Factors predicting interferon treatment response in patients with chronic hepatitis c: late viral clearance does not preclude a sustained response

OBJECTIVES

Because of the suboptimal efficacy, cost, and adverse effects of interferon in chronic hepatitis C (HCV), predictors have been sought to detect patients with a good treatment response. Also, markers for determining a poor response early in the course of therapy, such as the lack of early viral clearance, have been proposed.

METHODS

Ninety-seven patients with chronic hepatitis C were enrolled to receive leukocyte alpha-interferon according to a stepped-care management protocol. The final virological treatment response was evaluated in 74 patients after a 6-month post-treatment follow-up. The relationship between pretreatment and during-treatment variables and the long-term response was assessed.

RESULTS

Non-1 viral genotype, higher pretreatment ALT levels, and lower gamma-glutamyl transferase (GGT)/ALT ratios and GGT as well as younger age were significantly associated with a sustained response; a trend was also detected for lower serum ferritin levels. Normalization of ALT by 3 months was also a significant predictor of a long-term response. Of the 27 patients carrying the HCV genotype 3a, seven (26%) were still HCV RNA positive at 6 months. Of these patients, however, five (19%) still achieved a sustained virological response after treatment for up to 12 months.

CONCLUSIONS

In contrast to some previous reports, our results suggest that a late viral clearance after 6 months of interferon monotherapy may not preclude a favorable long-term response after a 12-month treatment, especially in patients carrying a non-1 HCV genotype. A low pretreatment GGT/ALT ratio is a predictor of a good treatment response.

Leukocyte interferon-alpha in the treatment of chronic hepatitis C in Finland

BACKGROUND

To evaluate the efficacy of leukocyte interferon in previously untreated patients with chronic hepatitis C, 97 patients were enrolled in a prospective study in Finland with a stepped-care management protocol.

METHODS

The treatment was initiated with 3 million units of interferon-alpha subcutaneously three times a week. At 3 months, if the serum alanine aminotransferase was still abnormal, the dose was doubled. If serum hepatitis C virus (HCV) RNA had turned negative at 6 months, the treatment was stopped; if it was still positive, treatment was continued for up to 12 months. All patients were followed up after treatment for 6 months. Altogether, 74 patients completed the treatment and follow-up periods.

RESULTS

Of all the originally enrolled patients 36% (35 of 97) achieved sustained virologic response, defined as HCV RNA negativity 6 months after the end of treatment. The commonest HCV genotype among these patients was 3a, and as many as 52% of such patients achieved sustained virologic response. Thirty-two per cent of the patients had HCV genotype 1a, 1b, or a mixture of these; a sustained response was achieved in only 6% of such patients but in 50% of patients with a non-1 genotype. Adverse effects caused treatment cessation for 10% of the patients and IFN dose reduction for 20%.

CONCLUSIONS

Monotherapy with human leukocyte interferon resulted in sustained virologic response in 36% of patients with chronic hepatitis C. In those infected with a HCV genotype other than 1, the sustained virologic response rate was 50%.

Serum, biliary, and fecal cholesterol and plant sterols in colectomized patients before and during consumption of stanol ester margarine

BACKGROUND

Cholesterol metabolic studies are simplified in colectomized patients because of rapid intestinal passage and reduced bacterial action.

OBJECTIVE

Our objective was to study the effect on cholesterol and plant sterol metabolism of feeding a margarine containing stanol ester to 11 colectomized patients.

DESIGN

A margarine containing 2 g stanol was consumed for 7-18 d. Serum, biliary, and fecal lipids were measured before and during consumption of the margarine.

RESULTS

Serum cholesterol concentrations and the ratio of plant sterol to cholesterol decreased after 1 d of consumption of stanol esters (P < 0.05). After 7 d, serum cholesterol decreased by 16% (P < 0.01), cholesterol absorption efficiency decreased by approximately 40%, and fecal output of cholesterol as neutral sterols (but not as bile acids) increased by 36%. Biliary bile acid composition and the molar percentage of biliary cholesterol were unchanged. Increased ratios of cholesterol precursor sterols in serum and bile indicated enhanced cholesterol synthesis during consumption of stanol esters; the percentage absorption of plant sterols and the ratios of plant sterols to cholesterol decreased, whereas serum and biliary plant stanols and their biliary secretion gradually increased. In feces, 95% of cholesterol and 90% of plant stanols were in unesterified form.

CONCLUSIONS

In colectomized patients, effective inhibition of cholesterol absorption and lowering of serum cholesterol concentrations and plant sterol ratios occurs within 1 d of the start of consumption of stanol esters. The composition of major bile lipids is unchanged, indicating that gallstone formation is unlikely. Small amounts of plant stanols are recovered in serum and bile during consumption of stanol esters but effectively are secreted through bile, thereby balancing the intake-induced increase in their absorption.

Serum dolichols in chronic cholestatic liver diseases

BACKGROUND/AIMS

Dolichols are long-chain polyisoprenoid alcohols. It has been suggested that they modify membrane fluidity, stability and permeability. Some lysosomal diseases are associated with elevated serum dolichol levels. Liver has been suggested to play an important role in the regulation of serum dolichol levels and biliary excretion of dolichols has been proposed to be the main elimination route for dolichols from the body. The possible effect of liver diseases on serum dolichol, however, is not known.

METHODS

We therefore studied the effect of early or intermediate primary biliary cirrhosis, primary sclerosing cholangitis and alcoholic liver cirrhosis on serum dolichol concentration. Furthermore, serum dolichol content was measured in patients with end-stage primary biliary cirrhosis, primary sclerosing cholangitis and chronic active hepatitis, waiting to be transplanted.

RESULTS

As compared to age-adjusted controls, serum dolichol was significantly increased in early and intermediate primary biliary cirrhosis (451+/-56 ng/ml vs. 225+/-13 ng/ml, p<0.0001) and primary sclerosing cholangitis (315+/-16 ng/ml vs. 224+/-7 ng/ml, p<0.0001). However, in alcoholic liver cirrhosis serum dolichol was unaffected. Serum dolichol content was also significantly elevated in patients with end-stage primary biliary cirrhosis (844+/-210 ng/ml vs. 225+/-13, p<0.001) and chronic active hepatitis (594+/-198 vs. 224+/-7 ng/ml, p<0.02). Furthermore, in patients with liver diseases serum dolichol concentration correlated positively with serum high density lipoprotein (HDL)-cholesterol (r = +0.50, p<0.0001).

CONCLUSIONS

Serum dolichol levels are elevated in all stages of chronic cholestatic liver diseases but not in alcoholic liver cirrhosis. Impaired biliary excretion of dolichols appears to be the primary explanation for this finding.

The sedimentable sterols in gallstone patients before and during ursodeoxycholic acid and simvastatin treatments

BACKGROUND

The insoluble material in supersaturated bile is prerequisite for the formation of gallstones. We therefore studied the biliary precipitable and soluble cholesterol and noncholesterol sterols, including the cholesterol precursor sterols (including lanosterol and lathosterols), and the plant sterols campesterol and sitosterol, and cholestanol, which usually reflect cholesterol synthesis and absorption, respectively, before and after a 6-month treatment with ursodeoxycholic acid (UCDA), 15.4 +/- 4 mg/kg/day (standard error of the mean) or simvastatin (40 mg/day) in 21 patients with cholesterol gallstones, to obtain further information about the factors contributing to the formation of gallstones.

