The Application of Poly(Phenylene) Type Polymers and Oligomers in Electroluminescent Color Displays

Due to their high photoluminescence efficiency (>30%), high environmental stability and the good charge transport properties the derivatives of poly(paraphenylene) (PPP), as the laddertype PPP (LPPP) and the oligomer hexaphenyl, are very suitable materials to realise efficient, stable, large area blue organic light-emitting diodes (OLEDs). The emission of blue OLEDs can be efficiently converted into all other emission colors either by an external color conversion technique (ECCT) or an internal color conversion technique (ICCT) and hence are very interesting for a number of display applications:

Firstly, we demonstrate the realisation of efficient red-green-blue (RGB) emission colors (representing the RGB-pixels in a multicolor display) by an external CCT. In this case the blue EL device is covered with highly fluorescenct dye/matrix layers, which are excited by the blue emission and emit photoluminescence light in a lower energetic range.

Secondly, a new method for producing efficient white light-emitting polymer diodes (which are interesting for e.g. backlight sources in liquid crystal displays) based on a blend of two polymers is presented: a blue light-emitting m-LPPP and a red-orange emitter poly(perylene-co-diethynylbenzene) (PPDB). The red-orange emission is created within the EL device (ICCT) by an excitation energy transfer from m-LPPP into the energetically lower lying states of PPDB. This internal excitation energy transfer is very efficient, so that only a concentration of 0.05 weight % PPDB in the polymer blend is required in order to obtain white light emission.

Predictors of antiviral treatment initiation in hepatitis C virus-infected patients: a Danish cohort study

Predictive factors for initiation of antiviral therapy in chronically infected hepatitis C virus (HCV) patients are not fully elucidated. The aim of this study was to determine predictive factors for initiation of treatment with standard or pegylated interferon either alone or combined with ribavirin. A Danish cohort of individuals chronically infected with HCV was used and observation time was calculated from the date of inclusion in the cohort to date of death, last clinical observation, 1 January 2007, or start of HCV antiviral treatment in treatment-naïve patients. Kaplan-Meier survival analysis was used to construct time to event curves. Cox regression was used to determine the incidence rate ratios as estimates of relative risk (RR) and 95% confidence intervals (CI). A total of 1780 patients were enrolled in the study. The cumulative chance of treatment initiation over 5 years was 33.0%. We found several strong predictors of treatment initiation: elevated alanine aminotransferase [>2 times upper limit (RR = 2.17, 95% CI 1.64-2.87), >3 times upper limit (RR = 3.64, 95% CI 2.75-4.81)], genotype 2 or 3 (RR = 1.86, 95% CI 1.49-2.31) and HIV co-infection (RR = 0.28, 95% CI 0.15-0.53). To our knowledge, this study is the first to estimate factors predicting initiation of antiviral treatment in patients with chronic HCV infection on a nationwide scale. We found that several of the factors predicting initiation of antiviral treatment correlate with factors known to predict a better response to treatment and factors known to increase the progression of liver disease.

Ascites fluid and plasma calprotectin concentrations in liver disease

BACKGROUND

Calprotectin, a marker of neutrophil activation, has been associated with a poor prognosis in alcohol-induced cirrhosis. The aims were to study concentrations of calprotectin in patients with various liver diseases, and to further investigate the prognostic value of calprotectin in cirrhosis.

METHODS

Plasma calprotectin concentrations were determined in 84 patients with alcohol-induced liver disease, 32 hepatitis B or C infected patients, 33 patients with liver disease of other aetiologies, 7 patients with combined aetiologies and in 24 patients with malignant disease. Thirty healthy individuals were included as controls. Ascites calprotectin concentrations were determined in patients with ascites (n = 75). Follow-up for survival was performed after a median observation period of 10 months.

RESULTS

Increased plasma and ascites calprotectin concentrations were observed in malignant disease compared to non-malignant disease (P < 0.0001). Plasma calprotectin concentrations were low in viral liver disease compared to patients with non-viral liver disease (P = 0.02) and to controls (P = 0.0002). Plasma calprotectin (>median) was a highly significant marker of poor survival in alcohol-induced cirrhosis (P = 0.001), but was of no prognostic value in non-alcohol-induced cirrhosis (P = 0.88). In decompensated cirrhosis high (>upper quartile) ascites calprotectin concentrations were associated with an increased mortality (P = 0.002), as were high (>median) plasma calprotectin levels (P = 0.009).

CONCLUSION

The prognostic importance of calprotectin in alcohol-induced cirrhosis is confirmed and demonstrated as specific for alcohol-induced liver disease. Low calprotectin levels are indicated in viral liver disease, and an association between high ascites calprotectin levels and malignant ascites was observed.

Interferon alfa-2b alone or combined with recombinant granulocyte-macrophage colony-stimulating factor as treatment of chronic hepatitis C

BACKGROUND

To compare the effect of combination therapy with interferon-alpha (INF-alpha) and granulocyte-macrophage colony-stimulating factor (GM-CSF) to monotherapy with INF-alpha in patients with chronic hepatitis C infection.

METHODS

Forty-five consecutive patients with chronic hepatitis C, all presenting with elevated serum alanine aminotransferases and viremia, were randomized to receive either 1) INF-alpha + GM-CSF for 3 months followed by INF-alpha alone for 9 months (n = 23) or 2) INF-alpha for 12 months (n = 22). Both drugs were administered 3 times weekly in doses of 3 mU (INF-alpha) and 50-100 microg depending on body weight (GM-CSF).

RESULTS

At baseline, there was no difference between the treatment groups in terms of age, sex, ALT level, viral load, genotype or histological activity and fibrosis in a pretreatment liver biopsy. After 12 months' treatment, more patients treated with GM-CSF+ INF-alpha compared to patients receiving monotherapy had normalized ALT, 65% and 32%, respectively (P = 0.03), but there was no difference in percentages of patients with viral clearance between the 2 groups, 48% and 32%, respectively (P = 0.27). At 6 months' follow-up, the biochemical response had declined to 35% in the combination therapy group and to 23% in the monotherapy group (P = 0.37); viral clearance had declined to 22% and 27%, respectively (P = 0.67), and the overall sustained response rate was 22% and 23%, respectively (P = 1.00).

CONCLUSIONS

Even though patients receiving INF-alpha + GM-CSF had a significant better biochemical response during treatment compared to patients receiving monotherapy, the sustained biochemical and virological response was not increased. Thus, GM-CSF hardly plays any role in the future treatment of chronic hepatitis C.

Inflammatory bowel disease evaluated by low-field magnetic resonance imaging. Comparison with endoscopy, 99mTc-HMPAO leucocyte scintigraphy, conventional radiography and surgery

BACKGROUND

To evaluate the use of low-field magnetic resonance imaging (MRI) in active inflammatory bowel disease (IBD).

