Mechanism of Action of Brodalumab May Correlate With Efficacy in Patients With Inflammatory Skin Diseases

Biologic therapy is used for systemic treatment of multiple inflammatory conditions, including moderate-to-severe plaque psoriasis. Brodalumab is an interleukin-17 (IL-17) receptor A antagonist indicated for the treatment of moderate-to-severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy and have failed to respond or have lost response to other systemic therapies. The unique mechanism of action of brodalumab, which blocks signaling mediated by multiple IL-17 family members, may play a key role in the overall efficacy, including in patients whose disease did not respond to other biologics. In this narrative review, we discuss the mechanism of action of brodalumab in inflammatory skin conditions, exploring how it relates to clinical and real-world efficacy, rescued responses after IL-17A inhibitor failure, and improvements in mental health and quality of life. J Drugs Dermatol. 2023;22(10):994-1000 doi:10.36849/JDD.7701.

Evaluation and Management of the Dysesthetic Patient

Dysesthesia is symptomatology that includes, but is not limited to, sensations of pain, burning, crawling, biting, numbness, piercing, pulling, cold, shock-like, pulling, wetness, and heat. These sensations can cause significant emotional distress and functional impairment in affected individuals. While some cases of dysesthesias are secondary to organic etiologies, most cases exist without an identifiable infectious, inflammatory, autoimmune, metabolic, or neoplastic process. Ongoing vigilance is required for concurrent or evolving processes, including paraneoplastic presentations. Elusive etiologies, unclear treatment regimens, and stigmata leave patients and clinicians with a difficult path forward marked by "doctor shopping," lack of treatment, and significant psychosocial distress. We addresses this symptomatology and the psychosocial burden that often comes with it. Although notoriously labeled as "difficult to treat," dysesthesia patients can be effectively managed, making life-changing relief possible for patients.

The Use of Brodalumab in Three Patients with Psoriasis and Psychiatric Comorbidities

Brodalumab, a first-in-class interleukin-17 (IL-17) receptor blocker, carries a black box warning for suicidal ideation and behavior, yet it is also one of the most powerful biologic agents in our armamentarium. We wish to highlight three patients with moderate-to-severe psoriasis and comorbid depression who were successfully treated with brodalumab. The patients were chosen by an expert panel comprising dermatologists, psychiatrists, and psychologists. Psoriasis disease severity was measured using the Psoriasis Area and Severity Index (PASI) score. All three patients experienced PASI 100 after treatment with brodalumab (N=3). Importantly, depressive symptoms improved or resolved in two out of three patients. One patient, who had a history of psychiatric hospitalizations, required in-patient psychiatric treatment during treatment. The use of brodalumab in patients with psoriasis can provide rapid-onset improvement in both skin and depressive symptoms.

A robust method for shift detection in time series

We present a robust and nonparametric test for the presence of a changepoint in a time series, based on the two-sample Hodges–Lehmann estimator. We develop new limit theory for a class of statistics based on two-sample U-quantile processes in the case of short-range dependent observations. Using this theory, we derive the asymptotic distribution of our test statistic under the null hypothesis of a constant level. The proposed test shows better overall performance under normal, heavy-tailed and skewed distributions than several other modifications of the popular cumulative sums test based on U-statistics, one-sample U-quantiles or M-estimation. The new theory does not involve moment conditions, so any transform of the observed process can be used to test the stability of higher-order characteristics such as variability, skewness and kurtosis.

Patient-perceived Emotional and Functional Benefits of Poly-L-Lactic Acid (PLLA) for the Treatment of Facial Volume Loss