METHODS

The sediment and supernatant fractions of duodenal bile samples were separated by ultracentrifugation and analyzed with gas-liquid chromatography.

RESULTS

At the base line (n = 21) 50% +/- 3% of biliary cholesterol and a variable amount of the noncholesterol sterols (from 14% of lanosterol to 62% of cholestanol) were in the sediment fraction. The pattern of the noncholesterol sterols in the sediment resembled that of gallstones described previously. At base line body mass index was positively related to the percentage of precipitable cholesterol in bile (r = 0.46, P < 0.05), and the serum sitosterol proportion negatively related to the molar percentage of biliary cholesterol and positively to that of bile acids (r = -0.46 and r = 0.50, P < 0.05 for both). UDCA decreased the precipitable percentage of cholesterol from 46% to 31% (P < 0.03) and simvastatin from 57% to 42% (P = 0.05). Both drugs also decreased the precipitable percentages of lathosterols and cholestanol while increasing that of lanosterol. In relation to cholesterol, the sediment to supernatant ratios of all methylsterols were increased, whereas those of polar lathosterols tended to decrease during UDCA treatment.

CONCLUSIONS

Patients with high body mass index have more precipitable cholesterol in their bile. Although both UDCA and simvastatin decreased the precipitable cholesterol, the bile still contained one-third of its cholesterol in the sedimentable form.

Long-term treatment of ulcerative colitis with ciprofloxacin: a prospective, double-blind, placebo-controlled study

BACKGROUND & AIMS

Although bacterial bowel flora may be one of the contributing factors in the pathogenesis of chronic mucosal inflammation, antibiotic treatment has no established role in ulcerative colitis. The aim of the study was to evaluate the role of ciprofloxacin in the induction and maintenance of remission in ulcerative colitis in patients responding poorly to conventional therapy with steroids and mesalamine.

METHODS

Ciprofloxacin (n = 38; 500-750 mg twice a day) or placebo (n = 45) was administered for 6 months in a double-blind, randomized study with a high but decreasing dose of prednisone and maintenance treatment with mesalamine including follow-up for the next 6 months. Clinical assessment and colonoscopic evaluation were performed at 0, 3, 6, and 12 months. Treatment failure, the primary end point, was defined as both symptomatic and endoscopic failure to respond.

RESULTS

During the first 6 months, the treatment-failure rate was 21% in the ciprofloxacin-treated group and 44% in the placebo group (P = 0.02). Endoscopic and histological findings were used as secondary end points and showed better results in the ciprofloxacin group at 3 months but not at 6 months.

CONCLUSIONS

Addition of a 6-month ciprofloxacin treatment for ulcerative colitis improved the results of conventional therapy with mesalamine and prednisone.

Antibodies to pyruvate dehydrogenase in primary biliary cirrhosis: correlation with histology

Antimitochondrial antibodies to pyruvate dehydrogenase are the hallmark of primary biliary cirrhosis. Their pathogenic role has not been proven, although antibodies to pyruvate dehydrogenase are bound to biliary epithelium. The aim of this study was to characterize serum IgA antibodies to pyruvate dehydrogenase and to evaluate their response to different treatment regimens. We also compared the level of antibodies with severity of histological lesions and the data of biochemical liver tests. Serum samples were collected at baseline and after 24 months from 61 primary biliary cirrhosis patients, whereas 23 patients were treated with ursodeoxycholic acid, 20 with colchicine, and 18 with placebo. ELISA was used to detect antibodies to pyruvate dehydrogenase. IgA and IgG were separated with jacalin and protein-A, respectively. Capacity of immunoglobulins to inhibit enzymatic activity was detected by spectrophotometric observation of the rate of enzyme reaction. 49 (80.3%) of the 61 patients possessed IgA antibodies to pyruvate dehydrogenase. Significant decrease in IgA antibodies was observed only in the ursodeoxycholic acid group (p<0.05). 15 of 18 IgA preparations and all 24 IgG preparations of patients' sera were inhibitory towards pyruvate dehydrogenase (mean inhibitory percent +/-SD: 42+/-33.4% and 79+/-22.4%, respectively, at a protein concentration of 100 microg/ml). The level of serum antibodies to pyruvate dehydrogenase correlated with several histological parameters (fibrosis, inflammatory infiltrate), but not with biochemical parameters. Our data reveal that IgA antibodies to pyruvate dehydrogenase inhibit enzyme function. The correlation between antibodies to pyruvate dehydrogenase and histological parameters might suggest the pathogenic role of these antibodies.

Cholesterol metabolism and serum and biliary noncholesterol sterols in gallstone patients during simvastatin and ursodeoxycholic acid treatments

Effects of long-term high-dose ursodeoxycholic acid (UDCA) and simvastatin treatments on cholesterol metabolism and biliary lipid compositions were compared in patients with cholesterol gallstones. Absorption and synthesis of cholesterol, serum and biliary noncholesterol sterols and lipids were determined in 14 patients randomized to UDCA (23-25 mg/kg/d) or simvastatin (40 mg/d) for 1 year. Simvastatin reduced serum low-density lipoprotein cholesterol by 55%, and UDCA, by 9%. Cholesterol absorption was decreased (35%) by UDCA, but nonsignificantly increased by simvastatin (P < .05 for difference of changes caused by the two drugs). Whole-body synthesis and biliary output of cholesterol were both significantly decreased only by UDCA. In addition, UDCA inconsistently increased the proportions of serum and biliary precursor sterols of cholesterol, known to reflect cholesterol synthesis, but did not affect their biliary secretions. Simvastatin, however, dramatically reduced serum and also biliary cholesterol precursor sterol proportions and their biliary secretions and increased proportions of serum and biliary plant sterols and cholestanol, known to reflect cholesterol absorption, but had no effect on their biliary secretion. Only UDCA significantly decreased the molar percentage of cholesterol, the lithogenic index, and the cholesterol/phospholipid (CH/ PL) ratio in bile, whereas both treatments inconsistently decreased the vesicular CH/PL ratio (P < .07 in both groups). It is concluded that both drugs decreased serum cholesterol and inhibited cholesterol synthesis, but had a differing influence on precursor sterols and the absorption of cholesterol. UDCA had more beneficial effects than simvastatin on the antilithogenic properties of bile.

Impaired absorption of cholesterol and bile acids in patients with an ileoanal anastomosis

BACKGROUND

No data exist on cholesterol absorption in patients with an ileoanal anastomosis (IAA).

AIMS

To study cholesterol absorption and its effects on cholesterol and bile acid metabolism in patients with an IAA.

PATIENTS AND METHODS

Cholesterol absorption, and serum, biliary, and faecal lipids were studied in 24 patients with an IAA and 20 controls.