METHODS

MRI was executed in a consecutive cohort of 28 patients with Crohn disease (CD) and in 17 with ulcerative colitis (UC) prior to glucocorticoid treatment (1 mg prednisolone orally/kg body weight/day). MRI was repeated after 2-3 weeks (22 CD, 12 UC), and again after treatment completion or prior to surgery (18 CD, 6 UC). Five bowel segments were evaluated separately. MRIs were blindly evaluated by two observers, and findings compared with 39 leucocyte scintigraphies, 38 endoscopies, 15 double-contrast barium enemas, 66 small-bowel radiographic examinations and surgery in 23 patients.

RESULTS

In CD, blinded evaluation revealed a kappa (kappa) of 0.84 (95% confidence interval (CI) 0.78-0.91). In UC, kappa was 0.66 (95% CI 0.55-0.78). Agreements regarding disease extension between MRI and other modalities in CD were found in 345 bowel segments out of 391 (88.2%) at risk, and in UC in 209/235 (88.9%). Colonic disease activity gradings by radiography and endoscopy correlated significantly with T2-signal intensity (SI(T2)) and increments in T1-signal intensity (%SI(T1)) in both diseases. Significant correlations between MRI indices of disease activity and CDAI in CD (MRI-SI(T2): P <0.0001: MRI% SI(T1): P=0.0008) and the Powell-Tuck index in UC (MRI% SI(T1): P=0.008) were found.

CONCLUSIONS

With low interobserver variation and high concordance of findings with other examinations. low-field MRI seems a valuable modality in active IBD. In addition, MRI expressions of disease activity correlate to clinical, radiographic and endoscopic disease activity.

Prevalence of hereditary haemochromatosis in late-onset type 1 diabetes mellitus: a retrospective study

BACKGROUND

Although genotyping studies suggest that hereditary haemochromatosis is one of the most common genetic disorders in white people, it is still thought of as an uncommon disease. Our aim was to test the hypothesis that hereditary haemochromatosis is a disease often overlooked in patients with late-onset type 1 diabetes mellitus, a late manifestation of untreated iron overload.

METHODS

We did a retrospective study in which we genotyped for the C282Y and H63D mutations in the haemochromatosis gene in 716 unselected Danish patients who developed type 1 diabetes mellitus after age 30 years and 9174 controls from the general Danish population. We also screened for hereditary haemochromatosis by assessment of transferrin saturation.

FINDINGS

More patients with diabetes (n=9, relative frequency 1.26%, 95% CI 0.58-2.37) than controls (23, 0.25%, 0.16-0.38) were homozygous for C282Y (odds ratio 4.6, 2.0-10.1, p=0.0001). These patients had unrecognised signs of haemochromatosis. Transferrin saturation and ferritin concentrations ranged from 57% to 102% and 17 microg/L to 8125 microg/L, respectively. Frequency of compound heterozygosity (C282Y/H63D) did not differ between patients with diabetes (eight) and controls (131) (odds ratio 0.8, 95% CI 0.4-1.7). Positive and negative predictive values of transferrin saturation greater than 50%, in identification of C282Y homozygosity, were 0.26 and 1.00, respectively. A saturation of less than 50% therefore excluded C282Y homozygosity, whereas a saturation of more than 50% suggested C282Y homozygosity.

INTERPRETATION

Measurement of transferrin saturation followed by genetic testing could prevent liver and heart problems and improve life expectancy in patients with diabetes. Population screening before the onset of diabetes might improve the outlook of patients even further, but will be less cost effective.

An open-labeled, randomized study comparing systemic interferon-alpha-2A and prednisolone enemas in the treatment of left-sided ulcerative colitis

OBJECTIVE

The aim of this study was to compare the treatment efficacies of subcutaneous interferon-alpha-2A (IFN-alpha-2A) injections versus prednisolone enemas in active left-sided ulcerative colitis in an open-labeled, randomized study.

METHODS

Sixteen ulcerative colitis patients received IFN-alpha-2A subcutaneously (dosage: first wk, 9 MIU three times weekly [t.i.w.]; second wk, 6 MIU t.i.w.; wk 3-12, 3 MIU t.i.w.), and 16 received prednisolone enemas for 30 days (100 ml once daily, 0.25 mg of prednisolone/ml). The Powell-Tuck Index, Inflammatory Bowel Disease Questionnaire (IBDQ) score, and rectal histological activities were assessed before and after treatment. Thirteen patients in the IFN-alpha-2A group and all 16 in the prednisolone enema group completed the treatment.

RESULTS

IFN-alpha-2A treatment showed significant improvements in the Powell-Tuck Index (p = 0.0002), IBDQ score (p = 0.002), and rectal histological activity scores (p = 0.02). In the enema group, significant improvements were found in the Powell-Tuck Index (p = 0.0009), whereas no significant improvements were detected in the IBDQ scores (p = 0.055) or rectal histological scores (p = 0.052). There were no differences between scores of the two groups either before or after treatment. Only moderate side effects from the IFN-alpha-2A treatment were seen during the first 2-4 wk of treatment.

CONCLUSION

IFN-alpha-2A treatment resulted in significant depression of the disease activity as reflected by the Powell-Tuck Index, IBDQ score, and histological disease activity scoring. The preliminary trial thus suggests that IFN-alpha-2A may be effective in the treatment of active left-sided ulcerative colitis. Larger, randomized trials are, however, warranted to confirm this finding, owing to possible type II errors in group comparisons.

Ethical aspects of clinical trials: the attitudes of participants in two non-cancer trials

OBJECTIVES

To investigate attitudes to clinical trials in non-cancer trial participants.

DESIGN

Questionnaires at entry, during, and after participation in a clinical study.

SETTING

Participants in: (i) ROC: a clinical study comparing systemic interferon-alpha-2A treatment vs. prednisolone enemas in ulcerative colitis; and (ii) MRCRUC: a clinical study investigating low-field magnetic resonance imaging as a new modality for the evaluation of patients with inflammatory bowel disease.

SUBJECTS

Thirty-two patients in ROC and 47 patients in MRCRUC.

OUTCOME MEASURES

Attitudes towards different aspects of clinical research.

RESULTS

The majority found scientific testing of clinical methods necessary, having positive attitudes towards both participation by themselves and others. The creation of a personal moral problem by denying participation was rejected by a large majority, and still both personal and altruistic motives for participation were highly rated. An important motive for accepting inclusion was the expectation of being 'a special patient' during the trial. The presence of research ethics committees controlling clinical research had a significant positive impact on decisions to participate, and drawing lots and blinding were found problematic by only a minority. Patients valued their satisfaction with participation in the trials highly, and would almost all accept a request to participate in future trials. The most important reason for this was a feeling of receiving better care and information than expected outside a trial setting, primarily determined by the patients seeing only one physician during the trials. A pronounced wish to obtain follow-up information was expressed.

CONCLUSION

Attitudes towards medical research are positive with both altruistic and nonaltruistic motives for participation. Expectations of being treated as 'a special patient' in the trial were important in accepting to participate. Seeing the same physician at control visits was an important factor for satisfaction with participation.

