Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia: CARE-FH Protocol

The Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia (CARE-FH) study aims to improve diagnostic evaluation rates for FH at Geisinger, an integrated health delivery system. This clinical trial relies upon implementation science to transition the initial evaluation for FH into primary care, attempting to identify individuals prior to the onset of atherosclerotic cardiovascular disease events. The protocol for the CARE-FH study of this paper is available online. The first phase of the project focuses on trial design, including the development of implementation strategies to deploy evidence-based guidelines. The second phase will study the intervention, rolled out regionally to internal medicine, community medicine, and pediatric care clinicians using a stepped-wedge design, and analyzing data on diagnostic evaluation rates, and implementation, service, and health outcomes.

Communicating personalized risk of diabetes and offering weight reduction program choice: Recruitment, participation, and outcomes

OBJECTIVE

Low patient recruitment into diabetes prevention programs is a challenge. The primary aim of this study was to demonstrate that an increased recruitment rate can be achieved by communicating personalized risk of progression to type 2 diabetes, estimating risk reduction with weight loss, and offering program choice. Secondary aims included program participation rate, weight loss, and short-term decreased diabetes risk.

METHODS

In this single-arm study, persons with prediabetes from 3 primary care sites received a letter that communicated their personalized risk of progression to diabetes within 3-years, estimated risk reduction with 5, 10, 15 % weight loss, reported in pounds, and offered a choice of 5 free, 6-month, programs. A one-sided test was used to compare the recruitment rate against the maximum expected rate of (10 %).

RESULTS

Recruitment response rate was 25.3 % (81/328, 95 % CI=[20.0 %, 29.4 %]) which was significantly higher than expected (p < 0.0001). Overall, 65 % of participants completed >75 % of contacts. BMI, HbA1c, and diabetes risk (all p < 0.0001) improved at 6 months; BMI (p < 0.0001) and HbA1c (p < 0.05) improved at 12 months.

CONCLUSION

Recruitment response rate was better than expected.

PRACTICE IMPLICATIONS

Communicating personalized risk and reduction estimates with a choice of programs resulted in favorable outcomes, sustained at 1-year.

Feasibility of blood testing combined with PET-CT to screen for cancer and guide intervention

Cancer treatments are often more successful when the disease is detected early. We evaluated the feasibility and safety of multicancer blood testing coupled with positron emission tomography-computed tomography (PET-CT) imaging to detect cancer in a prospective, interventional study of 10,006 women not previously known to have cancer. Positive blood tests were independently confirmed by a diagnostic PET-CT, which also localized the cancer. Twenty-six cancers were detected by blood testing. Of these, 15 underwent PET-CT imaging and nine (60%) were surgically excised. Twenty-four additional cancers were detected by standard-of-care screening and 46 by neither approach. One percent of participants underwent PET-CT imaging based on false-positive blood tests, and 0.22% underwent a futile invasive diagnostic procedure. These data demonstrate that multicancer blood testing combined with PET-CT can be safely incorporated into routine clinical care, in some cases leading to surgery with intent to cure.

Metabolic surgery and iron homeostasis

Iron deficiency and anaemia after metabolic surgery, potentially modifiable nutritional complications, are becoming an increasing cause for concern as prevalence increases with time and there is limited evidence supporting the effectiveness of the current guidelines for prophylactic oral iron supplementation and treatment for deficiency. Abnormalities in iron nutrition predisposing to deficiency are common in severely obese patients, and the low-grade systemic inflammation, also common to these patients, reduces the effectiveness of oral iron supplementation. The surgical procedures result in alterations of foregut anatomy and physiology, which limit iron absorptive capacity and daily food intake. These alterations and the limited effects of oral iron supplementation explain the high prevalence of postoperative iron deficiency and anaemia. This review outlines current mechanisms concerning the pathogenesis of disordered iron nutrition in patients with severe obesity, current gaps in knowledge, and opportunities for quality improvement.

All-Cause and Specific-Cause Mortality Risk After Roux-en-Y Gastric Bypass in Patients With and Without Diabetes

OBJECTIVE

This study assessed all-cause and specific-cause mortality after Roux-en-Y gastric bypass (RYGB) and in matched control subjects, stratified by diabetes status.

