVE

To characterize and evaluate hematopoietic colony-stimulating factor (CSF) use, including cost implications, in US academic health centers.

DESIGN

An observational study of patients who received granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) from September 1 to October 15, 1993.

SETTING

Thirty academic health centers in the US.

PARTICIPANTS

Five hundred sixty-five patients were evaluated.

MAIN OUTCOME MEASURES

The appropriateness of CSF use was assessed, based on consensus-derived indication guidelines and the Food and Drug Administration-approved product labeling. Indication, type of CSF, and dosage were considered in determining the appropriateness of CSF therapy.

RESULTS

Based on indication evaluation criteria, 71% of CSF use was appropriate, 7% was inappropriate, and 22% was unproven, although the majority of unproven use was deemed promising by the expert panel. Based on dosage evaluation criteria, 51% of CSF use was appropriate, 27% was inappropriate, and 22% was for promising and other unproven indications. More than 90% of the patients studied received G-CSF. Approximately 3.4% of patients who received G-CSF had an adverse event, compared with 22% of those who received GM-CSF. Approximately $791,000 was spent on CSF therapy in the 565 patients: $401,000 (51%) on appropriate indications and doses, $160,000 (20%) on inappropriate doses for appropriate indications, $124,000 (16%) on promising indications, and $106,000 (13%) on unproven or inappropriate indications.

CONCLUSIONS

Substantial costs are incurred currently for CSF therapy without adequate literature support. Further studies are warranted to justify promising but unproven uses of CSFs, as well as to clarify proper dosing, monitoring, and relative safety of CSFs.

Clinical evaluation units: a research agenda

A new model for evaluating quality rests on the tripod of outcomes research, practice pattern analysis, and the tenets of continuous quality improvement. The hospital-based locus for this tripod could be clinical evaluation units. This article describes the conceptual framework, study design, and research challenges associated with an ongoing project whose purpose is to assess the current status of these clinical evaluation units in academic medical centers nationwide.

Evaluation of ondansetron prescribing in US academic medical centers

BACKGROUND

The study objectives were to characterize the use of the antiemetic ondansetron, a serotonin subtype 3 receptor antagonist, in US academic medical centers, and to assess ondansetron prescribing with consensus-derived prescribing guidelines used as evaluation criteria.

METHODS

A multicenter, prospective, observational study was conducted in the inpatient and outpatient care areas of 23 US academic medical centers. A total of 670 patients received ondansetron (508 inpatients and 162 outpatients). The use of ondansetron was compared with consensus-derived prescribing guidelines on the basis of indication for use and dose administered.

RESULTS

Only 253 (37.8%) of the 670 patients satisfied for prescribing guidelines for both indication for use and dose administered. The remainder of the patients did not satisfy the guidelines, in whole or in part. If all ondansetron use had met the prescribing guidelines in the patients studied, a reduction in ondansetron use of 31% (16 185/52 260 mg) would have been realized. At an estimated cost of $5 per milligram, this reduction represents a potential cost savings of nearly $81,000, or $121 per patient studied.

CONCLUSION

Since its introduction in 1991, ondansetron has become a commonly used antiemetic in US academic medical centers. Although ondansetron is safe and effective in improving patients' tolerance of emetogenic therapies, including cancer chemotherapy, its high cost has added a significant burden to the pharmaceutical budgets of many institutions. The study data suggest that compliance with ondansetron prescribing guidelines, with elimination of indiscriminant use, could result in significant cost savings.

Shunt surgery versus endoscopic sclerotherapy for variceal hemorrhage: late results of a randomized trial

Between September 1982 and April 1988, 60 cirrhotic patients with prior variceal hemorrhage were randomized to undergo the placement of an elective shunt (distal splenorenal: 26; nonselective: 4) or long-term endoscopic sclerotherapy (n = 30). Eighty-six percent of patients had alcoholic cirrhosis, and 33% were classified as Child's class C. After a mean follow-up of 87 months, 60% of patients undergoing sclerotherapy and 17% of shunt patients experienced rebleeding (p < 0.001). Shunt patients have survived longer than those who had sclerotherapy (6-year survival rates of 53% and 26%, respectively; p < 0.05). In part because of the wide geographic distribution of patients, only 4 of 13 patients in whom sclerotherapy failed (31%) could undergo salvage by shunt surgery. Although hepatic portal perfusion was better maintained after sclerotherapy, there were no major differences between the groups in terms of post-therapy hepatic or psychoneurologic function. In a predominantly alcoholic cirrhotic patient population (half non-urban), the results of elective shunt surgery were superior to those of chronic endoscopic sclerotherapy with respect to the prevention of recurrent variceal hemorrhage and survival.