RESULTS

Fractional cholesterol absorption was significantly lower in the patients (36% versus 47% in controls). Surprisingly, the calculated intestinal influx of endogenous cholesterol was reduced so that the absolute absorption of cholesterol was decreased; elimination of cholesterol as faecal neutral steroids remained normal. Thus, the slightly increased cholesterol synthesis was mainly due to increased faecal bile acid excretion, which, in turn, was associated with reduced absorption and biliary secretion of bile acids. Serum total and low density lipoprotein (LDL) cholesterol and LDL triglycerides were lower in the patients. Molar percentage and saturation index of biliary cholesterol were slightly higher in patients with an IAA. Proportions of secondary bile acids in bile and faeces were diminished, and faecal unidentified bile acids were higher in patients.

CONCLUSIONS

Cholesterol absorption is significantly impaired in patients with an IAA, and is closely related to changes in serum and biliary lipids observed in these patients.

Expression and therapeutic response related to apolipoprotein E polymorphism in primary biliary cirrhosis

BACKGROUND/AIMS/METHODS

Apolipoprotein E polymorphism, affecting intestinal absorption and biliary secretion of bile acids, might also contribute to the variable course and response to drug treatment of primary biliary cirrhosis. To test this possibility, we studied the apo E gene frequency, and the expression and response to drug therapy in different apo E isoforms of 88 patients with primary biliary cirrhosis, randomized to ursodeoxycholic acid, colchicine or placebo treatments for 2 years.

RESULTS

The frequency of the epsilon2 allele was 2.4 times higher (p<0.01) in the patients with primary biliary cirrhosis compared with the Finnish population. At entry the patients with the epsilon4 allele were significantly younger (p<0.01) than those with other epsilon alleles, while the severity of primary biliary cirrhosis was similar in the three apolipoprotein E phenotypes. Liver enzymes, acute hepatic inflammation, serum total and low density lipoprotein cholesterol were decreased by ursodeoxycholic acid only in the patients with the epsilon4 and homozygous epsilon3 alleles, but not in those with the epsilon2 allele. Improvements of liver enzyme tests by ursodeoxycholic acid were more marked in the patients with the epsilon4 than other epsilon alleles.

CONCLUSIONS

The present data show that in primary biliary cirrhosis the epsilon2 allele is overrepresented, and suggest that the expression of primary biliary cirrhosis and response of the disease to ursodeoxycholic acid treatment are closely related to the apo E polymorphism.

Cholesterol metabolism and non-cholesterol sterols in patients with ileal pouch anastomosis

BACKGROUND

Previous studies suggest only minor changes in bile acid metabolism after panproctocolectomy with ileal pouch construction.

AIMS/METHODS

To investigate these changes further, we studied cholesterol absorption and serum, biliary and fecal non-cholesterol sterols and lipids in 12 ileal pouch patients and 10 controls.

RESULTS

In patients, cholesterol absorption was markedly reduced and was associated with low serum total and LDL cholesterol and LDL triglyceride levels, but surprisingly, cholesterol synthesis, as indicated by sterol-balance data or serum cholesterol precursor levels, was within low normal limits. The high proportions of serum plant sterol to cholesterol, particularly that of campesterol, were not related to cholesterol absorption, but were attributable to a markedly reduced biliary cholesterol secretion. Interestingly, in these patients the fractional absorption of campesterol was normal, whereas that of sitosterol, like cholesterol, was reduced and was positively related to the intestinal influx of cholesterol. The patients' serum cholestanol proportion was normal, but the proportion of the cholestanol formed during intestinal passage was significantly reduced (17.9% vs 65.2% in controls).

CONCLUSIONS

Thus ileal pouch patients are characterized by sterol malabsorption, lowered serum total and LDL-cholesterol levels, but unexpectedly without any increase in cholesterol synthesis. The lack of high serum cholestanol, shown earlier frequently in unoperated patients with ulcerative colitis, may indicate reversible cholestasis, a finding deserving further exploration.

Ursodeoxycholic acid treatment lowers the serum level of antibodies against pyruvate dehydrogenase and influences their inhibitory capacity for the enzyme complex in patients with primary biliary cirrhosis

A two-year randomized, double-blind, placebo-controlled clinical trial used paired serum samples from 122 patients with primary biliary cirrhosis to compare the effect of ursodeoxycholic acid and colchicine on their immune parameters. IgG antibodies to pyruvate dehydrogenase, the major autoantigen in primary biliary cirrhosis, were determined by enzyme-linked immunosorbent assay and immunoblot; enzyme inhibition assay against pyruvate dehydrogenase was used to test the changes of the functional reactivity of the serum autoantibodies. Treatment with ursodeoxycholic acid decreased both the level of IgG antibodies to pyruvate dehydrogenase (P < 0.01) and the inihibitory titer of the sera for pyruvate dehydrogenase (P < 0.01). Treatment with colchicine or placebo showed no statistically significant changes in either the antibody levels or the inhibitory titers. Ursodeoxycholic acid thus alters the immune parameters of patients with primary biliary cirrhosis. The mechanism of these changes needs further investigation.

The metabolism of cholestanol in primary biliary cirrhosis

BACKGROUND/AIMS

The concentration of serum cholestanol, a 5 alpha-saturated derivative of cholesterol, is increased in primary biliary cirrhosis proportionally to impaired liver function for unknown reasons. The purpose of this study was to analyze serum cholestanol level and its biliary and fecal elimination, and relate the results to cholesterol absorption and metabolism.

METHODS

Sixteen patients with primary biliary cirrhosis and 44 non-primary biliary cirrhosis controls were studied. Squalene and non-cholesterol sterols were analyzed by gas-liquid chromatography, cholesterol absorption by the peroral double-isotope continuous feeding method, and neutral and acidic sterols in bile and feces by gas-liquid chromatography.

RESULTS

In primary biliary cirrhosis, the mean level of serum cholesterol was normal, but the cholestanol/cholesterol proportion was increased 4-fold, and the proportion was related to the serum bile acid and bilirubin levels. The mean biliary cholestanol proportion and the biliary secretion rate were increased 5- and 2-fold, respectively, suggesting that at low cholestanol absorption cholestanol synthesis was increased. Calculated clearance of serum cholestanol into bile was decreased. The fecal output was within the control limits, so that intestinal cholestanol production was lowered in primary biliary cirrhosis. In addition, serum and biliary plant sterol proportions were increased in primary biliary cirrhosis, but their biliary secretion was unchanged, while those of cholesterol, bile acids, phospholipids, and cholesterol precursor sterols were markedly reduced.

CONCLUSIONS

We conclude that an enhanced cholestanol synthesis and a cholestasis-induced decrease in biliary clearance of serum cholestanol contribute to the excessively high serum cholestanol level in primary biliary cirrhosis. In addition, reduced bile acid synthesis may contribute to the increased serum cholestanol content.

Separation of proteins of nearly the same size but having different isoelectric points by convective electrophoresis

A method for separating proteins of nearly the same size but having different isoelectric points is presented. The method used is convective electrophoresis, which is based on the simultaneous effects of diffusion, electrical migration and opposing convective flow on the transport of proteins through a porous membrane. The pairs of model proteins used in this study were cytochrome c-lysozyme and human serum albumin-haemoglobin. The obtained results show that with a careful adjustment of pH these proteins can be separated by a continuous manner, and no coupling of protein fluxes could be detected in either case.