RESEARCH DESIGN AND METHODS

RYGB patients were matched by age, BMI, sex, and diabetes status at time of surgery to nonsurgical control subjects using data from the electronic health record. Kaplan-Meier curves and Cox regression were used to assess differences in all-cause and specific-cause mortality between RYGB patients and control subjects with and without diabetes.

RESULTS

Of the 3,242 eligible RYGB patients enrolled from January 2004 to December 2015, control subjects were identified for 2,428 (n = 625 with diabetes and n = 1,803 without diabetes). Median postoperative follow-up was 5.8 years for patients with diabetes and 6.7 years for patients without diabetes. All-cause mortality was reduced in RYGB patients compared with control subjects only for those with diabetes at the time of surgery (adjusted hazard ratio 0.44; P < 0.0001). Mortality was not significantly improved in RYGB patients without diabetes compared with control subjects without diabetes (adjusted hazard ratio 0.84; P = 0.37). Deaths from cardiovascular diseases (P = 0.011), respiratory conditions (P = 0.017), and diabetes P = 0.011) were more frequent in control subjects with diabetes than in RYGB patients with diabetes. RYGB patients without diabetes were less likely to die of cancer (P = 0.0038) and respiratory diseases (P = 0.046) than control subjects without diabetes but were at higher risk of death from external causes (P = 0.012), including intentional self-harm (P = 0.025), than control subjects without diabetes.

CONCLUSIONS

All-cause mortality benefits of RYGB are driven predominantly by patients with diabetes at the time of surgery. RYGB patients with diabetes were less likely to die of cardiovascular diseases, diabetes, and respiratory conditions than their counterparts without RYGB.

Changes in telomere length 3-5 years after gastric bypass surgery

Increased inflammation and oxidative stress associated with obesity can accelerate aging. Telomere length (TL) has the capacity to serve as an aging indicator at the cellular level. Obesity has a known association with shorter TL. This study evaluated TL of immune cells in a population of obese individuals who underwent gastric bypass surgery. Pre and post-operative DNA samples were available for 50 subjects who had gastric bypass surgery. DNA was analyzed via quantitative polymerase chain reaction (q-PCR) to determine TL. Changes in TL were evaluated by comparing TL at baseline to TL at 3-5 years post gastric bypass surgery. Sixty percent of the individuals in the study observed an increase in TL. Significant lengthening was observed for those with the shortest baseline TL (p=0.0011), but not for those with intermediate baseline TL (p=0.411) or longest baseline TL (p=0.207). Change in TL was negatively correlated with age and triglycerides but not correlated with weight loss induced by bariatric surgery. This study confirms that TL lengthening is observed post bariatric surgery and is the first to detect TL lengthening 3-5 years after surgery.

Gene expression profiling in subcutaneous, visceral and epigastric adipose tissues of patients with extreme obesity

Objective

The goal of the present study was to identify differences in gene expression between SAT, VAT, and EAT depots in Class III severely obese individuals.

Design

Human subcutaneous (SAT) and visceral (VAT) adipose tissues exhibit differential gene expression profiles. There is little information, however, about the other proximal white adipose tissue, epigastric (EAT) in terms of its function and contribution to metabolism.

Subjects and Methods

Using RNA from adipose biospecimens obtained from Class III severely obese patients undergoing open Roux-en-Y gastric bypass surgery, we compared gene expression profiles between SAT, VAT, and EAT, using microarrays validated by real time quantitative PCR.

Results

The three depots were found to share 1,907 genes. VAT had the greatest number of genes [66] expressed exclusively in this depot, followed by SAT [23], and then EAT [14]. Moreover, VAT shared more genes with EAT [65] than with SAT [38]. Further analyses using ratios of SAT/EAT, VAT/EAT, and SAT/VAT, identified specific as well as overlapping networks and pathways of genes representing dermatological diseases, inflammation, cell cycle and growth, cancer, and development. Targeted analysis of genes playing a role in adipose tissue development and function, revealed that Peroxisome proliferator-activated receptor Gamma Coactivator 1-alpha (PGC1-α) that regulates the precursor of the hormone Irisin (FNCD5), were abundantly expressed in all three fat depots, along with fibroblast growth factors (FGF) FGF1, FGF7, and FGF10, whereas, FGF19 and FGF21 were undetectable.

Conclusions

These data indicate that EAT has more in common with VAT suggesting similar metabolic potential. The human epigastric adipose depot could play a significant functional role in metabolic diseases and should be further investigated.

