Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

[Peritoneal tuberculosis: 27 cases in the suburbs of northeastern Paris]

SETTING

Peritoneal tuberculosis did not disappear from France during the 1990s.

OBJECTIVE

To determine the characteristics of peritoneal tuberculosis in the north-eastern suburbs of Paris.

METHOD

A retrospective study of cases diagnosed with peritoneal tuberculosis between 1990 and 1998 in five suburban hospitals in the north-east region of Paris.

RESULTS

Twenty-seven cases of adult peritoneal tuberculosis were diagnosed. There were nine women and 18 men, with a mean age of 37.5 years, 88.9% of whom were foreign born. General and digestive symptoms--abdominal pain and/or ascites--were present in 96.3% of the cases. The mean delay in treatment was 30 days. Peritoneal involvement was isolated in 25.9% of cases, and associated with pulmonary tuberculosis in 40.7% or hepatic tuberculosis in 25.9%. Co-infection with HIV (human immunodeficiency virus) was present 14.8% of cases. Culture of ascites fluid, laparoscopy and/or laparotomy (n = 17), with directed biopsy, aided in the formal diagnosis of peritoneal tuberculosis in 59.2%. One relapse and one case of multiresistance were observed. The mean duration of treatment was 9 months (range 6-12 months). Three patients received treatment with corticosteroids, and 91.2% of the patients achieved cure without sequelae.

CONCLUSION

Peritoneal tuberculosis is not rare in the Paris region. The diagnosis should be suspected in case with ascites and fever, and can be confirmed by laparoscopy with sampling for bacteriology and histology. The methods of treatment need to be standardised.

Short-term protein and energy supplementation activates nitrogen kinetics and accretion in poorly nourished elderly subjects

BACKGROUND

An increase in protein intake exerts a stimulating effect on protein kinetics in children, young adults, and healthy elderly persons. However, there are few data on the response to such dietary changes in malnourished elderly subjects, despite important medical implications in this population.

OBJECTIVE

The objective of this study was to determine the metabolic response to short-term nutritional supplementation in moderately malnourished elderly subjects.

DESIGN

The influence of 10 d of supplementation (1.67 MJ/d and 30 g protein/d) on body composition, resting energy expenditure, and whole-body protein kinetics was studied in 17 malnourished elderly patients and 12 healthy young adults. A control group of 6 malnourished elderly patients received no supplementation.

RESULTS

Supplemented elderly subjects had a significantly greater fat-free mass gain than did unsupplemented elderly subjects (1.3 and 0.1 kg, respectively; age effect, P < 0.05; diet effect, P < 0.02) and a significantly greater increase in fasting rate of protein synthesis than did young supplemented subjects (0.6 and 0.2 g*kg FFM(-1)*11 h(-1); age effect, P < 0.05). The net protein balance in the supplemented elderly subjects in the fed state was positively correlated with protein intake (r(2) = 0.46) and in the fasted state was negatively correlated with protein intake (r(2) = 0.27). The sum of these regressions is a line with increasingly positive net diurnal protein balance produced by increasing protein intake.

CONCLUSION

These data provide evidence of a short-term anabolic response of protein metabolism to dietary supplementation in malnourished elderly patients that is likely to improve muscle strength and functional status.

Effects of a high soy protein diet on intestinal polyamines and ornithine decarboxylase activity in rats

This study was performed to determine whether intestinal luminal polyamine concentrations are affected by a high soy protein diet when compared with a high casein diet or a normoprotein casein diet. We also determined the effects of these diets, with differences in polyamines content, on mucosal polyamines and ornithine decarboxylase (ODC) activity to assess cell proliferation. Three groups of eight male Wistar rats were fed either a 50% soy protein diet, a 50% casein diet, or an 18% casein diet as a control. After 4 weeks of feeding, both intestinal content and mucosa were recovered. Polyamines were assayed by high performance liquid chromatography. ODC activity was measured by the release of (14)CO(2) from (14)C-L-ornithine. Luminal putrescine and cadaverine concentrations were higher in the jejunum than in the ileum, suggesting an absorptive process. The highest concentrations of intestinal polyamines were observed in rats fed the soy protein diet (P < 0.05). Only minor differences were observed in mucosal polyamines according to the diets. ODC activity was also higher in the intestinal mucosa of rats fed the high soy protein diet (P < 0.05). These results suggest that intestinal luminal polyamine concentrations and ODC activity are modulated by the dietary protein source.

