5'-Nucleotidase activity is decreased in seminal plasma and spermatozoa from varicocele patients

5'-Nucleotidase is involved in sperm capacitation via the cAMP-adenosine pathway and in sperm motility via direct adenosine production from AMP. Since these functions are reduced in varicocele, the aim of this study was to investigate whether the enzyme levels were altered in sperm from varicocele patients. The mean (SD) international units (IU) of 5'-nucleotidase activity in seminal plasma from 35 varicocele III patients was 0.16(0.09) IU ml(-1) vs 0.35(0.13) IU ml(-1) in 53 controls, this decrease being statistically significant at p < or = 0.001. A significant decrease in activity, expressed as international units per mg of protein concentration in spermatozoa homogenates, was also observed with spermatozoa: 0.0018(0.0017) IU mg(-1) in varicocele III vs 0.0081(0.0060) IU mg(-1) in controls, at p < or = 0.001. Compared to controls, the activity decrease observed both in spermatozoa and seminal plasma from 45 men with varicocele I was not statistically significant at p < or = 0.05. To determine the diagnostic value of 5'-nucleotidase in assessing sperm fertility in varicocele III, we used the likelihood ratios method and best cut-offs were identified in receiver operating characteristic curves. With a prevalence of 36%, the post-test probability of infertility was 91% in spermatozoa and 78% in seminal plasma. The cut-off values of 5'-nucleotidase activity discriminating for fertile/unfertile semen were 0.2 IU ml(-1) in seminal plasma and 0.003 IU mg(-1) of protein in spermatozoa. Overall, determination of 5'-nucleotidase activity, especially in spermatozoa, can be useful to characterize different varicocele degrees as well as the sperm fertility potential.

Mortality in patients with coeliac disease and their relatives: a cohort study

BACKGROUND

Although previous studies have shown increased mortality in patients with coeliac disease and their relatives, no data are available in relation to different patterns of clinical presentation. We assessed mortality in patients with coeliac disease and their first-degree relatives.

METHODS

We enrolled, in a prospective cohort study, 1072 adult patients with coeliac disease consecutively diagnosed in 11 gastroenterology units between 1962 and 1994, and their 3384 first-degree relatives. We compared the number of deaths up to 1998 with expected deaths and expressed the comparison as standardised mortality ratio (SMR) and relative survival ratio.

FINDINGS

53 coeliac patients died compared with 25.9 expected deaths (SMR 2.0 [95% CI 1.5-2.7]). A significant excess of mortality was evident during the first 3 years after diagnosis of coeliac disease and in patients who presented with malabsorption symptoms (2.5 [1.8-3.4]), but not in those diagnosed because of minor symptoms (1.1 [0.5-2.2]) or because of antibody screening (1.2 [0.1-7.0]). SMR increased with increasing delay in diagnosis and for patients with poor compliance with gluten-free diet. Non-Hodgkin lymphoma was the main cause of death. No excess of deaths was recorded in relatives with coeliac disease.

INTERPRETATION

Prompt and strict dietary treatment decreases mortality in coeliac patients. Prospective studies are needed to clarify the progression of mild or symptomless coeliac disease and its relation to intestinal lymphoma.

Immune reaction against the cytoskeleton in coeliac disease

BACKGROUND

The cytoskeleton actin network of intestinal microvilli has been found to be rapidly impaired after gluten challenge in coeliac disease (CD). The aim of this study was to investigate the presence of an immune reaction towards cytoskeleton structures such as actin filaments in CD.

METHODS

Eighty three antiendomysial antibody positive CD patients (52 children and 31 adults) were studied at our outpatient clinics from 1996 to 1998 using indirect immunofluorescence, ELISA, and western blotting for antiactin (AAA) and antitissue transglutaminase (TGA) antibodies before and after a gluten free diet (GFD). Sixteen patients with smooth muscle antibody positive autoimmune hepatitis, 21 with inflammatory bowel diseases, seven with small bowel bacterial overgrowth, and 60 healthy subjects were studied as controls.