Factors affecting plasma postheparin diamine oxidase activity

Plasma postheparin diamine oxidase (DAO) activity has been evaluated for assessing disease activity in Crohn's disease (CD) and other intestinal disorders. Since the mechanism of the reduced plasma DAO activity is poorly understood, our aim was to determine the effect of extent and location of disease and prior resection and therapy on plasma DAO activity in Crohn's disease. Plasma postheparin DAO activity was significantly lower (17.4 +/- 3.0 vs 32.8 +/- 30.8 units/ml) and Crohn's disease activity index (178 +/- 105 vs 14 +/- 19, P less than 0.05) (CDAI) higher in 37 patients with CD compared to 30 normal volunteers. There was no overall correlation between DAO activity and CDAI. Effective medical or surgical therapy increased DAO activity and decreased CDAI, while clinical recurrence had the opposite effect. DAO activity was not related to the extent of small bowel disease (13.2 +/- 9.1; less than 30 cm, 18.5 +/- 11.8; 30-60 cm, and 5.7 +/- 6.4 units/ml; greater than 60 cm) or colonic disease (13.0 +/- 6.9 segmental vs 24.0 +/- 15.4 units/ml, pancolitis). DAO activity was similar with small or large bowel disease (14.3 +/- 10.6 vs 18.8 +/- 13.1 units/ml). Prior enterectomy or colectomy did not significantly influence DAO activity. DAO activity responds predictably after effective therapy and recurrence and may prove useful in monitoring individual patients with CD. Failure of extent and location of disease and prior resection to influence DAO activity suggests that DAO activity is not directly related to enterocyte mass.

Rabbit and human liver contain a novel pentacyclic triterpene ester with acyl-CoA: cholesterol acyltransferase inhibitory activity

Acyl-coenzyme A (CoA):cholesterol acyltransferase (ACAT) catalyzes the intracellular fatty acid esterification of cholesterol and is thought to play a key role in lipoprotein metabolism and atherogenesis. Herein we describe the purification and characterization of a novel pentacyclic triterpene ester from rabbit liver that has ACAT inhibitory activity. The inhibitor was purified by a combination of silicic acid chromatography and preparative thin layer chromatography. The compound inhibited both rabbit and rat liver microsomal ACAT activity with an IC50 = 20 microM. The lipid did not inhibit fatty acid incorporation into triglycerides, diglycerides, monoglycerides, or phospholipids nor did it inhibit plasma lecithin:cholesterol acyltransferase activity. However, rat liver microsomal acyl-CoA:retinol acyltransferase activity was inhibited by the terpene ester. Kinetic data are consistent with a mechanism in which ACAT is inhibited by the compound in an irreversible manner. The subcellular fractionation pattern of both ACAT activity and the ACAT inhibitor were similar in rabbit liver (both were approximately equally distributed in membranes that pelleted at 10,000 X g and 100,000 X g). A lipid with similar properties to the rabbit liver inhibitor was found in many other rabbit tissues, including adrenal and spleen, as well as in human liver. Rat liver did not contain this lipid. Structural analysis by NMR, mass spectrometry, and x-ray crystallography indicated that the rabbit liver inhibitor was a fatty acid ester (mostly stearate) of a pentacyclic triterpene acid. The carbon skeleton of the triterpene moiety is a new member of the olean-12-ene triterpene family. Both the negatively charged carboxylic acid group of the triterpene moiety and the esterified fatty acid group were necessary for the ACAT-inhibitory activity of the triterpene ester. Lastly, we present preliminary data which, together with the structural homology of the rabbit triterpene with known plant compounds, suggest the hypothesis that the triterpene moiety of the rabbit ACAT inhibitor arises from dietary absorption of a plant triterpene.