Net postprandial utilization of [15N]-labeled milk protein nitrogen is influenced by diet composition in humans

The aim of this study was to follow the fate of dietary nitrogen to assess the postprandial utilization of purified milk protein and to determine the acute influence of energy nutrients. For this purpose, a [15N]-labeling dietary protein approach was used. Twenty-five subjects swallowed an ileal tube and ingested [15 N]-milk protein alone or supplemented with either milk fat or sucrose. The absorption and postprandial deamination of dietary protein was monitored for 8 h. Sucrose delayed the absorption of protein longer than fat, but the ileal digestibility did not differ among groups (94.5-94.8%). Sucrose, but not fat, significantly reduced the postprandial transfer of [15N]-milk nitrogen to urea. Consequently, the net postprandial protein utilization (NPPU) of milk protein calculated 8 h after meal ingestion was 80% when ingested either alone or supplemented with fat and was significantly greater with sucrose (NPPU = 85%). This study shows that energy nutrients do not affect the nitrogen absorption but modify the metabolic utilization of dietary protein in the phase of nitrogen gain. Our method provides information concerning the deamination kinetics of dietary amino acids and further allows the detection of differences of dietary protein utilization in acute conditions. The diet composition should be carefully considered, and protein quality must be determined under optimal conditions of utilization.

Assessment of net postprandial protein utilization of 15N-labelled milk nitrogen in human subjects

The nutritional quality of milk proteins, evaluated both in terms of digestibility and postprandial oxidation and retention in human subjects, was investigated in this study. Five healthy adult volunteers were given 480 ml 15N-labelled milk (i.e. 190 mmol N). 15N was subsequently determined at the ileal level, using a naso-intestinal intubation technique, as well as at the faecal level. Plasma and urine were sampled for 8 h after meal ingestion. Dietary exogenous N recovered at the terminal ileum after 8 h reached 8.6 (SE 0.8) mmol while the amount collected in the faeces was 6.5 (SE 0.7) mmol after 5 d. The true ileal and faecal digestibilities were 95.5 (SE 0.4)% and 96.6 (SE 0.4)% respectively. The appearance of [15N]amino acids in the plasma was rapid and prolonged. The measurement of 15N in the body urea pool and in the N excreted in the urine allowed us to calculate the deamination occurring after [15N]milk protein absorption. The net postprandial protein utilization (i.e. NPPU = (Nabsorbed-Ndeaminated)/Ningested), calculated as an index of protein quality 8 h after milk ingestion, was 81.0 (SE 1.9)%. Our data confirm that milk protein has a high oro-ileal digestibility in man and demonstrate that milk protein has a high NPPU, an index corresponding to a period in which the dietary protein retention is maximal.

Effect of hepatic impairment on the pharmacokinetics of zolmitriptan

Zolmitriptan, an oral 5HT1D agonist for the acute treatment of migraine, is cleared from the systemic circulation mainly by hepatic metabolism. Consequently, changes in hepatic function may result in changes in the pharmacokinetics of zolmitriptan. This open, parallel-group study was conducted to compare the pharmacokinetics and tolerability of a single 10-mg dose of zolmitriptan in healthy subjects and patients with hepatic impairment. A total of 37 participants entered and completed the study, including 10 healthy volunteers, 11 patients with moderate hepatic impairment, 10 patients with severe hepatic impairment without ascites, and 6 patients with severe hepatic impairment with ascites. The metabolism of zolmitriptan was reduced in patients with severe hepatic impairment compared with healthy subjects, resulting in higher peak plasma concentrations (47%), increased exposure (226%), and prolonged half-life (157%). The changes were similar in the presence and absence of ascites. Smaller changes were observed in patients with moderate hepatic impairment. Plasma concentrations of the three major metabolites of zolmitriptan were reduced in the patients with hepatic impairment. Patients with moderate hepatic impairment require no dosage adjustment, but the recommended daily intake of zolmitriptan may need to be reduced in patients with severe hepatic impairment.

[15N]-labeled pea flour protein nitrogen exhibits good ileal digestibility and postprandial retention in humans

The aim of the present study was to evaluate postprandial absorption of pea protein as well as exogenous nitrogen retention in humans. For this purpose, after fasting overnight, seven healthy adults (4 males and 3 females) ingested [15N]-labeled pea protein (195 mmol N). Ileal effluents were collected for 8 h at 30-min intervals using a nasointestinal intubation technique. Urine and plasma samples were collected for 24 h. The [15N]-enrichment was determined in the intestinal samples, in the plasma amino acids and urea as well as in the urinary urea and ammonia fractions. The true gastroileal absorption of pea protein was 89.4 +/- 1.1%. This absorption was correlated with a significant increase (P < 0.05) in [15N]-enrichment in the plasma amino acids and in the nitrogen incorporated into the body urea pool for 1 h following pea ingestion. The enrichment remained significantly higher than the basal values in these pools 24 h after pea ingestion. The recovery of total urinary exogenous nitrogen after 22 h was 31.1 +/- 9.3 mmol N. Moreover, the kinetics of [15N]-labeled pea amino acids deamination reached a plateau of 39 mmol. Under these conditions, pea nitrogen retention represented 78% of the absorbed dietary nitrogen in healthy humans. The present results demonstrate the good true nitrogen digestibility and retention of pea protein in humans.