RESULTS

Fifty nine of 83 CD patients (28/31 adults (90.3%); 31/52 children (59.6%)) were positive for IgA and/or IgG AAA. Seventy seven (92.7%) were positive for IgA TGA. IgA AAA were strongly correlated with more severe degrees of intestinal villous atrophy (p<0.0001; relative risk 86.17). After a GFD, AAA became undetectable within five months.

CONCLUSIONS

Apart from the immune reaction against the extracellular matrix, we have described an immune reaction against the cytoskeleton in both children and adults with CD. As AAA are strongly associated with more severe degrees of villous atrophy, they may represent a useful serological marker of severe intestinal atrophy in CD.

Increased red cell distribution width and coeliac disease

BACKGROUND/AIMS

Despite availability of sensitive screening tests, coeliac disease is still underdiagnosed. To determine which haematochemical abnormalities might be more predictive of this condition, we reviewed the clinical records of our series of adult patients affected by coeliac disease.

METHODS

Six haematochemical parameters (haemoglobin, red cell distribution width, serum levels of iron, albumin, calcium and potassium) were evaluated in 126 consecutive adult untreated coeliac patients diagnosed since 1990.

RESULTS

Elevated red cell distribution width was the most frequent haematochemical abnormality, being present in 57.9% of our patients (Chi square analysis, p<0.01 versus other laboratory changes).

CONCLUSION

The increase of red cell distribution width was more common than iron-deficiency anaemia, a well-known indicator of coeliac disease. Elevated red cell distribution width can thus be considered a new predictor of coeliac disease and in the presence of this a search should be made for antiendomysial antibodies.

Transglutaminase and coeliac disease: endomysial reactivity and small bowel expression

This study was aimed at verifying whether tissue transglutaminase (tTG) is the sole autoantigen eliciting anti-endomysial antibodies in coeliac disease (CoD) and investigating tTG expression in normal and coeliac mucosa. Twelve anti-endomysial-positive coeliac sera and 12 anti-endomysial-negative control sera (10 microl, diluted 1:5-1:400 in PBS pH 7.3) were preincubated with 10, 20 or 50 microg guinea pig liver tTG at 4 degrees C overnight. Monkey oesophagus tissue slides were then tested with tTG-preincubated and non-preincubated sera to search for IgA anti-endomysial reactivity by indirect immunofluorescence. Moreover, six sections of monkey oesophagus were incubated with an anti-tTG mouse MoAb, six sections with an anti-cytokeratin mouse MoAb and six sections with only 3% bovine serum albumin. Finally, endoscopic duodenal biopsy sections obtained from 12 patients affected by untreated CoD, six patients affected by treated CoD and 10 biopsied controls were immunohistochemically stained with a peroxidase-conjugated anti-tTG MoAb. Our results show that (i) preincubation with tTG abolished endomysial immunofluorescence in most, but not in all, coeliac sera; (ii) the incubation of anti-tTG MoAb with sections of monkey oesophagus resulted in an immunofluorescence staining pattern similar but not identical to that of anti-endomysial-positive coeliac sera; (iii) although tTG expression was present at muscularis mucosae and pericryptal fibroblast in both normal and coeliac mucosa, it was slightly more marked and evident in the latter. Although our absorption experiment was performed with guinea pig liver tTG, we confirm that tTG is the predominant antigen of endomysial antibodies, but we speculate that, at least in some patients, it is not the only one.

Tissue transglutaminase antibodies in celiac disease

OBJECTIVE

Tissue transglutaminase is the antigen for antiendomysial antibodies, whose power in screening for celiac disease is well known. Our aim was to assess the efficacy of an ELISA assay for tissue transglutaminase antibodies.

METHODS

Tissue transglutaminase antibodies were analyzed in serum from 39 untreated celiac disease patients and 61 controls. Tissue transglutaminase was used as antigen, and test sera analyzed by ELISA. Results higher than 0.6 optical density were considered positive, lower than 0.4 negative, and between 0.4 and 0.6 borderline.