Arterial occlusions as a presenting feature of acute promyelocytic leukemia

Arterial thrombosis as a presentation of acute promyelocytic leukemia is uncommon. The authors report a patient who presented with a clot in the left external iliac artery and pulmonary emboli. The literature is reviewed.

Measurement of glucose and water transport in the human duodenum in vivo using a dialysis bag

BACKGROUND/AIMS

Only a few studies have evaluated duodenal absorptive or secretory function in humans. In the present study we determined duodenal glucose and water transport in humans in vivo.

MATERIAL AND METHODS

Duodenal glucose and water transport were studied in 27 healthy volunteers using a modification of the dialysis bag technique for measuring rectal water and sodium transport.

RESULTS

Net glucose absorption increased progressively over the range of glucose concentrations studied (10 mM to 100 mM) from 0.21 +/- 0.19 to 1.76 +/- 0.15 mM/cm2/90 min. Maximum water absorption occurred from the 10 mM glucose solution (35.87 +/- 7.5 microliters/cm2/90 min) and at a significantly greater rate than from the 80 mM glucose (11.60 +/- 4.0 microliters/cm2/90 min) and the 100 mM glucose (14.90 +/- 1.7 microliters/cm2/90 min solution.

CONCLUSION

This study demonstrates that glucose and water are absorbed by the human duodenum in vivo and that the dialysis bag technique can be adapted to measure transport processes in areas of the intestine other than the rectum.

Composition and preliminary evaluation of a hydrolyzed rice-based oral rehydration solution for the treatment of acute diarrhea in children

OBJECTIVE

The purpose of this study was to experimentally develop and clinically evaluate the safety and potential usefulness of a rice-based, short glucose polymer oral rehydration solution (ORS), Amylyte, in the treatment of acute diarrhea. Amylyte has a similar osmolality but a higher caloric density than the WHO ORS.

METHODS

Different amounts of rice were cooked in 500 ml of water containing salts (1.5 g NaCl, 600 mg KCl, and 150 mg CaCl2) with varying amounts of thermophilic amylase (252,500 modified Wohlgemuth units). Amylase (25 mg) thinned the gluey rice water when 100 g of rice was cooked in 500 ml of water for 10 minutes. The volume of the resultant supernatant (Amylyte) was approximately 250 ml. A two-part, clinical case study was performed. In study 1, 12 children with diarrhea and mild dehydration were studied to determine the safety of Amylyte. In study 2, Amylyte and the WHO ORS were given to 24 and 31 male children with acute diarrhea and moderate to severe dehydration, respectively.

RESULTS

92-96% of the rice amylose and amylopectin were converted to short polymers of glucose (3-9 molecules of glucose). The osmolality of 7,994 packages used to make the Amylyte solution ranged between 277-340 mOsm/kg. The mean electrolyte composition was Na+ = 68 mEq/L, K+ = 20 mEq/L, Cl = 73 mEq/L, the caloric density 425 kcal/L and rice proteins 0.7 g/L. In study 1, 12 children with diarrhea and mild dehydration were rehydrated successfully with Amylyte ORS and the diarrhea ceased within 48 hours. None developed clinical features of carbohydrate intolerance. In study 2, an open-label clinical case study, children with acute diarrhea given Amylyte ORS had significantly less stool output than children given the WHO ORS.

CONCLUSIONS

Amylyte ORS has the advantages of a higher caloric density than the WHO ORS and shares a simple preparation of appropriate osmolality and electrolyte composition. It can safely and effectively rehydrate children with acute diarrhea and dehydration.

Thermophilic amylase-digested rice-electrolyte solution in the treatment of acute diarrhea in children

OBJECTIVE

To compare the efficacy of an oral rehydration solution (ORS) containing short polymers of glucose derived from rice (Amylyte-ORS) and five times the caloric density of current ORS to the standard glucose-ORS (World Health Organization [WHO] = ORS) in the treatment of acute diarrhea in children.

