Consolidation in AML: Abundant opinion and much unknown

Consolidation therapy forms the backbone of post-remission therapy for AML and is uniformly accepted as an integral part of therapy designed to achieve long-term survival. The need for post-remission therapy was initially described over four decades ago and has since undergone many variations in terms of dosage, number of cycles and intensity of therapy. There is much empiricism in the current understanding of consolidation therapy and much that has not been rigorously studied. This review will consider the many aspects of consolidation therapy, focusing on the number of cycles, differences between young and older adults, first and subsequent remission as well as therapy prior to an allogeneic transplant. Emphasis will be given to differentiate strategies that are clearly evidence-based from those that have been incorporated into standard of care while bypassing the need for rigorous data-driven approaches. Finally, consideration will be given to the current ability to assess the minimal measureable residual disease and the impact that this may have on therapeutic paradigms, including superseding many of the time-honored prognostic features.

[INTERVENTIONS TO IMPROVE THE QUALITY OF THE INTERNSHIP YEAR]

AIMS

To describe three interventions that have improved the quality of the internship.

BACKGROUND

All medical school graduates are required to take a one year internship, rotating through various hospital departments. By various objective and subjective measures, the quality, benefit and efficacy of the internship varies significantly between departments and hospitals and also depends on where the interns studied.

METHODS

The interventions were: First, all graduates of foreign medical schools (FMG) were required to interview and present a patient, demonstrating practical knowledge of spoken and written Hebrew and basic medical terminology prior to the start of the internship. Second, on the first day of their internship in internal medicine the new interns participate in an orientation day, addressing multiple clinical, administrative and other components. Third, upon the completion of their rotation in internal medicine, the interns participate in an interactive session to help them prepare for their future career.

RESULTS

First, during the first 3 years after introducing the Hebrew test, 101 FMGs took the test, 89 (88%) passed the first time, the remainder passed the 2nd or 3rd test after another 1-3 months of studying Hebrew. Of 31 women, 30 (97%) passed the first time, compared to 59/70 (84%) of the men (p=0.065); 27/28 (96%) of Jewish interns passed the first time compared to 62/73 (85%) non-Jewish interns (p=0.99). Physicians report on the significantly increased ability of FMGs to participate in all activities from the onset of their internship. Second, upon completion of the orientation, 137 interns provided feedback of its 12 components; satisfaction was marked on a Likert scale (ranging from 1 [low] to 5 [high]) and ranged from 4.2±0.1 to 4.7±0.6; high/very high satisfaction with the various components ranged from 79% to 96%. Third, feedback was provided by 96 interns after participating in the interactive session helping to prepare for the future; satisfaction with the 5 components of the session ranged from 3.8±0.8 (on the acquired insight into the possibilities, scope and limitations regarding their future career) to 4.5±0.7 (regarding the relevance of such sessions). Sub-analysis revealed several statistically significant differences between male and female interns (male interns indicated these sessions to be more important to them than females, p<0.01), and FMG (as compared to graduates from Israeli medical schools) indicated that they had acquired relevant information more often (p<0.001).

CONCLUSIONS

Various interventions positively impact the quality, benefit and efficacy of the internship as observed by physicians working with the residents, as well as perceived by the interns themselves.

Clinical impact of Pseudomonas aeruginosa colonization in patients with Primary Ciliary Dyskinesia

BACKGROUND

Airway infections in Primary Ciliary Dyskinesia (PCD) are caused by different microorganisms, including pseudomonas aeruginosa (PA). The aim of this study was to investigate the association of PA colonization and the progression of lung disease in PCD.

METHODS

Data from 11PCD centers were retrospectively collected from 2008 to 2013. Patients were considered colonized if PA grew on at least two separate sputum cultures; otherwise, they were classified as non-colonized. These two groups were compared on the lung function computed tomography (CT) Brody score and other clinical parameters.

RESULTS

Data were available from 217 patients; 60 (27.6%) of whom were assigned to the colonized group. Patients colonized with PA were older and were diagnosed at a later age. Baseline forced expiratory volume at 1 s (FEV₁) was lower in the colonized group (72.4 ± 22.0 vs. 80.1 ± 18.9, % predicted, p = 0.015), but FEV₁ declined throughout the study period was similar in both groups. The colonized group had significantly worse CT-Brody scores (36.07 ± 24.38 vs. 25.56 ± 24.2, p = 0.034). A subgroup analysis with more stringent definitions of colonization revealed similar results.

CONCLUSIONS

Lung PA colonization in PCD is associated with more severe disease as shown by the FEV₁ and CT score. However, the magnitude of decline in pulmonary function was similar in colonized and non-colonized PCD patients.

Palliative Sedation at the End of Life

Palliative sedation (PS) is indicated for refractory symptoms among dying patients. This retrospective descriptive study examines PS in an Israeli hospice. Palliative sedation was defined as PS to unconsciousness (PSU), PS proportionate to symptoms (proportional palliative sedation [PPS]), or intermittent PS (IPS). Among 179 patients who died during 2012, PS was used among 21.2% (n = 38): (PSU 34.2%, PPS 34.2%, and IPS 31.6%), using midazolam (n = 33/38), halidol (21/38), and concurrent morphine (n = 35/38). Indications included agitation (71%), pain (36.8%), and dyspnea (21%). Survival following initiation of PS was 73 ± standard deviation 54 hours. No differences in survival were observed according to who initiated the decision to use PS (patients/medical staff/family) or type of PS (PSU/PPS/IPS). Survival following PS was longest with higher sedative doses, an observation that may help dispel fears concerning the use of PS to hasten death.

Docetaxel, cisplatin and leucovorin/fluorouracil in first-line advanced gastric cancer and adenocarcinoma of the esophagogastric junction: Results of the phase II GASTRO-TAX-1 trial

4561

Background: Phase II and III trials combining docetaxel, cisplatin and fluorouracil (DCF) every 3 weeks (wks) have shown superior efficacy but high rates of hematological toxicity in advanced gastric cancer. To reduce toxicity while containing the efficacy of DCF, we conducted a protocol using split doses of docetaxel (T), cisplatin (P), leucovorin (L), fluorouracil (F) (T-PLF). Methods: Chemo-naive patients (pts) with advanced gastroesophageal adenocarcinomas received T 50 mg/m2, P 50 mg/m2 day 1, 15, 29 and L 500 mg/m2 plus F 2,000 mg/m2 d1, 8, 15, 22, 29, 36 qd49. Because significant reductions to <80% of initial drug doses became necessary in 80% of pts, the regimen was amended after the first 15 pts. After the amendment the agents were administered as follows: T 40 mg/m2, P 40 mg/m2, L 200 mg/m2, F 2,000 mg/m2. The primary objective was the overall response rate (ORR) according to RECIST. Results: From 03/04 to 08/05 we included 60 pts: median age 53 yrs, (26–76); 24 pts had locally advanced tumors (LA) and 36 pts had metastatic disease (MET). Pts received a median of 2 (range 0–4) cycles. Reductions to <80% of drug doses were reported in 80% versus 60% of pts pre/post amendment. Reported adverse events were: neutropenia 23%, febrile neutropenia 5%, diarrhea 20%, nausea 8%, emesis 8% and fatigue 20%. The ORR according to RECIST was 46.6% (95%CI 33.3–61.4). Only 6.6% were primarily progressive. 23/24 pts with LA underwent secondary resection (96%). Complete resections (R0) were achieved in 87%. After a median follow-up of 25.5 months, median overall survival (OS) is 17.9 months (95%CI 11.5 -24.3). Median TTP is 9.4 months (95% CI 8.3–10.5). For pts with MET, median TTP is 8.1 months and median OS is 15.1 months. Conclusion: The T-PLF regimen is highly active, safe and has a favorable toxicity profile.

