Reduced glutamine content in colonic polyps

BACKGROUND

Glutamine is the most abundant amino acid in the body. It has a key role in nitrogen metabolism and is a major source of energy for the enterocyte and many other cells. Glutamine is also essential for tumor growth, and marked changes in organ glutamine metabolism are characteristic in cancer patients.

METHODS

We have investigated the catabolism of glutamine in a classic premalignant condition: the colonic adenomatous polyp. The content of glutamine and activity of two catabolic enzymes, glutamine transferase and phosphate-dependent glutaminase, were studied in normal colon and in polyp mucosa.

RESULTS

Free glutamine content and activity of glutaminase were significantly lower in polyps than in their adjacent mucosa. Glutamine transferase activity was significantly lower in polyp mucosa than in normal colon controls.

CONCLUSIONS

Adenomatous polyps might behave as a glutamine trap, channeling glutamine to protein and nucleic acid synthesis. These changes in glutamine catabolism could play a role in colonic neoplasia pathogenesis.

Folate synthesized by bacteria in the human upper small intestine is assimilated by the host

BACKGROUND & AIMS

Some intestinal flora are known to synthesize folate. The aim of this study was to determine whether folate synthesized by small intestinal flora is assimilated by the human host.

METHODS

Subjects with atrophic gastritis and healthy volunteers were studied before and after omeprazole administration. A double-lumen perfusion tube was placed in the duodenum. 3H-labeled P-aminobenzoic acid, a precursor substrate for bacterial folate synthesis, was perfused. Downstream intestinal aspirates and a 48-hour urine collection were obtained.

RESULTS

Atrophic gastritis and omeprazole administration were associated with increases in duodenal pH and in small intestinal flora. Bacterially synthesized folates were isolated from the intestinal aspirates. Tritiated 5-methyltetrahydrofolate, a major metabolite of folate, was isolated from the urine of omeprazole-treated subjects in greater quantities than from drug-free subjects (P<0.01); the quantity of tritiated 5-methyltetrahydrofolate in the urine of the subjects with atrophic gastritis was similarly elevated.

CONCLUSIONS

(1) Mild bacterial overgrowth caused by atrophic gastritis and administration of omeprazole are associated with de novo folate synthesis in the lumen of the small intestine; (2) the human host absorbs and uses some of these folates; and (3) the contribution to folate nutriture from this source remains unclear.

CSF inositol does not predict antidepressant response to inositol. Short communication

CSF inositol was reported to be reduced in depression and inositol has been reported to be effective in treatment of depression. We studied CSF inositol in 18 drug-free depressed patients and 36 normal controls; the depressed patients then participated in an open trial of 18 gm daily inositol treatment for 4 weeks. There was no difference in pre-treatment CSF inositol between depressed patients and controls. CSF inositol levels did not predict response on the Hamilton Depression Scale to 4 weeks of inositol treatment.

Rapamycin: distribution, pharmacokinetics, and therapeutic range investigations

Rapamycin (RAPA) is a potent immunosuppressive drug that is presently undergoing clinical trials. The most of the drug is sequestered in erythrocytes resulting in whole blood concentrations being considerably higher than plasma concentrations. The drug is metabolized by the same P450 3A enzyme that is involved in the metabolism of cyclosporine and tacrolimus. Structural elucidation of RAPA metabolites is required. The drug has a relatively long half-life in both humans and animals with 24-h trough concentrations being within the analytic range of high-performance liquid chromatography (HPLC) when immunosuppressive doses are administered. For RAPA, a proportionality is exhibited between trough concentrations and dose. In animal transplant models, trough concentrations of the drug appear to be related to immunosuppressive efficacy and drug-related side effects. The studies described here should provide the basis for establishment of therapeutic monitoring protocols for the drug.

Upper gastrointestinal hemorrhage associated with cutaneous application of diclofenac gel

We present four cases of upper gastrointestinal hemorrhage associated with the cutaneous application of diclofenac (Voltaren Emulgel). The patients' ages ranged from 24 to 85 yr. Three of the patients had used the medication three times daily for at least 2 wk before the onset of bleeding. In two cases, the treatment was indicated for backache which, retrospectively, was attributable to a peptic ulcer. In those two patients, the hemorrhage was massive, requiring blood transfusions. Because systemic absorption of nonsteroidal anti-inflammatory drugs from topical formulations has been documented, caution should be exercised when prescribing these formulations to patients with a history of peptic ulcer.