METHODS

The rice ORS (Amylyte-ORS) was obtained by adding thermophilic amylase (252,500 MW units) and salts (1.5 g NaCl, 600 mg KCl, and 150 mg CaCl2) to 100 g rice and boiling for 10 minutes in 500 mL water. This yields 250 mL Amylyte-ORS, which contains 92% to 96% short-chain glucose polymers, three to nine molecules in length, and provides 425 kcal/L, compared to 80 kcal/L for the WHO-ORS. One hundred forty-four male children, 4 months to 3 years of age, presenting with acute diarrhea and mild, moderate, or severe dehydration, were assigned by random allocation to receive either WHO-ORS or Amylyte-ORS. Data from 127 children were analyzed (57 received the WHO-ORS and 70 the Amylyte-ORS). Two children given Amylyte-ORS and 15 given the WHO-ORS were not included in the analysis because of improperly collected data or lost urine or fecal specimens. None were given antibiotics during the study. Free water and feeding were allowed after the children were rehydrated.

RESULTS

The clinical characteristics of the children in the two treatment groups were comparable. Five children who received the WHO-ORS and three children given Amylyte-ORS were treatment failures. Amylyte-ORS reduced diarrhea duration by 15% (41.4 +/- 2.5 vs 34.7 +/- 1.8 hours; P < .03) compared to the WHO-ORS, regardless of the severity of dehydration. In the Amylyte-treated group, ORS requirements were significantly less (234 +/- 15.2 vs 295 +/- 17.6 mL/kg; P < .01) and weight gain was significantly more (367.7 +/- 45.1 vs 199.2 +/- 38.2 g; P < .01) than in those given the WHO-ORS. The net intestinal fluid balance and total body fluid balance were similar in the two groups.

CONCLUSIONS

Amylyte-ORS effectively rehydrates children with acute diarrhea, reduces diarrhea duration, decreases ORS requirements, and improves weight gain compared to the WHO-ORS.

Enzyme therapy for pancreatic insufficiency: present status and future needs

Pancreatic enzyme extracts have been used for several decades to decrease maldigestion of macro- and micronutrients due to pancreatic insufficiency and to alleviate various abdominal symptoms, including the pain of alcohol-induced chronic pancreatitis and distal intestinal obstruction. Decreasing nutrient maldigestion and malabsorption in pancreatic insufficiency is of additional critical importance because improvement in nutritional status reduces morbidity and mortality. For example, pancreatic sufficient patients with cystic fibrosis (CF) demonstrate a slower decline in pulmonary function. In spite of the recognized importance of pancreatic enzymes, several problems exist with current preparations, and as newer enzyme preparations are marketed, proper evaluation becomes critical. There is a clear need to optimize the constituents of enzyme preparations, improve manufacturing processes, and find better sources of enzymes. Other issues that need addressing include standardization of the ratios of enzymes (lipase, amylase, protease) in these products; the stability of the enzymes at room temperature; the shelf life of the finished product; whether there are significant batch-to-batch differences; and the need for a USP reference standard.

Effect of a maltodextrin-electrolyte, a maltodextrin-nutrient-electrolyte and a standard electrolyte solution on water and electrolyte fluxes in the secreting rat intestine

The effects of a maltodextrin (dextrose equivalent 12)-electrolyte solution and a maltodextrin-electrolyte solution with added nutrients on net water and electrolyte transport in the secreting rat intestine was compared with the citrate-World Health Organization oral rehydration solution to determine the need for a clinical trial to evaluate the efficacy of these maltodextrin solutions in acute diarrhoea treatment. Cholera toxin consistently produced net water secretion (-36.5 +/- 9.9 mean +/- SEM microliter/min/g dry weight of intestine). All three solutions reversed the cholera toxin-induced net intestinal water secretion to net absorption. Significantly greater net water absorption occurred from the maltodextrin-electrolyte solution compared to the World Health Organization solution (P < 0.05) but not when compared to the maltodextrin-electrolyte-nutrient solution. Net sodium, potassium and chloride fluxes due to the World Health Organization-solution were not significantly different from the maltodextrin-electrolyte solution. These data provide a rationale for initiating a clinical trial.

Colonoscopic study of 50 patients with colonic tuberculosis

Fifty patients with colonic tuberculosis are reported in whom a colonoscopic diagnosis confirmed by histological examination was possible in 40. Bacteriological studies did not increase the diagnostic yield. Abdominal pain was the most common symptom (90%) and an abdominal mass the most common abnormal physical finding (58%). A nodular mucosa with areas of ulceration was the usual colonoscopic finding. Ileocaecal disease was found in 16, ileocaecal and contiguous ascending colon disease in 14, segmental colonic tuberculosis in 13, ileocaecal disease and non-confluent involvement of another part of the colon in five, and pancolitis in two patients. This report emphasises that colonoscopy is a useful procedure for diagnosing colonic tuberculosis and that segmental colonic tuberculosis is not uncommon.