Nonoperative emergency treatment of variceal hemorrhage

The nonoperative management of acute variceal hemorrhage can control acute hemorrhage and allow stabilization of the patient prior to definitive therapy to prevent further bleeding episodes. Balloon tamponade, endoscopic sclerotherapy, and pharmacotherapy can stop acute variceal bleeding. Endoscopic sclerotherapy has the highest reported success rate, decreases the incidence of early rebleeding, and is the recommended first method to control bleeding.

Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation

Biliary tract complications are a continuing source of morbidity after liver transplantation. In a 3.5-year period we performed 264 liver transplants in 226 patients (132 adults, 94 children). Biliary tract reconstruction was via Roux limb choledochojejunostomy (n = 144) or choledochocholedochostomy (n = 118). Fifty (19.1%) biliary complications occurred, and 35 (13.4%) necessitated operative repair. The incidence was similar in adults and children and after each method of reconstruction. Risk factors were vascular thrombosis and reduced-sized transplants. Diagnosis was based on the algorithmic use of multiple modalities with early biliary visualization. Roux limb complications usually occurred in the first month after transplant and necessitated operative intervention, whereas duct-to-duct problems appeared later and were more accessible to percutaneous or endoscopic manipulations. Eight (6.8%) patients required conversion to a Roux limb, whereas 8/15 (53.3%) cases of biliary stricture were successfully managed nonoperatively. Three (1.3%) patients and four (1.5%) grafts were lost as a result of biliary complications. One-year actuarial patient survival is 76.4% with a mean follow-up of 13.2 months. Early recognition of biliary complications and prompt interventional therapy can effectively prevent long-term sequelae. Although choledochocholedochostomy is more physiologic and expeditious, Roux-en-Y choledochojejunostomy remains a safe and versatile alternative and is the preferred method of reconstruction in select cases.

Preoperative evaluation, preparation, and timing of orthotopic liver transplantation in the adult

Orthotopic liver transplantation can provide a large number of patients with end-stage liver disease an opportunity for significant improvement in long-term survival and quality of life. Transplantation should not be considered a last-ditch attempt to save a dying patient. Early referral of patients to transplant centers will allow for further improvement in survival of patients after transplantation. Ongoing communication between the referring physician and the transplant team is important in keeping abreast of changes in the patient's status so that optimal timing of the transplant may be achieved.

Prothrombotic abnormalities in inflammatory bowel disease

Inflammatory bowel disease (IBD) is known to be associated with a thrombotic tendency, which is often attributed to thrombocytosis, elevated fibrinogen, or decreased antithrombin III. We prospectively studied eight patients with IBD, seven of whom had little or no disease activity, to determine if they had any laboratory abnormality known to be associated with an increased risk of thrombosis. Abnormalities in fibrinolysis were noted in five patients: four with high plasminogen activator inhibitor levels and one with poor release of tissue plasminogen activator following venous occlusion. Circulating immune complexes were present in the sera of five patients. Fibrinogen was mildly elevated in one patient, and two patients had mild thrombocytosis. Decreased levels of antithrombin III, protein C, or protein S were not observed. There appears to be a high incidence of abnormalities in fibrinolysis in inactive IBD, which may contribute to the high frequency of thrombosis seen in IBD. The presence of circulating immune complexes may contribute to vascular injury and thrombosis.

Rational uses of hepatic imaging modalities

Hepatic imaging studies have been a tremendous benefit in the care of patients with liver diseases. However, uncertainty regarding the rational use of these studies, as with other diagnostic studies, generally promotes overuse. Some principles emerge from the information reviewed here. Generally, duplicative studies with similar test characteristics add little to the diagnostic process, and oftentimes confuse it. Costs are difficult to calculate and usually do not enter into the selection process. The result of each test must be interpreted in light of the clinical process that prompted its use, and when it will not change the diagnostic or therapeutic approach regardless of the result, the test is probably not indicated. Finally, rational use of the studies depends on an understanding of the information that they can and cannot provide.