Predictors of mortality in patients admitted to hospital for acute upper gastrointestinal hemorrhage

BACKGROUND

We wanted to identify features of prognostic significance in patients admitted to hospital because of acute upper gastrointestinal (UGI) hemorrhage.

METHODS

A prospective, longitudinal study of 321 consecutive cases admitted during 1988-91 was carried out. The relative risk of mortality associated with each of the background, laboratory, and endoscopic features and the hospital course was calculated. Multiple stepwise logistic regression was used to define factors independently associated with mortality. Two models were evaluated, the first based on the data at presentation (history, physical findings, initial laboratory data) and the second based on the first, plus the endoscopic and follow-up data.

RESULTS

The overall mortality was 7.8%. At presentation the features associated with a significantly (p < 0.05) increased risk of mortality were (adjusted odds ratios in parentheses) age > or = 75 years (11.2), a history of cancer (12.1), blood in the gastric aspirate (9.6), and a systolic blood pressure < or = 90 mm Hg (6.4). The overall predictors of mortality were age > or = 75 years (12.7), blood in the gastric aspirate (18.9), serum creatinine level > or = 150 mumol/l (14.8), increased serum aminotransferase level (20.2), and persistent or recurrent bleeding (57.3).

CONCLUSIONS

In patients admitted to hospital because of UGI hemorrhage the prognosis depends on age, underlying diseases, hemodynamic status, and the persistence or recurrence of bleeding. The causes of bleeding were not relevant to the prognosis.

Predictors of mortality in hospitalized patients with secondary upper gastrointestinal haemorrhage

OBJECTIVES

To identify clinical, laboratory and endoscopic features of prognostic implication in patients who suffer an upper gastrointestinal haemorrhage whilst hospitalized for other causes.

DESIGN/SETTING

A prospective longitudinal study of 125 consecutive cases (89 males, 36 females) seen during 1988-1991 in a tertiary care university hospital.

MAIN OUTCOME MEASURES

The crude and adjusted relative risk of mortality associated with each of the various clinical, laboratory and endoscopic variables.

RESULTS

The rates of endoscopic haemostasis, persistent or recurrent bleeding and surgery to control bleeding were 48, 37 and 12%, respectively; the overall mortality was 28%. A significantly increased risk of mortality was associated with shock prior to onset of bleeding, sepsis, renal failure, cirrhosis, encephalopathy, presence of red blood in the nasogastric aspirate or per rectum, thrombocytopenia, hypoalbuminaemia, elevation of serum bilirubin, aminotransferases or urea levels, endoscopic evidence of active bleeding, the application of endoscopic haemostasis, rebleeding, transfusion of > or = 6 units of blood, surgical treatment or any subsequent complication. Use of nonsteroidal anti-inflammatory drugs (27%) was associated with a decreased mortality risk (odds ratio 0.2; P = 0.03). A multivariate analysis showed that the features at presentation which were independently associated with an increased risk of mortality were: a history of cirrhosis, sepsis, shock prior to onset of bleeding, hypo-albuminaemia and elevated serum aminotransferases.

CONCLUSION

The prognosis of secondary upper gastrointestinal haemorrhage depends on the underlying diseases and on the general condition of the patient, rather than on the actual cause of bleeding.

MRI anatomy of the rat kidney at 1.5 T in different states of hydration

The objective of this study was to determine correlation between structural anatomy and surface coil spin-echo MR imaging of the rat kidney and the effect of hydration state on MR signal intensities of the cortex and medulla. Twelve rats were studied in a pilot study with a 3-inch surface coil in a 1.5 T magnet under five different states of hydration. Serum and urine osmolality measurements were obtained immediately prior to each scan. Signal intensity measurements were made from both T1- and T2-weighted images of the cortex and medulla of both kidneys in each state of hydration. Gross and histological anatomy of the rat kidneys was correlated with the MR images. Four distinct layers were detected in vivo on MRI images of the rat kidney; these correlated with the histological layers. T1-weighted cortico-medullary differentiation was most pronounced at 48 h dehydration; T2 cortico-medullary differentiation was greatest at 72 h of dehydration. We concluded that different parts of the mammalian nephron can be identified by MR imaging and that cortico-medullary differentiation is affected by the hydration state of the animal.