Background: Facial volume loss can substantially impact self-perception of the affected individual and his to her social/professional interactions and opportunities. Persons who are perceived as more youthful and attractive are rated as nicer, more energetic, healthier, and more likely to be productive than those perceived to be older and unattractive. Objective: The goal of this study was to assess the changes in emotional and functional status of subjects treated with 2 to 4 monthly PLLA injections to the upper, mid, and lower face. Methods: Fifty subjects were recruited from two community dermatology centers in the United States (Bucks County, Pennsylvania, and Spokane, Washington). Two patient self-report measures were used-The Facial Volume Restoration Outcome Questionnaire and the Rosenberg Self Esteem Scale. Results: Approximately 30 percent of the subjects who completed pre- and post-injection instruments reported increased confidence, increased sense of control, more comfort with others, increased happiness when looking in the mirror, more happiness when their faces were touched, healthier eating, increased contentment, beliefs that they were seen as less stressed by others, increased happiness with their bodies, exercising more, and that their lives were better. Additionally, 43 percent felt more optimistic and 33 percent felt less anxious. The changes in self-esteem, which was self-reported on the Rosenberg scale, were very modest but also favorable. Investigator's Global Assessment (IGA) of facial volume loss improved from 2.2 at baseline to 1.2 at six-month follow-up assessment. Conclusion: Treatment of facial volume loss with PLLA was associated with improvements in patient-perceived emotional and functional status at six months after initial injection.

Executive functioning in high-IQ adults with ADHD

BACKGROUND

To examine the association between psychological tests of executive functioning and functional outcomes among high-IQ adults with attention deficit hyperactivity disorder (ADHD).

METHOD

Subjects were high-IQ adults with (n=64) and without ADHD (n=53). Subjects were administered a battery of neuropsychological tests assessing executive functioning.

RESULTS

High-IQ adults with ADHD performed less well than those without ADHD on several psychological tests of executive functioning, including the Wisconsin Card Sorting Test (WCST), Stroop Color and Word Test, Rey-Osterrieth Complex Figure Test (ROCF), California Verbal Learning Test (CVLT) and an auditory continuous performance test (CPT). Test performance in the high-IQ adult ADHD group, however, was average. In the entire sample, performance on several tests of executive functioning including the ROCF and the CVLT were significant predictors of real-world functioning.

CONCLUSIONS

High-IQ adults with ADHD perform less well on tests of executive functioning relative to high-IQ control participants. Performance on several tests of executive functioning was a significant predictor of functioning.

Tretinoin gel microsphere pump 0.04% plus 5% benzoyl peroxide wash for treatment of acne vulgaris: morning/morning regimen is as effective and safe as morning/evening regimen

Topical tretinoin and benzoyl peroxide (BPO) are often prescribed in combination for the treatment of acne vulgaris; however, these products have not traditionally been administered simultaneously because of the potential for tretinoin degradation by BPO as well as the instability of tretinoin in daylight. The primary objective of this randomized, investigator-blinded, 12-week, phase 4 trial was to determine non-inferiority of a once-daily morning combination regimen of 5% BPO wash + tretinoin gel microsphere (TGM) 0.04% pump versus a sequential regimen (BPO in the morning/TGM in the evening) in patients > or = 12 years old with moderate facial acne vulgaris. The primary efficacy endpoint was the change from baseline in total acne lesions; the primary safety endpoint was the change in cutaneous irritation scores. The 247 participants (mean age: 18.5 years) were randomized to either the morning/morning regimen (n = 123) or the morning/evening regimen (n = 124). The morning/morning regimen was determined to be non-inferior to the morning/evening regimen in reduction of total acne lesions. The tolerability of both regimens was comparable. The morning/morning regimen is a safe and effective treatment option for patients with moderate acne vulgaris.

Psychosocial sequelae related to acne: looking beyond the physical

The emotional impact of acne is influenced by numerous factors including age, psychosocial factors, severity of disease, social and familial networks and patient specific personalities. Adolescents are an emotionally vulnerable population, and acne can significantly burden their psychological resources. Looking beyond the physical manifestations of acne can add valuable clinical information aiding clinicians in choosing the most beneficial treatment regimens. Patients at high risk for psychological and/or physical harm can in need of psychiatric referral can also be better recognized.