The role of nontransplant procedures for sclerosing cholangitis

Twenty-five of 38 patients with sclerosing cholangitis underwent operative therapy at our institution. Seven patients with primarily extrahepatic obstruction had biliary bypass procedures and maintained normal liver function for 1 to 96 months. Biliary procedures were performed in 11 patients with combined intrahepatic and extrahepatic disease. Seven patients underwent subsequent liver transplantation because of deteriorating hepatic function, and two patients died before transplantation could be performed. Although there were no significant differences in outcome of liver transplantation whether or not a biliary procedure had been performed previously, previous biliary tract procedures influenced the type of biliary reconstruction performed, and two complications occurred as direct results of prior operations. Nontransplant procedures should be restricted to those patients with primarily extrahepatic obstruction, whereas liver transplantation should be considered the initial procedure of choice for patients with diffuse sclerosing cholangitis.

Comparative studies on the expression of tumor-associated glycoprotein (TAG-72), CA 19-9 and DU-PAN-2 in normal, benign and malignant pancreatic tissue

Expression of tumor-associated glycoprotein (TAG-72) was examined by immunohistochemistry in pancreatic specimens from normal donors, and from patients with chronic pancreatitis and pancreatic cancer, and was compared with expression of CA 19-9 and DU-PAN-2. In the normal pancreas, TAG-72 was expressed in fewer ductal and ductular cells than were CA 19-9 (p less than 0.05) and DU-PAN-2 (p less than 0.01 and 0.001 respectively), whereas in chronic pancreatitis all 3 antigens were expressed in ductal cells but only CA 19-9 and DU-PAN-2 in ductular cells (p less than 0.001). In the specimens from normal pancreas and chronic pancreatitis cases, TAG-72 was localized in the Golgi region, whereas CA 19-9 and DU-PAN-2 showed diffuse cytoplasmic and glycocalyx patterns. In pancreatic cancer, although the rate of expression of all 3 antigens was similar, their cellular localization differed significantly: only TAG-72 was expressed in the Golgi region (p less than 0.001), whereas CA 19-9 showed mainly glycocalyx (p less than 0.05) and/or intra-luminal patterns (p less than 0.01) compared with that of the other 2 antigens. We conclude that, due to differences in expression of TAG-72 in benign versus malignant cells, the monoclonal antibody against TAG-72 (B72.3) may be suitable for radio-immunodetection or radio-immunotherapy of pancreatic cancer.

Expression of blood group-related antigens ABH, Lewis A, Lewis B, Lewis X, Lewis Y, and CA 19-9 in pancreatic cancer cells in comparison with the patient's blood group type

Blood group A, B, H, Le, Leb, Lex, and Ley antigenicity as well as the expression of CA 19-9 were examined in pancreatic cancer specimens from 30 patients, using monoclonal antibodies to the respective antigen and immunohistochemical techniques, and the findings were correlated with the blood group types (ABO and Lewis) of the individuals. Compatible antigen expression was found in 82, 75, and 50% of tumors from patients with A, B, and O blood group types, respectively. Deletion of the compatible antigen was found in 10 (33%) of the cases, predominantly in patients of blood group O type, and incompatible expression (of B antigen only) in 4 (13%). Lea was detected in 87%, Leb in 90%, Lex in 30%, and Ley in 43% of the specimens, regardless of ABH and Lewis phenotype of the patients. Coexpression of Lea and Leb was found in 87%, of Lex and Ley in 13%, of Lea and Lex in 23%, and of Leb and Ley in 40% of the cases. CA 19-9 was expressed in 80% of the tumors; it was present in the tumor tissue of 21 of 22 patients from Lea-b+, in all 4 individuals from Lea+b-, but in none of the 4 patients from Lea-b- phenotype (P less than 0.01). Heterogeneity in the expression of each of the antigens was found. The overall results indicate that blood group antigen expression in pancreatic tumor differs from that of other gastrointestinal cancers and that the Lewis antigen expression in pancreatic cancer cells is independent of the blood group phenotype of the patients and thus may be useful as a tumor marker.