Effect of base precursors on water and electrolyte transport during oral hydration solution perfusion in secreting rat intestine

In situ steady-state, single-pass small intestine perfusions in rats were carried out to compare the effect of the bicarbonate and citrate World Health Organization oral rehydration solutions and a base precursor-free solution on intestinal water and electrolyte transport after inducing intestinal secretion with purified heat-stable Escherichia coli enterotoxin. When toxin was not perfused, the rates of water, sodium, and bicarbonate absorption were significantly greater from the bicarbonate-containing solution than from the citrate or base precursor-free solutions. Chloride absorption was greater from the base precursor-free solution, but this might reflect the higher chloride concentration of the perfusate. When toxin was perfused, there was no significant difference among the solutions in the rates of water, potassium, or chloride absorption. Sodium absorption occurred at significantly greater rates from both the bicarbonate and the base precursor-free solutions than from the citrate solution. Base precursor-containing solutions may not provide any advantage over a base precursor-free solution in stimulating water and sodium absorption in 5'-cyclic guanosine monophosphate mediated acute diarrhea.

Diagnosis of Strongyloides and hookworm infections: comparison of faecal and duodenal fluid microscopy

Faecal microscopical diagnosis of Strongyloides and hookworm infections is insensitive. We have therefore compared duodenal fluid and faecal microscopy for detection of these parasites in a group of 292 patients being investigated for gastrointestinal symptoms who were examined by both techniques. Thirty-three of these patients (8%) were infected with Strongyloides stercoralis and 88 (30%) had hookworm infections. Microscopical examination of up to 3 faecal specimens detected only 33% and 65% of patients with Strongyloides and hookworm infections, respectively. Microscopical examination of a single specimen of duodenal fluid was more sensitive for detection of strongyloidiasis, identifying 76% of patients; the parasite was found exclusively in duodenal fluid (and not in faeces) in 67% of patients. For hookworm, the diagnostic sensitivity was similar with both techniques but duodenal fluid microscopy detected some patients (35%) who had not been identified by faecal microscopy. This study confirms previous work indicating the insensitivity of faecal microscopy in these infections and emphasizes the need to consider routine examination of duodenal fluid to exclude chronic strongyloidiasis. This may have particular relevance for south-east Asian war veterans and immunocompromised patients.

Evaluation of the efficacy of oral rehydration solutions using human whole gut perfusion

Whole gut perfusion in humans was used to compare the effect on intestinal water and electrolyte transport of the World Health Organisation oral rehydration solution (solution II, composition in mmol/l: glucose 111, sodium 90, bicarbonate 30, potassium 20; 308 mOsm/kg); a hypertonic commercial oral rehydration solution (solution III, glucose 188, sodium 50, bicarbonate 20, potassium 20 mmol/l; 335 mOsm/kg); and three experimental bicarbonate free, hypotonic oral rehydration solutions: solution IV (glucose 111, sodium 60, potassium 20 mmol/l; 260 mOsm/kg), solution V (glucose 80, sodium 60, potassium 20 mmol/l; 219 mOsm/kg), and solution VI (glucose 80, sodium 30, potassium 20 mmol/l; 177 mOsm/kg). Perfusion of the intestine with a standard cleansing solution (solution I, sodium 125, potassium 10, bicarbonate 20, sulphate 40, mannitol 80 mmol/l; 275 mOsm/kg) confirmed published data on minimal water and sodium absorption. Experimental solution VI produced maximum water absorption (mean (SE) +1660.0 (29.8) ml/h) significantly greater than solution II (+1195.3 (79.5) ml/h), III (+534.7 (140.3) ml/h), IV (+1498.0 (42.7) ml/h), and V (+1327.7 (24.4) ml/h; p less than 0.05). Sodium absorption was significantly greater with solution II (+97.4 (7.9) mmol/h) compared to VI (+43.3 (7.8) mmol/h; p less than 0.01) but not compared to IV (+67.2 (13.0) mmol/h). A hypotonic oral rehydration solution such as solution VI may provide optimal replacement treatment for patients with acute diarrhoea.

