Toll-like receptor stimulation differentially regulates vasoactive intestinal peptide type 2 receptor in macrophages

Vasoactive intestinal peptide (VIP) was originally isolated as a vasodilator intestinal peptide, then as a neuropeptide. In the immune system, VIP is described as an endogenous macrophage-deactivating factor. VIP exerts its immunological actions in a paracrine and/or autocrine manner, through specific receptors. However, very little is known about the molecular regulation of VIP type 2 receptor (VPAC(2)) in the immune system. We now report that different toll-like receptor (TLR) ligands selectively regulate the VPAC(2) receptor gene and show a gene repression system controlled by key protein kinase signalling cascades in macrophages. VPAC(2) gene expression is regulated by gram-positive (TLR2 ligands) and gram-negative bacteria wall constituents (TLR4 ligands). Moreover, VPAC(2) is tightly regulated: TLR2- or TLR2/6- but not TLR2/1-mediated mechanisms are responsible for the induction of VPAC(2). TLR stimulation by viral or bacterial nucleic acids did not modify the VPAC(2) mRNA levels. Remarkably, imiquimod--a synthetic TLR7 ligand--led to a potent up-regulation of VPAC(2) gene expression. TLR5 stimulation by flagellin present in gram-positive and gram-negative bacteria did not affect VPAC(2) mRNA. The p38 mitogen-activated protein kinase (MAPK) activity accounted for the TLR4-mediated induction of VPAC(2) gene expression. Surprisingly, our data strongly suggest for the first time a tightly repressed control of VPAC(2) mRNA induction by elements downstream of MAPK kinase 1/2, PI3K/Akt, and particularly Jun-NH(2)-terminal kinase signalling pathways.

An open-label study of chronic polyethylene glycol laxative use in chronic constipation

BACKGROUND

Polyethylene glycol 3350 (MiraLAX, Braintree Laboratories Inc., Braintree, MA, USA) is approved for the short-term treatment of occasional constipation.

AIM

To extend the safety data of polyethylene glycol used for chronic treatment of chronic constipation.

METHODS

Study subjects who met defined criteria for chronic constipation were enrolled in this open-labelled, single-treatment multi-centre study to receive polyethylene glycol laxative as a single daily dose of 17 g for 12 months. Subjects returned to their study centres after 2, 4, 6, 9 and 12 months of treatment where blood and urine samples were collected and adverse events were reviewed. At each visit, subjects were queried for ROME constipation criteria and they rated their overall improvement using a global efficacy scale.

RESULTS

311 patients including 117, age 65 and older, were enrolled and received treatment at one of 50 centres. One hundred and eighty-four completed all 12 months of treatment. With respect to the 'Global Efficacy Assessment', depending on the month of observation, 80-88% of enrolled patients, and 84-94% of the elderly, were treated successfully. Similar results were obtained from secondary efficacy measures that assessed individual ROME constipation criteria at each visit. The response to treatment was durable over time. Over the 1-year course of study representing 218 patient-years at the labelled dose, medication-associated adverse effects were gastrointestinal complaints of diarrhoea, loose stool, flatulence and nausea. These effects were generally mild or moderate in severity. There were no clinically significant changes in haematology or blood chemistry, particularly electrolytes, for the study population as a whole or the elderly group.

CONCLUSIONS

Polyethylene glycol laxative is safe and effective for treating constipation in adult and elderly patients for periods up to 12 months, with no evidence of tachyphylaxis.

NAP, a peptide derived from the activity-dependent neuroprotective protein, modulates macrophage function

NAP is an eight-amino acid neuroprotective peptide NAPVSIPQ; it is the smallest active element derived from the recently cloned activity-dependent neuroprotective protein (ADNP). NAP readily enters the brain from the blood. It will be important to learn whether NAP, in addition to its neuroprotective activity, also might influence immune-mediated inflammation. Here, we report that: (a) macrophages express ADNP; (b) expression of ADNP in macrophages responds to VIP; and (c) NAP downregulates the key inflammatory cytokines tumor necrosis factor (TNF-alpha), interleukin-16 (IL-16), and IL-12 in macrophages. These findings indicate that ADNP/NAP can play an important role in immune regulation as well as in neuroprotection, which may be mutually related processes.