A randomized, placebo-controlled, cross-over study of ginger extracts and ibuprofen in osteoarthritis

OBJECTIVE

Alternative medicine is used extensively by patients with chronic pain due to e.g., osteoarthritis. Only few of these drugs have be tested in a controlled setting and the present study was undertaken to examine the effect of ginger extract, one of the most popular herbal medications.

DESIGN

Ginger extract was compared to placebo and Ibuprofen in patients with osteoarthritis of the hip or knee in a controlled, double blind, double dummy, cross-over study with a wash-out period of one week followed by three treatment periods in a randomized sequence, each of three weeks duration. Acetaminophen was used as rescue medication throughout the study. The study was conducted in accordance with Good Clinical Practice (European Guideline for GCP).

RESULTS

A ranking of efficacy of the three treatment periods: Ibuprofen>ginger extract>placebo was found for visual analogue scale of pain (Friedman test: 24.65, P< 0.00001) and the Lequesne-index (Friedman test: 20.76, P< 0.00005). In the cross-over study, no significant difference between placebo and ginger extract could be demonstrated (Siegel-Castellan test), while explorative tests of differences in the first treatment period showed a better effect of both Ibuprofen and ginger extract than placebo (Chi-square, P< 0.05). There were no serious adverse events reported during the periods with active medications.

CONCLUSION

In the present study a statistically significant effect of ginger extract could only be demonstrated by explorative statistical methods in the first period of treatment before cross-over, while a significant difference was not observed in the study as a whole.

[Amyloidosis. A review]

Amyloidosis is a heterogenous group of diseases, all characterized by extracellular deposition of amyloid either systemically or localized. Of wellknown diseases are Alzheimer's dementia, AL-amyloidosis (e.g. in multiple myeloma) and AA-amyloidosis (e.g. in rheumatoid arthritis). Amyloid is composed of three components of which the fibrillary component is the basis of amyloid classification. Many types of amyloid have a systemic distribution and give rise to varying symptoms. The diagnosis is based on biopsy, preferably of abdominal subcutis. The prognosis is poor, however, recent investigations on the three-dimensional structure of the P-component provide hope for future therapy.

[Amyloidosis: rapid course of AL-amyloidosis in a patient without myelomatosis]

A case of severe AL-amyloidosis in a 72-year-old man is presented. Amyloid was especially deposited in the kidneys and the liver. The patient died one year after diagnosis with impaired kidney function and severe ascites. Despite the type of amyloid (AL-type), multiple myelomata or lymphoproliferative disease could not be demonstrated.

Evaluation of treatment response in active Crohn's disease by low-field magnetic resonance imaging

BACKGROUND

To evaluate low-field magnetic resonance imaging (MRI) in detecting therapeutic response in active Crohn's disease during treatment with systemic steroids.

METHODS

Eight patients with active Crohn's disease were examined before and during treatment with systemic steroids (1 mg/kg/day) using low-field MRI (0.1 T) in transverse and coronal planes before and after an intravenously administered bolus of gadodiamide. Five healthy persons were once examined in the same way. MRI images were evaluated without knowledge of diagnosis, treatment, or findings of endoscopy, conventional radiography, and surgery. Proximal and mid small bowel, terminal ileum, right-sided colon, transverse colon, and left-sided colon were evaluated separately.

RESULTS

Statistically significant differences were shown for both signal intensity on T2- (SIT2) and increment in signal intensity on T1-weighted images after contrast (%SIT1) when comparing diseased bowel segments with both nondiseased bowel segments (SIT2: p = 0.0001; %SIT1: p = 0.0009) and segments from the control group (SIT2: p < 0.00005; %SIT1: p < 0.00005). In 53 of 56 bowel segments evaluated (95%), agreement was found between findings by MRI, conventional radiography, endoscopy and/or surgery regarding disease extension. Extension was underestimated in two patients. All bowel segments in the control subjects were evaluated to be normal on MRI. Significant correlation was found between both SIT1 (p < 0.0025) and %SIT1 (p < 0.025) versus endoscopic activity gradings. During treatment, significant decrements of both SIT2 (p < 0.00005), %SIT1 (p = 0.002), and bowel wall thickness (p = 0.03) were found.

CONCLUSIONS

Low-field MRI seems to be a promising noninvasive method in the evaluation of response regarding both disease extension and activity in Crohn's disease during treatment with systemic steroids.

Active Crohn's disease and ulcerative colitis evaluated by low-field magnetic resonance imaging

BACKGROUND

Our aim was to evaluate low-field magnetic resonance imaging (MRI) in the assessment of disease extension and activity in inflammatory bowel disease.

METHODS

Nineteen patients with Crohn's disease (CD), 8 with ulcerative colitis (UC), and 5 healthy controls (HC) were examined using MRI (0.1 T) before and after intravenously administered gadodiamide and glucagon. MRI images were evaluated in a blinded fashion and compared with findings at endoscopy, double-contrast barium enema, small-bowel follow-through, and surgery.

RESULTS

Comparisons of diseased with both non-diseased bowel segments and segments from HC showed significant differences for both CD and UC with regard to signal intensity on T2-weighted (SI(T2)) images and post-contrast increment of signal intensity on T1-weighted images (%SI(T1). Agreements with regard to disease extension in CD between MRI and other examinations were 97%, underestimating the extension in two patients. For SI(T2) in CD a cut-off value of 1.0 showed a predictive value of a positive finding (PVpos) = 1.0 and a predictive value of a negative finding (PVneg) = 0.96. For %SI(T1) in CD a cut-off value of 15.0% showed values of PVpos = 0.95 and PVneg = 0.92. Agreements between MRI and conventional methods (disease extension) in UC was 87.5%. Extension was underestimated in two patients and overestimated in two patients as compared with barium enemas. Values of PVpos were 1.0 (SI(T2) >1.0) and 1.0 (%SI(T1) >15.0%), respectively, with corresponding values of PVneg being 0.94 and 0.94.

CONCLUSION

Low-field MRI seems a promising non-invasive, non-radiating method in the evaluation of inflammatory bowel disease.

Doppler ultrasound assessment of TIPS patency and function--the need for echo enhancers

PURPOSE

The aim of this study was to illustrate the versatility of an i.v. administered echo enhancer for Doppler US assessment of TIPS patency and function.

MATERIAL AND METHODS

A total of 22 Doppler US evaluations of TIPS patency and function were performed in 5 patients with alcoholic cirrhosis and recurrent oesophageal bleeding who had been treated with TIPS. TIPS patency was evaluated by means of colour or power Doppler US. The volume flow (VF) was assessed in the TIPS and in the portal vein by spectral Doppler. The ratio of the VF in the TIPS to the VF in the portal vein (T/P ratio) was used to express the functional status of the TIPS. If Doppler signals were inconclusive or absent, echo-enhanced US was performed.

RESULTS

In 22 follow-up Doppler US examinations, echo-enhanced Doppler US was required in 7 cases (29%). The Doppler enhancement persisted in the range of 3-5 min. No adverse effects were observed. An apparently normal TIPS function reflected a T/P ratio in the range of 0.44-1.10, median 0.78 +/- 0.20 (2SD).