Fasting and postprandial polyamine concentrations in the human digestive lumen

Polyamines are essential to cellular proliferation and differentiation. The gastrointestinal tract could represent a major source of polyamines in the body; however, there is little information regarding the presence of polyamines in the human intestinal chyme, and the source of these intraluminal polyamines remains unclear. The aims of our study were to determine the concentrations and flow rates of polyamines in the human intestinal lumen and to estimate the contribution from food to these concentrations. Polyamine concentrations and flow rates were determined after 12 h of fasting in jejunal (n = 25) and ileal (n = 9) effluents collected by the slow-marker perfusion technique. Kinetic studies were performed after water ingestion (no polyamines) in the jejunum (n = 6) and ileum (n = 5) and in the jejunum after a yogurt test meal (polyamine content: 2.8 mumol putrescine, 2.1 mumol cadaverine, 2.1 mumol spermidine, and 1.9 mumol spermine; n = 9). There were significant polyamine concentrations in the lumen of the human gut during the fasting state, suggesting endogenous secretion. Higher polyamine concentrations were observed in the jejunum than in the ileum (P < 0.05), suggesting proximal absorption. Kinetic studies showed a 25% transitory increase in the jejunal putrescine flow rate after ingestion of the yogurt test meal, suggesting that dietary polyamines are fully absorbed.

Role of salivary and seric epidermal growth factor in pathogenesis of reflux esophagitis in chronic alcoholics and nondrinkers

Our objective was to investigate the putative role of epidermal growth factor (EGF) in esophagitis pathogenesis in both nondrinkers and chronic alcoholics. We studied the EGF serum level, the EGF salivary concentration, and the esophageal EGF receptor expression in different groups of patients with esophagitis: nondrinkers with typical symptoms of gastroesophageal reflux (N = 12) and chronic alcoholics (N = 12), and in controls: chronic alcoholics without esophagitis (N = 16) and healthy nondrinkers (N = 12). All patients had an endoscopy with esophageal biopsies, 24-hr esophageal pH-metry, and esophageal manometry. EGF serum levels and EGF salivary concentrations were determined by radioimmunoassay. EGF receptor expression was determined by immunohistochemistry. Both the EGF serum level and the EGF salivary concentration remained constant, 328 +/- 21 pg/ml and 305 +/- 48 pg/ml, respectively, regardless of alcohol intake and the presence or absence of esophagitis. In addition, the presence of esophagitis did not affect the EGF receptor expression. These results suggest that seric and salivary EGF is not involved in the pathogenesis of reflux esophagitis in nondrinkers and in chronic alcoholics.

The gastro-ileal digestion of 15N-labelled pea nitrogen in adult humans

The aim of the present study was to determine the gastro-ileal behaviour of pea protein in humans. For this purpose, twelve healthy volunteers were intubated with an intestinal tube located either in the jejunum (n 5) or in the ileum (n 7). After fasting overnight, they ingested 195 mmol N of [15N]pea. Intestinal samples were collected for 6 h in the jejunum and for 8 h in the ileum. Before meal ingestion the basal liquid flow rate (ml/min) was 2.01 (SD 0.31) in the jejunum and 2.02 (SD 0.33) in the ileum. After meal ingestion the liquid phase of the meal peaked in the 40-60 min period in the jejunum and in the 150-180 min period in the ileum. The jejuno-ileal transit time of the liquid phase of the meal was 102 min. The basal flow rate of endogenous N (mmol N/min) was 0.22 (SD 0.15) in the jejunum and 0.16 (SD 0.10) in the ileum. The endogenous N flow rate peaked significantly (P < 0.05) in the jejunum in the 40-60 min period whereas no stimulation of endogenous N could be detected in the ileum after meal ingestion. A significantly increased (P < 0.05) concentration of exogenous N was detected in the jejunum during the 20-320 min period and during the 90-480 min period in the ileum. The overall true gastro-ileal absorption of pea N was 89.4 (SD 1.1)% with 69 (SD 14)% absorbed between the stomach and the proximal jejunum and 20.4% between the proximal jejunum and the terminal ileum. The percentage of ethanol-insoluble fraction (PN) in the exogenous N at the terminal ileum increased significantly (P < 0.05) to 75% after 360 min. These results suggest that heat-treated pea protein has a digestibility close to that of animal protein.