Protective role for plasmid DNA-mediated VIP gene transfer in non-obese diabetic mice

Studies focused on the development of diabetes in NOD mice-a model for human type 1 diabetes-have revealed that an autoimmune inflammatory process is produced by the effect of Th1 cells and their secreted cytokines. DNA vaccination has been shown to be an effective method for modulating immunity in viral infections and experimental autoimmune diseases, including diabetes. VIP's immunomodulatory properties are partly mediated by skewing the pattern of cytokines from a proinflammatory response to an anti-inflammatory response. Using gene delivery to express VIP, we interfered in the immune process leading to diabetes in prone, cyclophosphamide-treated NOD mice. Our results extend the role of VIP in the control of immunoregulatory networks and open new perspectives for immunointervention through VIP-based gene therapy.

The modulatory role of melatonin on immune responsiveness

Afterhe successful discovery of the melatonin molecule by Aaron B Lerner et al at Yale University in 1958, melatonin and the pineal gland, a tiny endocrine gland situated at the center of the human brain, have primarily been considered in terms of their effects on the endocrine and reproductive systems. During the last decade, a substantial body of research has defined melatonin as a remarkable molecule with pleiotropic effects on the immune system. Moreover, its synthesis cannot be considered as exclusively endocrine; key immunocompetent cells have the functional enzymatic machinery for melatonin synthesis, paving the wayfo r complex intracrine, autocrine and paracrine regulatory loops. The immunomodulatory role of melatonin, with regard to infection, inflammation and autoimmunity, is outlined here, and the evidence discussed in this review strengthens the notion that the nature of an immune response may be modified, and therefore therapeutically manipulated, by circadian effector signals.

Local versus global interactions in nonequilibrium transitions: A model of social dynamics

A nonequilibrium system of locally interacting elements in a lattice with an absorbing order-disorder phase transition is studied under the effect of additional interacting fields. These fields are shown to produce interesting effects in the collective behavior of this system. Both for autonomous and external fields, disorder grows in the system when the probability of the elements to interact with the field is increased. There exists a threshold value of this probability beyond which the system is always disordered. The domain of parameters of the ordered regime is larger for nonuniform local fields than for spatially uniform fields. However, the zero field limit is discontinous. In the limit of vanishingly small probability of interaction with the field, autonomous or external fields are able to order a system that would fall in a disordered phase under local interactions of the elements alone. We consider different types of fields which are interpreted as forms of mass media acting on a social system in the context of Axelrod's model for cultural dissemination.

Influence of the oceanographic conditions during spring 2003 on the transport of the Prestige tanker fuel oil to the Galician coast

Hydrographic data collected during the cruise HIDROPRESTIGE were combined with meteorological and dynamic data provided by remote sensors and drifting/moored buoys, to describe the surface circulation of the Northern Iberian basin in March-April 2003. Sea surface winds transported the floating Prestige oil slicks from the sinking area to the continental slope off the Rías Baixas in 1/2 month: the surface current intensity was 2% of the wind intensity and it was rotated clockwise 5 degrees from the wind direction. Mesoscale cyclonic and anticyclonic structures west of 10 degrees W increased the residence time of oil patches in the Northern Iberian basin, as compared with the expected southwards flow of the Iberian current (IC). On the other hand, the Iberian poleward current (IPC) formed a marked surface front with coastal waters, preventing the entry of fuel oil into the rías. PAHs in the surface layer during the cruise were <0.5 microgL(-1), except in the Galicia bank (approximately 1 microg L(-1); where the Prestige tanker was still leaking) and the vicinity of Cape Fisterra (approximately 1.5 microg L(-1); where the convergence front between the IPC and coastal waters vanished).