Plasma postheparin diamine oxidase activity. Development of a simple technique of assessing Crohn's disease

Plasma diamine oxidase (DAO) activity may reflect intestinal involvement in Crohn's disease. The purpose of this study was to develop a simple heparin stimulation test for assessing postheparin plasma diamine oxidase activity in Crohn's disease. Ten volunteers and five patients with Crohn's disease received 1000 units and 3000 units of heparin intravenously and plasma samples were obtained at timed intervals. Plasma DAO activity increased significantly, compared with basal values, 30 minutes after 3000 units of heparin in both volunteers (26.2 +/- 5.0 vs. 4.5 +/- 0.5 units/ml) and patients with Crohn's disease (14.6 +/- 2.0 vs. 4.0 +/- 1.1 units/ml, P less than .05) and was significantly greater in the volunteers. There was no significant increase in DAO activity after 1000 units of heparin. Plasma DAO activity increased significantly within 15 minutes after 3000 units of heparin and remained at this high level at 60 minutes. Postheparin DAO activity correlated with the integrated area under the DAO activity curve. Plasma DAO activity correlated with the Crohn's Disease Activity Index in the patients with Crohn's disease. Plasma DAO activity, 30 minutes after the intravenous administration of 3000 units of heparin, should reflect intestinal involvement in Crohn's disease.

Intestinal mucosa diamine oxidase activity reflects intestinal involvement in Crohn's disease

The activity of diamine oxidase (DAO), an enzyme found in the apical villous cells of the small intestine mucosa, should reflect the status of the intestinal mucosa. Our purpose was to determine whether DAO activity in the intestinal mucosa is diminished in patients with Crohn's disease and correlates with the severity of histological changes. Mucosal DAO activity was determined in 42 tissue specimens from patients with Crohn's enteritis (n = 15), Crohn's colitis (n = 9), and ulcerative colitis (n = 11), and from patients with no intestinal disease (n = 7). DAO activity was estimated by the metabolism of [14C]putrescine. Histologic changes were graded on a scale of 0-4. Normal histology was graded as zero, mild edema, and inflammation in the lamina propria as one, crypt abscess formation and inflammation as two, more severe inflammation plus or minus granulomata as three, and most severe inflammation with active ulceration as four. Tissue DAO activity was significantly less in patients with ileitis (4.8 +/- 3.6) compared with those with Crohn's colitis (15.0 +/- 11.6), ulcerative colitis (16.8 +/- 19.7), and normal intestine (17.6 +/- 14.3 U/mg protein/h, p less than 0.05). Intestinal DAO activity showed a positive correlation with the histologic scores. Recurrence of Crohn's disease developed postoperatively in two patients with low tissue DAO activity (1.4 and 2.9 U/mg protein/h). Intestinal DAO activity is diminished in patients with Crohn's ileitis and correlates with the severity of histologic changes. Tissue DAO activity might prove useful in predicting the risk of recurrence or anastomotic complications after resection for Crohn's disease.

Correlative study on expression of CA 19-9 and DU-PAN-2 in tumor tissue and in serum of pancreatic cancer patients