Gastrojejunal kinetics and the digestion of [15N]beta-lactoglobulin and casein in humans: the influence of the nature and quantity of the protein

The evolution and luminal effects of different quantities of casein and beta-lactoglobulin were investigated in the upper jejunum of 35 volunteers who ingested 400 mL water with either beta-lactoglobulin or casein in either low or high doses (72.6 mmol N, Lbetalg; 71.7 mmol N, LCas; 368.2 mmol N, Hbetalg; 386.8 mmol N, HCas). The flow rate of the liquid effluents as well as the nitrogen movements were measured and the exogenous ([15N]) and endogenous nitrogen fractions analyzed in the upper jejunum after milk protein ingestion. The basal jejunal liquid flow rate (mL/min) was 3.88+/-1.84 and peaked in the 0-20 min period for water (9.92+/-3.72) and Lbetalg (7.27+/-3.08) and during the 20-40 min period for LCas (5.69+/-2.49), HCas (6.32+/-1.85), and Hbetalg (6.11+/-2.31). One hour after water, LCas, Lbetalg, Hbetalg, and HCas ingestion, 100%, 95%, 85%, 71%, but only 38% of the liquid phase of the meal were passed through the jejunum, respectively. The flow rate of the endogenous nitrogen was 12.93+/-5.22 mmol N/h before meal ingestion; remained unchanged after water, LCas or Hbetalg ingestion; but increased significantly (P<0.05) after Lbetalg and HCas ingestion. The net disappearance of exogenous nitrogen in the upper jejunum 240 min after HCas, Lbetalg, LCas and Hbetalg ingestion was 82.6+/-9.5%, 61.6+/-9.6%, 58.4+/-14.7%, and 44.7%+/-24.4%, respectively. The exogenous fraction of protein nitrogen recovered in the upper intestinal lumen represented 43.3% of the ingested Hbetalg nitrogen, but only 4.9% of the ingested HCas nitrogen. In conclusion, casein and beta-lactoglobulin present differences in both the intestinal kinetics of amino acid delivery and in the nature of the products in the intestinal lumen. These differences have to be taken into account from both nutritional and physiologic points of view for the utilization of these proteins in humans.

Absence of human papillomavirus DNA detected by polymerase chain reaction in French patients with esophageal carcinoma

BACKGROUND & AIMS

Recent studies have suggested that esophageal human papillomavirus infection could be a risk factor for esophageal squamous cell carcinoma. The aim of this study was to evaluate the prevalence of human papillomavirus DNA sequences in the esophagus of French patients with esophageal squamous cell carcinoma.

METHODS

Multiplex polymerase chain reactions with consensus primers directed to the L1 gene or specific primers for human papillomavirus types 6, 11, 16, 18, 31, and 33 directed to E6 gene (40 cycles followed by restriction mapping of the amplified products) were used to determine the presence of human papillomavirus DNA sequences in esophageal squamous cell carcinoma (n = 75), normal adjacent mucosa (n = 49), and metastatic lymphadenopathies (n = 5). As an internal control, a target located in the embryonic myosin heavy-chain gene was used in each reaction.

RESULTS

Human papillomavirus DNA sequences could not be detected in any of the tumoral samples, the normal adjacent mucosa, or the metastatic lymphadenopathies.

CONCLUSIONS

Human papillomavirus seems not to be implicated in esophageal carcinogenesis, at least in French patients, because the viral genomes are not associated with esophageal squamous cell carcinomas.

Exogenous and endogenous nitrogen flow rates and level of protein hydrolysis in the human jejunum after [15N]milk and [15N]yoghurt ingestion

Milk and yoghurt proteins were 15N-labelled in order to measure the flow rate of exogenous N during digestion in the human intestine. After fasting overnight, sixteen healthy volunteers, each with a naso-jejunal tube, ingested either [15N]milk (n 7) or [15N]yoghurt (n 9). Jejunal samples were collected every 20 min for 4 h. A significant stimulation of endogenous N secretion was observed during the 20-60 min period after yoghurt ingestion and the 20-40 min period after milk ingestion. The endogenous N flows over a 4 h period did not differ between the groups (44.3(SEM 6.5) mmol for milk and 63.5(SEM 5.9) mmol for yoghurt). The flow rates of exogenous N indicated a delayed gastric emptying of the yoghurt N compared with N from milk. The jejunal non-protein N (NPN) flow rate increased significantly after milk and yoghurt ingestion due to an increase in the exogenous NPN flow rate. The NPN fraction of exogenous N ranged between 40 and 80%. The net gastro-jejunal absorption of exogenous N did not differ significantly between milk (56.7(SEM 8.5)%) and yoghurt (50.9(SEM 7)%). The high level of exogenous N hydrolysis is in accordance with the good digestibility of milk products. Fermentation modifies only the gastric emptying rate of N and does not affect the level of diet hydrolysis, the endogenous N stimulation or the digestibility rate.