The use of melatonin as a vaccine agent

Molecules with immunomodulatory properties determine the magnitude and quality of immune responses specific for the coadministered antigen. Melatonin is considered a biological-response modifier of the immune system with broad application in veterinary medicine. In seasonally-breeding animals, the indolamine is able to improve reproductive performance. With the purpose of expanding new advantageous roles for melatonin, we investigated the effect of subcutaneous slow-release melatonin implants in the humoral response after a vaccination. We reported here a new feature of melatonin as an adjuvant-like system towards Dichelobacter nodosus (A1 and C serotypes)--the bacterium which cause ovine footrot--the most important cause of lameness in sheep. Antibody titres determined by both agglutination and ELISA techniques were substantially higher and were sustained for a longer duration than non-implanted animals. Remarkably, the effect of melatonin was completely dependent on the presence of aluminium hydroxide. The finding that melatonin enhances a defined immune response in vivo opens new perspectives for the improvement of Th2-biased immune responses by alum adjuvants.

Analysis of sweet diterpene glycosides from Stevia rebaudiana: improved HPLC method

An improved analytical method was developed which may be applied to quality control of stevioside and rebaudioside A contents in dried leaves of Stevia rebaudiana before processing; in a selective sampling program searching for plants of higher yield in diterpene glycosides content; or when a large number of samples are sent to the laboratory for analysis. The procedure developed involves two steps: solvent extraction followed by an isocratic HPLC analysis. The sample, 1 g of dried leaves of S. rebaudiana, is ground and solvent-extracted with EtOH 70% (w/w) in Erlenmeyer flasks by shaking for 30 min in a 70 degrees C water bath. After the extract was cooled, it was filtered and analyzed by HPLC using an NH(2) column (250 x 4.6 mm) and a mixture of acetonitrile/water (80:20, v/v) as mobile phase, pH 5 adjusted with acetic acid. The detection was in the UV range at 210 nm (0.04 AUFS). Quantitation was performed by means of an external standard calibration curve for each analyte which had been obtained from standard solutions of pure stevioside and rebaudioside A. Working under these conditions there were no observed interference effects. The method saves time in sample preparation, and reduces sample handling and chromatographic analysis time, while having little loss of precision [coefficient of variation (CV%) between 1.8% and 3.0%] and recovery [between 98.5% and 100.5%]. The method was applied to 30 samples of S. rebaudiana from Misiones (Northeastern Argentina), and the stevioside content found ranged between 3.78 and 9.75% (weight) whereas Rebaudioside A content ranged between 1.62 and 7.27% (weight).

Chronic hepatitis C: implications for the primary care clinician

The seeds of an epidemic were sown 2 decades ago, and PAs need to be alert for those at risk for developing chronic hepatitis C before cirrhosis, liver failure, or liver cancer develops. Identifying the patient at risk is as uncomplicated as asking the right questions in the right setting.

Biliary cystadenoma: rare variant of intrahepatic cystic disease

Intrahepatic nonparasitic cystic disease is rare and may be of congenital or neoplastic origin. The most frequent symptoms and signs are nonspecific and include pain, nausea, fullness, increased girth, and palpable mass. Interventional therapy is reserved for symptomatic patients, which usually corresponds to cysts >5 cm in diameter. Retrospective analysis revealed 26 cases of intrahepatic cystic disease over 15 years at our institution. We discuss the case of a patient who had bilobular biliary cystadenomatous disease, a rare, benign variant of intrahepatic nonparasitic cystic disease.

Iron depletion is not effective in inducing a virologic response in patients with chronic hepatitis C who failed to respond to interferon therapy

OBJECTIVE

Some studies have suggested that increased iron stores may impact negatively on the response to interferon in patients with chronic hepatitis C infection. We performed this prospective trial to determine the effects of iron depletion on ALT and HCV-RNA levels in patients with chronic hepatitis C infection and to assess whether the response to interferon in patients who had previously failed to respond to interferon was enhanced by iron depletion.

METHODS

Patients with chronic hepatitis C resistant to interferon therapy and no evidence of iron overload underwent weekly phlebotomies until the serum ferritin level was below lower limits of normal for the subject's age and sex. Patients were then started on interferon-alpha2b, 3 million units subcutaneously three times per week for a period of 24 weeks. Iron studies, ALT, and HCV-RNA levels were monitored at baseline, after phlebotomy and at 12 and 24 weeks of interferon therapy.