CONCLUSION

The i.v. administration of echo enhancers would seem to be indicated in the assessment of the TIPS function if conventional Doppler US fails to prove normal TIPS patency and function. The T/P ratio may be a convenient monitoring parameter for reflecting the TIPS function.

[Transjugular intrahepatic portosystemic shunt. Treatment of patients with recurrent bleeding from esophageal varices]

We report the results of transjugular intrahepatic portosystemic shunt (TIPS) procedure in six patients with liver cirrhosis and recurrent bleeding or acute intractable bleeding from oesophageal varices in spite of multiple sessions of sclerotherapy. Median follow-up was 15 months (range 1-24 months). The procedure was technically successful in all patients without procedure-related morbidity or mortality. Four of the procedures were performed electively and two as an emergency procedure. The portosystemic pressure gradient decreased to below 12 mmHg following TIPS implantation and the shunt bloodflow was one quarter to three-quarters of the portal bloodflow determined by Doppler ultrasound. Recurrent bleeding occurred in one patient but was amenable to endoscopic sclerotherapy. In this patient the shunt had developed a stenosis that was treated by balloondilatation and insertion of an additional stent six months following the initial procedure, and no further bleeding occurred. The remaining five patients had no rebleeding episodes. Repeated Doppler examinations in the followup period demonstrated patency of all shunts. None of the patients developed portosystemic encephalopathy. One patient died of cerebral haemorrhage, unrelated to TIPS, 16 months following implantation. Another patient died 14 months following TIPS due to acute mesenteric occlusion and septicaemia. We conclude that TIPS is feasible and effective in selected patients with liver cirrhosis and persistent or recurrent variceal bleeding following repeated endoscopic therapy.

[Penicillin treatment of non-nosocomial pneumonia in Danish medical departments. A questionnaire]

This study describes the most common penicillin-regime for hospitalized patients with community-acquired pneumonia in Denmark. One hundred and seventy-one consultant physicians received an anonymous questionnaire, 85% were returned and 75% were evaluated. The most common regime is a treatment duration of six to ten days with 3-6 million IU of penicillin daily given in three doses. The most common route of administration is intravenously until the patient's body temperature drops. Then the same dose is given orally. Variations in strategy were revealed and call for further investigations to establish and maintain restrictive antibiotic regimes.

Magnetic resonance imaging of Crohn disease: early recognition of treatment response and relapse

A patient with active Crohn disease was evaluated by MRI at admission, clinical remission, and a new relapse. The MRI-estimated disease extension correlated with surgical findings, whereas ultrasonography underestimated and a small bowel series overestimated the extension. MRI disclosed the disappearance of intestinal edema at the time of clinical remission and, in contrast to ultrasonography, showed an abscess and a fistula, confirmed by surgery, at the new relapse.

Tolerability of interferon alpha-2b, a possible new treatment of active Crohn's disease

BACKGROUND AND AIMS

Due to the need for new principles for the treatment of Crohn's disease and due to the documented immunomodulatory effects of interferon alpha, the tolerability and effect(s) of interferon alpha-2b (Introna) in active Crohn's disease were examined in a pilot study.

METHODS

Five patients with active Crohn's disease (activity index (CDAI) scores of 235-517), were treated with interferon alpha-2b for 12 weeks.

RESULTS

All patients tolerated the treatment, but developed influenza-like symptoms, which were fully controlled by paracetamol. Two patients obtained partial remission with a decline in activity index scores of 39% and 50%. The activity of 2',5'-oligoadenylate synthetase, which together with two other interferon-induced proteins, neopterin and beta 2-microglobulin were increased during treatment, indicated clearly an in vivo uptake of interferon. Sedimentation rate, C-reactive protein, orosomucoid, albumin, specific inflammatory markers: soluble interleukin-2 alpha-receptors (sIL-2R) and intercellular adhesion molecule-1 (ICAM-1) did not show any changes before or after treatment.

CONCLUSION

Future multicentre investigations are required to evaluate the clinical effect of interferon alpha-2b treatment in active Crohn's disease.

The treatment effect of alpha interferon in chronic hepatitis B is independent of pre-treatment variables. Results based on individual patient data from 10 clinical controlled trials. European Concerted Action on Viral Hepatitis (Eurohep)

Alpha interferon induces HBeAg seroconversion in about one third of treated patients and has become an established treatment of chronic hepatitis B. A number of smaller studies have suggested that response to treatment is more likely to occur in patients with higher levels of transaminases, with recent (adult) onset, a history of acute hepatitis, low levels of HBV DNA and in heterosexual males. The aim of this European co-operative study was to estimate the effect of alpha interferon more accurately and to evaluate the influence of host pre-treatment variables on the effect of interferon. Individual data were collected from 751 patients from 10 controlled clinical trials on alpha interferon (lymphoblastoid or recombinant) treatment for chronic hepatitis B. Alpha interferon was administered to 496 patients, while 255 were untreated controls. Individual patient data were analysed by survival analysis (log rank test and Cox regression analysis), stratified by trial, with the disappearance of HBeAg as the major endpoint. The results showed that the HBeAg disappearance rate with or without interferon treatment was higher in patients with high aminotransferase levels, with a history of acute hepatitis and in male heterosexual patients disregarding HIV status. If HIV-positive patients were excluded, the effect of sexual orientation was not significant. Therapy with alpha interferon increased the a priori HBeAg disappearance rate by a factor of 1.76; the relative treatment effect of alpha interferon was independent of the tested pretreatment host variables, but dependent on the total (intended) interferon dose (low dose < or = 200 MU/m2 increased HBeAg disappearance by a factor 1.37; medium/high dose > or = 200 MU/m2 increased HBeAg disappearance by a factor 2.05). In conclusion, this meta-analysis suggests that the effect of alpha interferon is less than previously assumed and independent of pretreatment host variables tested. It confirms the higher therapeutic benefit of a total dose exceeding 200 MU/m2 and of selection of patients based on disease activity and immune reactivity. Although all patient seem to have the same relative benefit, the absolute benefit of alpha interferon treatment seems to be greatest in patients with high transaminase levels and with a history of acute hepatitis.

[Plasmapheresis as life-saving treatment in acute hepatic failure]

Emergency liver transplantation is the treatment of choice in acute liver failure without signs of spontaneous regeneration. However, many patients rapidly contract irreversible neurological complications before transplantation can be performed. We used high-volume plasmapheresis to increase the time span to obtain a donor liver. Four patients with acute liver failure of unknown cause and a galactose elimination capacity indicative of a virtually extinct liver function were assigned maximum priority for liver transplantation. Plasmapheresis were performed daily until transplantation. Each time 8-10 liters of patient plasma were replaced with an equal volume of fresh donor plasma. There were no major complications. None of the patients developed irreversible neurological complications for 48-144 h at which time liver transplantation was performed. High volume plasmapheresis increases the time to obtain a donor liver for emergency liver transplantation and optimizes the condition for the surgical procedure.