The serum levels of CA 19-9 and DU-PAN-2 antigens and their expression in tumor tissue were examined in 22 pancreatic cancer patients and the results were correlated with the Lewis (Le) blood group phenotypes of the individuals. In tumor tissue, CA 19-9 was expressed in 17 of 22 (77%) specimens. The negative cases included three patients with Lea-b-, one with Lea+b- and the other with Lea-b+ phenotypes. DU-PAN-2 antigen was expressed in 20 of 22 (91%) cancer tissues. The two DU-PAN-2-negative cases were CA 19-9-positive. The combination of two markers increased the sensitivity to 100%. In the serum, CA 19-9 level was elevated (greater than 37 U/ml) in 16 of 21 (73%) cases. All Lea-b- patients had values less than 37 U/ml. An elevated level of DU-PAN-2 (greater than 300 U/ml) was detected in 14 of 21 (67%) patients including three cases with Lea-b- type. In only one patient were both antigens below the cutoff levels so that the combination of two biomarkers elevated the sensitivity to 95%. The study indicated that the cocktail of 19-9 and DU-PAN-2 antibodies might increase the sensitivity and specificity for clinical diagnosis of pancreatic cancer. In 19 of 21 (90%) cases, the serum CA 19-9 level correlated with the expression of the antigen in the cancer tissue. Discrepancy was seen in two cases; one patient had an elevated level of CA 19-9 in the serum, but lacked this antigen in the cancer cells. In the second case, the situation was reversed. For DU-PAN-2, positive correlation was seen in 14 of 21 (67%) cases. Six of seven patients with low DU-PAN-2 levels expressed the antigen in their tumor cells, and one patient with DU-PAN-2-negative cancer tissue had an elevated level of this marker in the serum. Thus, CA 19-9 expression in serum corresponded more closely to expression in tissue than did that of DU-PAN-2 antigen. The serum levels of these antigens, however, is likely due to multiple factors, only one of which is the qualitative and quantitative expression of the antigens in tumors.

Relationship of carbohydrate antigen 19-9 and Lewis antigens in pancreatic cancer

Carbohydrate antigen (CA) 19-9 identified by a murine monoclonal antibody against a colorectal carcinoma antigen is thought to be a sialylated Lewis (Le)a blood group antigen and occurs in high concentration in serum of patients with pancreatic carcinoma. This study was designed to identify the relationship between Lewis antigens and CA 19-9 in patients with pancreatic cancer. The following analyses were performed in 20 pancreatic cancer patients: Lea and Leb antigen phenotype in saliva (modified enzyme-linked immunosorbent assay) or on red cells (hemagglutination); CA 19-9 levels (radioimmunoassay) in serum; and CA 19-9 and Lea and Leb expression (immunoperoxidase assay) on tumor tissue. Lea-b- patients based on salivary phenotype failed to express CA 19-9 in tumor tissue and had normal or low levels of CA 19-9 (less than 37 units/ml) in serum (P = 0.0011, versus Lea+b- and Lea-b+ patients). Eighty-eight % of Lea+b- and Lea-b+ patients had elevated serum CA 19-9 levels (greater than 37 units/ml). All Lea+b- and Lea-b+ patients expressed both Lea and Leb antigens in tumor tissue. These results support the view that Lea-b- pancreatic cancer patients cannot manufacture CA 19-9. Surprisingly, Lea-positive patients express Leb antigen in tumor tissue; in this subgroup, Leb antigen may be a tumor-specific biomarker.

Comparative studies on expression of CA 19-9 and DU-PAN-2 in pancreatic cancer tissue

Thirty-eight human pancreatic cancer cases were examined by immunohistochemistry for expression of CA 19-9 and DU-PAN-2 antigens by the respective monoclonal antibodies. CA 19-9 was expressed in 82% and DU-PAN-2 in 87% of cases. A combination of two antibodies increased the reactivity to 97%. Six CA 19-9-negative cases were DU-PAN-2 positive and 4 DU-PAN-2-negative cases expressed CA 19-9. In only 1 case (an anaplastic carcinoma), neither of the antibodies was reactive with cancer cells. The reactivity of tumor cells with each of the antibodies varied from case to case, and, within the same tumor, from one area to another. Histologically, all but one tumor were adenocarcinomas. Thirty-five cases showed areas of either a moderate degree of differentiation (16 cases), poor differentiation (11 cases) or anaplastic areas (8 cases). Although both antigens were expressed in a greater number of cancer cells in well differentiated areas, and less frequently in poorly differentiated and anaplastic regions, the difference in antigen expression in relation to the degree of tumor differentiation was not statistically significant. The cellular localization of the antigens varied. DU-PAN-2 was primarily localized within the cytoplasm, whereas CA 19-9 was found mostly on the luminal cell surface and in luminal content of the glandular structure. In tumor-free pancreatic tissue, adjacent to the tumor, CA 19-9 was detected almost exclusively in the cells of large and medium sized ducts, whereas DU-PAN-2 was primarily expressed in terminal ductular and centrocinar cells. The results indicate that a cocktail of CA 19-9 and DU-PAN-2 antibodies could increase the likelihood of identifying a biomarker in most patients with pancreatic cancer.