RESULTS

Thirty-three patients were enrolled, 28 completed the study. A mean of 7.2 units of blood were removed to achieve iron depletion. ALT levels decreased significantly with phlebotomy (142 IU/L before phlebotomy vs 82 IU/L after phlebotomy; p < 0.001), but log HCV-RNA levels remained unchanged (6.49 before phlebotomy vs 6.51 after phlebotomy). Interferon therapy did not improve ALT levels further. HCV-RNA levels were minimally reduced during interferon therapy (log HCV-RNA 6.49 before interferon vs 6.00 after 24 weeks of interferon therapy). Two patients achieved a virologic end of treatment response, both relapsed within 3 months after discontinuation of interferon. No patient achieved a sustained virologic response.

CONCLUSIONS

In patients who previously failed treatment with interferon, iron depletion induced by phlebotomy improves ALT levels but is ineffective in achieving viral eradication in patients retreated with interferon 3 million units three times per week.

Immune globulin and vaccine therapy to prevent hepatitis A infection

The hepatitis A virus is usually transmitted person-to-person due to fecal-oral exchange of virus. Approximately 30,000 infections are reported each year in the United States, with the actual incidence being much greater. Prophylaxis with immune globulin has had a minimal impact on the overall incidence of hepatitis A. The recent availability and proven efficacy of a hepatitis A vaccine offers the hope that the incidence of infection may be substantially reduced. Pre- and postexposure prophylaxis should be targeted to individuals at increased risk of either acquiring infection, transmitting infection, or developing fulminant hepatitis, or to help control epidemics. This article reviews the current literature and discusses recommendations for pre- and postexposure prophylaxis against hepatitis A virus.

Management of acute liver failure

Acute liver failure represents one of the most challenging conditions in gastroenterology. In most cases, there is no effective therapy making supportive intensive care the most important management tool. These patients frequently develop multi-organ failure, placing them at risk of systemic infections, cerebral edema, hemodynamic instability, coagulopathy and various renal and metabolic complications. Successful management of the patient with acute liver failure requires an understanding of the pathophysiology and management of these complications. An overview of acute liver failure and its most common complications is presented.

Vibrio vulnificus infection: an important cause of septicemia in patients with cirrhosis

Vibrio vulnificus, a virulent gram-negative organism, is a normal inhabitant of coastal waters, including the Gulf of Mexico. Vibrio vulnificus infection has been recognized as a cause of fatal septicemia in chronically ill patients, particularly those with chronic liver disease. We report the case of a patient with chronic liver disease who had V vulnificus septicemia 2 days after eating raw oysters harvested in the Gulf Coast. Vibrio vulnificus septicemia should be suspected in all patients with underlying medical illnesses, particularly cirrhosis, who present with a febrile illness days after eating seafood or being exposed to saltwater. Physicians should advise their patients with cirrhosis and other chronic debilitating illnesses not to eat raw or undercooked seafood.

Management of ascites. Paracentesis as a guide

All patients with new-onset ascites or with known ascites and any change in their condition, such as the appearance of fever, abdominal pain, renal insufficiency, or encephalopathy, should undergo diagnostic paracentesis to characterize the ascitic fluid, detect infection, and aid differential diagnosis. A serum-ascites albumin gradient greater than 1.1 g/dL indicates portal hypertension. Spontaneous bacterial peritonitis is a common and serious complication of ascites and is best diagnosed by the number of neutrophils in the ascitic fluid. Patients with the condition should be treated with parenteral antibiotics, and response to therapy should be assessed with repeated paracentesis. Hospitalized patients with low-protein ascites should receive antibiotic prophylaxis. Sodium restriction and diuretics are the cornerstones of therapy for ascites. In refractory cases, alternative forms of therapy, such as large-volume paracentesis, peritoneovenous shunting, or transjugular intrahepatic portosystemic shunting, may be of benefit. Patients with refractory ascites should be considered for liver transplantation.

Cytomegalovirus hepatitis mimicking an acute exacerbation of chronic hepatitis B

We report the case of a 29-year-old woman who had acute cytomegalovirus hepatitis superimposed on previously unrecognized chronic hepatitis B infection. We then review the diagnostic approach to acute hepatitis and positive hepatitis B surface antigen.