[Garcin syndrome. Clinical aspects and diagnosis of a rare cranial nerve syndrome with special reference to computerized tomography and nuclear magnetic resonance image findings]

Garcin syndrome is an ipsilateral step-by-step deterioration of all 12 brain cranial nerves, first described in 1927. The underlying cause is usually a sarcoma or carcinoma of the skull base. The pathogenesis of the Garcin syndrome is chiefly determined by the slow localized growth of these tumors, rather than by their histology and primary localisation. The prognosis is as a rule unfavourable. The findings on computed and magnetic resonance tomography are important for an early diagnosis. Two cases of Garcin syndrome are reported, one of which was probably due to a tonsillar carcinoma, while the other was caused by a mucinous adenocarcinoma of the nasopharynx.

Colonic epithelial dysplasia or carcinoma in a regional group of patients with ulcerative colitis of more than 15 years duration

Colonoscopic screening for neoplasia was performed in a regional group of ulcerative colitis patients with a disease duration of greater than or equal to 15 years. A total of 121 patients, aged less than 80 years, were invited to participate, of whom 100 (83%) accepted colonoscopy, including biopsies in 15 standard locations of the entire colon, plus additional biopsies from all visible lesions. Unequivocal dysplasia was found in one patient with extensive colitis and a disease duration of 31 years. A polyp with highly differentiated adenocarcinoma was found in the sigmoid colon of a patient with intermittent rectum involvement, 37 years after the ulcerative colitis diagnosis had been made. Biopsy specimens from the remaining 98 patients showed no signs of dysplasia or cancer. Thus the frequency of pre-malignant or malignant changes is very low compared with the results of similar studies, and the rationale for general colonoscopic surveillance programmes for such patients is open to question.

Prevalence of hepatobiliary dysfunction in a regional group of patients with chronic inflammatory bowel disease

A regional group of outpatients with chronic inflammatory bowel disease (ulcerative colitis, n = 396, and Crohn's disease, n = 125) was biochemically screened to estimate the prevalence of hepatobiliary dysfunction. Among the 396 patients with ulcerative colitis, 69 (17%; 95% confidence limits, 14-22%) had at least 1 abnormal laboratory value. Serum bilirubin was elevated in 5%, alkaline phosphatases in 8%, aspartate aminotransferases in 4%, and alanine aminotransferases in 8% of the patients. Two per cent had decreased plasma coagulation factors (2.7 and 10) and serum albumin. Further diagnositc evaluation consisting of ultrasonography, liver biopsy, and endoscopic retrograde cholangiography was performed in patients who had biochemical values more than twice the upper normal limit in two consecutive blood tests within a fortnight. Six patients (1%) fulfilled this criterion. Three patients had primary sclerosing cholangitis, of whom two were primarily diagnosed; one patient had cholangiocarcinoma also primarily diagnosed; and two patients were found to have alcoholic hepatic damage. Among the 125 patients with Crohn's disease, 38 (30%; 95% confidence limits, 23-38%) had at least 1 abnormal laboratory value. Serum bilirubin was elevated in 2%, alkaline phosphatases in 18%, asparetate aminotransferases in 3%, and alanine aminotransferases in 10% of the patients. One per cent had decreased plasma coagulation factors (2.7 and 10) and serum albumin concentrations. Three patients (2%) fulfilled the criteria for further evaluation as described above. One patient appeared to have epithelioid granuloma in the liver and one patient had alcoholic liver disease, whereas one patient refused further examination.(ABSTRACT TRUNCATED AT 250 WORDS)

[Epicrisis. A report from the county of Copenhagen]

During a random week in 1987, 35% of the general practitioners from all of the municipalities in the County of Copenhagen participated in a questionnaire survey whose objective was to illuminate the quality, expedition time, and possible problems associated with the letter of discharge (LD), an important link between the primary and secondary medical services. It can be concluded that the expedition time for a large number of LD's from the hospitals of Copenhagen County is unacceptably lengthy. A surprisingly large number of patients visited their own general practitioner during the week following discharge with questions about the information which had been given them during their hospital stay, regardless of agreements for ambulatory monitoring at the department from which they had been discharged. A preliminary LD can, to a certain extent, alleviate the problems brought about by the lack af an LD but ought not to replace or delay the issuance of the actual LD, and is a more expensive solution. The quality and content of the LD can be evaluated generally as good, but could be improved if the recommended follow-up treatment and information to the patients and relatives is routinely carried out.

Surecut 0.6 mm liver biopsy in the diagnosis of cirrhosis

Liver biopsy with the 0.6 mm (23 gauge) Surecut needle was compared to conventional Menghini biopsy in the diagnosis of cirrhosis. Seventy-seven consecutive patients (mainly alcoholics) with a clinical indication for liver biopsy had both biopsies performed simultaneously. In 71 patients sufficient material for a morphological diagnosis concerning liver architecture was obtained with both biopsy techniques (Surecut insufficient in 5 cases and Menghini insufficient in 2 cases). The biopsies were classified as cirrhosis or non-cirrhosis. There was agreement in 69 cases (97%, confidence limits 90-100%). Using the result of the Menghini biopsy as the final diagnosis, the predictive values for a positive and negative diagnosis for the Surecut needle were 96% and 98%, respectively. There were no complications to either of the biopsies. It is suggested that the 0.6 mm Surecut biopsy may be used in the diagnosis of cirrhosis in cases where conventional Menghini needle biopsy is contraindicated.

[Can measurement of oral or axillary temperature replace rectal temperature measurements?]

The Craftemp thermometer is an electrical device for measurement of oral and axillary temperatures. The applicability of this thermometer in clinical practice was investigated by comparison with rectal temperatures measured with a mercury thermometer. Ninety-five patients hospitalized in a medical department participated in the study. The median differences between rectal/oral and rectal/axillary temperatures were 0.8 degrees C and 1.2 degrees C, respectively. The range of the extrarectal measurements was unacceptably wide. In previous studies of the Craftemp thermometer, few investigators performed the temperature measurements on hospitalized patients and found the electrical thermometer usable. In the present investigation the measurements were performed by the permanent staff during their daily routine. It was concluded, that the oral and axillary temperatures measured with an electrical thermometer were unsuitable for determination of body temperature in patients hospitalized in a medical department.

[Is hepatitis B antigenemia a risk in adjuvant cytostatic treatment of breast cancer?]

One-hundred and fifteen consecutive patients with breast cancer were examined for hepatitis B. All the patients received adjuvant chemotherapy. The median age was 46 years (range 26-54 years). None of the patients were found to be HBsAg-positive. The prevalence of HbsAg was within the limits of 0-0.026 (95% confidence interval). Vaccination of patients receiving chemotherapy is not indicated. Furthermore, regular HBsAg screening among patients under 55 years cannot be recommended.