The impact of continuity of nursing care personnel on patient satisfaction

Although continuity in nursing care is valued highly by nurses, there is little research that demonstrates its value to patients. In this study, the relationship of nursing care continuity to patient satisfaction was examined. Overall patient satisfaction was not related to continuity of nursing care, but nursing continuity on specific shifts was related to satisfaction with discrete aspects of care, such as involvement of patients and families in care.

Upper gastrointestinal hemorrhage. Comparison of the causes and prognosis in primary and secondary bleeders

BACKGROUND

Hemorrhage from the upper gastrointestinal (UGI) tract is defined as primary when it is the cause of admission to hospital and as secondary when it complicates the course of patients admitted to hospital for other causes. The objective of this study was to compare the background features, course, and outcome of patients with primary and secondary bleeding.

METHODS

All patients who underwent upper endoscopy because of acute UGI bleeding during 1988-91 in a tertiary care university hospital were studied longitudinally. The background features of primary bleeders (n = 321) were compared with those of secondary bleeders (n = 125). From the primary bleeders, a group was matched to the secondary bleeders by age, sex, use of nonsteroidal anti-inflammatory drugs (NSAIDs), and liver disease. The laboratory and endoscopic findings, hospital course, and mortality were compared in the two groups.

RESULTS

Secondary bleeders were on the average 5 years older than primary bleeders and were significantly more likely to have ischemic heart disease, chronic lung disease, and chronic renal failure. Use of corticosteroids, H2 blockers, antacids, and anticoagulants in this group was significantly more prevalent, whereas the use of NSAIDs was similar in the two groups. The case-control analysis showed a similar distribution of the causes of bleeding in the two groups. However, rebleeding, endoscopic hemostasis, and complications were more frequent in secondary bleeders. The mortality in secondary bleeders was 28%, compared with 10% in matched primary bleeders, for a relative risk of 3.8 (p = 0.0002).

CONCLUSION

Secondary hemorrhage is associated with an increased mortality, which is related to the underlying diseases and not to a difference in the causes of bleeding.

The medical/surgical nurse program. A flexible response to the changing patient care environment

The medical/surgical nurse program at Stanford University Hospital was designed to provide patient care units with clinical professional support to manage emergency or other unpredictable situations in a challenging healthcare environment. As a result of this program, staff members have access to clinical nursing experts who provide valuable support to improve patient care services in the most cost-effective manner.

Occurrence of cancer in Alzheimer and elderly control patients: an epidemiologic necropsy study

Epidemiologic necropsy provides an accurate measure of the occurrence rates of diseases. To determine the occurrence of cancer in Alzheimer patients as well as in non-Alzheimer elderly controls, we examined autopsy reports of 575 control and 71 Alzheimer cases aged 50-100 years for histologic evidence of cancer. We compared expected rates of cancers calculated from the National Cancer Institute's Surveillance, Epidemiology and End Result (SEER) Program data to rates observed at autopsy using a chi-squared test. To determine whether there was an association between the occurrence of cancer and Alzheimer disease, we compared rates for all cancer and three specific cancers in Alzheimer and control patients using an odds ratio test. We found from fourfold to 98-fold more cancer in Alzheimer patients and controls than that expected from SEER data. There was no statistical difference in the autopsy incidence of total, lung, or prostate cancer between Alzheimer patients and controls. However, the occurrence of pancreatic cancer was 6.7-fold higher in Alzheimer patients than in control subjects. Controlling for multiple comparisons, the odds ratio for pancreatic cancer in Alzheimer's disease was significantly higher than in controls (p < 0.001). Our results indicate that cancer occurs more frequently than expected in both Alzheimer patients and control subjects. In addition, there may be an association between the occurrence of certain cancers and Alzheimer's disease.