Serum cholesterol, cholesterol precursors and plant sterols in different inflammatory bowel diseases

The role of cholestasis and ileal dysfunction on sterol metabolism was studied in 79 patients with inflammatory bowel diseases (IBDs) and in 23 irritable bowel syndrome (IBS) controls by determining serum sterol/cholesterol proportions. The sterols included cholesterol precursors (delta 8-cholestenol, desmosterol and lathosterol), markers of cholesterol synthesis, cholestanol and plant sterols (campesterol and sitosterol), markers of cholesterol absorption and biliary secretion. The IBD patients were subgrouped into distal ulcerative colitis (dUC, n = 21), pancolitis (pUC, n = 29), ileal Crohn's disease (iCD, n = 20) and colonic Crohn's disease (cCD, n = 9). The cholestanol proportions were increased in the 3 colonic IBD groups, up to two times in cCD patients and seven times in a case with clinically overt primary sclerosing cholangitis, but were within the control IBS levels in the patients with iCD. The sitosterol, but not campesterol, proportion was significantly increased only in the pUC group. In the iCD group only the serum precursor sterol proportions, especially those for delta 8-cholestenol and lathosterol, were elevated probably due to ileal dysfunction induced bile acid malabsorption and compensatorily increased cholesterol synthesis. In conclusion, the findings suggest that the increased cholestanol proportion in colonic IBD is determined mainly by impaired biliary elimination of this sterol, while in ileal affision the dominating change in sterol balance is activated cholesterol synthesis. Thus increased serum cholestanol is a novel finding in colonic IBD, apparently indicating the presence of subclinical cholestasis in a marked number (20-50%) of IBD patients.

Serum cholestanol, cholesterol precursors, and plant sterols during placebo-controlled treatment of primary biliary cirrhosis with ursodeoxycholic acid or colchicine

A randomized placebo-controlled 2-year study was performed in 69 patients with primary biliary cirrhosis (PBC) on serum lipids during ursodeoxycholic acid (URSO) and colchicine treatments. In addition to serum bilirubin and alkaline phosphatase (AFOS), two variables considered to reflect liver function, serum lipoproteins, cholesterol precursors (squalene, delta 8-cholestenol, lathosterol and desmosterol), markers of cholesterol synthesis, cholestanol and plant sterols (campesterol and sitosterol), markers of liver function and cholesterol absorption, were studied before and during the treatments. Serum bilirubin was inconsistently improved by URSO, whereas improvement of AFOS values was better by URSO than colchicine, especially in patients with initially more advanced PBC. Serum total cholesterol was reduced by both drugs, very low-density lipoprotein (VLDL) and high-density lipoprotein (HDL) cholesterol by URSO. Cholesterol precursor sterols were increased by both URSO and colchicine mainly in patients with initially less severe PBC. On the other hand, the cholestanol values were markedly increased initially, and the values were related to bilirubin during the 2-year period, were further increased in the placebo group, and reduced in the URSO and colchicine groups, so that the improvement was highest in the URSO-treated patients with the severe form of PBC. The increase of the serum plant sterols, particularly that of sitosterol, was retarded by the two drugs so that the campesterol/sitosterol ratio, which was related to serum bilirubin, was increased especially in the cases with initially more advanced PBC.(ABSTRACT TRUNCATED AT 250 WORDS)

A placebo-controlled trial of primary biliary cirrhosis treatment with colchicine and ursodeoxycholic acid

BACKGROUND/AIMS

Ursodeoxycholic acid (UDCA) and colchicine have beneficial effects in primary biliary cirrhosis (PBC). The efficacy of colchicine and UDCA in PBC was compared in a 2-year placebo-controlled study (n = 90).

METHODS

Clinical events, laboratory test results, and liver histology were recorded at the beginning and end of the trial.

RESULTS

There were significantly fewer dropouts for hepatic reasons with UDCA than with placebo. Pruritus was reduced by both active drugs. Colchicine improved liver function test results only modestly, whereas UDCA significantly decreased the serum activities of aminotransferases, alkaline phosphatase, and gamma-glutamyltransferase compared with colchicine and placebo. Serum total bilirubin levels were decreased only by UDCA. Both colchicine and UDCA reduced serum cholesterol levels, and UDCA also reduced high-density lipoprotein cholesterol levels. Furthermore, UDCA reduced the serum levels of immunoglobulin (Ig) M and IgG, and colchicine reduced IgG levels compared with placebo. The elevated serum level of aminoterminal propeptide of type III procollagen remained unchanged by colchicine or UDCA, whereas the serum level of carboxyterminal propeptide of type I procollagen was significantly decreased by UDCA. UDCA significantly decreased ductular proliferation compared with colchicine or placebo.

CONCLUSIONS

These data suggest that UDCA frequently is superior to colchicine and especially to placebo in the treatment of PBC.

Metabolism of cholesterol and low- and high-density lipoproteins in primary biliary cirrhosis: cholesterol absorption and synthesis related to lipoprotein levels and their kinetics

Cholesterol absorption, elimination, and synthesis, and low-density lipoprotein (LDL) and high density lipoprotein (HDL) kinetics were studied in patients with mild to severe primary biliary cirrhosis (PBC) (n = 16) to show how this cholestatic disease modified cholesterol and lipoprotein metabolism as compared with healthy controls (n = 50). Serum total and lipoprotein cholesterol and triglyceride levels were similar in the two groups, but in PBC, especially in severe forms, very low density lipoprotein (VLDL) was rich in apoprotein (apo) B and cholesterol and low in triglycerides, whereas LDL was rich in triglycerides and low in esterified cholesterol, and HDL was enriched by surface lipids, phospholipids, and free cholesterol. In severe PBC, the fractional catabolic rate (FCR) for LDL apo B was reduced. The transport rate (TR) for LDL apo B was unaffected and it tended to correlate with the LDL apo B and LDL cholesterol levels in PBC, whereas in the controls the LDL apo B concentration was regulated by both the FCR and TR, and LDL cholesterol was regulated only by FCR. FCR for apo A-I in HDL was unaltered in PBC, but TR for apo A-I was reduced in the severe cases. Cholesterol absorption efficiency was significantly reduced in PBC (14.5 +/- 3.0% in severe PBC and 34.0 +/- 2.5% in mild PBC vs. 47.4 +/- 1.4% in the controls, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Absorption, metabolism, and serum concentrations of cholesterol in vegetarians: effects of cholesterol feeding

Serum concentrations and metabolism of cholesterol were studied in vegetarians basally and during a dietary cholesterol load. Cholesterol absorption efficiency was normal and synthesis was slightly enhanced, even though serum cholesterol precursors were not increased. The serum concentrations of total and low-density-lipoprotein cholesterol were decreased proportionally to the reduced intake and absolute absorption of cholesterol. Fecal plant sterols were negatively correlated with the absorption efficiency of cholesterol and positively with fecal sterols and cholesterol synthesis, suggesting interference of high plant sterol intakes with cholesterol absorption. Cholesterol saturation and bile acid composition of the bile were not changed. The increased serum plant sterol-cholesterol ratios were positively related to the intake and negatively to the biliary secretion of plant sterols. Cholesterol feeding increased absolute cholesterol absorption and serum concentrations of total and low-density-lipoprotein cholesterol, did not change absorption efficiency or synthesis of cholesterol, but increased fecal cholestanol excretion.