Shunt surgery versus endoscopic sclerotherapy for long-term treatment of variceal bleeding. Early results of a randomized trial

In September 1982, a prospective randomized trial comparing shunt surgery and endoscopic sclerotherapy for the elective management of variceal hemorrhage in patients with cirrhosis was initiated. Twenty-seven patients have received shunts (distal splenorenal = 23, nonselective = 4) and 30 patients have had chronic sclerotherapy. Eighty-six per cent of patients had alcoholic cirrhosis and 33% were Child's class C. After a mean follow-up of 25 months, 19% of shunt and 57% of sclerotherapy patients have had rebleeding (p = 0.003). Kaplan-Meier survival analysis reveals similar 2-year survival rates for shunt (65%) and sclerotherapy (61%) groups. Only two of 10 sclerotherapy failures have been salvaged by surgery. Posttherapy quantitative hepatic function, frequency of encephalopathy, and cumulative medical costs were similar for both groups. Hepatic portal perfusion and portal pressure at 1 year were better maintained by sclerotherapy than by distal splenorenal shunt. In conclusion, endoscopic sclerotherapy and shunt surgery provide similar results with respect to survival, hepatic function, frequency of encephalopathy, and costs. Sclerotherapy is an acceptable, but not superior, alternative to shunt surgery for treatment of variceal hemorrhage.

Spontaneous closure of an end biliary fistula

Most biliary cutaneous fistulas are side fistulas that communicate with the main biliary ductal system. As long as distal obstruction is not present, nearly all fistulas will close spontaneously. The present case of an end biliary fistula due to transection of an aberrant bile duct during cholecystectomy and its successful nonoperative management demonstrate that end fistulas can sometimes be managed without operative intervention.

The many uses of the U tube

U tube placement was employed as an adjunct to complicated biliary procedures in 14 patients. We found the transhepatic tubes to be useful for stenting biliary anastomoses, maintaining biliary drainage, delivering localized irradiation, and acting as permanent external conduits. The tubes remained in placed an average of 15 months and as long as 40 months. The frequency of cholangitis was minimized by frequent tube exchange. The U-shaped configuration makes tube exchange easy and inexpensive to perform.

Blood-group antigen expression during pancreatic cancer induction in hamsters

The expression of blood group-related and tumor-associated antigens was examined in pancreatic adenocarcinomas and in the normal pancreas of hamsters to determine if this expression correlated with the host blood group and/or stage of carcinogenicity, respectively. Pancreatic tumors were induced by 4 weekly treatments of hamsters with N-nitrosobis(2-oxopropyl)amine (BOP) and analyzed immunohistochemically during different stages of tumor progression with polyclonal antibodies (PoAbs) and monoclonal antibodies (MoAbs) against A, B, O and Lewis (Le) isoantigens, including X, Y and CA 19-9 monosialoganglioside (gastrointestinal cancer antigen, GICA), as well as with PoAbs detecting human carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP) and the beta-subunit of human chronic gonadotropin (beta-HCG). The red blood cells of both control and tumor-bearing hamsters expressed AB and Le(a+b+)-like blood group types, as detected by polyvalent antisera. However, none of the MoAbs reacted with the hamster red blood cells. In the pancreas, all PoAbs against blood group antigens reacted with hyperplastic ducts and ductules at very early stages of carcinogenesis, as well as with neoplastic lesions, but not with normal pancreatic cells, except for the acinar cells, which were stained with PoAb-B, PoAb-Lea and PoAb-Leb. None of the MoAbs showed any affinity for the normal pancreatic cells; however, they reacted to various degrees with induced hyperplastic and neoplastic tissue. Reactivities of several MoAbs with malignant cells were greater than those with hyperplastic lesions: MoAb-B was highly reactive with all induced lesions, MoAb-A less reactive, and MoAb-H and MoAb-Ley (which has 6 sugar chains) detected only some cancer cells. Neither of the two MoAb-Lex (with 5 carbohydrate chains) reacted with carcinoma cells, although they did bind to a few hyperplastic cells. Neither MoAb-Lea and MoAb CA 19-9, nor PoAbs against CEA, AFP and beta-HCG, reacted with any normal, hyperplastic or malignant cells. These results demonstrate the differential reactivity of these PoAbs and MoAbs in normal and malignant pancreatic tissue and show that blood group antigens, especially the B isoantigens, are specific markers for induced pancreatic duct tumors in hamsters.