[Table: see text]

Bacteriobilia in percutaneous transhepatic biliary drainage: occurrence over time and clinical sequelae. A prospective observational study

BACKGROUND

In the diagnosis and treatment of biliary disorders, establishing percutaneous transhepatic biliary drainage (PTBD) is an invasive procedure that can potentially lead to infectious complications in both the short and long-term. We therefore prospectively analysed the time course and spectrum of biliary bacteria in patients undergoing PTBD.

METHODS

Forty-nine patients (19 F, 30 M; mean age 64 years) with malignant (65%) or benign (35%) biliary disorders were included, 20 of whom had a newly established PTBD (group A), while the remaining 29 had already had their PTBD in situ (group B) for a mean of 8 months. Bacteriological analyses of bile and blood were carried out, and clinical symptoms and laboratory values were obtained.

RESULTS

Biliary bacteria were found in 60% of cases during the initial PTBD placement, and 24 h later this rate had already increased to 85%; two or more microorganisms were found in 40% initially and in 70% after a few days. At later PTBD exchanges, bacteriobilia was found in 100%, with all patients harbouring multiple organisms. Whereas the initial spectrum was mixed, Escherichia coli and enterococci (97% each), Klebsiella (73%) and Bacteroides species (37%) later predominated; Candida increased initially from 15% to 80%, but later decreased to 30%. Clinical signs of cholangitis were observed in 30% initially (no sepsis), but decreased to 6% at later exchanges.

CONCLUSIONS

Bacteriobilia is initially a frequent, and later a regular, event in PTBD; however, clinically significant complications are rare during the long-term course and limited to the initial, more invasive, phase of PTBD. A knowledge of the bacterial spectrum is important for selecting appropriate antibiotic coverage if complications arise and/or major interventions such as surgery are planned.

Treatment of achalasia: the short-term response to botulinum toxin injection seems to be independent of any kind of pretreatment

BACKGROUND

It has been suggested that intrasphincteric injection of botulinum toxin (BTX) may represent an alternative therapy to balloon dilatation in achalasia. The aim of the present study was to test the effectiveness of botulinum toxin injections in achalasia patients, as assessed using lower oesophageal sphincter pressure (LOSP) and symptom scores, and to compare the response in patients with different types of pretreatment (no previous treatment, balloon dilatation, myotomy, BTX injection).

METHODS

Forty patients who presented with symptomatic achalasia were treated with BTX injection (48 injections in 40 patients). Some of the patients had received prior treatment (seven with myotomy, seven with dilatation and eight with BTX). The symptoms were assessed using a global symptom score (0-10), which was evaluated before treatment, 1 week afterwards, and 1 month afterwards. Manometry was also carried out before and after treatment. Three different selections of patients were studied: all patients; untreated patients; and patients with prior BTX, dilatation, or myotomy.

RESULTS

After BTX injection, there was a significant reduction in LOSP (before, 38.2+/-11.3 mmHg; 1 week after, 20.5+/-6.9 mmHg; 1 month after, 17.8+/-6.8 mmHg; P < 0.001). The global symptom score and symptom subscores (dysphagia, regurgitation, chest pain) were significantly decreased after 1 week and 1 month. When the beneficial effects following BTX injection were compared (untreated vs. pretreated), neither changes in LOSP nor beneficial effects on the symptom scores significantly differed. After 6 months, 67.7% of all treated patients were still in symptomatic remission (subgroups: previously untreated patients, 61.5%, n = 26; prior dilatation, 71.4%, n = 7; prior myotomy, 71.4%, n = 7; prior BTX, 73.9%, n = 8).

CONCLUSIONS

BTX injection offers an alternative treatment for achalasia which is safe and can be performed in an outpatient setting. The initial response to BTX, in terms of symptom scores and LOSP, appears to be independent of any prior treatment. A number of patients do not adequately respond to balloon dilatation or myotomy, which are the first-line treatment modalities in achalasia patients. BTX injection can be performed in these patients, and symptomatic benefit can be expected in the same percentages as with BTX injection in untreated patients.

Treatment of achalasia: botulinum toxin injection vs. pneumatic balloon dilation. A prospective study with long-term follow-Up

BACKGROUND AND STUDY AIMS

In patients with achalasia, intrasphincteric injection of botulinum toxin (BTX) has been suggested as an alternative regimen to balloon dilation and has been shown to be superior to placebo injection. The aim of the present study was to test the effectiveness, the long-term outcome and the cumulative costs of BTX injection in consecutive patients with symptomatic achalasia in comparison with pneumatic balloon dilation.

PATIENTS AND METHODS

37 patients, who presented with symptomatic achalasia between January 1994 and December 1996 were treated with either BTX injection (n = 23) or pneumatic dilation (n = 14). Patients with short-term or long-term symptomatic failures of the initial procedure were treated again, either with the same or with the alternative method, depending on the initial response and on the patient's wish. Symptoms were assessed using a global symptom score (0 - 10) which was evaluated before treatment and 1 week, 1 month and then every 6 months after the treatment. In addition, body weight and recurrence of symptoms were noted and manometry was carried out before and after treatment. The patients were regularly contacted for the long-term follow-up.

RESULTS

There were significant improvements in the global symptom scores of all patients treated, in both the BTX injection group (before 8.2 +/- 1.3, after 3.0 +/- 1.6) and the dilation group (before 8.3 +/- 1.1, after 2.3 +/- 1.9). There was also a significant decrease of lower esophageal sphincter pressure after treatment in the BTX group and the dilation group. There were no significant differences with regard to overall treatment failure and long-term outcome between patients who had or had not received previous treatment. No major complications were encountered in either group. An actuarial analysis over 48 months comparing patients receiving BTX injection or balloon dilation demonstrated that after 12 months neither therapy was significantly superior. After 24 months a single pneumatic dilation was superior to a single BTX injection, and after 48 months all patients treated by BTX injection had experienced a symptomatic relapse. In contrast, 35 % of all patients treated by dilation and 45 % of patients treated successfully by dilation were still symptom-free in an intention-to-treat analysis after 48 months. When the overall costs of treatment and further treatment after recurrence were compared, dilation and BTX injection showed a similar cost-effectiveness (costs per symptom-free day) after 48 months.

CONCLUSIONS

BTX injection, which can be performed in an outpatient setting, is as safe and cost-effective as balloon dilation in symptomatic achalasia. Taking into account the lower long-term efficacy of BTX injection therapy, however, it is an alternative only in a minority of older or high-risk patients.

Treatment of symptomatic diffuse esophageal spasm by endoscopic injections of botulinum toxin: a prospective study with long-term follow-up

BACKGROUND

Diffuse esophageal spasm is a rare esophageal motility disorder for which there are no satisfactory pharmacologic alternatives for treatment. The aim of this study was to investigate whether botulinum toxin (BTX) injection is an effective short- and long-term treatment for patients with symptoms caused by diffuse esophageal spasm. Whether recurrence of clinical symptoms can be successfully retreated by BTX injection was also studied.