A combination of subcutaneous recombinant interleukin-2 and recombinant interferon-alpha in the treatment of advanced renal cell carcinoma or melanoma

In this phase II study, we have evaluated the efficacy and toxicity of low-dose subcutaneous (s.c.) recombinant interleukin-2 (IL-2) and recombinant interferon (IFN)-alpha in 16 patients with advanced renal cell carcinoma (RCC) and in 4 patients with advanced melanoma. The complete course on this protocol comprised 6 weeks of s.c. IL-2 plus IFN-alpha followed by a 2-week rest period. The treatment was moderately strenuous for patients, requiring frequent dose reductions; only eight cycles (30%) could be administered to 75-100% of the projected dose. Main side-effects were fever, fatigue, hypotension, liver toxicity, neurotoxicity and skin reactions. Among the evaluable 17 patients, two responses (one partial, one complete) were seen in patients with RCC. This regimen proved to be rather toxic and yielded a modest response rate of 15% in RCC, but initial findings concerning the duration of survival seem promising.

Metabolism of cholesterol and apolipoprotein B in celiac disease

To test the association of cholesterol malabsorption with cholesterol and lipoprotein metabolism, we determined low-density lipoprotein (LDL) apolipoprotein (apo) B kinetics simultaneously with measurements of cholesterol absorption and synthesis in six patients with celiac disease (CD) before and during the gluten-free diet (GFD). The basal condition was characterized by low cholesterol absorption, enhanced cholesterol synthesis, and high removal and transport rate of LDL apo B. The GFD markedly improved cholesterol absorption and decreased intestinal influx of cholesterol, fecal neutral steroids, and cholesterol synthesis. Of plasma total and lipoprotein cholesterol levels, only plasma high-density lipoprotein (HDL) was enhanced by the GFD proportionately to cholesterol absorption. The plasma LDL apo B level remained unchanged because of simultaneous decreases in the fractional catabolic rate (FCR) and transport rate of LDL apo B. In fact, the more cholesterol absorption was improved by the GFD, the more the FCR and transport rate for LDL apo B were decreased, and their reductions were closely related to the decrease in cholesterol synthesis. The present results show that cholesterol absorption, cholesterol synthesis, hepatic B/E receptor activity, and LDL apo B transport rate are closely associated with each other and that their levels can change markedly with no detectable change in serum levels of LDL cholesterol or apo B.

Hemorrhagic gastropathy in epidemic nephropathy

A patient with epidemic nephropathy (NE) and with gastrointestinal symptoms and hemorrhagic gastropathy prompted us to study further 10 consecutive patients with NE. Gastroscopy was carried out within 1 to 4 weeks after the beginning of the symptoms, and in every case a hemorrhagic gastropathy was observed. Hemorrhagic lesions were more marked, the shorter the elapsed time interval from the beginning of symptoms. Hemorrhagic changes were always more prominent in the proximal than in the distal part of the stomach. In 7 of 10 patients lesions were also observed in the duodenum. Colonoscopy was done in one patient and it showed similar spotty hemorrhages, suggesting that hemorrhagic lesions were not limited to the gastroduodenal mucosa only. Histological studies disclosed that the hemorrhagic lesions were associated with edema in the lamina propria, but without inflammatory changes. Follow-up gastroscopy in three patients 3 to 8 weeks later showed disappearance of hemorrhagic lesions in every patient. Thus, these results show for the first time that hemorrhagic gastropathy is a common finding in NE, and it may explain the abdominal symptoms and gastrointestinal bleeding in some of these patients. However, the mechanism of the hemorrhagic lesions needs further exploration.

The effective charge number and diffusion coefficient of cationic cytochrome c in aqueous solution

The diffusion coefficient and the effective charge number of cytochrome c as a function of ionic strength, temperature and pH have been measured. The measurements were carried out using a method based on a convective diffusion process across a porous membrane. The effect of ionic strength was studied in an NaCl solution the concentration of which varied from 0.001 to 1.0 M. The temperature range studied was 10-50 degrees C, and the pH values studied were 4.0, 6.5 and 8.25. The diffusion coefficient is fairly constant as a function of ionic strength and pH, and Walden's rule is valid in the temperature range studied. The effective charge number is practically constant (ca. 2) in the concentration range studied, except in 0.001 M solution, where it is the same as the titrated value. The charge number decreases slightly in the temperature range 10-30 degrees C, but seems to drop suddenly to zero at ca. 40 degrees C. Measurements using heavy water (D2O) as a solvent instead of water did not give zero charge at 40 degrees C for cytochrome c.

Cholesterol malabsorption in pancreatic insufficiency: effects of enzyme substitution

Defective lipolysis, steatorrhea, and hypocholesterolemia characterize pancreatic insufficiency. Lipid metabolism in pancreatic insufficiency was studied by measuring serum lipoproteins, cholesterol absorption with double labels and serum plant sterols, and bile acid and cholesterol synthesis with fecal and dietary steroid analysis and cholesterol precursor sterols before and during exogenous pancreatic enzyme substitution. Baseline fecal fat, masses, bile acids and neutral steroids, and cholesterol synthesis were increased, whereas cholesterol absorption was markedly reduced. In fact, the present data suggest that sterol absorption may be disturbed more sensitively than fat absorption in pancreatic insufficiency. Enzyme substitution significantly reduced fecal fat, masses, bile acids and neutral steroids, and synthesis of cholesterol and improved cholesterol absorption in relation to serum cholesterol, although normal values were not obtained. Serum level of high-density lipoprotein cholesterol was significantly elevated by exogenous enzymes, whereas levels of cholesterol or triglycerides in other lipoproteins remained unchanged. Improved sterol absorption increased also serum levels of plant sterols and reduced levels of cholesterol precursors and cholesterol synthesis and precursor sterol-plant sterol ratios. Thus, reduced intestinal lipolysis with expanded oil phase appears to be a major reason for impaired cholesterol absorption, causing enhanced cholesterol and, consequently, bile acid synthesis and reduced serum cholesterol level. Exogenous enzyme substitution seems partly to correct these abnormalities, improvements of which can be monitored by the gas-liquid chromatographic determination of serum plant sterols or cholesterol precursor-plant sterol ratios.

Effects of selenium supplementation on blood and urine selenium levels and liver function in patients with primary biliary cirrhosis

To study the mechanism of the reduced serum selenium concentration in patients with liver damage we administered 200 micrograms (2.53 mumol) selenium daily as selenium-rich yeast to 8 patients with primary biliary cirrhosis and 8 healthy controls over 16 weeks. Initially selenium concentrations in serum were 24% lower (P less than 0.001) in patients than controls. During supplementation serum selenium levels increased in both groups but the difference between them persisted. Throughout the study whole blood selenium levels and glutathione peroxidase activities were also somewhat lower (P = NS) in patients than controls. Selenium supplementation had no effect on whole blood glutathione peroxidase activities in either group. The basal 24 h urinary excretion of selenium was similar in both groups but was increased more by supplementation in patients than controls. Selenium administration did not influence the liver function of the patients. We conclude that impaired hepatic production of selenium-containing serum compounds is the most likely explanation for the reduced serum selenium concentration in patients with primary biliary cirrhosis.