Jejunal water and sodium secretion occurs in chronic idiopathic intestinal pseudo-obstruction

We observed jejunal water and sodium secretion in two patients with chronic idiopathic intestinal pseudo-obstruction by standard perfusion techniques. The ability of glucose to reverse this secretory state was impaired. These observations suggest that a jejunal secretory state may contribute to the diarrhea in chronic idiopathic intestinal pseudo-obstruction.

Acetate absorption in the normal and secreting rat jejunum

Acetate absorption was studied in rat jejunum using steady state perfusion in vivo. Absorption conformed to apparent saturation kinetics and was similar in magnitude to glucose absorption. When compared with normal saline, acetate perfusion was associated with luminal alkalinisation. There was no difference in total CO2 secretion when similar rates of acetate and glucose absorption were compared, suggesting that total CO2 secretion was the result of mucosal metabolism. Absorption of acetate and propionate were mutually inhibitory. Acetate absorption was also inhibited by Tris-Hepes pH 7.0. When the gut was pretreated with cholera toxin to induce a secretory state, acetate absorption was reduced by 41.9%. This effect could be reproduced if similar water secretion was osmotically induced by the addition of mannitol. These data suggest that acetate is absorbed, at least, partially by non-ionic diffusion in the rat jejunum and that its absorption is reduced in the secreting intestine by solvent drag.

Jejunal and ileal glucose-stimulated water and sodium absorption in tropical enteropathy: implications for oral rehydration therapy

Intestinal glucose and water absorption in response to glucose has been studied in tropical enteropathy with a view to determine the optimum glucose concentration in oral rehydration solutions for use in the tropics. Maximum jejunal water and sodium absorption occurred from an 80-mM glucose-sodium chloride solution (-285.7 +/- 46.0 ml/30 cm/h and -31.8 +/- 3.8 mM/30 cm/h, respectively) during in vivo steady-state jejunal perfusion. At perfusate glucose concentrations greater than 250 mM, however, jejunal water and sodium secretion occurred. In the ileum, maximum glucose-stimulated water absorption (-91.1 +/- 27.1 ml/30 cm/h) was significantly less than in the jejunum. Glucose absorption demonstrated saturation kinetics in both the jejunum and ileum. The half-saturation concentration was higher in the jejunum (167 mM) compared to the ileum (28 mM). This study suggests that the optimal glucose concentration for oral rehydration solutions used in the tropics should be 80 mM, as lower and higher concentrations result in diminished jejunal water absorption.

The relative merits of faecal and duodenal juice microscopy in the diagnosis of giardiasis

We compared the diagnostic accuracy of microscopical examination of multiple faecal specimens with duodenal juice examination in the diagnosis of giardiasis. Of 292 patients who had stool microscopy and duodenal aspirate, Giardia were identified in either stools or duodenal fluid from 73 patients (25%). Giardiasis was diagnosed in 62 (73%) with the first faecal specimen, but examination of 3 specimens increased the diagnostic yield to 85%. Giardia, however, were found in only 32 of 73 duodenal aspirates examined (44%). This finding is contrary to the widely held belief that duodenal fluid examination is superior to stool microscopy for the diagnosis of giardiasis. The 2 approaches are complementary, however, since Giardia was found in duodenal fluid, only, from 15% of patients.

Food-based solutions are a viable alternative to glucose-electrolyte solutions for oral hydration in acute diarrhoea--studies in a rat model of secretory diarrhoea

A survey of acute diarrhoea and its treatment, in 3 groups of villages in south India, revealed that use of the World Health Organization oral rehydration solution (WHO-ORS) was poor or virtually non-existent and that several liquid foods were given to children during acute diarrhoea. The effects of the most commonly used, boiled and cooled supernatants of these liquid foods [rice (Oryza sativa)-water, ragi (Eleusine coracana)-water, arrowroot (Maranta arundinacea)-water], and tender coconut-water, and of the bicarbonate- and citrate-WHO-ORS on intestinal water transport were evaluated using a rat model of secretory diarrhoea. All solutions either decreased cholera toxin-induced net water secretion (arrowroot-water) or reversed it to net absorption. Ragi-water produced maximum net water absorption, significantly greater than the WHO oral rehydration solutions. WHO-ORS utilization is poor in some developing countries, and locally used food-based solutions could be used for maintaining hydration or correcting the dehydration due to acute diarrhoea once their effectiveness has been proved by clinical trials.