Evaluation of serological pseudorabies tests for the detection of antibodies during early infection

Six enzyme-linked immunosorbent assays, a latex agglutination test, and the standard microtitration serum virus neutralization test were compared for their ability to detect antibodies against pseudorabies virus (PRV) during the early stages of infection. Thirty-five pigs were infected intranasally with 10(5)-10(7) TCID50 of either the Iowa 4892 pneumotropic or the Becker strain of PRV. Blood samples were drawn from experimentally inoculated animals on days 4-10, 14, and 21 postchallenge. Test sensitivity estimates and comparisons among tests were made for each sampling day over the 21-day monitoring period. Results of this study demonstrated differences among tests in 1) the time from inoculation to initial antibody detection, 2) the time to detect > or = 95% of the infected pigs, and 3) the time from initial antibody detection to determination of > or = 95% as positive. By day 10 postchallenge, no statistically significant difference in diagnostic sensitivity was observed among the 8 tests compared in the study.

Gastro-duodenal injury associated with intake of 100-325 mg aspirin daily

During the year 1991, 43 patients with upper gastrointestinal bleeding and one with severe epigastric pain associated with intake of non-steroidal anti-inflammatory drugs were admitted for emergency endoscopy to our unit. Fourteen patients (33%) had been treated with 100-325 mg aspirin daily, 11 of them for at least one year. The mean age of this group was 71. Only two patients had a previous history of peptic ulcer. Five patients used anticoagulants or antiplatelet drugs concomitantly with aspirin. The endoscopic diagnosis of the sources of bleeding was erosive gastritis in eight patients, gastric ulcer in four, duodenal ulcer in five and oesophageal ulcer in one. Our results support findings by other groups, showing that doses of aspirin as low as 75 mg daily should be used in the management of elderly patients with thrombo-embolic disease.

Influence of dose and route on transmission of encephalomyocarditis virus to swine

The susceptibility of swine to infection with encephalomyocarditis virus (EMCV) was assessed. Transmission of EMCV in a single exposure by gavage or intranasal routes was highly dose dependent. In a direct comparison, animals were exposed to EMCV by gavage, intranasal, intramuscular, intratracheal, or transdermal routes. A higher proportion of animals exposed by transdermal (5/5), intratracheal (5/5), or intramuscular (5/5) routes than those exposed by intranasal (2/5) or gavage (3/5) routes became infected. The large quantity of virus required to infect animals intranasally or orally suggests that transmission by these routes may not occur routinely in the field. Transmission of EMCV by wound contamination (transdermally) has not been reported previously. Although EMCV was recovered from rectal, external genitalia, and pharyngeal swabs, there was no evidence of pig-to-pig transmission of EMCV from experimentally infected animals to comingled sentinels.

Neutrophil mediators, Pseudomonas, and pulmonary dysfunction in cystic fibrosis

Proteolytic enzymes derived from inflammatory cells or Pseudomonas aeruginosa may destroy lung matrix in cystic fibrosis (CF). Antielastases appear to be overwhelmed by large amounts of free neutrophil elastase (NE) activity in lower respiratory tract secretions, and proteolytic or oxidant stress is thought to account for such deficiency. The purpose of this study was to measure NE and myeloperoxidase activity in bronchoalveolar lavage fluid (BAL) from patients with CF and to correlate levels of these mediators with the degree of airflow obstruction and density of P. aeruginosa in BAL. We measured NE activity in BAL fluid from 14 patients with respiratory exacerbations of CF. NE complexed with alpha 1-antiprotease in peripheral blood was measured in 13 of the 14 patients subjected to BAL and in 21 additional patients who did not undergo BAL. Because oxidants generated by myeloperoxidase may contribute to increased elastase activity via inactivation of alpha 1-antiprotease, myeloperoxidase activity in BAL was also measured. We found that elastase activity in BAL correlated significantly with the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC ratio) (r = -0.80, p < 0.001) and FEV1 percent predicted (r = -0.62, p = 0.02). Myeloperoxidase activity also significantly correlated with airflow obstruction (FEV1/FVC ratio, r = -0.70, p = 0.005; FEV1 percent predicted, r = -0.52, p = 0.05). However, the degree of airflow obstruction, NE activity, myeloperoxidase activity, or total neutrophils in BAL did not correlate with the density of P. aeruginosa (CFU/ml) or total pathogen burden in BAL fluid.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute upper gastrointestinal bleeding in Jerusalem 1988-91: causes, characteristics and relation to nonsteroidal anti-inflammatory drugs