Functional characteristics of duodenal ulcer patients and their first-degree relatives

The behaviour of acid secretion, serum pepsinogen I and II (PG I and PG II) and morphology of the gastric mucosa were analyzed in 59 duodenal ulcer probands (DU probands), their 199 first-degree relatives and 228 control subjects. DU probands had as a rule antral gastritis with normal or slightly altered corpus mucosa, and higher mean peak acid output (PAO), PG I and II levels than their relatives and controls. Sibs of DU probands differed from their controls mainly with regard to morphology which showed features characteristic of DU probands, i.e. antral gastritis with normal or slightly altered corpus mucosa. Moreover, high PAO levels were found highly significantly more often in sibs of DU probands (13%) than in controls (6%). Likewise, the prevalence of endoscopic signs of active or past duodenal ulcer were present in sibs highly significantly more often than in controls and they accumulated in the subgroup of sibs with high PAO or PG I levels. It seems probable that the occurrence of high PAO and PG I levels in sibs of DU probands can be considered as signs of increased liability to duodenal ulcer. PAO and PG I were as expected significantly higher in male than in female probands, relatives and controls. Exclusion of cases of corpus gastritis decreased the levels but the sex difference persisted. PAO, PG I and II revealed a significant increase of the levels in middle age followed in older age in case of PAO and PG I by a significant decrease. The decrease was abolished when the cases of corpus gastritis were excluded suggesting an effect of gastritis. However, the earlier increase of the levels remained virtually unaffected although there was a uniform decrease of the mean values. This suggests the participation of factors unrelated to gastritis. The nature of the factors remains unknown, but literature data and data derived from our recent study suggest involvement of anatomical factors such as an increase in the size of acid and PG I secreting area.

Helicobacter pylori and duodenal ulcer. A study of duodenal ulcer patients and their first-degree relatives

Out of 59 duodenal ulcer (DU) probands and their 199 first-degree relatives Giemsa-staining for the determination of Helicobacter pylori (HP) was performed in 51 probands and 155 relatives. Controls were matched by age and sex from a family sample representing the same geographical area. In all, 155 controls were found for the probands and relatives. The occurrence and score of HP density showed an excellent correlation with morphology of the mucosa, signs of acute inflammation and presence of gastric metaplasia in the duodenal bulb. The prevalence of HP was 94% in DU probands and significantly higher than in their relatives and controls. In sibs of DU probands the prevalence of HP (64%) was also significantly higher than in controls (51%) obviously due to the presence of a subgroup of sibs with signs of active or past duodenal ulcer disease, which show higher than expected prevalence of HP, and of acid hypersecretion and high levels of serum pepsinogen I (PG I). Peak acid output (PAO), serum pepsinogen I and II and fasting serum gastrin levels were in relatives without atrophy higher in HP positive than negative cases but significant differences were present only with regard to the pepsinogens. The occurrence of HP positivity as well as of high PAO and pepsinogen levels might be considered risk factors of DU disease in close relatives of DU probands. On the other hand, the significance of HP positivity as cause of abdominal complaints is doubtful, in view of the complete lack of correlation between HP and morphology and complaints in the present study.

Low prevalence of hepatitis C antibodies in chronic liver disease in Finland

High prevalence of hepatitis C antibodies (anti-HCV) have been found in the Middle- and Southern European countries in connection with chronic liver diseases. In a study of Finnish chronic liver disease patients no anti-HCV antibodies were found in 22 autoimmune chronic active hepatitis, in 5 chronic persistent hepatitis and in 38 alcoholic liver disease patients. 2/30 primary biliary cirrhosis patients were anti-HCV positive. As a comparison 3/9 patients with acute community acquired non-A non-B hepatitis and 28/48 i.v. drug addicts had anti-HCV antibodies. The results indicate that HCV infections in Finnish chronic hepatitis patients are rare.

Biliary lipid composition in monozygotic and dizygotic pairs of twins

The relative contribution of genetic factors to biliary and serum lipid composition was studied in 17 monozygotic and 18 dizygotic middle aged male pairs of twins. Cholesterol precursors, squalene and Methylated sterols which reflect the activity of cholesterol synthesis were also measured. Pairwise intraclass correlations were determined for monozygotic and dizygotic twin pairs and heritability estimates were calculated. Molar % of biliary cholesterol and percentage distribution of biliary cholic acid and particularly deoxycholic acid showed significant pairwise correlations within the monozygotic but not the dizygotic pairs. Similar correlations were found for total biliary methylsterols and of the methylsterol subfractions for the two methostenols but not for squalene, lanosterol and dimethylsterols. In serum, the precursor sterols, but not squalene, showed even higher pairwise correlations in the monozygotic twins than the corresponding precursors in bile. Molar per cent of bile acids and phospholipids and cholesterol saturation index were not correlated significantly in either twin pairs, but the pairwise correlations tended to be higher in the monozygotic than in the dizygotic pairs. Gall stones were found in seven monozygotic and three dizygotic subjects. Two monozygotic twin pairs were concordant for gall stones; all the dizygotic pairs were discordant. Overall, these data suggest that molar percentage of biliary cholesterol, bile acid composition, cholesterol synthesis, bile cholesterol saturation, and gall stone formation may be under a significant genetic control.

Serum plant sterols and lathosterol related to cholesterol absorption in coeliac disease

The concentrations of the plant sterols, campesterol and beta-sitosterol in serum, normally correlate with the efficiency of cholesterol absorption, whereas the concentration of lathosterol, a cholesterol precursor sterol, closely parallels changes in cholesterol synthesis. In this study we explored whether the plant sterol concentrations in serum in coeliac disease are determined by cholesterol absorption and whether they alone or with the serum lathosterol concentration, could be used for screening the activity of coeliac disease. In six patients the plant sterol concentrations in serum were significantly lower than in 17 control subjects, the reduction being more marked for campesterol than for beta-sitosterol: the serum lathosterol concentration was significantly higher than in the control subjects. The opposite changes in serum plant sterols and lathosterol were recorded in patients on a gluten-free diet. The plant sterol concentrations in serum (nmol/mg of cholesterol) were positively correlated with each other, and with the percentage absorption of cholesterol and with xylose absorption; they were negatively correlated with faecal fat, but not with faecal plant sterols. Thus, the low plant sterol concentrations in serum in coeliac disease were attributable to their impaired absorption, which in turn was closely associated with the absorption of cholesterol. The serum campesterol concentration clearly distinguished the untreated patients from the controls, whereas the use of serum beta-sitosterol, and the serum ratios of lathosterol/plant sterol resulted in some overlapping with the controls. It is suggested that the plant sterols in serum might be worth of determining when screening patients for coeliac disease and especially when testing their adherence to the gluten-free diet.