15N-labeled immunoglobulins from bovine colostrum are partially resistant to digestion in human intestine

To evaluate true ileal digestibility of bovine immunoglobulins, seven healthy human adults ingested a 15N-labeled preparation of an immunoglobulin concentrate. After fasting overnight, subjects drank 400 mL of immunoglobulin concentrate (77 mmol), and ileal effluents were collected for 8 h at 20-min intervals using a naso-intestinal intubation technique. In addition to osmolality and pH, the concentrations of exogenous and endogenous nitrogen and ions (Na+, K+, Cl-, Ca2+, Mg2+) in the effluents were measured. Bovine immunoglobulin concentrations (IgG, IgM, IgA) were estimated by a radial immunodiffusion technique. The mean flow rate of the liquid phase was 22.3 +/- 6.1 mL/20 min and did not vary significantly during the collection period. No change was observed for osmolality, pH or Na+, K+ and Cl- concentrations. Two hours after meal ingestion, Ca2+ and Mg2+ concentrations increased significantly (P < 0.05). The recoveries of nitrogen of ingested IgG and IgM still immunologically active were 19 +/- 3% and 19 +/- 4%, respectively. No IgA was detected in the ileum. Mean digestibility of the exogenous nitrogen fraction was 79 +/- 3%. In comparison to literature data, which show that other milk proteins have ileal digestibilities of > 90%, our results demonstrate a lower ileal digestibility of bovine immunoglobulins in humans.

Quantitative analysis of transforming growth factor beta 1 messenger RNA in the liver of patients with chronic hepatitis C: absence of correlation between high levels and severity of disease

Transforming growth factor beta 1 (TGF beta 1) is a cytokine involved in liver fibrogenesis. Previous semiquantitative studies of patients with chronic viral hepatitis showed that liver TGF beta 1 messenger RNA (mRNA) was increased, compared with normal controls and with patients with chronic hepatitis C virus (HCV) infection who responded favorably to interferon alfa (IFN alpha) treatment. To evaluate its potential prognostic significance, we measured liver TGF beta 1 mRNA, using a new competitive reverse gene amplification assay, in a total of 35 patients with chronic HCV. This technique was reproducible and sensitive; we could measure as few as 5,000 molecules of TGF beta 1 mRNA per microgram of total liver RNA. In patients with chronic HCV, the mean level of TGF beta 1 mRNA was 200-fold higher than in controls. However, no correlation could be found between TGF beta 1 mRNA and either the biological (serum amino-terminal peptide of type III procollagen) and histological (Knodell scores) indices of liver fibrosis or a favorable response to IFN alpha therapy. In 9 patients, second liver specimens were obtained after treatment; in most cases, TGF beta 1 mRNA levels and hepatic histological findings varied in parallel. These data are consistent with the hypothesis that TGF beta 1 plays a role in stimulating liver fibrogenesis during chronic HCV, despite the lack of prognostic value of TGF beta 1 mRNA levels measured before treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Nitrogen movements in the upper jejunum lumen in humans fed low amounts of casein or beta-lactoglobulin

OBJECTIVES AND METHODS

To compare the progression of milk proteins in the upper part of the digestive tract, gastro-jejunal nitrogen movements were studied in 6 healthy human volunteers after beta-lactoglobulin and casein ingestion. 400 mL of water (control), purified beta-lactoglobulin (20 g/L) or casein (20 g/L), each adjusted to 25 microCi with 14C-polyethylene glycol, were given per os. Samples were collected in the stomach and 20 cm below the Treitz ligament every 20 min for 2 hours and measured for volume, osmolarity, ions and nitrogen content.

RESULTS

The jejunal flow rate peaked in the 0-20 min period following water and beta-lactoglobulin ingestion, and in the 20-40 min period after casein ingestion. The gastric half-emptying time (T1/2 min) of the liquid phase was significantly different (P < 0.05) for water (12.1 +/- 0.8), beta-lactoglobulin (14.5 +/- 3.3) and casein (26.5 +/- 9.3). Before ingestion of the test meals, the basal rate of nitrogen was 9.14 +/- 4.09 mmol/h in the jejunum. The total nitrogen content in the jejunum peaked significantly in the 0-20 min period after beta-lactoglobulin ingestion and the 20-40 min period after casein ingestion. The apparent gastro-jejunal protein absorption values were 63% for casein and 66% for beta-lactoglobulin in the 120 min period.

CONCLUSIONS

These results show that beta-lactoglobulin and casein behave differently in the upper part of the digestive tract due to different gastric emptying rates.