Malignancies following long-term azathioprine treatment in chronic liver disease. A report from the Copenhagen Study Group for Liver Diseases

One hundred and fifty-four patients with histologically verified non-alcoholic chronic liver disease were randomized to azathioprine or prednisone treatment. After a median of 91 months observation time, the cause of death was assessed retrospectively. Autopsy was performed in 82% of 71 deaths. In the azathioprine group 33% (13/39) died from malignant neoplasia, and in the prednisone group (13%) (4/32) (p = 0.08). Considering a possible fatal outcome as a consequence of treatment, this finding urges caution in the long-term application of azathioprine at the usual dose level.

Updating prognosis and therapeutic effect evaluation in cirrhosis with Cox's multiple regression model for time-dependent variables

A multivariate Cox regression analysis with time-dependent variables has been performed on the data of 415 patients with cirrhosis included in a controlled clinical trial of 10-15 mg prednisone daily versus placebo. The analysis showed that a poor prognosis was associated with a low prothrombin index, marked ascites, GI bleeding, high age, high daily alcohol consumption, high bilirubin and alkaline phosphatase and low albumin values, little liver connective tissue inflammation, and poor nutritional status. Prothrombin index and ascites showed significant interaction with the treatment in such a manner that high prothrombin index and absence of ascites were associated with a beneficial effect of prednisone, whereas low prothrombin index and presence of ascites were associated with a harmful effect of prednisone treatment. The final model was validated in independent patients by comparing their actual survival with that predicted from the model, using a split-sample testing technique. The prognostic factors were combined with an index that can be used to update prognosis whenever changes occur in the clinical status of a patient during the course of the disease. The probability of surviving the next 3 or 6 months can be estimated from the prognostic index at any time during the course. The index may be of value for the correct timing of special therapeutic procedures such as liver transplantation.

Changes of laboratory variables with time in cirrhosis: prognostic and therapeutic significance

The time change of laboratory variables in cirrhosis was studied by analysis of data from 488 patients with cirrhosis included in a controlled clinical trial of long-term prednisone vs. placebo. In the placebo group, a marked regression towards normal was seen within 3 months of entry into the trial (increase in serum albumin, acetylcholinesterase, cholesterol, hemoglobin and decrease in erythrocyte sedimentation rate). The subsequent course did not show a clear pattern, except for a slight increase in serum bilirubin and decrease in albumin. When studied in relation to the time of death in patients dying from a "hepatic" cause, marked increase in bilirubin and decrease in prothrombin index, albumin and cholesterol were seen in the year prior to death with little change before that time. In the prednisone group, a more marked decrease in bilirubin, SGOT, alkaline phosphatase, gamma-globulin, sulfobromophthalein retention, erythrocyte sedimentation rate and increase in leukocytes, prothrombin index and cholesterol were seen during the first 3 months. In relation to time of death from a "hepatic" cause, similar changes were seen as in the placebo group except that alkaline phosphatase increased and cholesterol did not decrease. A beneficial effect of prednisone on survival, as expressed by a previously developed therapeutic index, was associated with decrease in SGOT, alkaline phosphatase and gamma-globulin within the first 3 months. An increase in SGOT during prednisone seemed to be associated with harmful effects of therapy.

Immunosuppressive treatment of HBsAg-positive chronic liver disease: significance of HBeAg

In a randomized clinical trial in 148 patients of azathioprine vs. prednisone treatment of chronic aggressive hepatitis and/or nonalcoholic cirrhosis, 20 were HBsAg positive on entry. In this subgroup sequential serum samples were investigated for HBs and HBe markers by radioimmunoassay. At the time of evaluation, 13 patients were still alive; their median age was 53 years (25 to 72) and median follow-up time was 46 months (23 to 82). Of 16 patients with cirrhosis, 5 of 7 with persistence of HBeAg died, compared with 2 of 9 with anti-HBe. In three patients with anti-HBe, HBeAg reappeared several times with simultaneous rise in transaminase values. The overall survival was 65% after 5 years. The prognosis of HBsAg-positive chronic liver disease seemed to depend on the presence of cirrhosis and HBeAg rather than on improvement in biochemical activity during immunosuppressive treatment.

A therapeutic index that predicts the individual effects of prednisone in patients with cirrhosis

Our aim was to construct an index that accurately predicts the degree of benefit or harm that prednisone therapy holds for patients with liver cirrhosis. The admission and survival data of 488 patients with cirrhosis who participated in a controlled clinical trial of prednisone in a dosage of 10-15 mg daily (251 patients) versus placebo (237 patients) and who were observed for up to 12 yr were analyzed using Cox's multiple regression model. Four variables each provided significant therapeutic information: antinuclear factor (p = 0.02) and large piecemeal necroses (p = 0.02) were associated with a beneficial effect, whereas ascites (p = 0.0004) and large regenerative nodules (p = 0.0007) were associated with a harmful effect of prednisone. From these four variables a therapeutic index was constructed. For a given patient the therapeutic index is a measure of how big the effect will be if prednisone is given. The gain in survival time obtained by administering prednisone according to the therapeutic index was estimated to be 349 yr, mainly confined to 217 patients with a significant positive (121) or negative (96) therapeutic index. The therapeutic index may prove useful for the optimal administration of prednisone treatment in new patients with cirrhosis.

Differences in the etiology of chronic non-alcoholic liver disease in Naples and Copenhagen

A group of patients with non-alcoholic chronic liver disease from Copenhagen (148) and one from Naples (116) were investigated for the presence of viral and autoimmune serological variables by standardized methods. There were more hepatitis B virus (HBV)-induced cases among the Italians (38.8 versus 15.5%), but the sex ratio and biochemical activity were not different from the Danish ones. Autoimmune markers were much more frequent and in higher titers in Danish HBV-negative patients than in Italian ones. Fewer were women, and thus few Italians fit the theory of autoimmune pathology; rather, their chronic liver disease is caused by other hepatitis viruses than B.

Prognostic value of Child-Turcotte criteria in medically treated cirrhosis

The Child- Turcotte criteria (CTC) (based on serum bilirubin and albumin, ascites, neurological disorder and nutrition) are established prognostic factors in patients with cirrhosis having portacaval shunt surgery. The objective of this study was to evaluate the prognostic value of CTC in conservatively treated cirrhosis. Patients (n = 245) with histologically verified cirrhosis from a control group of a controlled clinical trial were studied. Data at entry into the trial were used to classify patients according to CTC. Survival curves for up to 16 years were made, and survival rates were compared using the log-rank test. Survival decreased significantly with increasing degree of abnormality (A----B----C) of albumin (p less than 0.001), ascites (p less than 0.001), bilirubin (p = 0.02) and nutritional status (p = 0.03). Survival was insignificantly influenced by neurological status (p = 0.11) probably because none of the patients had hepatic coma at entry into the trial. The five variables in CTC were combined to a score. With increasing score, the median survival time decreased from 6.4 years (score 5) to 2 months (scores 12 or more). Furthermore, the mortality from hepatic failure, gastrointestinal bleeding or hepatocellular carcinoma increased significantly with increasing score. CTC provide valuable and easily obtainable prognostic information in cirrhosis. However, CTC are inferior to a prognostic index based on multivariate analysis of prognostic factors.