Alfentanil for conscious sedation during colonoscopy

This investigation was designed to determine whether the narcotic alfentanil, a relatively new fentanyl derivative with rapid onset of action and offset of activity, alone or in combination with midazolam has advantages over the traditional meperidine and midazolam regimen for conscious sedation. Thirty-five subjects were randomized to receive an initial dose of narcotic and sedative with additional narcotics or sedatives administered as needed. Subjects receiving no midazolam sedative (alfentanil and placebo group, n = 13) had less desaturation and had the need for supplemental oxygen less often than those receiving alfentanil and midazolam (n = 11) or meperidine and midazolam (n = 11). There were no differences as assessed by patient and colonoscopist for tolerance and discomfort, procedure ease, recovery time, complications, electrocardiogram, and blood pressure. Baseline evaluation did not predict the need for supplemental oxygen. We concluded that alfentanil, with or without a sedative, has no advantage over the commonly used meperidine and midazolam regimen.

Effect of radiation and radioprotection on small intestinal function in canines

Radiation with doses > 7.5 Gy damages the canine intestinal mucosa, and pretreatment with WR2721 reduces this damage. However, the effects of radiation and of WR2721 on in vivo intestinal transport are unclear. Therefore, we determined canine survival, intestinal transport, and mucosal histology following unilateral abdominal irradiation. Isoperistaltic ileostomies were prepared in 23 dogs under general anesthesia and aseptic conditions. After a three-week recovery period, animals were given either placebo or WR2721, 150 mg/kg intravenously, 30 min prior to 10 Gy cobalt-60 abdominal irradiation. Ileal transport and histology were determined in both groups before exposure and one, four, and seven days after irradiation. Seven-day survival was significantly improved by pretreatment with WR2721 (91% vs 33%, P < 0.02). On day 4, both mucosal integrity and net intestinal absorption were significantly better (P < 0.05) after WR2721 than after placebo. Thus, radiation-induced damage to the ileal mucosa is accompanied by a reduction in net ileal absorption of water and electrolytes in vivo. In addition, pretreatment with WR2721 improves animal survival while reducing ileal damage and improving intestinal absorption.

Serologic diagnosis of viral hepatitis

Recent advances have made available to the clinician multiple serologic tests for the diagnosis and evaluation of acute and chronic viral hepatitis. While the multiplicity of tests available can be confusing, selective use of these serologic tests tailored to the clinical situation can be of great value in identifying the agent causing the liver disease. I present a clinically oriented discussion of the serologic tests available to diagnose viral hepatitis.

Evaluation of patients who meet clinical criteria for irritable bowel syndrome

OBJECTIVE

To determine which test would yield the most useful clinical data in evaluation of irritable bowel syndrome (IBS).

METHODS

One hundred ninety-six patients who met the International Congress of Gastroenterology criteria for irritable bowel syndrome were prospectively evaluated with hematological, biochemical, and metabolic laboratory testing, as well as a structural evaluation of the colon.

RESULTS

complete blood count, sedimentation rate (ESR), serum chemistries, thyroid profile, and urinalysis were normal or yielded no useful clinical information. Stool examinations for parasites were also normal. Structural evaluations (barium enema, x-ray, and flexible sigmoidoscopy or colonoscopy) revealed abnormalities, including colon cancer (1), polyps (9), colitis (1), melanosis coli (2), diverticulosis (17), and hemorrhoids (11). Forty-eight subjects (25.8%) had lactose maldigestion confirmed by H2 breath lactose testing. Prior to formal testing, 25 (52%) of these subjects were unaware of the relationship between lactose-containing foods and their symptoms.

CONCLUSIONS

1) ESR, thyroid profiles, and parasite examinations had no diagnostic yield in this study and, without specific clinical indication from history and physical examination, should not be part of the "routine" IBS evaluation. 2) Lactose hydrogen breath testing is encouraged for patients with and without milk intolerance who present with IBS.

Colorectal cancer screening: is one-year surveillance sigmoidoscopy necessary?

OBJECTIVES

To assess the diagnostic yield of the 1-yr follow-up flexible sigmoidoscopy examination for the detection of colonic neoplasia in a colorectal cancer screening program.