Metabolism and time-course excretion of murideoxycholic acid, a 6 beta-hydroxylated bile acid, in humans

The metabolism and time-courses of urinary and fecal excretions of murideoxycholic acid (MDCA; 3 alpha,6 beta-dihydroxy-5 beta-cholanoic acid), a 6 beta-hydroxylated bile acid, was investigated in man. The study was carried out in two groups of subjects. Six cholecystectomized patients fitted with a cystic duct drain ingested 100 mg of a tracer dose of 3H-MDCA. Time-course of radioactivity in plasma was then followed for an 8-h period. Biliary, urinary and fecal excretions of radioactivity were measured for a 5-day period and excreted MDCA metabolites were identified. Five lithiasic patients with intact enterohepatic circulation ingested 500 mg of the same tracer dose of 3H-MDCA. Radioactivity in plasma was followed for a 49-h period and urinary and fecal excretions of radioactivity were measured daily for 7 days. In the first group, the excretion of the radioactivity by the three routes (bile+urine+feces) reached 97.8 +/- 1.5% of the ingested dose but dropped to 75 +/- 8.3% (urine+feces) in patients in the second group. In cholecystectomized patients, the estimation of intestinal MDCA absorption was dependent on cystic duct drain flow rate and gave values ranging from 20% to 87%. The biological half-life of MDCA in lithiasic patients averaged 3.4 +/- 0.7 days. Radioactivity appeared in the plasma in the first hour and reached a maximum 6 and 3 h after the beginning of the experiment in group I and II respectively. In the second group, another peak of radioactivity in plasma was observed just after breakfast.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of phloroglucinol on rectosigmoid motility stimulated by a test meal. Study in patients with irritable bowel syndrome]

Twenty patients (15 women, 5 men, mean age: 46.3 +/- 11.82 years, mean weight: 70.9 +/- 8.83 kg) presenting with a 8.5 +/- 4.7 years' history of irritable bowel syndrome associated predominantly with postprandial abdominal pain were recruited into the study. They underwent, after an enema, a rectosigmoid manometry (4 channels, low compliant infusion pump and catheters) before and after a 1000 kcal standardized meal. At the end of the meal they were administered intravenously phloroglucinol (two 40 mg ampoules) or placebo (two ampoules). Both treatments were strictly similar and the order of administration was randomly assigned Motor activity at the rectum, rectosigmoid, lower sigmoid and sigmoid level was determined using a motor index calculated for each 15 min period. Three preprandial and four postprandial indices were calculated. Both groups were statistically similar for sex ratio, age and history of disease. A slight difference was noted for mean weight: the caloric instake per kg of weight was a little higher in the phloroglucinol group. Mean preprandial indices were comparable in both groups. Variance analysis showed that the increase in postprandial motor indices was statistically less pronounced in the phloroglucinol group than in the placebo group. In the placebo group a clear cut increase in motor activity was assessed, which was not observed in the phloroglucinol group. This variation of motricity, which was observed at every level, was more pronounced for the first two postprandial indices than for the last two ones. These results suggest that phloroglucinol is able to reduce rectosigmoid motor response after a test meal. This could explain its activity in abdominal pain associated with irritable bowel syndrome.

[Obstructive jaundice caused by granulomatous stenosis of the extrahepatic bile ducts in sarcoidosis]

A 37-year-old black West Indian woman with sarcoidosis developed obstructive jaundice due to stenosis involving the entire length of the common hepatic bile duct associated with stenosis of the cystic duct. Neither gallstones nor extrahepatic biliary tract lymph node involvement were found. Stenosis was ascribed to biliary involvement of sarcoidosis because of the presence of noncaseating granulomas in the cystic duct and the gallbladder neck. There was no hepatic involvement. Cholecystectomy and left hepaticojejunostomy were performed. Postoperative recovery was unremarkable. Jaundice disappeared and liver tests returned to normal values. This case report underlines the importance of verifying the patency of the extrahepatic biliary tract before severe cholestasis can be ascribed to intrahepatic involvement of sarcoidosis.

Comparison of two sucralfate dosages presented in tablet form in duodenal ulcer healing

Two hundred twenty-two patients with endoscopically proven duodenal ulcers participated in a controlled trial to assess and compare the effects of two dosage regimens of sucralfate tablets on ulcer healing, i.e., 1 g four times daily (group A, n = 131) and 2 g twice daily (group B, n = 128). Healing was defined as complete re-epithelialization. Clinical and endoscopic assessments were performed after four weeks (Day 28) and, if complete healing was not achieved, after four more weeks (Day 56). After four weeks, in group A (n = 114: eight patients were lost and nine were withdrawn), the ulcers had healed in 90 patients (79 percent), and in group B (n = 108: six patients were lost and 14 were withdrawn), the ulcers had healed in 80 patients (74 percent). The cumulative healing rates after eight weeks were 94 percent in group A and 95 percent in group B. No serious adverse effect was observed in either group. These results suggest that sucralfate tablets in a dosage of 2 g twice daily are as effective as 1 g four times daily in the treatment of acute duodenal ulcers and could lead to better patient compliance.