Prognostic factors in cirrhosis identified by Cox's regression model

In a controlled clinical trial in 488 patients with chronic liver disease treated with prednisone or placebo, survival data were analyzed using Cox's proportional hazards model. A total of 162 variables were screened separately for prognostic and/or therapeutic effect by log-rank analyses, whereby 46 clinical, biochemical, serological, and histological variables were isolated. Another five variables traditionally found to be important in patients with liver disease were included. After extensively checking the assumptions of the model, the 51 variables were, by a step-wise procedure, reduced to a final model. It comprised, besides a treatment indicator, 12 variables with significant (p less than 0.05) prognostic or therapeutic effect. The following eight variables had a significant prognostic effect: sex, age, prothrombin, acetylcholinesterase, eosinophil leucocytes in liver parenchyma, liver cell necrosis, inflammation in liver connective tissue, and efferent veins in parenchymal nodules. A prognostic index based on the final model is formed allowing calculation of 5 years survival probability. The usefulness of the prognostic index was tested by a cross-validation method, and no statistical significant difference was found between the estimated and observed survivorship functions.

Conversion of micronodular cirrhosis into macronodular cirrhosis

The conversion from micro- to macronodular cirrhosis is claimed to be a general phenomenon. In this study, the conversion was quantitated by means of liver needle follow-up biopsies and autopsy in 156 patients followed in a controlled clinical trial of prednisone treatment in cirrhosis. In the initial biopsy, 75 patients were classified as micronodular cirrhosis, and of them, 68 had macronodular cirrhosis at autopsy indicating a conversion ratio of about 0.9 in 10 years. This may overestimate the true conversion ratio slightly since conversion in many cases only was demonstrated at autopsy where the diagnosis of macronodular cirrhosis is made with greater certainty than from a needle biopsy. The median time interval between the diagnosis of micro- and macronodular cirrhosis was 2.25 years which is a maximum estimate of the conversion time due to irregular spacing between biopsies (or biopsy and autopsy). No significant difference was found between the conversion time in females and males. The conversion was faster in patients not drinking alcohol compared to patients drinking alcohol, but the difference was not significant. Prednisone treatment tended to accelerate the conversion, but not significantly.

Main causes of death in cirrhosis

The main causes of 436 deaths among 532 patients with cirrhosis followed up for up to 16 years constituted liver failure (24%), liver failure with gastrointestinal bleeding (13%), gastrointestinal bleeding (14%), primary liver cell carcinoma (4%), other liver-related causes (2%), infections (7%), cardiovascular diseases (22%), extrahepatic malignancies (9%), and other non-liver-related causes (5%). Totally, 57% died of liver-related causes. A high frequency of liver-related death was found among patients with a short observation time, high biochemical activity, pronounced change in liver architecture, ascites, and other signs of a poor prognosis at the time of diagnosis. The findings favoured the hypothesis that cirrhosis of the liver is a disease with an initial active and a subsequent inactive phase. Half of the patients were treated with prednisone, but this had no detectable influence on the distribution of causes of or on the frequency of single causes of death as infections or gastrointestinal bleeding. The group of patients responding favourably to prednisone treatment with regard to survival (non-alcoholic women without ascites) showed causes of death not different from those of the total material.

The accuracy of the clinical diagnosis in acute hepatitis and alcoholic liver disease. Clinical versus morphological diagnosis

Microfilms were prepared from the case histories of 357 consecutive patients submitted to liver biopsy for the first time so that all information after the time of the liver biopsy was erased. The microfilms were assessed by four clinicians, and the pre-biopsy diagnostic proposals were graded according to the degree of certainty and were compared with the results of the liver biopsies. Out of 357 patients, 200 had a history of alcoholism, of whom 172 had alcohol-induced changes in the liver biopsies: 80 cases of alcoholic cirrhosis, 84 cases of steatosis, and 8 cases of alcoholic hepatitis without cirrhosis. In 65 of the 80 patients with biopsy-verified alcoholic cirrhosis the clinical pre-biopsy diagnosis was in agreement with the histological findings. In 51 cases in which the clinical diagnosis of alcoholic cirrhosis was given as moderately certain or very certain, 4 clinically incorrect diagnoses occurred. No incorrect diagnoses occurred in the 35 cases in which the clinicians claimed the greatest diagnostic accuracy. In the 84 patients with steatosis in the liver biopsies the clinicians felt uncertain or moderately certain about all but 2 patients, and 14 incorrect diagnoses occurred. In none of the 8 patients with histological alcoholic hepatitis without cirrhosis was a correct clinical diagnosis made. The clinical pre-biopsy diagnosis of acute hepatitis was in agreement with the results of the liver biopsies in 52 out of 57 patients. In 51 cases in which the clinical diagnosis of acute hepatitis was given as moderately certain or very certain, 1 clinically incorrect diagnosis occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver biopsy in chronic aggressive hepatitis. Diagnostic reproducibility in relation to size of specimen

For the purpose of evaluating the reproducibility of the main diagnosis in liver needle biopsies and estimating the size of the specimen for an acceptable accuracy, 100 liver specimens selected from the daily routine, all 25 mm or more in length, were investigated. The material consisted of specimens from 50 patients with chronic aggressive hepatitis (CAH; including 37 without and 13 with suspicion of cirrhosis), 6 with macronodular cirrhosis, 5 with micronodular cirrhosis, 10 with acute viral hepatitis (including 3 with suspicion of chronicity), 10 with primary biliary cirrhosis, 6 with chronic persistent hepatitis, and 13 with other diagnoses. The specimens were investigated without knowledge of clinical data in five sessions with an increasing amount of tissue made visible. The predictive value of a diagnosis present (diagnostic specificity) and a diagnosis absent (diagnostic sensitivity) was used in evaluating the efficiency of the diagnosis made on the visible part of the biopsy. For CAH (with and without suspicion of cirrhosis) the number of biopsies with the correct diagnosis increased significantly with increasing amounts of tissue visible (p less than 0.01), and the required length for an acceptable accuracy of CAH was 15 mm. The diagnostic sensitivity for CAH was very high (94%) with only 5 mm tissue available and constant through all sessions.

Prednisone and chronic liver disease. II. Clinical versus morphological criteria for selection of patients for prednisone treatment

A prospective, unblinded, randomized trial of treatment of cirrhosis and chronic aggressive hepatitis (CAH) with prednisone included 484 patients who were divided using both the clinical criteria: non-alcoholic females without ascites, and the morphological criterion: presence of a liver biopsy showing CAH. A total of 164 patients (34%) satisfied the three clinical criteria and biopsies from 95 patients (20%) showed CAH. By a cross-tabulation method between the two sets of criteria, four groups were formed. Evaluation of the treatment effect by means of relative death rate showed that the clinical criteria identified both a group of patients with a beneficial effect of prednisone (p less than 0.05) and a group with a harmful effect of the treatment (p less than 0.05). Patients with CAH also had a significant beneficial treatment effect, but patients without CAH showed only an insignificantly harmful effect of treatment. Patients fulfilling both sets of criteria had a beneficial effect of prednisone (p less than 0.05) and patients lacking both sets had a significantly harmful treatment effect. A significantly better survival was found in patients satisfying the clinical criteria without CAH in the biopsy than in patients with CAH and not fulfilling the clinical criteria (p = 0.03). In both the groups of patients with disagreement between the two sets of criteria, a trend towards a beneficial effect of prednisone was found. It is concluded that the simple clinical criteria in comparison with the histological criteria identify a larger group of patients with a beneficial effect of treatment.