METHODS

Data were prospectively collected for flexible sigmoidoscopies performed between July 1991 and July 1992 as part of the University of South Alabama Colon Cancer Registry.

RESULTS

A total of 217 subjects with an age-related risk of colon carcinoma and no evidence of occult blood by stool examination were enrolled. One hundred and sixteen underwent initial sigmoidoscopic examination, and 101 had a 1-yr surveillance examination. Ten of the 116 patients (8.6%) undergoing initial surveillance sigmoidoscopy were found to have neoplastic lesions. In contrast, only 1/101 (1%) patients undergoing 1-yr follow-up surveillance sigmoidoscopy was found to have a neoplastic lesion. Neoplastic lesions in both groups were adenomas. No carcinomas were found.

CONCLUSIONS

These data suggest that the 1-yr surveillance sigmoidoscopy adds little to the diagnostic yield of colon cancer screening.

Is a Hemoccult-positive rectal examination clinically significant?

To determine the clinical significance of finding occult blood in a stool sample obtained during digital rectal examination of patients with no gastrointestinal complaints, we reviewed the records of patients who had colonoscopy for this indication. Of the 185 patients (average age, 59.4 years) who met study criteria, 48 were inpatients when the Hemoccult-positive rectal examination was recorded. Neoplastic lesions were found in 28% of the patients (51/185). Thirteen of the lesions were adenocarcinomas and 38 were adenomatous polyps. Seventy-five patients (41%) had normal findings on colonoscopy. Nonneoplastic lesions were found in the remaining 32%. Comparison of patients with neoplastic lesions and patients with nonneoplastic lesions showed no significant difference with respect to the presence of anemia (43% vs 48%), inpatient status at the time of positive rectal examination (23% vs 29%), or sex. Although the mean age was similar in patients with and without neoplastic lesions (60.5 and 56.8 years, respectively), no neoplastic lesions were found in patients less than 45 years old. We conclude that testing stool obtained during rectal examination for occult blood does not increase the rate of false-positive results, and positive test should prompt a structural evaluation of the colon to detect neoplasia in patients with an age-related risk for colon carcinoma.

Hepatitis E as a cause of acute non-A, non-B hepatitis

Hepatitis E seems to be responsible for most epidemics of non-A, non-B hepatitis in developing countries. While hepatitis E is not endemic in the United States, it should be considered in the differential diagnosis of the traveler with non-A, non-B hepatitis. We describe a patient with acute hepatitis E, confirmed by serologic testing, after recently returning from India and discuss current knowledge about the pathogenesis, clinical features, and diagnosis of hepatitis E.

Abnormal liver enzyme levels. The spectrum of causes

Asymptomatic patients with persistent elevation of liver enzyme levels require further tests to detect the cause of hepatobiliary injury. The magnitude of enzyme elevation does not reflect severity of disease. The pattern of enzyme elevations, ie, hepatocellular or cholestatic, should be used to guide the evaluation.

Abnormal liver enzyme levels. Clinical evaluation in asymptomatic patients

Chronic elevation of liver enzyme levels requires attention, because it may indicate serious liver disease. The pattern of elevation, whether hepatocellular or cholestatic, is used to guide the evaluation. The goal is to diagnose treatable forms of liver disease. Occasionally, a diagnosis cannot be established with noninvasive screening tests, and regular follow-up is then recommended. The role of liver biopsy in such cases is controversial.

Barrett's esophagus: lack of association with adjuvant chemotherapy for localized breast carcinoma

This study was designed to prospectively, endoscopically, and histologically determine the prevalence of Barrett's esophagus in patients who had received adjuvant chemotherapy for localized breast carcinoma. Fifteen white women who received cyclophosphamide, methotrexate, and 5-fluorouracil (N = 8) or cyclophosphamide, adriamycin, and 5-fluorouracil (N = 7) chemotherapy underwent esophagogastroduodenoscopy and esophageal biopsy a mean 31.1 months (median, 11 months) after completion of full-course chemotherapy. Twelve of 15 patients had experienced oral ulcerations, diarrhea, or odynophagia during chemotherapy. In no patient was Barrett's esophagus identified endoscopically or histologically. This study fails to demonstrate an increased prevalence of Barrett's esophagus in breast carcinoma patients who had received adjuvant chemotherapy.