RESULTS

Optical density of the serum from the patients with untreated celiac disease (median: 1.41; range: 0.33-1.47) were significantly higher than the controls (median: 0.32; range: 0.17-0.68; p < 0.0001; 95% confidence interval 0.87-1.08). Thirty-three patients with untreated celiac disease were positive, 4 borderline, and 2 negative. Fifty-five controls were negative, 4 borderline, and 2 positive. If we consider borderline results to be positive, sensitivity is 94.8% and specificity 90.1%. None of the controls gave results higher than 0.7 optical density. Apart from the 2 negative patients with untreated celiac disease, the two groups overlapped only between 0.4 and 0.7 optical density.

CONCLUSIONS

Because of the high sensitivity (approximately 95%) and technical simplicity, tissue transglutaminase antibodies may prove useful for the screening of celiac disease in population at low or medium risk of celiac disease. To avoid duodenal biopsies in patients without celiac disease, the specificity of the screening procedure may be increased by confirming with antiendomysial antibodies by immunofluorescence on human umbilical cord in individuals with results between 0.4 and 0.7 optical density.

Bone mass and metabolism in Whipple's disease: the role of hypogonadism

BACKGROUND

Whipple's disease, like other malabsorption syndromes, ought to predispose to osteopenia. We therefore evaluated bone mass and mineral metabolism in a cohort of patients with this condition.

METHODS

Twelve male patients with Whipple's disease and 36 male age-matched healthy subjects took part in the study. None of the patients complained of diarrhea at the time of the study. Bone mineral density at the lumbar and femoral level and serum levels of indices of bone and mineral metabolism and of gonadal function were measured.

RESULTS

Bone mineral density at the total femur and femoral neck were significantly lower in patients with Whipple's disease than in healthy volunteers, whereas no significant difference was found at the lumbar level. In patients with Whipple's disease serum levels of type-I collagen teleopeptide (ICTP) and sex-hormone-binding globulin were significantly higher, whereas serum levels of testosterone and luteinizing hormone were significantly lower than in healthy volunteers. Moreover, testosterone correlated significantly (P < 0.05) with lumbar bone mineral density (r(s) = 0.64) and serum ICTP levels (r(s) = -0.63).

CONCLUSIONS

In patients with previously treated Whipple's disease and without any current symptoms of malabsorption, bone loss is generally moderate and linked to the presence of hypogonadism.

Tissue transglutaminase antibodies for coeliac disease screening

We have prospectively searched for IgA anti-transglutaminase antibodies by an enzyme-linked immunosorbent assay test in 20 untreated coeliacs and 21 patients with small bowel diseases other than coeliac disease consecutively referred to our Malabsorption Clinic. All the untreated coeliacs and one out of 21 disease controls turned out to be positive for the presence of these antibodies. The use of the enzyme-linked immunosorbent assay test for anti-transglutaminase antibodies could represent a new screening test for coeliac disease, in fact, this new enzyme-linked immunosorbent assay test has an absolute sensitivity and a satisfactory specificity and, in comparison to antiendomysial antibodies, is less expensive and avoids the ethical problems related to the use of monkey oesophagus.

Antineutrophil cytoplasmic antibodies in inflammatory bowel disease: diagnostic tool or research procedure?

Antineutrophil cytoplasmic antibodies, initially detected in the sera of patients with Wegener's granulomatosis and other forms of systemic vasculitides, have also been observed in patients with inflammatory bowel disease, with a higher prevalence in ulcerative colitis. In this study, we investigated the prevalence of these antibodies in the sera of 42 patients with ulcerative colitis and 48 patients with Crohn's disease, and the possible correlations with disease activity and extent, extraintestinal complications, and therapy. Antineutrophil cytoplasmic antibodies were found in 30 out of the 42 patients with ulcerative colitis (71.4%); only 16 out of the 48 patients (33.3%) with Crohn's disease were positive (p < 0.001), and the prevalent pattern was perinuclear. No correlations with disease activity and extent, extraintestinal complications, or surgical or medical treatment were found. Our data indicate that in the case of inflammatory bowel disease, the search for antineutrophil cytoplasmic antibodies still remains a research procedure and cannot be used for clinical diagnosis.

Doppler ultrasonographic evaluation of splanchnic blood flow in coeliac disease

BACKGROUND

Current knowledge on splanchnic haemodynamics in coeliac disease is limited and incomplete.

AIM

To evaluate splanchnic arterial and venous blood flow in coeliac disease.