METHODS

Nine symptomatic patients (6 women, 3 men; 57-86 years) with manometrically proven diffuse esophageal spasm underwent BTX injection. One hundred IU BTX were diluted in l0 mL of saline solution and injected endoscopically at multiple sites along the esophageal wall beginning in the region of the lower esophageal sphincter and moving proximally in 1- to 1.5-cm intervals, and into endoscopically visible contraction rings. Symptom scores based on an analogue scale for dysphagia, regurgitation, and noncardiac chest pain were assessed before and after therapy, 1 day thereafter, and at 1 and 6 months.

RESULTS

Symptoms improved immediately in 7 (78%) patients after 1 injection session. After 4 weeks 8 (89%) patients were in remission with a decrease in total symptom score. The total symptom score decreased from a median 8.0 (interquartile range: 6.75; 9.0) before treatment to 2.0 (1.5; 3.75) after 1 day (p < 0.01) and to 2.0 (interquartile range: 0.75; 3.0) after 1 month (p < 0.01). After 6 months all 8 patients with a response at 1 month still had a symptom score of 3 or less without further treatment. Subsequently 4 patients required reinjection 8, 12, 15, or 24 months after the initial treatment with similarly good results. No serious adverse effects were observed.

CONCLUSIONS

BTX injection at several levels of the tubular esophagus is an effective treatment for patients with symptoms caused by diffuse esophageal spasm. Symptom relapse can be effectively treated by repeated BTX injection.

Life-threatening gastrointestinal bleeding due to a jejunal lesion of Henoch-Schönlein purpura

The case of a 56-year-old patient with Henoch-Schönlein purpura (HSP) and fulminant gastrointestinal bleeding is reported. The patient was admitted to hospital because of palpable purpura on both legs, painful joints and diffuse abdominal pain. Suspected HSP was histologically proven and treated with prednisolone. Despite recovery, acute gastrointestinal bleeding, with melena and a drop in hemoglobin concentration from 11.2 to 4.2 g/dl, occurred 30 days after medication was started. Immediate endoscopic examination of the upper gastrointestinal tract showed no signs of bleeding whereas colonoscopy showed fresh blood and blood clots in the terminal ileum and the colon. Since the bleeding source could not be detected endoscopically, mesenteric angiography was performed, demonstrating active bleeding from a jejunal artery. Thereafter the bleeding source was located by intraoperative peroral enteroscopy and treated by resection of a short segment of jejunum.

A new system for rapid large-caliber percutaneous transhepatic drainage in patients with obstructive jaundice: a prospective randomized trial

BACKGROUND AND STUDY, AIMS: Percutaneous access to the biliary tract is an important diagnostic and therapeutic tool in the management of biliary diseases. It is usually chosen when the endoscopic approach via endoscopic retrograde cholangiopancreatography (ERCP) fails, or is not possible. Once established, the percutaneous tract is then used for the treatment of biliary stones and strictures. To establish a percutaneous tract with a caliber large enough for cholangioscopy to be performed, or for a large-bore permanent drainage tube to be inserted, stepwise dilation up to 14 Fr or 16 Fr is usually required. We present here a new method of rapid dilation using specially designed materials, including a stiffenable guide wire and specially adapted bougies.

PATIENTS AND METHODS

Consecutive patients undergoing percutaneous drainage for biliary diseases were included in this prospective study, over a 19-month period. After establishment of a 10-Fr transpapillary drain, the patients were randomly assigned to either conventional percutaneous transhepatic biliary drainage (PTBD) or stepwise dilation using the new method, aiming at a need for only one further session, using a specially designed stiffenable metal guide wire of 6.6 Fr and plastic bougies. The details of the procedure (duration, materials used, technical ease), initial and later complications, assessment by the patients, and procedural costs were compared between the two groups.

RESULTS

Of the 60 patients included, 29 were randomly assigned to group I (the new method) and 31 to group II (the conventional approach); there were no significant differences between the two groups in terms of clinical data or biliary pathology. The clinical efficacy of PTBD was similar in the two groups, although three patients in group II were switched to the new procedure because of failure of dilation using the conventional approach. The rates of major complications (four of 29 in group I, five of 31 in group II) and patient tolerance were also similar. However, the new procedure led to a significant reduction in the cumulative procedure duration (20.1 minutes vs 30.1 minutes), mean number of sessions (1.1 vs. 1.7), and mean number of hospital days (2.0 vs 5.5), and was therefore also cost-effective, reducing costs from a mean of 5813 to 2581 German marks (DM) per patient.

CONCLUSIONS

The new system for rapid establishment of large-caliber PTBD offers significant advantages in terms of saving hospital resources while maintaining clinical efficacy.

[Hemosuccus pancreaticus (bleeding into the pancreatic duct). A rare complication of pancreatitis]

HISTORY AND ADMISSION FINDINGS

A 41-year-old man was admitted because of recurrent tarry stools and dizziness. Chronic pancreatitis induced by alcoholism was known. The main abnormal laboratory finding was anaemia (haemoglobin 4.6 g/dl, erythrocytes 2.28/fl).

INVESTIGATIONS, TREATMENT AND COURSE

At endoscopy of the oesophagus, stomach and duodenum, fresh blood was found in the duodenum, a small trickle of blood coming from the papilla of Vater. Endoscopic retrograde cholangiography discovered no abnormality in the biliary system. Selective contrast imaging of the pancreatic duct demonstrated a short prepapillary stenosis and a prestenotic dilatation (up to 15 mm diameter) of the pancreatic duct with a cloudy contrast filling defect. After catheter withdrawal from the pancreatic duct blood spurted from the papilla. Emergency angiography revealed pseudoaneurysmatic dilatation of the gastroduodenal artery in the region of the head of the pancreas. At selective catheterization this artery was successfully occluded with metal coils placed both proximally and distally to the source of bleeding.

CONCLUSION

Gastrointestinal bleeding is a rare but potentially life-threatening complication of pancreatitis. When searching for bleeding in the upper gastrointestinal tract, the papilla of Vater should be looked for as a possible source. Bleeding from the pancreas occurs particularly in pancreatitis, pancreatic pseudocyst or pancreatic tumour.

Regulation of gastrin, somatostatin and bombesin release from the isolated rat stomach by exogenous and endogenous gamma-aminobutyric acid

BACKGROUND/AIMS AND METHODS

gamma-Aminobutyric acid (GABA) is localized in epithelial cells and intrinsic nerve fibers of the gastric mucosa raising the possibility of a regulatory role for this transmitter. Therefore, it was the aim of the present study to examine the effect of exogenous and endogenous GABA on the neuroendocrine functions of the isolated perfused rat stomach.