Changed profile of peptic ulcer disease in hospital patients during 1969-1984 in Finland

The annual number of hospital discharges for peptic ulcer decreased in Finland from 1969 to 1974, mainly because of a smaller number of men with uncomplicated peptic ulcer disease. After the mid-1970s the number of hospital admissions remained stable, whereas the number of elderly patients increased. From 1979 to 1984 the number of hospitalizations for perforated ulcers remained stable, whereas those for ulcer haemorrhages increased, the increase being most marked in the older age groups. The age-specific mortality from peptic ulcer remained stable from 1969 to 1984 and rose thereafter among old patients. The risk of death from peptic ulcer was about 10-fold higher in patients over 75 years old than in younger age groups, and about half of the deaths caused by peptic ulcer occurred in patients over 75 years old. The men to women ratio among hospitalized patients decreased from 3.5 in the late 1960s to 2.1 in the 1980s, and the gastric ulcer to duodenal ulcer ratio was about 1.1 throughout the observation period.

Inheritance of high density lipoprotein and lipoprotein lipase and hepatic lipase activity

The role of genetic and environmental factors in the regulation of plasma high density lipoprotein (HDL) was estimated in 17 monozygotic (MZ) and 18 dizygotic (DZ) male twins randomly selected from the Finnish Twin Cohort Study. In addition to HDL cholesterol, we determined the HDL subfractions, HDL2 and HDL3, and the major HDL apoproteins (apo) A-I and A-II. The activities of lipoprotein lipase (LPL) and hepatic lipase (HL) were also assayed from postheparin plasma to get information on their possible contribution to the heritability of HDL. Evidence for the genetic component in the regulation of plasma HDL received support from the heritability estimate of 0.34. The different heritability estimates of HDL2 and HDL3 (h2 of 0.56 and less than 0, respectively) support the idea that the HDL subfraction distribution might be important in the genetic regulation of plasma HDL level. This also received support from the heritability of apo A-I (h2 = 0.66), mainly varying in HDL2, and the lack of it in apo A-II, found mainly in HDL3. These conclusions were strengthened by standardizing the data with relative ponderosity. Postheparin plasma HL activity had a high pairwise correlation coefficient in the MZ twins (r = 0.80, p less than 0.001), whereas LPL displayed no within-pair correlation. Neither of the lipolytic enzymes, LPL or HL, showed any correlation in the DZ twins. Therefore, it is suggested that part of the genetic regulation of the HDL and its subfraction distribution might be mediated through the activity of HL.

The role of fat and bile acid malabsorption in diarrhoea of coeliac disease

The contribution of various factors to diarrhoea in coeliac disease (CD) was evaluated by measuring jejunal villous height, faecal masses, faecal fat, and faecal bile acids in 8 healthy subjects and in 37 consecutive patients before and during a gluten-free diet (GFD) and while receiving cholestyramine. Jejunal villous height was inversely correlated with faecal fat but not with faecal mass or faecal bile acids. A strong positive correlation was found between faecal fat and faecal mass and between the respective changes caused by GFD in these variables, whereas the correlations between faecal bile acids and faecal volume or between these changes caused by GFD were weak or nonsignificant. The cholestyramine treatment enhanced faecal bile acid and fat excretions and increased faecal volume without a significant effect on faecal solids or on the frequency of bowel movements, which in turn was significantly reduced by GFD. Thus, the present results show that the impaired fat absorption owing to mucosal damage of the upper small intestine markedly contributes to faecal volume and the frequency of bowel movements in CD and may be an important factor responsible for diarrhoea in coeliac patients, whereas no evidence was obtained for bile acid diarrhoea in CD.

Serum cholesterol precursor sterols in coeliac disease: effects of gluten free diet and cholestyramine

Enhanced biliary secretion and high faecal excretion of cholesterol are associated with increased cholesterol synthesis in coeliac disease. We have further investigated cholesterol synthesis in coeliac disease by determining the concentrations of faecal steroids and cholesterol precursors in serum, with and without a gluten free diet and while taking cholestyramine. The levels of unesterified methyl sterols and free and esterified lathosterol, but not those of squalene and desmosterol, were increased in proportion to the level of cholesterol synthesis, as measured with the sterol balance technique. Serum esterified methyl sterol concentrations were also slightly higher but, unlike free methyl sterols or lathosterol, they were not significantly correlated with cholesterol synthesis. The gluten free diet decreased the level of cholesterol synthesis, and the levels of lathosterol and free methyl sterols. There was less decrease in the concentration of esterified methyl sterols, and an insignificant decrease in the concentrations of squalene and desmosterol. Cholestyramine lowered the serum cholesterol concentration and increased that of serum free methyl sterols less in the patients than in the controls, and the increase was proportionate to increase of cholesterol elimination (or synthesis). The increase of serum free methyl sterols per unit of the increase of cholesterol elimination (or synthesis) was three times higher in the bile acid malabsorption caused by cholestyramine than in the cholesterol malabsorption caused by gluten enteropathy. On the other hand, the decrease in the level of serum cholesterol relative to the increase in cholesterol elimination (or synthesis) was higher in cholesterol malabsorption due to coeliac disease than in cholestyramine induced bile acid malabsorption. Effective secretion of newly synthesised and/or absorbed cholesterol directly into the bile could be a factor in the marked decrease of the serum cholesterol concentration in coeliac disease.

Enhanced synthesis of cholesterol and its precursors in jejunal mucosa in coeliac disease

Patients with coeliac disease have a greatly enhanced whole body synthesis of cholesterol, but its origin is not known. In this paper the synthesis and concentrations of cholesterol and its precursors, squalene and methyl sterols, were studied in jejunal biopsies from healthy volunteers and adult patients with coeliac disease. The incorporation rates of 14C-acetate and 3H-mevalonate into non-saponifiable lipids (sum of squalene, methyl sterols and cholesterol) were increased 14 and six times in the damaged mucosa, respectively. The cyclisation rate of mucosal squalene and the conversion of squalene to cholesterol were also increased, indicating that cholesterol synthesis was activated before mevalonate, probably at the step of HMG-CoA reductase, and also after mevalonate and squalene. The steps from squalene to cholesterol were apparently not rate limiting because the mucosal concentrations and the percentage distribution of squalene and sterols were similar in the patients and in the controls. A positive correlation of the cholesterol synthesis with the number of crypt cells, suggests that the expanded crypt cell population contributed to the enhanced intestinal cholesterologenesis. Furthermore, the serum cholesterol level was negatively correlated with the 14C- and 3H-counts in the mucosal cholesterol and with the cyclisation rate of squalene probable signs of regulatory role of serum low density lipoprotein cholesterol in intestinal cholesterol synthesis. Consequently, provided that the synthesis of mucosal cholesterol is as high in vivo as in vitro it could contribute to the highly increased overall synthesis of cholesterol in the patients with coeliac disease.