Acne quality of life and patient satisfaction following treatment with tretinoin pump

Patient satisfaction and quality of life are important considerations when assessing products used to treat acne vulgaris, as these factors may affect treatment adherence and subsequent treatment outcomes. The objective of this analysis was to determine patient satisfaction and improvement in quality of life after treatment with tretinoin gel microsphere (TGM) in a pump dispenser. Assessments were made during a phase IV, prospective, 12-week, open-label, community-based trial in which 544 patients who were dissatisfied with their current acne treatments received TGM 0.04% or 0.1% in addition to < or = 2 concurrent non-retinoid acne therapies. At week 12, significant improvement was reported in both patient acne therapy satisfaction and in the overall mean Acne Quality of Life Index scale (P < 0.0001 versus baseline for both measures). The majority of patients (82.3%) rated the pump dispenser as an "excellent" or "very good" means of dispensing medication, and 86.0% rated their overall satisfaction with the pump treatment application as "very satisfied" or "extremely satisfied." The results of this study indicate that the use of TGM in a pump dispenser in patients with acne vulgaris is associated with significant increases in both quality of life and patient satisfaction.

Depression and quality of life in psoriasis

Psoriasis is a chronic inflammatory hyperproliferative disease of the skin, scalp, nails, and joints. The physical symptoms of psoriasis include itching, irritation, burning/stinging, sensitivity, and pain. Patients also suffer psychological distress, especially as a result of stigmatization, self-consciousness, and embarrassment, which can in turn affect employment and social activities. Relatively high rates of depression are reported in patients with psoriasis. Inflammatory cytokines such as tumor necrosis factor alpha, interferon gamma, and other type 1 cytokines play an important role in the pathogenesis and comorbidities of psoriasis. Data from both animal and human studies suggest that these cytokines are linked to depression. Some psoriasis treatments have demonstrated improvements in symptoms of psoriasis as well as in measures of depression and health-related quality of life. Physicians managing patients with psoriasis must be aware of the psychological effects of psoriasis and need to use a multifaceted approach to managing this disease, focusing on both the physical and psychological aspects.

Is adult attention deficit hyperactivity disorder a valid diagnosis in the presence of high IQ?

BACKGROUND

Because the diagnosis of attention deficit hyperactivity disorder (ADHD) in higher education settings is rapidly becoming a contentious issue, particularly among patients with high IQs, we sought to assess the validity of diagnosing ADHD in high-IQ adults and to further characterize the clinical features associated with their ADHD.

METHOD

We operationalized high IQ as having a full-scale IQ120. We identified 53 adults with a high IQ who did not have ADHD and 64 adults with a high IQ who met diagnostic criteria for ADHD. Groups did not differ on IQ, socio-economic status or gender.

RESULTS

High-IQ adults with ADHD reported a lower quality of life, had poorer familial and occupational functioning, and had more functional impairments, including more speeding tickets, accidents and arrests. Major depressive disorder, obsessive-compulsive disorder and generalized anxiety disorder diagnoses were higher in high-IQ adults with ADHD. All other psychiatric co-morbidities, including antisocial personality disorder and substance abuse, did not differ between the two high-IQ groups. ADHD was more prevalent in first-degree relatives of adults with ADHD relative to controls.

CONCLUSIONS

Our data suggest that adults with ADHD and a high IQ display patterns of functional impairments, familiality and psychiatric co-morbidities that parallel those found in the average-IQ adult ADHD population.

Neurocognitive impairment in unaffected siblings of youth with bipolar disorder

BACKGROUND

There is growing evidence for the familiality of pediatric bipolar disorder (BPD) and its association with impairments on measures of processing speed, verbal learning and 'executive' functions. The current study investigated whether these neurocognitive impairments index the familial risk underlying the diagnosis.

METHOD

Subjects were 170 youth with BPD (mean age 12.3 years), their 118 non-mood-disordered siblings and 79 non-mood-disordered controls. Groups were compared on a battery of neuropsychological tests from the Wechsler Intelligence Scales, the Stroop Color Word Test, the Wisconsin Card Sorting Test (WCST), the Rey-Osterrieth Complex Figure (ROCF), an auditory working memory Continuous Performance Test (CPT) and the California Verbal Learning Test-Children's Version (CVLT-C). Measures were factor analyzed for data reduction purposes. All analyses controlled for age, sex and attention-deficit/hyperactivity disorder (ADHD).