RESULTS

Infusion of GABA (10(-8), 10(-6), 10(-4) M) caused a significant increase in gastrin release by 187 +/- 98, 328 +/- 43 and 493 +/- 84 pg/20 min and a significant decrease in somatostatin secretion by -540 +/- 203, -867 +/- 96 and -893 +/- 195 pg/20 min, respectively. Release of bombesin-like immunoreactivity (BLI) remained unchanged during infusion of GABA at the concentrations employed. The gastrin and somatostatin responses to 10(-4) M GABA were completely inhibited by the GABA(A) antagonist bicuculline (10(-5) M) and the cholinergic blocker atropine(l0(-7) M), whereas the GABAB antagonist CGP 35348 (5 x 10(-5) M) was ineffective. To evaluate the contribution of endogenous GABA in the vagal regulation of gastric neuroendocrine functions, gastrin, somatostatin and BLI responses to electrical stimulation of the vagal nerves were examined in the presence of bicuculline. Vagal stimulation (10 V, 10 Hz, 1 ms) induced a significant inhibition of somatostatin release by - 518 +/- 78 pg/10 min, which was attenuated to -259 +/- 143 pg/10 min (p < 0.05) in the presence of bicuculline. Atropine (10(-7) M) turned vagally induced inhibition of somatostatin release into a stimulation by 928 +/- 266 pg/10 min which was not altered by additionally infused bicuculline. Vagally stimulated gastrin release was reduced from 397 +/- 47 to 217 +/- 72 pg/10 min (p < 0.05) by bicuculline, while atropine had no effect. Vagally induced BLI release was not altered by bicuculline and atropine. Since the effect of bicuculline on vagally induced gastrin release was independent of cholinergic mechanisms, a potential direct effect of GABA on gastrin release was examined in isolated rabbit antral G cells. In this preparation carbachol (10(-4) M) and neuromedin C (10(-9) M) significantly stimulated gastrin release from 2.6 +/- 0.4 to 4.9 +/- 0.3 and 8.5 +/- 0.9% of the total cellular content, respectively, while GABA (10(-10)-10(-3) M) changed neither basal nor carbachol- and neuromedin C-stimulated gastrin release.

CONCLUSION

The present data confirm that exogenous GABA stimulates gastrin release and inhibits somatostatin release from the isolated rat stomach via GABA(A) receptors by activating cholinergic neurotransmission. Furthermore, it was shown for the first time that endogenous GABA contributes to the vagal regulation of gastrin and somatostatin release from the rat stomach. Inhibition of somatostatin secretion by endogenous GABA is mediated by cholinergic mechanisms, whereas stimulation of gastrin release is mediated by pathways unrelated to the cholinergic system and bombesin peptides.

Long-term outcome in patients with advanced hilar bile duct tumors undergoing palliative endoscopic or percutaneous drainage

OBJECTIVE

Advanced tumors of the hepatic duct bifurcation (Klatskin tumors) present problems to the endoscopist in deciding which procedure to use for palliative treatment of the resulting cholestasis--endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD), or both. There are technical difficulties with all forms of treatment for stenoses in the hilar region and intrahepatic bile ducts, and there are as yet no clear data on which type of drainage is feasible or preferable.

SUBJECTS

59 consecutive patients (30 men, 29 women; mean age 71 years) underwent palliative treatment for malignant hilar bile duct tumors of Bismuth stages II-IV during a three-year period (1992-94).

METHOD

A retrospective analysis was carried out, and long-term follow-up data were obtained from telephone interviews with the patients, relatives, or referring physicians.

RESULTS

The 59 patients were treated using ERCP (n = 20) or PTBD (n = 39). Three died within 30 days, and six were lost to follow-up. Clinically adequate drainage was achieved in 78% (n = 46) of the total patient group. Patient survival was a median of six months (range 0.5-38), and was slightly longer when the primary drainage procedure was successful (7.5 months). Initial complications occurred in 11% after ERCP and in 33% after PTBD, with a 30-day mortality of 5%. After the initial intervention, five patients who received ERCP treatment had to be switched to PTBD during the longer-term course. Three of these five patients died within 30 days of the PTBD insertion.

CONCLUSIONS

Palliative treatment in patients with advanced Klatskin tumors is still suboptimal, even when combined endoscopic and percutaneous techniques are used in the same institution, allowing treatment to be tailored to the individual patient's needs. There is therefore a need for improvements in existing forms of treatment, as well as for the development of new forms of treatment.

Endohyperthermia--experimental evaluation of a new therapeutic approach for treatment of biliary carcinoma

BACKGROUND AND STUDY AIMS

To improve the prognosis of patients with unresectable, locally advanced bile duct carcinoma, new treatment strategies need to be evaluated. Hyperthermia has been successfully applied as part of multimodal therapy in esophageal and rectal carcinoma. We performed in-vitro and in-vivo experiments with a new intraluminal hyperthermia system in the biliary tract.

METHODS

A radiofrequency system (13.56 MHz, Endoradiotherm XERT-200A; Olympus Optical Co., Tokyo, Japan) was used with a special intraluminal microelectrode (diameter 4.5 mm, length 40 mm) covered by a silicone balloon with cooling water and a large counter electrode for focusing the electromagnetic field around the electrode. The heating capacity of the endohyperthermia unit was examined in vitro in a muscle-equivalent phantom (agar 4 %), in isolated livers of pigs and cows, as well as in vivo in anesthetized sheep. Continuous thermometry was done with thermosensors at the applicator surface, and with multichannel thermocouple probes in the environment of the applicator.

RESULTS

Endohyperthermia induced a homogeneous heating of the phantom and the isolated liver bile duct preparation to a temperature > or = 40 degrees C in an area at least 10 mm in depth. After placement of the applicator into the common bile duct of anesthetized sheep, endohyperthermia led to a consistent and repeatable heating of the surrounding tissue to 40.5 +/- 0.5 degrees C at 1 cm distance, and 39.9 +/- 0.7 degrees C at 2 cm distance. Blood pressure, heart rate, and systemic temperature did not change in vivo. Histological examination of the bile duct showed superficial mucosal necrosis (depth 100-200 microm), microvascular damage with petechiae, congestion and edema of the bile duct wall and adventitia after hyperthermia treatment in vivo.

CONCLUSIONS

The intraluminal endohyperthermia system produces consistent and repeatable heating of the surrounding tissue. Since effective thermal power can reach a depth of up to 2 cm, tumors may also be heated adequately.

Initial experience with a new Yamakawa-type prosthesis for long-term percutaneous transhepatic drainage

BACKGROUND AND STUDY AIMS

In a previous study evaluating the problems of long-term percutaneous transhepatic biliary drainage (PTBD) using Yamakawa-type prostheses in patients with benign and malignant stenoses, breakage of the tube proved to be a serious problem, occurring in 19.7 % of PTBD exchanges. As a consequence of these results, a new PTBD tube made of Tecothane has been developed.

PATIENTS AND METHODS

From September 1997 to September 1998, this new PTBD tube was applied in 64 patients (39 men, 25 women; median age: 70, range 29-89) in the treatment of benign (n = 30) or malignant stenoses (n=31; three stenoses remained indeterminate), and the course was followed.

RESULTS

A total of 134 stent exchanges were performed, 52 of these being ahead of schedule (39 %). Not a single case of breakage occurred. However, other PTBD-related problems remained unchanged. Patients accepted the new prosthesis very well; among 19 patients who had experience of both the new one and the conventional one, 11 had preferences-eight for the new one and three for the old one.

CONCLUSIONS

This new Tecothane prosthesis has solved the problem of PTBD breakage, which was often accompanied by serious problems. As was to be expected, other PTBD-related problems were not substantially affected. Nevertheless, this new tube represents progress in the percutaneous treatment of biliary stenoses.

Anti-TNF antibody in Crohn's disease--status of information, comments and recommendations of an international working group

The chimeric anti-TNF antibody Remicade (Infliximab) has recently been approved for human use by the FDA and is now available on the market. Since there is considerable interest in this kind of treatment among patients with Crohn's disease, an international working group has summarized the presently available information about efficacy, side effects and possible problems of this treatment. Studies show that Remicade is effective in the treatment of active Crohn's disease, maintaining remission and fistulae. The working group does not see Infliximab as a first-line treatment for Crohn's disease. It may be used in active phase recurrent disease, chronic active disease and fistulae if standard treatment was not successful. For the surveillance special attention has to be given to the unknown malignancy rate of Infliximab. Infusion should be performed in an institution, routinely performing intravenous infusions and a two-hour surveillance of the patients should be guaranteed to recognize anaphylactic reactions or acute side effects. There is presently no information indication that the combination with immunosuppressants might increase risks or side effects of this treatment. Due to the limited information available the working group would prefer to use Remicade in studies only and recommends central collection and documentation of all data on efficacy and side effects for the next year.