Prednisone treatment of chronic liver disease. I. Chronic aggressive hepatitis as a therapeutic marker

A liver biopsy material comprising 477 biopsies from 477 patients included in a prospective, unblinded, randomized trial of treatment of cirrhosis with prednisone has been re-evaluated using new and more restrictive histological criteria for the diagnosis of cirrhosis and chronic aggressive hepatitis (CAH). The material was divided according to the likelihood of cirrhosis being present: (A) cirrhosis (287 patients), (B) probably cirrhosis (101 patients) and (C) compatible with but not diagnostic for cirrhosis (89 patients). Each group was further divided according to the presence (I) or absence (II) of CAH. A total of 98 patients fulfilled the histological criteria for CAH. The effect of prednisone concerning survival was evaluated in each group. In the total group of patients with CAH a significant beneficial effect of prednisone was found (p = 0.04). Among these patients the subgroup with cirrhosis in addition (group I A) also showed a significant effect of prednisone, while groups I B and I C only had a trend towards a beneficial effect (p = 0.44 and p = 0.36, respectively). In patients without CAH in the biopsy (Group II, A + B + C), no effect of prednisone was seen although a trend towards a harmful effect was found in patients with cirrhosis (Group II A). Control patients with CAH in all three subgroups had an insignificantly shorter survival than patients without CAH. All the CAH groups significantly more often included female patients with no history of alcoholism and a lower frequency of spider naevi. In addition, the CAH groups were more active as judged by biochemical and histological variables. It was further disclosed that the presence of large piecemeal necroses indicated a favourable effect of prednisone treatment, while alcoholism, ascites and male sex acted as indicators for an unfavourable treatment effect.

Azathioprine versus prednisone in non-alcoholic chronic liver disease (CLD). Relation to a serological classification

One hundred and forty-eight patients with non-alcoholic cirrhosis or chronic aggressive hepatitis entered a prospective, unblinded, randomized trial on the effect of azathioprine versus prednisone. For all 148 patients, there were no differences in survival related to the two drugs. In 99 patients the disease was classified as autoimmune, in 23 as posthepatitic, and in 26 as cryptogenic. No significant differences were seen in survival between these three groups of patients and no differences in survival related to the two drugs were registered within any of the groups. The autoimmune group included the patients with the biochemically most active disease, and a statistically significant reduction in activity was obtained with prednisone as well as azathioprine. Most remarkably, the frequencies of the autoantibodies were reduced parallel to the biochemical improvement in these patients. Immunosuppressive treatment was found to be rather ineffective in posthepatic chronic liver disease of type B; however, no signs of activation of the hepatitis B virus were seen.

Prevalence of hepatitis B virus infection among alcoholic patients with liver disease

The aim of this investigation was to elucidate a possible role of hepatitis B virus (HBV) in the pathogenesis of liver diseases in alcoholics. Two hundred and fifty-three alcoholics with liver disease were admitted to two medical departments in Copenhagen during a 15 months period. Seventy-nine patients (31%) showed serological signs (HBsAg, anti-HBs) of previous or active HBV infection. This is a significantly higher prevalence than found in an age-matched control population. Among the 79 patients with HBV markers, a total of 11 was found to be HBsAg-positive. From these 11 patients liver specimens were available for re-evaluation in nine cases. In only three of these liver biopsies, morphological changes indicating alcohol as the aetiological cause were found. In conclusion, different or concomitant aetiology must be considered in alcoholics with liver disease.

Aspects of the natural history of gastrointestinal bleeding in cirrhosis and the effect of prednisone

The natural history of gastrointestinal bleeding in cirrhosis has been studied using prospectively collected data of 532 patients included in a randomized clinical trial with a regular follow-up of up to 12 yr. Of the total 199 patients who experienced gastrointestinal bleeding, 95 (48%) bled from esophageal or gastric varices, 67 (34%) bled from peptic ulcer or gastritis, and 37 (18%) had either insufficient evidence of the source (33) or mixed sources (4). In the total group of patients the cumulative percentage of patients in whom varices had been demonstrated of patients in whom varices had been demonstrated by radiography increased from 12 to 90 in 10 yr, while that of bleeding from varices increased from 7 to 40. In 104 patients who bled for the first time during the trial period (trial bleeding patients) the median number of bleeding episodes was one (range 1-8). In these patients the fatality from bleeding from varices was 82%. The risk of rebleeding from varices was 81%, and 4 yr after the first bleeding the cumulative survival had decreased to less than 10%. Rebleeding was significantly less frequent and survival significantly higher in patients bleeding from sources other than varices. Prednisone reduced the occurrence rate of varices, bleeding from varices, and death from bleeding varices in nonalcoholic females without ascites, 40% of whom fulfilled the histologic criteria of chronic active hepatitis. Prednisone significantly increased the occurrence rate of varices inpatient with ascites and of bleeding from varices in alcoholic patients. Prednisone significantly increased the occurrence rate of peptic ulcer in males and in patients without chronic active hepatitis.

Increased extravasation and lymphatic return rate of albumin during diuretic treatment of ascites in patients with liver cirrhosis

During steady state the overall lymphatic return rate of albumin equals the transvascular escape rate of albumin [TERalb, i.e. the fraction of intravascular mass of albumin (IVMalb) passing to the extravascular space per unit time] provided local back-transport is negligible, as previously substantiated in patients with cirrhosis. In nine untreated patients with cirrhotic ascites, TERalb (as determined from the disappearance of intravenously injected radiodinated serum albumin) was on the average 8.5% IVMalb X h-1 (range 4.6-12.7). This value is higher than that of normals (mean 5.9% IVMalb X h-1, range 4.3-7.4, P less than 0.05, one-sided tests). During diuretic treatment TERalb increased to a mean of 13.0% IVMalb.h-1 (range 9.2-22.2), which is significantly higher compared to the untreated state (P less than 0.05) and compared to normals (P less than 0.01). In the untreated condition IVMalb was mean 1.24 mmol (range 0.96-1.64), and this value increased by 20% (P less than 0.01) to an average of 1.49 mmol (range 1.36-1.79) during diuretic treatment. The average increase in IVMalb (0.25 mmol) corresponded to 45% of the intraperitoneal mass of albumin in the untreated state (mean 0.59 mmol), indicating a net transport of albumin from the peritoneal cavity to the plasma during diuretic treatment. The results suggest an increased lymphatic drainage of albumin during diuretic treatment, which may play a role in amelioration of cirrhotic ascites.