RESULTS

Principal components analyses with a promax rotation yielded three factors reflecting: (1) processing speed/verbal learning, (2) working memory/interference control and (3) abstract problem solving. The CPT working memory measure with interference filtering demands (WM INT) was only administered to subjects aged > or =12 years and was therefore analyzed separately. BPD youth showed impairments versus controls and unaffected relatives on all three factors and on the WM INT. Unaffected relatives exhibited impairments versus controls on the abstract problem-solving factor and the WM INT. They also showed a statistical trend (p=0.07) towards worse performance on the working memory/interference control factor.

CONCLUSIONS

Neurocognitive impairments in executive functions may reflect the familial neurobiological risk mechanisms underlying pediatric BPD and may have utility as endophenotypes in molecular genetic studies of the condition.

Phase 4 study to assess tretinoin pump for the treatment of facial acne

It is well known that the setting of clinical trials for registration studies do not necessarily represent efficacy seen in clinical practice, where physicians have the flexibility to select, combine, and change the acne treatment prescription. In this phase 4, open-label, multicenter, community-based study, 544 patients who were dissatisfied with their current acne treatment received tretinoin gel microsphere (TGM) 0.04% or 0.1% in a pump dispenser for 12 weeks. Patients were allowed the use of up to 2 other concurrent acne therapies, not including other retinoids. A total of 361 patients received TGM 0.04% and 183 received TGM 0.1%. Compliance was high (defined as 75% to 100% of prescribed doses taken) for approximately 95% of patients in both groups at every evaluation. At week 12, the mean modified Global Acne Grade score (mGAGs) and the investigator global evaluation (IGE) demonstrated significant (P<.0001) improvement from baseline for both concentrations, with 72% having at least moderate improvement. In approximately 25% of patients, acne was assessed as cleared or almost cleared. Most side effects were characteristic of topical retinoids. These results indicate TGM in a pump dispenser as an effective, well-tolerated acne treatment that is associated with a high rate of compliance.

Stability of executive function deficits into young adult years: a prospective longitudinal follow-up study of grown up males with ADHD

OBJECTIVE

Although individuals with attention deficit-hyperactivity disorder (ADHD) commonly exhibit deficits in executive functions that greatly increase the morbidity of the disorder, all available information on the subject is cross sectional.

METHOD

Males (n = 85) 9-22 years with ADHD followed over 7 years into young adulthood were assessed on measures of sustained attention/vigilance, planning and organization, response inhibition, set shifting and categorization, selective attention and visual scanning, verbal and visual learning, and memory. A binary definition of executive function deficits (EFDs) was defined based on a subject manifesting at least two abnormal tests 1.5 standard deviations from controls.

RESULTS

The majority of subjects maintained EFDs over time (kappa: 0.41, P < 0.001; sensitivity: 55%, specificity: 85%, positive predictive value: 69%, and negative predictive value: 75%).

CONCLUSION

Considering the morbidity of EFDs, these findings stress the importance of their early recognition for prevention and early intervention strategies. EFDs are stable over time.

Exploratory analysis and a stochastic model for humusdisintegration

Ulrich (1981) supposes in the hypothesis of humusdisintegration that the balance between polymerisation and breakdown of organic material may be disturbed in chemically well buffered European forest soils. This new aspect of aluminium toxicity may cause nitrogen exceedance in forest ecosystems and subsequent seasonal nitrate output (Eichhorn and Hutterman, 1999). In a research program the substances in the seepage water are monitored in a small woodland in central Germany. We explore these multivariate data for examining possible influences on the process of humusdisintegration and its temporal evolution. As a result, a regression model for carbon is developed, which includes covariables, i.e., other substances, as well as spatial and temporal terms describing systematic variability. Especially iron and aluminium turn out to be very influential in the model. So far our work is a basic step for monitoring the seepage water data by means of stochastic modelling.

Dimension reduction for highdimensional online-monitoring data in intensive care

Nowadays high dimensional data in intensive care medicine can be captured, stored, and retrieved with the help of clinical information systems. Intelligent alarm systems are needed for an adequate bedside decision support, in the course of which the detection of qualitative patterns in physiologic monitoring data such as outliers, level changes, or trends aims at a proper classification of the patients state. Statistical time series techniques have already been applied successfully to the analysis of single physiological variables. The simultaneous online analysis of the multivariate patient curve yields further challenges. We describe methods for reducing the dimension and for keeping the computational efforts necessary for monitoring low. We present preliminary results of an ongoing study on monitoring critically ill patients.