Long-term results of percutaneous transhepatic biliary drainage for benign and malignant bile duct strictures

BACKGROUND

Long-term percutaneous transhepatic biliary drainage (PTBD) is a valid alternative to surgery in patients with benign or malignant bile duct strictures in whom endoscopic drainage has failed. However, few data are available on the long-term outcome with percutaneous drainage, specially when the application of Yamakawa-type prostheses is considered.

METHODS

During 1996, 48 patients who were either treated with primary PTBD insertion followed by PTBD exchanges (n = 15) or who presented only for exchange of an earlier PTBD (n = 33) were included in the study. Thirty-one patients had malignant strictures, and 17 had benign ones. The PTBD catheters were scheduled for exchange every 3 months or earlier if signs and symptoms of obstruction or other problems were present. The data were collected prospectively during each follow-up visit and included both symptoms and the status and function of the PTBD at the time of exchange.

RESULTS

Although PTBD was highly effective in relieving jaundice (progression of cholestasis was observed in only 2 cases), 73 of the 157 PTBD exchanges (47%) had to be carried out earlier than scheduled. Premature exchange was needed for clinical reasons, such as fever indicating PTBD dysfunction, in only 19% of these cases. The other reasons were related to the PTBD catheter and consisted of bile leakage alongside the drain (33%), PTBD disconnection or complete dislocation (30%), or occlusion suspected during regular flushing of the drain (15%). In most cases exchanging the drain was sufficient to solve the problem; in cases of complete dislocation, dilation of the same tract (n = 6) or fresh puncture and establishment of a new drainage site (n = 2) were necessary. Reducing the PTBD exchange interval from 3 to 2 months would have decreased the number of premature stent exchanges by 26%.

CONCLUSIONS

Although PTBD is an effective method of biliary drainage, there are frequently minor problems-mostly catheter-related-which require premature exchange of the drain in almost half of the cases, and this may affect the patients' quality of life. Improvements in PTBD materials and catheter design are therefore needed. The effectiveness of reducing the intervals between PTBD exchanges should also be examined.

[Polyposis of the gastrointestinal tract as a manifestation of diffuse follicular lymphatic hyperplasia]

HISTORY AND ADMISSION FINDINGS

A 21-year-old previously healthy Turkish man who had been living in Germany for 15 years was admitted because of worsening cramp-like abdominal pain with nausea, vomiting and watery diarrhoea. Palpation elicited diffuse muscular guarding over the entire abdomen and a mass of about 8 cm in the right lower abdomen.

INVESTIGATIONS

Abnormal laboratory results were erythrocyte sedimentation rate (55 mm), C-reactive protein (6.2 mg/dl), total bilirubin (2.1 mg/dl), creatine kinase (137 U/l) and thymidine kinase (5.5 U/l). There was a slight leucocytosis (13,700/microliter) and mild anaemia (haemoglobin 13.4 g/dl) with a normal differential count. Listeria ivanovii was repeatedly cultured from stool. Ultrasonography and computed tomography of the abdomen demonstrated a 6 cm mass in the right lower abdomen, splenomegaly (15.5 x 5 cm) and several lymphomas, up to 1.8 cm in diameter. Endoscopy revealed dense, in part grass-like, polyps, 3 to 6 mm deep, in the mucosa from the terminal ileum to the rectum, and to a lesser extent also in the duodenum. Histological examination of the polyps demonstrated diffuse follicular hyperplasia without evidence of malignancy.

TREATMENT AND COURSE

On antibiotic treatment with ofloxacin (2 x 400 mg intravenously) the symptoms quickly regressed, but the endoscopic findings remained unchanged.

CONCLUSION

Diffuse follicular lymphatic hyperplasia manifested itself in this patient as diffuse gastrointestinal polyposis. Listeria ivanovii cannot be ruled out as a causative factor.

Role of vagal fibers and bombesin/gastrin-releasing peptide-neurons in distention-induced gastrin release in rats

In the rat the exact role of vagal fibers and the interaction between the extrinsic and intrinsic neural system in distention-induced gastrin release are still a matter of debate. Accordingly, the aim of the present study was to examine the contribution of afferent and efferent vagal fibers as well as intrinsic neurons on gastrin response to gastric distention. In anesthetized rats graded gastric distention by 5, 10 and 15 ml saline for 20 min caused a significant volume-dependent increase of plasma gastrin levels by 12+/-6 pg/ml (5 ml saline, n = 8, P =0.05), 26+/-7 pg/ml (10 ml saline, n = 10, P < 0.05) and 37+/-7 pg/ml (15 ml saline, n = 8, P < 0.01 ), respectively. To examine the role of the extrinsic vagal innervation, gastrin response to distention was studied in anesthetized rats after bilateral truncal vagotomy (n = 9) or selective afferent vagotomy following pretreatment with capsaicin (n = 6). Stimulation of gastrin release by 10 ml distention in sham-operated control rats was reversed to an inhibition after truncal vagotomy (26+/-7 vs. -11+/-4 pg/ml; P<0.05) and capsaicin-treatment (37+/-18 vs. -34+/-11 pg/ml; P<0.05). A contribution of cholinergic mechanisms to this vagovagal-mediated stimulation of distention-induced gastrin release was excluded, since atropine (100 microg/kg/h; n = 8) further augmented distention-stimulated gastrin release. Since bombesin/gastrin-releasing peptide (GRP)-neurons contribute to vagally stimulated gastrin secretion, we have examined gastrin response to distention in the presence of the specific bombesin-receptor antagonist D-Phe6-BN(6-13)OMe (400 microg/kg/h: n = 10). This bombesin-antagonist completely reduced distention-stimulated gastrin release in vivo. In contrast, distention of the isolated, extrinsically denervated stomach significantly decreased gastrin release by 13+/-5 pg/min (5 ml saline, n = 8, P < 0.05), 28+/-8 pg/min (10 ml saline, n = 11, P < 0.05) and 35+/-10 pg/min (15 ml saline, n = 8, P < 0.01), respectively, without changing the activity of bombesin/GRP-neurons. Distention-induced decrease of gastrin release was attenuated to 50 percent by atropine (10(-7) M: n = 10) or tetrodotoxin (TTX) (10(-6) M; n = 10), respectively. These data demonstrate, that in anesthetized rats distention-stimulated gastrin secretion depends on the activation of a vagovagal reflex and intrinsic bombesin/GRP-neurons. In contrast distention of the isolated rat stomach inhibits gastrin release in part via intrinsic cholinergic pathways and other as yet unknown mechanisms.