Xylose transport in the human jejunum

D-Xylose transport in the human jejunum was studied in vivo using a standard intestinal perfusion technique, and also in vitro in human jejunal brush border membrane vesicles. Initial D-xylose concentrations were linearly related to D-xylose absorption rates, a finding consistent with passive diffusion. Perfusion of D-xylose with varying D-glucose concentrations were aimed at examining D-xylose-D-glucose jejunal cotransport. D-Xylose absorption rates from a 30 mM D-xylose perfusate did not change significantly when 10, 30, or 60 mM glucose were added (-3.0 +/- 0.62 vs -3.34 +/- 0.71, -3.82 +/- 0.81, and -4.56 +/- 0.72 mM/30 cm/hr, respectively; minus indicates net absorption) suggesting an absence of a cotransport system. In brush border membrane vesicles, xylose uptake was partially inhibited by D-glucose and phlorizin. These data suggest that jejunal D-xylose absorption, at concentrations used clinically, is by passive diffusion, which process completely overrides a minor D-glucose cotransport component. The D-xylose tolerance test, therefore, reflects jejunal mucosal surface area and mucosal permeability to D-xylose and not nutrient carbohydrate absorption.

Effect of bicarbonate, acetate, and citrate on water and sodium movement in normal and cholera toxin-treated rat small intestine

Bicarbonate, citrate, or acetate are commonly included in oral rehydration solutions to correct acidosis and possibly because of their ability to promote water and sodium absorption. We have investigated the effect of these anions on water and sodium transport in normal and also in secreting (cholera toxin-treated) rat small intestine using a single-pass perfusion technique. In normal jejunum bicarbonate and acetate produced net absorption, and citrate net secretion of both water and sodium. In normal ileum all anions produced net absorption of water and sodium. In the secreting jejunum, however, bicarbonate had no effect on water and sodium secretion, whereas acetate and citrate actually enhanced the secretory state for both water and sodium. None of these anions had any effect on water and sodium secretion in the ileum. These observations suggest that normal and secreting intestine are qualitatively different with regard to handling of these organic anions. The addition, therefore, of bicarbonate, acetate, or citrate to oral rehydration solutions may have no beneficial effect with regard to the promotion of water and sodium absorption in the secreting intestine during acute diarrhoeal states and could actually be deleterious.

Efficacy of oral rehydration solutions in a rat model of secretory diarrhea

Controversy continues regarding the ideal composition of glucose/electrolyte solutions used for oral rehydration of infants and children with acute diarrhea. We have used cholera toxin-treated rat small intestine as a model of secretory diarrhea to assess the efficacy of oral rehydration solutions by intestinal perfusion. All solutions tested reversed net water secretion but a hypotonic bicarbonate-free solution was more effective than other solutions, including the World Health Organization oral rehydration solution (p less than 0.003). Net sodium secretion persisted with all solutions tested but there was a significant linear relationship between sodium concentration of the solution perfused and net sodium transport (r = 0.75, p less than 0.05). Cholera toxin treatment alone and in combination with perfusion of oral rehydration solutions significantly reduced plasma sodium concentration and osmolality (p less than 0.05), the effects being most marked with low sodium solutions. Although direct parallelism between observations in this animal model of secretory diarrhea and human diarrheal disease has not been established as yet, the model may be useful in assessing clinical efficacy of new oral rehydration solutions and in systematic analysis of the relative benefits of their individual components.

Spiral organisms in the human jejunum

Spiral organisms were found in close apposition to the jejunal mucosa in a patient with idiopathic intestinal pseudoobstruction. Such organisms are generally not found in the jejunum and their presence in this patient was considered to be related to intestinal stasis, and possibly to diarrhea.

Diagnosis of giardiasis by specific IgM antibody enzyme-linked immunosorbent assay

An enzyme-linked immunosorbent assay (ELISA) was used to detect serum IgM and IgG antibodies against Giardia in fifty-two patients with diarrhoea from the United Kingdom and south India. Serum anti-Giardia IgM responses occurred in patients with giardiasis; in two of three patients studied longitudinally IgM levels had fallen to normal 2-3 weeks after treatment. At serum dilutions of 1/200 to 1/400 there was almost complete separation of ELISA readings between patients with Giardia and Giardia-free controls; the sensitivity and specificity of the ELISA were both 96%. Serum anti-Giardia IgG was detected in patients and controls but was unable to distinguish current from previous infection.