Online pattern recognition in intensive care medicine

In intensive care physiological variables of the critical-ly ill are measured and recorded in short time intervals. The existing alarm systems based on fixed thresholds produce a large number of false alarms. Usually the change of a variable over time is more informative than one pathological value at a particular time point. Intelligent alarm systems which detect important changes within a physiological time series are needed for suitable bedside decision support. There are various approaches to modeling time-dependent data and also several methodologies for pattern detection in time series. We compare several methodologies de-signed for online detection of measurement artifacts, level changes, and trends for a proper classification of the patient s state by means of a comparative case-study.

Evaluation of magnetic resonance cholangiography in the management of bile duct stones

HYPOTHESIS

Magnetic resonance cholangiography (MRC) offers the potential for accurate, noninvasive detection of common bile duct stones (CBDSs) before cholecystectomy, and for a consequent reduction in the incidence of preoperative negative diagnoses associated with endoscopic retrograde cholangiography (ERC).

DESIGN

Prospective cohort study: MRC results were correlated with ERC (high-risk patients) or intraoperative cholangiography (moderate-risk patients).

SETTING

A university hospital providing primary, secondary, and tertiary care.

PATIENTS

Seventy patients with suspected CBDSs scheduled to undergo elective cholecystectomy between April 15, 1997, and September 30, 1998. Forty patients were considered at high risk and 30 at moderate risk for CBDSs, according to results of liver function tests and sonograms of the upper abdomen.

MAIN OUTCOME MEASURES

Confirmation or exclusion of CBDSs by MRC was assessed by a panel of radiologists who were unaware of the ERC results. Results of ERC and intraoperative cholangiography were analyzed by the investigating gastroenterologists or surgeon.

RESULTS

Results of MRC were positive for CBDSs in 21 (52%) of 40 high-risk patients, a finding confirmed by preoperative ERC in 19 (90%) of 21 patients. Results of MRC were positive for CBDSs in 6 (20%) of 30 moderate-risk patients, all of which were confirmed by intraoperative cholangiography. Finally, CBDSs were present in 19 (48%) of 40 high-risk patients and 6 (20%) of 30 moderate-risk patients (P = .02). Overall sensitivity and specificity of MRC were 100% and 95.6%, respectively; the positive and negative predictive values were 92.6% and 100%, respectively.

CONCLUSIONS

Magnetic resonance cholangiography is a reliable, noninvasive method for the detection or exclusion of CBDSs, and seems to reduce the frequency of negative diagnoses associated with ERC. Magnetic resonance cholangiography revealed no CBDSs in 19 (48%) of 40 patients at high risk for CBDSs. Thus, MRC-based diagnosis has the potential to reduce the number of invasive preoperative diagnostic procedures and their associated risks and overall health care costs.

[The aspiration and swallowing of foreign bodies. The management of the aspiration or swallowing of foreign bodies during dental treatment]

The purpose of this article is to draw attention to the possible complications of foreign body ingestion or aspiration associated with dental treatment, especially oral implant treatment. A guide for the management of swallowed or inhaled objects is given. When the object cannot be coughed out, then it is mandatory to take frontal and lateral chest roentgenograms to identify the object's position in the intestinal system or in the tracheobronchial tree. In case of ingestion, attempts should be made to recover the foreign object by esophagoscopy. Aspirated foreign bodies should be removed within 24 hours. Acute obstruction can be life threatening and delaying the removal of foreign objects may make a bronchoscopy technically more difficult. The clinician must be aware of the complications involved in accidentally inhaling or ingesting foreign bodies during dental treatment. Patients at greater risk of swallowing or aspirating foreign objects need to be identified and extra preventive steps must be taken to avoid such complications.

[Pruritus in liver disease: case report with discussion]

In this article a young woman presenting with generalized pruritus and elevated liver enzymes is described. The broad differential diagnosis is discussed. We observed the appearance of antimitochondrial antibodies (AMA) and the diagnosis of early primary biliary cirrhosis (PBC) could be established and documented histologically. The case report concludes with the discussion of the therapeutical possibilities for PBC.