Role of endogenous bombesin-peptides during vagal stimulation of gastric acid secretion in the rat

The stimulatory effect of exogenous bombesin and its related mammalian peptides on gastric acid secretion and gastrin release has been examined in detail, while the regulatory role of endogenously released bombesin-like peptides is largely unknown. Accordingly we have determined the effect of a specific bombesin receptor antagonist during vagal stimulation of gastric acid secretion and gastrin release. In anesthetized rats electrical stimulation of the vagal nerves (10 V, 10 Hz, 1 ms) significantly increased plasma gastrin levels by 82 +/- 11 pg/20 min (P < 0.01) and gastric acid output by 99.4 +/- 9.9 mueq/20 min (P < 0.01). Intravenous infusion of the specific bombesin receptor antagonist D-Phe6-BN(6-13)OMe (400 nmol/kg/h) significantly reduced vagally induced increase of plasma gastrin levels by 70% to 29 +/- 8 pg/20 min (P < 0.05 vs control) and vagally stimulated gastric acid output by 40% to 57.4 +/- 10.6 mueq/20 min (P < 0.05 vs control). To demonstrate that the residual gastrin and acid response is due to non-bombesinergic mechanisms and not to an inadequate dose of the receptor antagonist, the latter was tested against gastrin-releasing peptide (GRP) at the maximally effective concentration of 300 pmol/kg/h, which resulted in an even 50% higher increase of plasma gastrin levels compared to vagal stimulation. The dose of the antagonist employed (400 nmol/kg/h) was sufficient to abolish GRP-induced stimulation of gastrin and gastric acid secretion. Previously it has been postulated that endogenous bombesin-peptides can stimulate acid secretion via gastrin-independent mechanisms. To investigate this possibility further the effect of the antagonist was examined on vagally induced acid secretion while gastrin levels were restored to the range of the respective control experiments. In presence of the antagonist the infusion of gastrin-17 (15 pmol/kg/h) in addition to vagal stimulation elevated plasma gastrin to levels not different from those during vagal stimulation alone. With identical plasma gastrin levels the bombesin receptor antagonist had no effect on vagally stimulated acid secretion (86.3 +/- 10.7 mueq/20 min vs 99.4 +/- 9.9 mueq/20 min in the controls; n.s.). In conclusion, the present data demonstrate for the first time that in rats in vivo endogenous bombesin peptides contribute to vagal stimulation of gastrin release and gastric acid secretion. Furthermore, endogenous bombesin-peptides exert their action on parietal cell function via an increase of gastrin release, while non-gastrinergic mechanisms are unimportant under the experimental conditions employed.

Influence of the L-arginine-nitric oxide pathway on vasoactive intestinal polypeptide release and motility in the rat stomach in vitro

Endogenous nitric oxide (NO) plays an important role as non-adrenergic, non-cholinergic inhibitory transmitter in the gastrointestinal tract, especially in sphincter regions. The aim of this study was to investigate the influence of NO on pyloric motility and on the release of vasoactive intestinal polypeptide (VIP) in the isolated perfused rat stomach in vitro. Therefore, pyloric motility was continuously recorded by a special sleeve manometry catheter placed in the pyloric region and the concentration of VIP was determined in the venous effluent of the portal vein. Arterial perfusion with the nitrate agonist sodiumnitroprusside led to a dose-dependent reduction of the pyloric motility index (basal 166 +/- 48 mm Hg/min: sodiumnitroprusside 10(-6) M 30 +/- 20 mmHg/min: sodiumnitroprusside 10(-4) M 0: n = 8. P < 0.001) while VIP release was not influenced significantly. Inhibition of endogenous NO production by the NO-synthase inhibitor NG-nitro-L-Arg (L-NNA) significantly increased pyloric motility (basal motility index 175 +/- 28 mmHg/min: L-NNA 10(-4) M 348 +/- 48 mmHg/min: n = 8, P < 0.05). This effect was completely blocked by addition of L-Arg 10(-3) M (125 +/- 45 mm Hg/min: n = 8, P < 0.01), L-NNA and L-Arg both did not influence VIP release. Stimulation of the vagal nerve (VS: 20 V, 20 Hz, 1 ms) led to a significant decrease of the pyloric motility index (basal 181 +/- 15 mmHg/min; n = 7, P < 0.05), which was consistent even after addition of L-NNA 10(-4) M (basal 338 +/- 58 mmHg/min; VS 228 +/- 30 mmHg/min; n = 7, P < 0.05). Vagal stimulation increased VIP release significantly (basal 14.9 +/- 1.4 pmol/l; VS 20.1 +/- 2.6 pmol/l; n = 7, P < 0.05) while L-NNA had no influence on vagally induced VIP release. From these data, we conclude that the pylorus of the rat is under a tonic inhibition by endogenously released NO. Under the conditions studied. NO seems not to mediate the inhibitory effect of vagal stimulation exclusively and there seems to be no interaction between NO and VIP in the rat pylorus.

Gastrin secretion from primary cultures of rabbit antral G cells: stimulation by inflammatory cytokines

BACKGROUND & AIMS

In Helicobacter pylori-induced gastritis, local production of cytokines may favor hypergastrinemia as an endocrine link between H. pylori-induced gastritis and duodenal ulcer. The aim of this study was to characterize cytokine effects on cultured rabbit antral G cells.

METHODS

Monolayers (14.2% +/- 2.9% G cells) were studied after 48 hours in primary culture.

RESULTS

Interleukin (IL) 1 beta (50% effective concentration [EC50], 5.3 +/- 0.4 ng/mL) and tumor necrosis factor (TNF) alpha (EC50, 5.5 +/- 0.5 ng/mL) stimulated gastrin release to 50% of the maximal response to 10(-9) mol/L neuromedin C. Stimulation by the maximally effective concentration of IL-1 beta (10 ng/mL) was inhibited by the human IL-1 receptor antagonist (100 ng/mL; inhibitory constant, 23.0 ng/mL), which prefers type I over type II IL-1 receptors. The response to the maximally effective concentration of TNF-alpha (10 ng/mL) was markedly inhibited by monoclonal antibody H398, an antagonist at TNF P55 receptors (inhibitory constant, 1.7 micrograms/mL), whereas monoclonal antibody utr1, an antagonist at TNF P75 receptors, was ineffective. Stimulation by IL-1 beta and TNF-alpha was additive to the responses to neuromedin C and O2-dibutyryl adenosine 3',5'-cyclic monophosphate. IL-6 and IL-8 (0.1-50 ng/mL) were ineffective.

CONCLUSIONS

IL-1 beta and TNF-alpha stimulate gastrin secretion via receptors potentially residing on rabbit antral G cells themselves. We speculate that G cells express type I IL-1 receptors and TNF P55 but not TNF P75 receptors.

Treatment of esophagorespiratory fistulas with silicone-coated self-expanding metal stents

Nine self-expanding silicone-coated modified Gianturco metal stents were inserted in 8 patients (mean age, 58.2 years) for palliation of malignant esophagorespiratory fistulas caused by esophageal (n = 5) or bronchial (n = 3) carcinoma. One patient with a fistula above a 12-cm-long malignant stenosis received two overlapping stents. The implantation procedure was well tolerated by all patients under intravenous sedation and analgesia. After release, the stents expanded to their full diameter, leading to complete occlusion of the fistulas and bridging of the concomitant stenoses. Two patients with lung cancer received an additional tracheobronchial stent before esophageal stent insertion. Failure to maintain complete contact between the proximal stent margin and the esophageal wall led to insufficient sealing of the fistula of 1 patient and recurrent aspiration, manifested 6 days after stent implantation (overall success, 87.5%). The other patients could swallow semi-solid food until death. Seven patients died of advanced metastatic disease after 21 to 121 days (mean, 54 days) and 1 patient of massive hemoptysis 10 days after stent placement, which could be regarded as a complication (procedure-related mortality rate, 12.5%). These preliminary results suggest that peroral insertion of the modified silicone-coated Gianturco stent is a rapid, reasonably safe, and effective procedure for palliation of malignant esophagorespiratory fistulas.