Autoantibodies to gliadin-binding 90 kDa glycoprotein in coeliac disease

Patients with untreated coeliac disease were found to have high concentrations of circulating antibodies to 90 kDa glycoprotein, a mannose rich protein found in skin and intestinal mucosa. In contrast, patients with active Crohn's disease or ulcerative colitis had antibody concentrations within the normal range. In coeliac disease the antibody concentrations fell significantly after gluten withdrawal. 90 kDa glycoprotein bound gliadin in a carbohydrate and calcium dependent manner. The results show that circulating antibodies directed against a gliadin-binding antigen are present in coeliac disease. 90 kDa glycoprotein may be a receptor for gliadin; in susceptible subjects ligand receptor interaction may result in cytotoxicity and antibody formation.

Increased biliary lipid secretion in celiac disease

Direct measurements of biliary lipid outputs, cholesterol absorption, and fecal steroids were carried out in celiac patients before and during a gluten-free diet to show whether an enhanced flux of cholesterol into the gut (found earlier in these patients) is due to increased biliary output or mucosal secretion of cholesterol, or both. The bile flow rate and the secretion of biliary cholesterol, phospholipids, and bile acids were significantly increased in celiac disease and appeared to be normalized by effective gluten-free diet. A significant amount of cholesterol originated from the intestinal mucosa, but the amount was not consistently increased in the celiac patients. Fractional absorption of cholesterol was low, but due to enhanced biliary secretion the amount of cholesterol absorbed was mostly within the normal limits so that fecal neutral steroids of biliary origin and cholesterol synthesis were markedly increased in celiac disease. Despite high biliary bile acid secretion, fractional absorption of bile acids was enhanced. Thus, the effective ileal conservation of bile acids could have contributed to increased bile acid-dependent secretion of biliary cholesterol. The enhanced biliary and fecal output of cholesterol should ultimately be balanced by augmented cholesterol synthesis, but the closer site of the synthesis and regulatory mechanisms between cholesterol and lipoprotein metabolism need further exploration.

Occurrence of antibodies to teichoic acid in patients with diseases other than staphylococcal infection

To determine the usefulness of the teichoic acid antibody (TAA) test in conditions where unspecific viral and bacterial antibodies are often encountered, we measured TAA by the gel-diffusion method in 475 patients without known staphylococcal disease; they included 213 patients with arthritis, 108 with liver diseases, 100 with gastro-intestinal disorders and 54 with acute pharyngitis. Positive controls were 104 patients with Staphylococcus aureus bacteraemia and 203 healthy adults were negative controls. Thirteen (6%) of the healthy adults had positive TAA titres (greater than or equal to 4), and the highest titre was 8 in two people (1%). Positive titres were found in 38% of patients with S. aureus bacteraemia and high titres (greater than or equal to 8) were seen in 24%. Among the patients with arthritis, positive TAA titres were found significantly more often than in healthy controls in patients with Yersinia arthritis (p less than 0.01) and systemic lupus erythematosus (SLE; p less than 0.02). In other patient groups, the percentage of positive TAA titres did not differ significantly from that in healthy adults. Eight (2%) of the 475 patients without known staphylococcal infection had TAA titres greater than or equal to 8 but these high titres were not associated with any particular disease group. Only two of these eight patients had slightly raised antibody to staphylococcal alpha-haemolysin. We conclude that the TAA test cannot be used as a reliable indicator of septic staphylococcal disease in patients with Yersinia arthritis or SLE, but that in general, TAA titres greater than or equal to 8 point strongly to S. aureus infection even in patients with autoimmune or liver diseases.

Biliary lipid secretion in chronic cholestatic liver disease

Biliary lipid secretion rates, faecal steroids, and serum lipids were studied in patients with chronic cholestatic liver disease mainly primary biliary cirrhosis. The biliary secretion of cholesterol, bile acids, and phospholipids was markedly decreased as compared with those in the control group and in general correlated negatively with the serum cholesterol and triglyceride values. The molar percentage of cholesterol was increased in the hepatic bile. This suggests that, in cholestatic liver disease, in contrast with the normal state, the hapatic bile may be supersaturated postprandially. Faecal bile acids and neutral sterols of cholesterol origin were decreased proportionately to the corresponding biliary lipid secretion rates. In fact, both biliary and faecal steroid outputs were only about a half or less than those in the controls, indicating that the fractional absorption was not changed but absolute absorption and faecal steroid excretion were low in patients with chronic cholestatic liver disease. Thus, despite low cholesterol and bile acid absorption, cholesterol and bile acid synthesis is low. A negative correlation between faecal steroids and serum cholesterol suggests that the high serum cholesterol level contributed to regulation of cholesterol synthesis.

Cholesterol absorption, elimination and synthesis in coeliac disease

Hypocholesterolaemia and high faecal elimination of cholesterol was explored by measuring the percentage of cholesterol absorbed, faecal steroids, serum cholesterol and dietary cholesterol in patients with coeliac disease before and after a gluten free diet. From these data, the total and endogenous flux of cholesterol into the gut and the amount of cholesterol absorbed could be calculated. The mean faecal bile acid excretion was normal, but faecal endogenous steroids and thus faecal total steroids, and the cholesterol synthesis, were increased in the patients. The percentage of cholesterol absorbed was quite low (15.1 +/- 2.1 (SEM) v. 34.1 +/- 2.5 in the controls), and it was attributable to a mucosal damage in the upper small intestine, suggesting that this played a primary role in the high faecal sterol loss. However, the influx of endogenous cholesterol into the gut had increased, so that in absolute terms the absorption of cholesterol was low only inconsistently. The gluten-free diet caused the opposite changes in the absorption percentage and influx of cholesterol into the gut, while the amount of cholesterol absorbed was only insignificantly increased. Serum cholesterol was significantly correlated with the cholesterol absorbed (r = 0.36; P less than 0.01), faecal endogenous steroids (r = -0.30; P less than 0.05), and cholesterol synthesis (r = -0.29; P less than 0.05). Furthermore, the rise in serum cholesterol during the gluten-free diet correlated negatively with the changes in cholesterol (r = -0.55; P less than 0.05) and bile acid (r = -0.77; P less than 0.01) synthesis. These associations and the lack of correlations between the amounts of cholesterol absorbed and synthesized suggest that the serum cholesterol level and regulation of cholesterol synthesis are interrelated in coeliac disease.

Endoscopic and clinical findings in first-degree relative of duodenal ulcer patients and control subjects

The first-degree relatives of duodenal ulcer patients and of control probands were evaluated clinically and by gastroduodenal endoscopy for prevalence of duodenal ulcer. The control probands were randomly selected from a control population. 199 relatives of 51 duodenal ulcer probands were interviewed, and 154 of these were endoscoped. 154 control relatives who had been endoscoped were matched with the DU relatives according to sex and age. Endoscopic evidence of present or past duodenal or pyloric ulcer was present in 20 (13.0%) of the DU relatives and in only 6 (3.9%) of the control relatives (p less than 0.01). The frequency of macroscopic duodenitis and gastric erosions was also significantly higher (p less than 0.05) in DU relatives than in controls. A history of epigastric pain was obtained in 54 (35.1%) of endoscoped DU relatives and in 24 (15.6%) of control relatives (p less than 0.01). This study has shown an increased prevalence of endoscopic evidence of duodenal ulcer in the first-degree relatives of duodenal ulcer patients. The finding that duodenitis is also more prevalent in DU relatives than in controls support the view that duodenitis is linked with duodenal ulcer.