[Maintenance therapy of ulcer disease. Comparative multicenter study of sucralfate, cimetidine and a placebo]

Relapse rates were studied in one hundred patients in a multicentric, randomized trial during and after maintenance therapy comparing sucralfate, cimetidine and placebo. These patients were previously treated by cimetidine for peptic ulcer and were considered cured after endoscopic examination. Outpatients were randomly assigned to a 6 month maintenance treatment with either cimetidine (600 mg daily), sucralfate (300 mg daily) or a placebo. All patients underwent endoscopic evaluation after 3 and 6 months of therapy. A clinical évaluation was performed 6 months after all treatment had ceased. Clinical and endoscopic results proved the significant superiority of both sucralfate and cimetidine over the placebo. Remission rates with sucralfate were respectively 80,4 p. 100 after 6 months and 68,5 p. 100 after 12 months. These results were slightly superior to those observed with cimetidine (69,3 p. 100 and 61,3 p. 100). However, this difference is not statistically significant. Results for the placebo group were 47,9 p. 100 and 37,7 p. 100. Sucralfate is an effective medication in preventing the recurrence of peptic ulcer. Its pharmacological action, its few side effects and its effectiveness seem to make this medication very interesting in treating the ulcerous disease.

[Diet and rectocolonic cancers. Results of a case-control study]

In a case-control study performed in an hospital of the North-Eastern Paris area, nutritional intakes of 94 patients with colorectal carcinoma were compared with those of 94 control patients, matched for age and sex. Results were expressed as mean daily nutrients and energy intakes. This dietary survey covered the "present period" (i.e. prior to the hospitalisation) and the "past-period" in case of striking and prolonged changes in dietary habits. Whatever the site of carcinoma (the rectum and sigmoid or the remaining colon) there was no statistically significant difference between patients and controls (in both sexes) for the following parameters: a) total energy intake, b) proportions of lipids, proteins and fat expressed as percentages of total energy intake, c) minerals, d) vitamins and e) dietary fibers. In women with colorectal carcinoma, a decrease in alcohol and lipid consumptions was observed. In patients with rectal or sigmoid carcinoma past alcoholic intakes were higher in both sexes. These results do not allow any clear epidemiological conclusion. In spite of their cost and length prospective studies are probably the only way to answer the difficult question of which dietary factors may be found in colorectal carcinoma.

Cholesterol turnover in human plasma lipoproteins: studies with stable and radioactive isotopes

The kinetics of cholesterol labeling was studied in the plasma lipoproteins of three subjects who had received an oral dose of octadeuterated cholesterol and an intravenous administration of 3H-cholesterol and 14C-mevalonate or 13C-acetate. After each labeled cholesterol pulse into the plasma (absorption, exchange, or synthesis), the isotopic concentrations of free and esterified cholesterol became identical after 120 h. Before this time, very low-density lipoprotein free cholesterol appeared more easily exchangeable than high-density and low-density lipoprotein free cholesterol, high-density lipoproteins were shown to be a source for very low-density lipoprotein cholesterol esters and the role of very low-density lipoproteins associated with chylomicrons was demonstrated in the initial transport of dietary cholesterol. The rates of the various processes involved in cholesterol turnover were calculated. The total cholesterol inflow into the plasma by absorption and synthesis, determined by long-term kinetic data (18 or 28 wk) was consistent with the result obtained by sterol balance for the total cholesterol outflow from the plasma (fecal excretion and conversion into bile acids).

[Cholesterolemia and pyrexy (author's transl)]

During pyretic diseases from any origin, total plasma cholesterol level decreases and its values are frequently below 1 g per liter. This observation could be expected because it conforms with the following theory : 1) cholesterol synthesis in an organism is proportional to consumed energy, 2) plasma cholesterol level is the lower as cholesterol synthesis is high.

[Cholesterolemia and pyrexy (author's transl)]

During pyretic diseases from any origin, total plasma cholesterol level decreases and its values are frequently below 1 g per liter. This observation could be expected because it conforms with the following theory: 1) cholesterol synthesis in an organism is proportional to consumed energy, 2) plasma cholesterol level is lower as cholesterol synthesis is high.

[Angio-follicular lymph node hyperplasia or Castleman tumour in contact with a mesenteric tuberculosis lymphadenopathy (author's transl)]

The authors report a case of angio-follicular lymph node hyperplasia in contact with a mesenteric tuberculous lymphadenopathy. Three laparotomies performed close together, lead them to confirm that a localized antigenic stimulation associated with considerable hemodynamic disturbances in the venous and lymphatic systems may be the cause of an angio-follicular lymph node hyperplasia in a non-lymphoid organ.

Fluctuations in blood cholesterol level: a rational analysis

Laws governing rat and human blood cholesterol levels have been previously described. These laws reveal that cholesterol in the plasma constitutes an open non-linear system. In this hypothesis, the present paper attempts to explain the variations of cholesterolemia. As in every dynamic system, fluctuations can be observed after changes either in the orders of the system (inputs), or in the values of the parameters. The response of the system (cholesterolemia fluctuations) is analyzed in these various circumstances.