Effect of endogenous opioids on vagally induced release of gastrin, somatostatin and bombesin-like immunoreactivity from the perfused rat stomach

The aim of the present study was to evaluate the effect of the opiate receptor antagonist naloxone on vagally stimulated secretion of bombesin-like immunoreactivity (BLI), somatostatin and gastrin from the isolated rat stomach, which was perfused via the celiac artery with Krebs-Ringer buffer. Vagal stimulation was performed for 10 min with 1 ms, 10 V and 2, 5, 10 or 20 Hz, respectively. In control experiments BLI release increased significantly above basal secretion during a stimulation frequency of 10 Hz (1367 +/- 357 pg/10 min; P < 0.001) and 20 Hz (996 +/- 202 pg/10 min; P < 0.01), but not at 2 and 5 Hz. In comparison to the controls naloxone (10(-6) M) significantly increased BLI secretion at 5 Hz by 573 +/- 150 pg/10 min (P < 0.05), but attenuated the BLI response to higher stimulation frequencies of 10 and 20 Hz to 284 +/- 143 pg/10 min (P < 0.001) and 490 +/- 114 pg/10 min (P < 0.01), respectively. At 2 Hz naloxone had no effect on BLI release. As shown previously the cholinergic blocker atropine (10(-7) M) induced a significant BLI release during vagal stimulation at 2 Hz (680 +/- 233 pg/10 min; P < 0.01) and 5 Hz (935 +/- 324 pg/10 min; P < 0.05), but was without effect at 10 and 20 Hz compared to the controls. The effects of the combination of naloxone and atropine were similar to naloxone and atropine alone. Naloxone had no effect on vagal or GRP-induced regulation of gastrin and somatostatin release.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional characterization of a muscarinic receptor stimulating gastrin release from rabbit antral G-cells in primary culture

In previous studies carbachol-induced stimulation of gastrin release from antral G-cells in primary culture suggested the presence of muscarinic acetylcholine receptors on this cell type. Therefore, we attempted to pharmacologically characterize the muscarinic acetylcholine receptor subtype involved. Enzymatically isolated rabbit antral mucosal cells (0.8% G-cells) were separated by counterflow elutriation yielding a fraction (1.7% G-cells) that was placed in culture on collagen-coated well plates. After 24-36 h of culture 13.0 +/- 2.4% of total adherent cells were immunoreactive for gastrin as shown by immunocytochemical staining using the avidin-biotin complex method. In this preparation basal gastrin release ranged from 3.3 +/- 0.3 to 4.1 +/- 0.3% of total cellular content. Maximal gastrin release in response to the acetylcholine receptor agonist carbachol (10(-4) M) or the selective muscarinic receptor agonist arecaidine propargyl ester (10(-4) M) was 8.5 +/- 0.4% and 7.6 +/- 0.4% of total cellular content, respectively. The EC50 values were 3.7 +/- 0.5 x 10(-6) M carbachol and 1.8 +/- 0.4 x 10(-6) M arecaidine propargyl ester. At a concentration of 10(-6) M the non-selective muscarinic receptor antagonist atropine and the muscarinic M3 receptor preferring antagonist hexahydro-sila-difenidol (HHSiD; M3 > or = M1 > M2) completely inhibited gastrin release in response to carbachol (Ki values: 52 x 10(-9) M atropine and 29 x 10(-9) M HHSiD) and arecaidine propargyl ester (Ki values: 11 x 10(-9) M atropine and 13 x 10(-9) M HHSiD).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of bombesin antagonist D-Phe6-BN(6-13)OMe on vagally induced gastrin release from perfused rat stomach

The aim of the present study was to evaluate the effect of the bombesin antagonist D-Phe6-BN(6-13)OMe (BN-antagonist) on vagally stimulated gastrin release from the isolated rat stomach, which was perfused via the celiac artery with Krebs-Ringer buffer. Vagal stimulation was performed for 10 minutes with 1 ms, 10 V and 10 or 2 Hz, respectively. Gastrin secretion increased significantly during stimulation with 10 and 2 Hz. BN-antagonist was added to the perfusate at the concentration of 10(-6) M, which induced a significant reduction of vagally stimulated gastrin release at 10 Hz (619 +/- 65 vs. 252 +/- 62 pg/10 min, p < 0.05), but not at 2 Hz (564 +/- 117 vs. 493 +/- 113 pg/10 min, p > 0.05). In contrast, atropine (10(-7) M) reduced significantly the gastrin response at 2 Hz (270 +/- 78 pg/10 min, p < 0.01), but not at 10 Hz (446 +/- 87 pg/10 min, p > 0.05). The combination of BN-antagonist and atropine elicited an inhibition of vagally stimulated gastrin release similar to each substance when given alone. Basal gastrin release was not changed by the BN-antagonist. The present data suggest, that in the rat stomach endogenously released bombesin-related peptides contribute to the noncholinergic stimulation of gastrin release at higher stimulation frequencies (10 Hz), however, bombesin-related peptides are not involved, when lower stimulation frequencies (2 Hz) are employed. At both stimulation frequencies additional mechanisms are activated which are noncholinergic and not related to bombesin peptides.

Contribution of neural intrapancreatic non-cholinergic non-adrenergic mechanisms to glucose-induced insulin release in the isolated rat pancreas

In the isolated rat pancreas the effect of intrapancreatic non-adrenergic non-cholinergic nerves was examined upon insulin, glucagon and somatostatin release during perturbations of perfusate glucose. Elevation of glucose from 1.6 to 8.3 mmol/l increased insulin and somatostatin secretion and inhibited glucagon release. The first phase of insulin secretion was significantly reduced by the neurotoxin tetrodotoxin to 55% of the controls (p < 0.05). The somatostatin response was attenuated by tetrodotoxin while the change of glucagon remained unaffected. In contrast the combined adrenergic and cholinergic blockade with atropine, phentolamine and propranolol (10(-5) mol/l) did not modify the insulin, glucagon and somatostatin response. When glucose was changed from 8.3 to 1.6 mmol/l, the reduction of insulin and somatostatin release was not modified by tetrodotoxin, but stimulation of glucagon was significantly attenuated by 60-70% (p < 0.03), which was similar to the effect of combined adrenergic and cholinergic blockade. Subsequently, the effect of neural blockade was examined during more physiological perturbations of perfusate glucose levels. When glucose was changed from 3.9 to 7.2 mmol/l, tetrodotoxin also attenuated first phase insulin response by 40% while cholinergic and adrenergic blockade had no effect. The nitric oxide synthase inhibitor NG-Nitro-L-arginine-methyl-ester (L-NAME) did not alter the glucose-induced insulin response indicating that nitric oxide is not involved in this mechanism. It is concluded that neural non-adrenergic non-cholinergic mechanisms contribute to the first, but not second phase of glucose-induced insulin release. Non-adrenergic non-cholinergic effects do not participate in regulation of glucagon and somatostatin secretion under the conditions employed.(ABSTRACT TRUNCATED AT 250 WORDS)

GLP-1-(7-36) amide, -(1-37), and -(1-36) amide: potent cAMP-dependent stimuli of rat parietal cell function