Foreign body in the lung for 45 years without symptoms

Patients with foreign bodies in the bronchopulmonary tree seldom remain asymptomatic for long (Abdul Majid et al. 1976). We report here a patient who aspirated a 22 carat gold safety-pin at 10 years of age and who continues to be free of respiratory symptoms 45 years later.

Effect of prostacyclin (PGI2) on water and solute transport in the human jejunum

Prostacyclin is an arachidonic acid metabolite, synthesised throughout the gastrointestinal tract, which has different effects on water and electrolyte transport across a variety of mammalian gastrointestinal epithelia. Using a perfusion technique in the human jejunum of 11 healthy subjects in vivo, the effect of intravenous prostacyclin, 4 ng/kg/min, on jejunal water and solute transport from a glucose electrolyte solution was investigated. In the prostacyclin group (n = 5), prostacyclin was infused intravenously from 70-150 minutes, and buffer administered iv from 0-70 and 150-210 minutes. In the buffer group (n = 6), iv buffer was administered from 0-210 minutes. In the prostacyclin group, net jejunal absorption of water was inhibited from 90-120 min (p less than 0.05), 150-180 min (p less than 0.01) and 180-210 min (p less than 0.01), of sodium was inhibited from 90-120 min (p less than 0.05), 120-150 min (p less than 0.05), 150-180 min (p less than 0.01) and 180-210 min (p less than 0.01), and of chloride was inhibited from 90-120 min (p less than 0.05), 120-150 min (p less than 0.005), 150-180 min (p less than 0.01) and 180-210 min (p less than 0.01). Prostacyclin had no effect on net movement of glucose, potassium or bicarbonate. These results are consistent with a role for prostacyclin in the endogenous humoral regulation of water and electrolyte transport in the human jejunum.

Acetate and citrate stimulate water and sodium absorption in the human jejunum

Using a standard perfusion technique, the organic anions acetate (50 mmol/l) and citrate (5 mmol/l) have been shown to stimulate absorption of water and sodium from the human jejunum. These observations may support further the rationale for including acetate or citrate in oral rehydration solutions for the treatment of acute diarrhoeal disease in humans.

Nufenoxole, a new antidiarrhoeal agent, inhibits fluid secretion in the human jejunum

Nufenoxole is an orally active antidiarrhoeal agent which binds to opioid receptors in the brain and myenteric plexus of the intestine. A perfusion technique has been used to investigate the effect of nufenoxole (1 mg/kg intrajejunally) on water and solute transport stimulated by the secretagogue, dioctyl sodium sulphosuccinate, in the human jejunum in vivo. Nufenoxole reversed the direction of jejunal transport of salt and water from net secretion to net absorption. These changes in water and electrolyte transport were inhibited by intravenous naloxone, the opioid antagonist. Nufenoxole possesses potent antisecretory properties, which are mediated via opioid receptors and may contribute to its antidiarrhoeal action in man.

Separation of hydrophobic and hydrophilic forms of gamma-glutamyltransferase from human serum by hydrophobic chromatography on phenyl-Sepharose CL-4B: studies on normal sera and sera of patients with liver disease

A new method is described for the separation of hydrophobic and hydrophilic forms of gamma-glutamyltransferase (GGT) present in human serum using hydrophobic chromatography on phenyl-Sepharose CL-4B columns. The analysis of sera of 30 normal healthy people showed that 71.49 +/- 8.73% (mean +/- SD) of the GGT was in the hydrophilic form. In sera from 52 patients with various liver diseases the major part of the total enzyme was hydrophobic GGT, contributing 67.38 +/- 13.8% of the total GGT activity. Elevated total serum GGT and a hydrophobic to hydrophilic ratio of more than one helped in diagnosing hepatobiliary disease in 51 of 52 patients. Papain digestion of serum converted hydrophobic to hydrophilic GGT, which was similar to soluble form of liver GGT. The results are discussed in relation to the proposed mechanisms of release of GGT from the liver to the circulation.