Case report: esophageal metastasis from breast carcinoma presenting as achalasia

Metastatic breast carcinoma to the esophagus most often presents with a mid-esophageal stricture. Involvement of the gastroesophageal junction by breast carcinoma is distinctly unusual. The authors report the case of a 78-year-old woman who presented with clinical and radiologic features of achalasia secondary to breast carcinoma, metastatic to the gastroesophageal junction. Metastatic breast cancer to the gastroesophageal junction should be added to the list of conditions mimicking achalasia.

Benign and metastatic tumors of the esophagus

With the widespread use of fiberoptic endoscopy, benign esophageal tumors are being identified with increasing frequency. It is important to be familiar with the radiologic, endoscopic, and histologic features of these tumors so that appropriate therapy may be facilitated. Overall, the prognosis of patients with benign esophageal tumors is excellent. These tumors must not be confused with the much more common malignant tumors, which carry a dismal prognosis. Metastatic tumors may involve the esophagus, and esophageal symptoms may be the presenting symptoms of an extraesophageal malignancy. Endoscopic biopsy specimens frequently show a normal mucosa. The endoscopist should be aware of this and pursue further workup to exclude extraesophageal malignancy when indicated. As endoscopic ultrasonography becomes routinely available, it will improve the characterization of these lesions and allow more benign esophageal lesions to be safely removed using endoscopic methods.

[Cortical and trabecular bone lesions in insulin-dependent diabetes mellitus]

To determinate which type of bone is damaged in IDDM, we assessed the bone mineral content (BMC) in both cortical and trabecular bones, in a group of 48 IDDM patients without hepatic or kidney diseases, or any other pathology with implications in the mineral metabolism. For the evaluation techniques of single photon absorptiometry (SPA) and double photon absorptiometry (DPA) were used. All the patients controlled their disease with insulin. The results showed the presence of osteopenia in both types of bone. It was more evident in male group. In the patients group the mean value of serum osteocalcin (BGP) was significantly decreased (2.34 +/- 1.05) in comparison with the controls (p less than 0.001). The deficient of BMC is neither related with the parameters of new bone formation nor with the time of disease evolution.

Occupational and industrial toxin exposures and the gastrointestinal tract. Gastrointestinal Toxicology Subcommittee of the American College of Gastroenterology Patient Care Committee

The subcommittee on Gastrointestinal Toxicology of the Patient Care Committee of the American College of Gastroenterology has reviewed potential effects of exposures to occupational and industrial hazards on the gastrointestinal tract, liver and pancreas. This review is presented to 1) share clinical data concerning gastrointestinal toxicology, 2) emphasize the paucity of available information to the practicing clinician, and 3) stimulate basic research interest in this field.

Current medical management of cirrhotic ascites

The presence of ascites may indicate a number of hepatic and extra-hepatic disorders. This situation requires comprehensive evaluation to determine the underlying cause. The evaluation and management of ascites in patients with known cirrhosis is very important since this manifestation of portal hypertension has a detrimental effect on the prognosis for such patients.

Sucralfate used as adjunctive therapy in patients with severe erosive peptic esophagitis resulting from gastroesophageal reflux

A total of 36 patients with grade 2 or greater erosive esophagitis and an abnormal 24-h pH monitor study, were treated in a randomized, double-blind fashion to assess the efficacy of sucralfate suspension as adjunctive therapy to cimetidine for severe esophagitis secondary to gastroesophageal reflux. Treatment consisted of cimetidine, 300 mg qid and either sucralfate suspension (1 g/10 ml) or an identical placebo suspension, 10 ml after meals and 20 ml hs. Patients were treated for 12 wk unless endoscopic healing occurred earlier. Initial evaluation and monthly follow-up consisted of symptom monitoring, endoscopic evaluation and pre- and post-therapy esophageal manometry, Bernstein test, and 24-h pH monitoring. The combination of cimetidine and sucralfate suspension was superior to cimetidine alone in improving daytime heartburn symptoms (p less than 0.05) but not nighttime heartburn, dysphagia, or regurgitation. Sucralfate plus cimetidine improved the overall endoscopic outcome of esophagitis more than cimetidine alone (p less than 0.05). More patients exhibited endoscopic healing in the adjunctive sucralfate group than in the cimetidine-only group. Endoscopic healing, however, was not statistically different between groups. We conclude that sucralfate used as adjunctive therapy to cimetidine resulted in improvement of some of the symptoms of reflux, and probably increases the likelihood of complete healing of esophagitis, compared with cimetidine alone.