Hemodynamic effects of the somatostatin analog lanreotide in humans: placebo-controlled, cross-over dose-ranging Echo-Doppler study

Because of their vasoactive effects, somatostatin and its analogs are increasingly used in the management of complications of chronic liver diseases such as variceal bleeding. Postprandial hyperemia augments splanchnic blood flow, subsequently increasing portal pressure. The aim of this study was to explore effects of the somatostatin analog, lanreotide, on food-stimulated hemodynamic parameters in healthy human subjects. A dose-response curve was constructed in eight healthy male subjects in a placebo-controlled cross-over study. On 4 different days, either 0 (placebo), 50, 100, or 200 microg/h of lanreotide was infused intravenously in random order, starting at 45 minutes for 7 hours. On each day, a liquid test meal (Ensure plus, 1.5 kcal/mL) was perfused intraduodenally at a rate of 3 mL/min over 7 hours after a 45-minute basal period. Diastolic arterial pressure (dBP), heart rate (HR), superior mesenteric arterial (SMA) average flow velocity (SMA-V), SMA pulsatility index (SMA-PI), portal venous volume flow (PV-F), and renal artery (RA) resistance index (RA-RI) were measured on regular intervals (flows using Echo-Doppler technology). Lanreotide at all doses abolished food-stimulated splanchnic hyperemia both in the SMA and PV over 7 hours. The fall in dBP and increase in HR after food perfusion were blunted under lanreotide. Food as well as lanreotide did not modify RA-RI. In summary: 1) lanreotide inhibits food-induced splanchnic hyperemia in normal subjects; 2) in parallel, systemic hemodynamic alterations to food stimulation are abolished with lanreotide; and 3) renal vascular resistance is unchanged. Because of its persistent splanchnic vasoconstrictive effect, lanreotide should be tested in patients with portal hypertension.

Celiac disease transmitted by allogeneic non-T cell-depleted bone marrow transplantation

We observed the occurrence of celiac disease following allogeneic bone marrow transplantation in a patient transplanted for acute leukemia. The marrow donor was his HLA-identical sister, who had suffered from celiac disease since birth. The post-transplant period was characterized by recurrent episodes of diarrhea. Detailed workup showed atrophic intestinal mucosa on histology and anti-gliadin and anti-endomysium antibodies in the serum, features that were not present before transplantation. GVHD was absent at that time. The patient remains free of symptoms on gluten-free diet and slight immunosuppression. This case suggests transmission of celiac disease by bone marrow transplantation and supports the T cell concept in celiac disease.

[External quality control in the medical laboratory: evaluation of 12 ring trials 1994-1996]

The regulations for reimbursement of laboratory tests provide that such tests will be paid for by social insurance institutions only if the laboratories participate in internal and external quality control schemes. Twelve surveys of the external quality assessment scheme of MQ Zürich (Association for Medical Quality Control) were evaluated. We analyzed the imprecision and inaccuracy of the participant results depending on the analytical system or methods used. Furthermore, the number of participants who met the quality criteria published by FKGRAL (Expert Committee for Overall Revision of Analysis List) was determined. The deviations from the internationally recommended or reference methods respectively were within +/-33% for the metabolites and enzymes if native plasma was used as control sample. If lyophilized samples were used, 5 deviations observed were > +/-33% (maximum +99%). For hematologic parameters the deviations were in the range of +/-10%. The CV's were 5.7-17.6% for wet chemistry methods used by the participants and 4.5-15.1% for the other methods. (Cobas Ready, Ektachem, Reflotron, Vision). For hematologic parameters we found CV's between 4.5 and 14.0%. 69-83% of the participants using wet chemistry methods met the FKGRAL criteria, while 86-98% of participants using one of the other system obtained adequate results. The corresponding figure for the hematologic parameters was 83-93%. The nature of the control samples (native samples or lyophilizate) did not influence the number of participants who successfully passed the survey. The study showed that the surveys are an adequate tool for determining participants with inadequate analytical performance, and in many cases the survey results make it possible to propose the necessary educative measures.