We investigated the effect of glucagon-like peptide 1 (GLP-1)-(7-36) amide and its molecular variants GLP-1-(1-37) and GLP-1-(1-36) amide on enzymatically dispersed enriched rat parietal cells using [14C]aminopyrine accumulation as a measure of H+ production. GLP-1-(7-36) amide was 100 times more potent than GLP-1-(1-37) and GLP-1-(1-36) amide in stimulating [14C]aminopyrine accumulation. At their maximally effective concentrations, GLP-1-(7-36) amide (10(-8) M), GLP-1-(1-37) (10(-6) M), and GLP-1-(1-36) amide (10(-6) M) reached 80-90% of the response to 10(-4) M histamine. However, the peptides were 100-10,000 times more potent than histamine, which induced maximal [14C]aminopyrine accumulation at 10(-4) M. Stimulation by GLP-1 was dependent on the presence of a phosphodiesterase inhibitor and was not altered by pertussis toxin. Ranitidine failed to affect the response to the GLP-1 variants. Stimulation of H+ production by GLP-1 was accompanied by an increase in the formation of adenosine 3',5'-cyclic monophosphate (cAMP) but not by changes in phosphoinositol breakdown. In stimulating [14C]aminopyrine accumulation, the GLP-1 variants acted additively to threshold but not to maximal concentrations of histamine, suggesting that histamine and GLP-1 activate the same cAMP pool. In contrast, in anesthetized rats GLP-1-(7-36) amide (10-500 ng.kg-1.h-1) had no effect on basal and pentagastrin-stimulated acid secretion in vivo. We conclude that GLP-1 exerts a direct stimulatory effect on rat parietal cells. This potent effect is mediated by cAMP and is independent of H2 receptors. In vivo direct stimulation by GLP-1 of the parietal cells might be counterbalanced by indirect inhibitory mechanisms that are excluded in the in vitro cell system.

Comparison of GLP-1 (7-36amide) and GIP on release of somatostatin-like immunoreactivity and insulin from the isolated rat pancreas

The effect of equimolar doses of GIP and GLP-1 (7-36amide) on insulin and somatostatin secretion in the isolated perfused rat pancreas was compared. At a perfusate glucose concentration of 70 mg/dl GLP-1 (7-36amide) 10(-9) and 10(-8) M and GIP 10(-9) M elicited a significant stimulation of insulin while GIP 10(-8) M and lower doses of both peptides (10(-11) and 10(-10) M) were ineffective. At elevated perfusate glucose levels of 150 mg/dl both peptides stimulated insulin release at 10(-11), 10(-10), 10(-9) and 10(-8) M but not at 10(-12) M. The insulin response at the higher glucose level was significantly greater compared to the effect of the same doses at normoglycemic conditions. Somatostatin release was stimulated significantly by GLP-1 (7-36amide) at 10(-10) and 10(-9) M at perfusate glucose level 70 mg/dl. At a glucose concentration of 150 mg/dl this effect was abolished. GIP did not alter somatostatin release at a perfusate glucose concentration of 70 mg/dl while at 150 mg/dl only the highest dose of GIP (10(-8) M) stimulated somatostatin release significantly. In conclusion, the present data demonstrate that in vitro in the rat pancreas both peptides are equally effective secretagogues of insulin release at normal and moderately elevated perfusate glucose levels. In contrast, somatostatin secretion is stimulated by GLP-1 (7-36amide) at normoglycemic conditions while only a rather high and presumably pharmacological dose of GIP is a stimulus of somatostatin secretion at moderate hyperglycemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of naloxone on vagally-induced gastric acid secretion in rats

Previous studies in man and dogs have demonstrated that endogenous opioids participate in the stimulation of cephalic phase gastric acid secretion during indirect activation of the vagus. Since the effect of naloxone during direct vagal activation is unknown gastric acid secretion was assessed during electrical stimulation of the distal cut ends of both vagal nerves. In overnight fasted anesthetized rats the distal ends of the bisectioned cervical vagi were stimulated with 10V, 5Hz, 5 msec for 15 min. Vagal stimulation elicited an increase of gastric acid secretion by 5.6 mumol/min. Naloxone (1 mumol/kg.h) augmented gastric acid secretion significantly. Since this effect of naloxone was in contrast to previous data possible mechanisms of action of naloxone were examined that might help to explain this apparently inhibitory action of endogenous opioids on vagally-induced gastric acid secretion. The additional infusion of atropine or hexamethonium abolished the stimulatory effect of naloxone on vagally-induced acid secretion completely indicating that the action of naloxone depends on cholinergic background activity. Combined blockade of alpha- and beta-adrenergic receptors with phetolamine and propanolol reduced vagally-induced acid secretion in controls and during naloxone to a similar degree. Both adrenergic blocking agents also reduced the residual acid secretion observed during atropine or atropine + naloxone infusion. Measurements of plasma gastrin levels suggested that the naloxone-induced changes of acid secretion were not due to alterations of gastrin secretion. In summary these data demonstrate that vagally-induced acid secretion in anesthetized rats is largely due to cholinergic mechanisms with a small but separate contribution of adrenergic mechanisms. Endogenous opioids are activated during peripheral vagal stimulation attenuating vagally-induced acid secretion by modulation of cholinergic but not adrenergic mechanisms.

[Somatostatin and opioids, secretin and VIP--protectors of the mucosa?]

Somatostatin is located predominantly in D-cells of the antral and fundic area of the stomach and in the duodenal bulb. Furthermore, somatostatin is contained in neurons of the extrinsic and intrinsic nervous system. Somatostatin inhibits gastric acid, pepsin and gastrin secretion, and it stimulates gastric mucous secretion. All in all, somatostatin could exert protection of the gastric mucosa by reduction of aggressive and augmentation of protective mechanisms. There is, however, no evidence for a role of somatostatin in the pathogenesis of peptic ulcer. Endogenous opioids which have to be considered as potential peptidergic neurotransmitters increase vagal and postprandial gastric acid secretion and accordingly cannot be considered as a protective factor. Vasoactive intestinal peptide (VIP), also a peptidergic neurotransmitter, reduces acid and stimulates mucous and bicarbonate secretion. If this is of physiological relevance remains to be established. Secretin might be a protective factor for the gastric mucosa by stimulating mucous and bicarbonate secretion. On the other hand, it augments pepsin secretion which might attenuate any potential protective effects of secretin.

Interaction between endogenous opioids, cholinergic and adrenergic mechanisms during vagally-induced gastrin release in rats

Endogenous opioids are present in neurons of the vagus and the intrinsic nervous system and they are colocalized with gastrin in antral G-cells. This raises the possibility that endogenous opioids modulate gastrin release. Stimulation of both cervical vagi (10V, 5Hz, 5ms) elicited an increase of arterial plasma gastrin levels at intragastric pH7 or pH2. The response at pH2 was 30% of that at luminal pH7. Atropine reduced vagally stimulated gastrin levels substantially. At luminal pH2 the small residual noncholinergic response was mediated neither by adrenergic mechanisms nor by endogenous opioids. At luminal pH 7 adrenergic blockade with phentolamine and propranolol reduced vagally stimulated gastrin by 60%. In the presence of atropine adrenergic blockade elicited only a small inhibitory effect suggesting that vagal activation of adrenergic mechanisms depends on atropine-sensitive cholinergic pathways. Blockade of opiate receptors by naloxone had no effect on vagal gastrin release, however, the noncholinergic gastrin response was reduced significantly by naloxone, suggesting that cholinergic mechanisms normally restrain activation of endogenous opioids during vagal stimulation. Naloxone had no effect on the noncholinergic, nonadrenergic stimulation of gastrin levels. These data suggest that endogenous opioids can contribute to vagal gastrin release provided the cholinergic restraint is blocked and adrenergic mechanisms stimulate endogenous opioids. In conclusion a major role of endogenous opioids in the regulation of vagal gastrin release can not be detected.