Increased incidence of pancreas-related complications in patients with postoperative pancreatitis

The incidence and significance of pancreas-related complications (pseudocysts, abscesses, and fistulas) were evaluated in 100 patients with acute pancreatitis. Alcoholic (40 percent), biliary (20 percent), and postoperative (15 percent) pancreatitis were seen most frequently. Eighteen patients had severe pancreatitis (3 or more Ranson's criteria). The overall mortality rate was 8 percent, and there were 16 pancreas-related complications. Pancreas-related complications developed in eight patients (53 percent), including two pseudocysts, four abscesses, and two fistulas. The incidence of pancreas-related complications was significantly greater in the postoperative group than in the overall 9 percent incidence in the other groups (p less than 0.005). Half of these patients required operation for their complications. Patients with postoperative pancreatitis are at a markedly increased risk of pancreas-related complications. Since these complications occur even in apparently mild cases of pancreatitis, these patients should be followed closely to detect pancreas-related complications.

Colchicine-binding properties of hepatic tubulin. The role of "time-decay"

Determination of total and polymerized tubulin in the liver by the [3H]colchicine-binding assay is hampered by rapid loss of binding sites. One solution, which has been proposed to overcome this problem, is the use of a "time-decay" corrected assay that extrapolates to an initial binding capacity based on the results of testing multiple aliquots of liver supernatants over time. If such an approach is valid, it follows that the extrapolated initial value should be independent of the rate of time-decay. To test this relationship, we modulated the half-life (T1/2) for time-decay of a fixed amount of hepatic microtubule-derived tubulin using various concentrations of organic acids, sodium glutamate and glucose-1-phosphate. We found that the initial binding capacity based on simple first order decay did vary with the T1/2. Similar results were also obtained with bovine brain tubulin added to hepatic supernatants. These results indicate that the quantification of hepatic tubulin derived by extrapolated time-decay values is inaccurate and may overestimate the actual amount of tubulin present, especially when time-decay is rapid.

Ascites progressing to an abdominal mass due to extramedullary hematopoiesis in a patient with agnogenic myeloid metaplasia (AMM)

We report a patient with long-standing agnogenic myeloid metaplasia who developed ascites which progressed over 6 months to a massive solid peritoneal mass as a consequence of intraperitoneal extra-medullary hematopoiesis. The clinical and radiographic features of this unusual case are presented.

Clinical and biochemical course of alcoholic liver disease following sudden discontinuation of alcoholic consumption

It has been our impression that clinical deterioration and worsening of liver tests of patients with alcoholic liver disease (ALD) is common immediately following hospitalization and cessation of ethanol intake. In order to determine the frequency of such deterioration and characterize features which may identify those patients who initially deteriorate, we analyzed the standard liver tests and clinical parameters of liver function following hospitalization of 273 cases of ALD, and correlated these with histologic patterns and hospital course. We found that moderate liver test worsening following hospitalization is frequent in patients with ALD, especially alcoholic hepatitis. The presence of alcoholic hyalin in patients with alcoholic hepatitis did not correlate with liver function or frequency of biochemical worsening, but did correlate with mortality. Biochemical deterioration did not correlate with clinical deterioration or mortality, unless complications such as bleeding, sepsis, or pancreatitis occurred. Spontaneous clinical deterioration of our patients in the absence of precipitating factors was rare. We conclude that worsening of liver tests following hospitalization frequently occurs in patients with ALD, does not necessarily imply presence of complications (e.g., biliary obstruction, sepsis, other liver injury), but should suggest the presence of alcoholic hepatitis.