Pseudopsychodermatologic disease

Just as psychodermatologic disorders can mimic real dermatologic conditions, real dermatologic or other bona fide physical problems such as neurologic disorders can also mimic psychodermatologic disorders. This article illustrates several cases of pseudopsychodermatologic disorders. When faced with a difficult patient or baffling case, sometimes there is a tendency to "jump to conclusions" with regard to the psychogenic origins of the case. It is important to be cognizant of the possibility that one may be missing a real organic disorder if one does not keep an open mind with regard to diagnosis of the patient's skin condition.

Early glycogenolysis and late glycogenesis in human liver after intravenous administration of galactose

Galactose is incorporated by a different metabolic pathway than glucose. Its contribution to glycogen synthesis has not been studied in humans. We administered galactose (0.5 g/kg iv) to overnight-fasted normal human volunteers and examined its effects on hepatic glycogen synthesis and hepatic glucose output (HGO). Hepatic glycogenesis was assessed noninvasively, determining glycogen concentration by 13C magnetic resonance spectroscopy (MRS) and liver volume by magnetic resonance imaging. HGO was determined by [6,6-2H2]glucose and gluconeogenesis calculated by adding the amount of hepatic glycogenesis to the HGO. After galactose administration, liver glycogen concentration (baseline 254 +/- 11 mmol/l) decreased in the first 45 min to 207 +/- 15 mmol/l (P < 0.05) and increased thereafter to 313 +/- 7 mmol/l (P < 0.01). Net hepatic glycogenesis was 101 +/- 12 mmol over 150 min. HGO (baseline 14.3 +/- 1.9 mumol.kg-1.min-1) increased threefold in the first 15 min and then returned to baseline. The average rate of gluconeogenesis was 12.3 mumol.kg-1.min-1. Intravenous galactose leads to an increase in hepatic glycogen and hepatic glucose output in normal humans. Competitive inhibition of UDP-glucose pyrophosphorylase by UDP-galactose could explain the apparent glycogenolysis observed early after galactose administration. 13C MRS in combination with a stable isotope tracer is a noninvasive and safe method to study hepatic carbohydrate metabolism in humans.

Separation of the two most closely related isoenzymes of alkaline phosphatase by two-dimensional electrophoresis

Seminoma is the most frequent testicular germ cell tumor. While effective curative treatment of the disease is available today, there is to date no tumor marker suited for the diagnosis and follow-up. Several authors have suggested that the germ-cell-specific isoenzyme of alkaline phosphatase (GCAP) might be valuable for this purpose. GCAP shows 98% sequence homology with the placental isoenzyme of alkaline phosphatase (PLAP). Both display a high degree of phenotypic heterogeneity. Until now all attempts to raise an antibody reacting specifically with GCAP have failed. Consequently there is no immunological assay that allows the measurement of GCAP in the presence of PLAP. Two-dimensional electrophoresis with a sigmoid immobilized pH-gradient of 3-10 for the first dimension makes it possible to differentiate clearly between these two closely related isoenzymes. Additionally, it resolves their many phenotypic variants. This is of special interest, since malignant transformation affects the glycosylation patterns of many glycoproteins. For the detection of GCAP and PLAP in two-dimensional electrophoresis it is essential to purify the raw tissue extracts thoroughly. A chromatographic method suited for this purpose is presented.

[Helicobacter pylori resistance against metronidazole in Switzerland: implications for eradication therapy?]

Gastroduodenal ulcers are strongly associated with Helicobacter pylori (HP) infection. Successful eradication drastically diminishes ulcer recurrence. Most of the eradication schemes include metronidazole (Flagyl). The present study was designed to establish the metronidazole resistance rate in Switzerland. Antral biopsies were taken in 153 patients with suspected ulcers (115 men, 38 women, mean age 46 +/- 16 [SD] years) during upper endoscopy for bacteriological testing. Metronidazole resistance (> 8 micrograms/ml) was found in 47/153 (31%) of the isolates. Resistance was found in no case to amoxicillin (Clamoxyl) (0/104 = 0%) and only in 3% (2/66) to clarithromycin (Klazid). Metronidazole resistance of HP in a third of the isolates studied is comparable to numbers found in other European countries. These findings raise the question whether eradication schemes including metronidazole without prior sensitivity testing are justified. Amoxicillin and clarithromycin appear to be valid alternatives.