We analyzed 321 consecutive episodes of community-based acute upper gastrointestinal bleeding admitted to the Hadassah University Hospital in Jerusalem during 1988-91. Of these 71% were in males aged 56.2 +/- 1.2 years (mean +/- SE) and 29% were in females (67.9 +/- 1.7 years, P < 0.001). The main diagnoses were duodenal ulcer (39.5%), gastric ulcer (16.9%), esophageal varices (10.0%), erosive gastritis (8.2%) and esophagitis (7.5%). The distribution of these diagnoses differed significantly between the genders (P = 0.0003). In males the prevalence of duodenal ulcer and of esophageal varices was higher, and that of gastric ulcer and esophagitis lower, than in females. Gastric ulcer patients were oldest, were the least likely to have received anti-ulcer medications prior to admission, and had the highest levels of urea and the lowest levels of hemoglobin on admission. Use of nonsteroidal anti-inflammatory drugs increased significantly with age and was reported in 35% of the cases (aspirin in doses < 1.0 g/day in 21%, nonsalicylate anti-inflammatory agents in 11%, aspirin plus other anti-inflammatory drugs in 3%). Use of systemic corticosteroids was reported in 4%. The most distinctive features of the population with acute upper gastrointestinal bleeding in the present study compared to other series were the significantly higher proportion of duodenal ulcers and the lower proportion of Mallory-Weiss tears.

Does dietary calcium supplementation reduce the risk of colon cancer?

Several recent studies have examined the hypothesis that calcium supplementation (1.2-2.0 g/day) protects against colon cancer in persons at high risk. The effect of supplementation was assessed by comparing the labeling index of rectal biopsy specimens before and after supplementation. Although in most studies the labeling index tended to decrease during supplementation, the results were inconsistent. It is also unclear whether the decrease in the index correlates with a decrease in occurrence or recurrence of colonic tumors. Use of calcium prophylaxis for persons at risk for colon cancer should be reserved for controlled clinical trials.

Analgesic activities of PEM-420, the active eutomer of pemedolac

PEM-420, the active isomer of pemedolac, inhibited the writhing responses induced by phenylbenzoquinone (PBQ), acetic acid, and acetylcholine in mice with ED50's of 0.80, 0.92, and 0.075 mg/kg p.o., respectively. In the rat acetic acid writhing assay, PEM-420 exhibited an ED50 value of 8.4 mg/kg p.o. In the Randall-Selitto test, PEM-420 raised the pain threshold of the yeast-injected paw (ED50 = 0.55 mg/kg p.o.). Like other NSAIDs, PEM-420 inhibited the PBQ-induced production of PGI2 and PGE2 in the mouse peritoneal cavity, with ED50 values of 0.5 and 1.2 mg/kg p.o., respectively. It had weak ulcerogenic liability in rats (acute UD50 = 99 mg/kg p.o. in fasted rats; subacute UD50 = 74 mg/kg/day for 4 days in fed rats). The data indicate that PEM-420 is a potent and safe peripheral analgesic.

[Rubber-band ligation of esophageal and cardiac varices]

Esophageal sclerotherapy was the treatment of choice for bleeding esophageal varices in the past decade. It is effective for treating acute variceal bleeding, as well as eradicating esophageal varices for secondary prevention of bleeding. However, in more than 20% of patients sclerotherapy involves complications, some of which are serious. The high complication rate suggested the development of a new method that should be at least as effective and as easy to perform as sclerotherapy, but with fewer complications and side-effects. Endoscopic variceal ligation was developed at the University of Colorado and described in 1986. It is reported to control active variceal bleeding in about 90% of patients, and to eradicate varices in about 80% of surviving patients. Complications are rare. We have adapted the method in our unit and here describe out preliminary experience in 11 patients.