METHODS

In 22 coeliac (13 untreated, nine treated) patients and in nine healthy subjects the following variables were assessed: vessel diameter and mean flow velocity in portal vein, splenic vein, superior mesenteric vein, and superior mesenteric artery. Peak systolic velocity, end diastolic velocity and pulsatility index were also determined in the superior mesenteric artery. Five patients of the untreated group were re-evaluated after nine months on a gluten free diet.

RESULTS

Significant differences in haemodynamic variables between the three groups were shown only in the superior mesenteric artery. An increase in both mean flow velocity and end diastolic velocity and a reduction in pulsatility index occurred in untreated patients compared with treated patients (p < 0.002; p < 0.04; p < 0.035) and with healthy controls (p < 0.001; p < 0.025; p < 0.0003). Similar results were obtained for the five patients evaluated before and after treatment (p < 0.03; p < 0.02; p < 0.03), in whom the mean flow velocity in the superior mesenteric vein also decreased after treatment (p < 0.05). No significant differences were noted between treated coeliac patients and healthy controls.

CONCLUSIONS

In untreated coeliac disease there is a hyperdynamic mesenteric circulation that decreases after treatment.

Influence of pattern of clinical presentation and of gluten-free diet on bone mass and metabolism in adult coeliac disease

Since no information is available on bone derangements in subclinical coeliac disease (CD), we evaluated bone mineral density (BMD, expressed as z score) at lumbar spine, by X-ray dual-photon absorptiometry, and serum indices of bone metabolism and remodeling in 14 subclinical or silent patients, 10 classical patients, and 15 healthy volunteers all on a gluten-containing diet. In the subclinical group, BMD at lumbar spine was significantly higher than in the classical group (-1.3 +/- 0.8, 73% vs. -2.6 +/- 0.6, 88%, respectively; p < 0.001), but significantly lower than in volunteers (+0.4 +/- 1.1, 104%; p < 0.001). Similar changes were observed in serum calcium, whereas, as regards parathyroid hormone, no significant difference was found between subclinical and classical patients. 25-vitamin D was significantly lower, and 1,25-vitamin D was significantly higher in subclinical and classical patients than in healthy volunteers. Indices of bone remodeling were higher in the subclinical and classical groups than in the volunteers, but lower in the subclinical than in classical patients. Eight subclinical and 8 classical patients were reexamined after a period of gluten-free diet (GFD), and in both groups BMD had significantly improved. Our results show that osteopenia is a frequent feature also in subclinical CD, although the extent of bone and mineral metabolism derangements is lower than in classical CD. GFD is able to normalize BMD in subclinical and to significantly improve it in classical patients.

[Intestinal malabsorption, celiac disease and associated lymphoma: from symptoms to diagnosis]

The clinical consequences of intestinal malabsorption are extremely variable and a dissociation between malabsorption, malabsorption syndrome and enteropathy is often noted. Enteropathy does not always results in malabsorption and in an alteration of the tests exploring the absorptive function. The following have particular relevance in clinical practice: coeliac disease, malabsorption induced by microbiologic agent (including Whipple's disease), post-surgical malabsorption and selective carbohydrate malabsorption. In particular, coeliac disease has been analyzed in its various aspects, from studies with organ cultures to immunological hypotheses, from the classical variety to subclinical forms and to serious complications, such as enteropathy-associated T cell lymphoma. Malabsorption syndromes are dramatically underdiagnosed: in the typical case of coeliac disease, enteropathy represents a clinical iceberg, and the discovery of the submerged portion, represented by the polymorphous subclinical varieties, has just started. As far as intestinal malabsorption is concerned, the main clinical problem regards diagnosis.

Subclinical coeliac disease: an anthropometric assessment

OBJECTIVES

To evaluate the prevalence of malnutrition in patients with untreated coeliac disease (CD) according to their pattern of presentation, and the effect of gluten-free diet (GFD) upon nutritional status.

DESIGN

Cohort prospective study.

SETTING

All subjects were seen at the outpatient 'malabsorption' clinic of the Department of Medical Pathology I, University of Bologna (referral centre), Bologna.