Serum lactate dehydrogenase in murine leprosy: source and isozymes

The bulk of the lactate dehydrogenase (LDH) that increases in the serum of mice infected with Mycobacterium lepraemurium (MLM) derives from the liver and corresponds to the isozyme V. MLM-induced granulomas continuously arise in the liver and steadily increase in size until the animal's death. Growing granulomas push the adjacent hepatocytes away and cause them to disrupt and to release their cytoplasmic contents, including LDH. The LDH is then picked up by the infiltrating phagocytes and/or admixed with the circulating blood. Other LDH-containing organs (including the testis with its additional isozyme LDH-X) in the infected or normal animals do not seem to significantly contribute to the serum levels of LDH. The study of the liver-associated histochemical and biochemical changes in this controlled model of murine leprosy allows us to gain insight into the overall pathology of this mycobacteriosis. In some respects this sheds light on the liver involvement in human leprosy; a subject on which results of all sorts have been published.

Diagnostic laparoscopy: a prospective review of 100 cases

The perceived role of laparoscopy in the management of liver disease has changed because of the widespread use of image-guided biopsy. Laparoscopy, however, permits direct inspection of the liver surface and the abdominal cavity, as well as tissue sampling. In order to assess the utility of laparoscopy, and specifically, the diagnostic value of direct visualization of the liver surface, we prospectively collected information on 100 consecutive patients undergoing laparoscopy. The contribution of the laparoscopic findings to patient management and the predictive value of the laparoscopic diagnosis compared to histology were assessed. Laparoscopy had a 95% diagnostic yield. Liver surface characteristic consistent with malignancy, cirrhosis, or fibrosis were sensitive and specific predictors of histologic findings. We conclude that laparoscopy continues to be a valuable diagnostic procedure, especially in cases where accurate assessment of the liver architecture is required.

Saliva: its role in health and disease

Saliva serves many functions in the upper digestive tract, with its roles in esophageal physiology, digestion, and gastric cytoprotection having been documented by many studies in the recent literature. Understanding the multiple functions of saliva and the consequences of its absence is of paramount importance to gastroenterologists. We present a clinically oriented review of the literature on the role of saliva in the upper gastrointestinal tract and review the many problems associated with lack of saliva. We also discuss the management of xerostomia.

Comparison of stationary vs ambulatory 24-hour pH monitoring recording systems

Twenty-four-hour pH monitoring of the esophagus is frequently performed to assess gastroesophageal reflux. We performed a prospective study to determine if results obtained from stationary and ambulatory pH recording systems are comparable. Two groups of patients were studied. Group I consisted of 12 patients monitored simultaneously by both a stationary and an ambulatory pH recording system, each system having a separate pH and reference electrode. In group II, in order to eliminate electrode variability, 10 patients were monitored simultaneously with both systems and a common single pH and reference electrode. In group I, significant correlations were found in six reflux parameters measured and in the 24-hr composite score (r greater than or equal to 0.8722). However, in three of the 12 patients, marked discrepancies were noted in the composite score calculated by the stationary and ambulatory recording systems. Small variations in the pH level recorded by different pH electrodes may have accounted for the discrepancies. In group II, where electrode variability was eliminated, a better correlation was noted between all parameters measured (r greater than or equal to 0.991), and no discrepancies were noted between calculated composite scores. We concluded that the stationary and ambulatory recording systems tested are comparable in measuring 24-hr esophageal pH.

Cytogenetic and clinical findings in ten 45,X/46,XY patients

We report ten cases with 45,X/46,XY karyotype. Cytogenetic and clinical findings have been compared. No constant relationship was found either between blood and gonadal karyotype, or between karyotype and gonadal morphology.