Paraneoplastic pemphigus appearing as bullous pemphigoid-like eruption after palliative radiation therapy

Paraneoplastic pemphigus is a recently described disease in which patients have polymorphous skin lesions suggestive of both erythema multiforme major and pemphigus vulgaris in association with internal neoplasms, especially non-Hodgkin's lymphoma. These patients have characteristic autoantibodies that bind specific epidermal proteins. A Nikolsky-negative bullous pemphigoid-like eruption developed within the radiation therapy field in a 72-year-old man receiving palliative treatment for recurrent large cell lymphoma. The eruption rapidly progressed to a Nikolsky-positive bullous process more typical of pemphigus vulgaris with extensive involvement of respiratory epithelia. Despite aggressive treatment with high-dose corticosteroids and antibiotics, the patient rapidly succumbed. Results of immunofluorescence studies and autopsy findings confirmed the diagnosis of paraneoplastic pemphigus.

Failed endopyelotomy: implications for future surgery on the ureteropelvic junction

During the last 8 years we performed 212 endopyelotomies with an overall success rate of 86%. To determine if the failed endopyelotomies resulted in a more difficult subsequent open corrective procedure, we compared the procedures and outcomes of 15 failed endopyelotomies with 16 control patients undergoing pyeloplasty who had not undergone a previous endopyelotomy. The variables of duration of the surgical procedure, average estimated blood loss, average number of transfusions and average length of hospitalization were analyzed for both groups. No statistically significant differences were detected for any of these variables. We conclude that despite a previously failed endopyelotomy, a subsequent open operation on the ureteropelvic junction, although slightly more difficult, was not associated with an increased morbidity rate nor less successful than de novo pyeloplasty. Therefore, we continue to advocate endopyelotomy as the procedure of choice for obstruction of the ureteropelvic junction.

Noninvasive observation of hepatic glycogen formation in man by 13C MRS after oral and intravenous glucose administration

The formation of glycogen in the liver of normal volunteers was followed noninvasively with 13C magnetic resonance spectroscopy (MRS) under two different conditions: a) intravenous infusion of [1-13C]glucose under hyperglycemic and hyperinsulinemic clamp conditions, and b) oral intake of glucose in the form of a bolus. For the intravenous infusion, [1-13C]glucose with an enrichment level of 99% was employed. The C1 signals of alpha- and beta-glucose could be detected in the human liver already after an infusion period of 8 min. However, an increase in the glycogen signal was observed only after a prolonged infusion of about 60 min. Changes in the glycogen signal correlated well with the time course of insulin and glucagon during the measurement. Experiments showed also that liver glycogen formation in man can be followed noninvasively by 13C-MRS using nonlabeled glucose or [1-13C]glucose with a low level of enrichment (6.6%). The use of nonlabeled glucose may therefore simplify the quantitation of net liver glycogen synthesis since it can be based directly on changes in the natural abundance 13C MRS glycogen signal, avoiding label dilution through the various metabolic pathways of glucose. The glucose uptake, estimated from the increase in the glycogen signal, was consistent with findings from more complex and invasive studies of glucose uptake in the liver. The average liver glycogen concentration in 12 h overnight fasted volunteers (n = 18) without any special dietary preparation was assessed to be 229 +/- 34 mM (minimum = 160 mM; maximum = 274 mM).

[Unusual intestinal manifestations of tuberculosis]

In an 87-year-old Swiss female referred with complaints of bloody diarrhea and weight loss, colonoscopy revealed three ulcers in the rectum and colon. Cultures from the colonic ulcers were positive for Mycobacterium tuberculosis. There was no evidence of pulmonary infection. One week after adequate therapy was begun, a perforation occurred at the rectosigmoid junction. The sigmoid was resected and left-sided colostomy was performed. Seven days after surgery the patient died. Clinical features, diagnosis and morphological changes of intestinal tuberculosis are discussed.