SUBJECTS

Eighty consecutive patients with CD (48 with classical and 32 with subclinical presentation), 15 patients with dermatitis herpetiformis (DH) and 40 healthy volunteers (members of the hospital staff).

MAIN OUTCOME MEASURES

The nutritional status was evaluated by anthropometric measurements (percentage of ideal body weight for height and sex, percentage of standard triceps skinfold thickness and percentage of ideal arm-muscle circumference).

RESULTS

The overall prevalence of malnutrition in our series of CD patients was 53%. Prevalence of malnutrition (actual body weight less than 90% of the ideal) was significantly higher in classical coeliacs (67%) than in subclinical ones (31%, P < 0.002), in patients with DH (13%, P < 0.0003) and in healthy volunteers (13%, P < 0.0001). At diagnosis, percentage values of ideal body weight, triceps skinfold thickness and arm-muscle circumference were significantly lower (P < 0.0001, P < 0.0002 and P < 0.0003, respectively) in classical coeliacs (84.5 +/- 10.6, 71.2 +/- 28.1 and 87.1 +/- 10.8, respectively) than in subclinical coeliacs (95.5 +/- 9.1, 105.6 +/- 41.0 and 94.8 +/- 10.6, respectively). After GFD, 33% of classical and only 3% of subclinical coeliacs were still malnourished.

CONCLUSIONS

Prevalence of malnutrition in CD is lower than was previously thought. CD patients with classical presentation may require a longer period of GFD to achieve a significant improvement of their nutritional status, with respect to those with subclinical presentation, probably because of a greater extent of intestinal damage. Finally, a careful evaluation of dietary habits is usually sufficient to identify incomplete adherence to GFD as the reason for nonimprovement of the nutritional status in patients with CD.

[Effectiveness of and tolerability to oral desmopressin in the treatment of central diabetes insipidus]

Intranasal desmopressin represents the treatment of choice in Central Diabetes Insipidus. Nevertheless, this route of administration bears some practical disadvantage, linked to either difficult delivering technique, or the status of nasal mucose. The antidiuretic effectiveness of oral desmopressin has been recently demonstrated, both in experimental animals and in man. In our study we compared oral vs. intranasal desmopressin efficacy in 13 patients affected by Central Diabetes Insipidus. The results show that the peroral administration of Desmopressin at a mean dose of 500-600 micrograms/die determines an antidiuretic effect comparable to that of intranasal route, without affecting body weight, arterial pressure and chemical analysis. Side effects, generally limited to the first week of treatment, were described (nausea, vomiting, headache, dizziness [corrected], bitter taste, epygastralgia, asthenia, epystassis), inducing 4/13 patients to withdrawal the trial.

Non-absorbable antibiotics and small bowel bacterial overgrowth

The normal gastrointestinal flora includes no more than 10(3) organisms/ml of gastric aspirate and no more than 10(5) organisms/ml of duodenal or jejunal juice. The organisms are primarily gram-positive and aerobic bacteria. In particular anatomical or functional predisposing conditions, an abnormal colonization takes place in the small bowel with microbial concentrations > or = 10(7)/ml of aspirate and with a predominance of anaerobes and coliforms. At times this small bowel bacterial overgrowth remains asymptomatic, but more often leads to a true malabsorption syndrome with symptoms, such as diarrhoea, weight loss and megaloblastic anemia. The most accurate procedure for confirming the presence of this condition is represented by the bacterological analysis of the jejunal aspirate. The routine use of this method is, however, notably hindered by the need for intubation of the patient and by the lack of laboratories suitably equipped for anaerobe culture. As an alternative to this complex procedure, numerous non-invasive tests have been perfected over the last few years, including the glucose- or lactulose- H2 breath test. The main aim of the treatment of the small bowel bacterial overgrowth is the suppression of the bacterial colonization using antimicrobial therapy. Among the local-action non-absorbable antibiotics, rifaximin, was shown to have bactericidal activity against aerobes and anaerobes bacteria, such as bacteroides, lactobacilli and clostrides. In controlled clinical trials the antibiotic has demonstrated therapeutic efficacy in bacterial origin diarrhoea, in porto-systemic encephalopathy, in diverticulosis and, finally, in small bowel bacterial overgrowth.