[Caecal perforation in a patient with Sezary syndrome treated by corticosteroids (author's transl)]

The authors report of a case of caecal perforation in a patient with Sezary syndrome who was submitted to systemic corticosteroids a few days before that complication. Caecal perforations during corticosteroid treatment appear to be rare, the known causes being essentially carcinoma, ischaemia and colectasia in inflammatory colitis. In the case reported, there was no associated intestinal lesion. The prognosis is usually severe, mainly on account of the lack of explicit symptoms.

A new view of human cholesterolemia

As the inflows in the cholesterol system by absorption and synthesis are known, laws governing the cholesterolemia of rats in dynamic equilibria have recently been deduced. The method of analysis used for rats was applied in this theoretical work to data obtained by various authors with normal men. Because the sum of the inflows are only furnished, the method cannot be developed completely. Nevertheless it appears that the laws should be common to rats and humans. According to this hypothesis, the major deduction is that the dynamics of plasma cholesterol is assured by a process whose parameter is a linear function of the synthesis flow. Consequently the concentration of cholesterol of the synthesis source is as lower as the synthesis flow higher. The turnover of alimentary cholesterol in the plasma follows that of synthesized cholesterol. Hence an increase of the synthesis flow also causes a decrease in the concentration of cholesterol from the alimentary source. Simultaneously however this latter concentration is proportional to the absorption flow of alimentary cholesterol. Application of the analysis method to data obtained from patients with various disorders suggests that their cholesterol-system is intrinsically the same as that of normal men. But it could not be shown whether the values of two constants involved in the parameter equation are modified or not.

Effects of dietary fiber and salt mixtures on the cholesterol metabolism of rats

The isotopic dilution method, which permits the in vivo measurements of the rates of the processes involved in cholesterol turnover, has been applied to rats fed a commercial stock diet or a basal semipurified diet in which either the nature and proportions of the source of dietary fiber or the salt mixture were changed. The cholesterolemia was about 100 mg/100 g in rats fed agar-agar, cellulose, bran or the stock diet. Pectin addition (5%) lowered significantly the plasma concentration of cholesterol (70 mg/100 g). Changes in the source of dietary fiber or salt mixture have moderate effects on the absorption coefficient of dietary cholesterol (range 58.2%-82%). In comparison to agar-agar, cellulose at 2.3% in the diet significantly lowered this coefficient, but larger amounts of cellulose (6.8% or 12.3%), or pectin (5%) were without effect, while bran addition (10%) tended to slightly decrease cholesterol absorption. Hence, high levels of cellulose in the diet increased the absorption coefficient in comparison to a low cellulose diet. A decrease of this coefficient was also observed when the calcium content of the diet was increased. Cholesterol biosynthesis and fecal excretion were inversely correlated to the absorption coefficient of dietary cholesterol in rats fed all of the semipurified diets indicating, as previously shown, that the intestine was the major source of biosynthesized cholesterol diverted into the plasma. However, feeding a commercial stock diet greatly increased the cholesterogenesis and the fecal elimination of bile acids, suggesting a high hepatic cholesterogenesis.

Controlled trial of chenodeoxycholic therapy for radiolucent gallstones. A multicenter study

134 patients with radiolucent gallstones were randomly allocated to receive either placebo or 1 of 3 different doses of chenodeoxycholic acid (CDCA); 750, 1,500, or 3,000 mg). The initial dose was lowered if not well tolerated. 107 patients were treated for more than 3 months. Among them, stones dissolved in 21 and were smaller in 25 patients. Partial or complete dissolution occurred in 4 of the 13 receiving 375 mg/day, 14 of 37 receiving 750 mg, 24 of the 38 receiving 1,500 mg and 4 of 8 receiving 3,000 mg/day. The number of responders to the therapy was significantly greater in the groups of patients receiving 1,500 mg/day or 17-24 mg/kg body weight than in any other group. However, side effects, i.e., diarrhea and transaminase increase, are also dose related. It appears from this study that the optimal dose of CDCA may be between 17 and 20 mg/kg body weight.

[Immunologic changes and infections in alcoholic cirrhosis]

The authors explored humoral and cellular immunity in 50 cases of alcoholic cirrhosis. The levels of the three serum immunoglobulins were greater than normal. IgM was significantly higher. The levels of antipolio antibodies (types I, II and III) were significantly higher in cirrhosis than in controls. The antistreptolysin and antistaphylolysin titers showed that the differences between levels found in cirrhosis and in controls were not significant. After taking the Sabin polio vaccine, variations in antipolio antibodies remained within normal limits, considering the high levels noted before taking the vaccine. Total serum complement was normal in 90% of the estimtions carried out. The results of the intradermal reactions were dissociated. Tuberculin skin tests were negative in 35% of cases of cirrhosis and in 14.3% of controls. In skin tests for candida and streptococcal antigen, differences between cirrhotics and controls were not significant. The absolute figure for blood lymphocytes per mm-3 was, in half the cases, less than normal.