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Cough and wheezing are the predominant symptoms of acute bronchitis. Hitherto, the evaluation of respiratory symptoms was limited to subjective methods such as questionnaires. The main objective of this study was to objectively determine the time course of cough and wheezing in children with acute bronchitis. The impact of nocturnal cough on parent’s quality of life was assessed as secondary outcome. In 36 children (2–8 years), the frequency of nocturnal cough and wheezing was recorded during three nights by automated lung sound monitoring. Additionally, parents completed symptom logs, i.e., the Bronchitis Severity Score (BSS), as well as the Parent-proxy Children’s Acute Cough-specific Quality of Life Questionnaire (PAC-QoL). During the first night, patients had 34.4 ± 52.3 (mean ± SD) cough epochs, which were significantly reduced in night 5 (13.5 ± 26.5; p

Patrick Fischer,1 Volker Gross,1 Johannes Kroenig,2 Andreas Weissflog,3 Olaf Hildebrandt,2 Keywan Sohrabi,1,4 Ulrich Koehler2 1Faculty of Health Sciences, University of Applied Sciences, Giessen, Germany; 2Department of Pneumology, Intensive Care and Sleep Medicine, University Hospital of Marburg and Giessen, Marburg, Germany; 3Clinical Research Department, Thora Tech GmbH, Giessen, Germany; 4Institute for Medical Informatics, Justus-Liebig-University Giessen, Giessen, Germany Purpose: Chronic cough is one of the main symptoms of COPD. Ambulatory objective monitoring provides novel insights into the determinants and characteristics of nighttime cough in COPD.Materials and methods: Nighttime cough was monitored objectively by LEOSound lung sound monitor in patients with stable COPD II–IV. In 30 patients, with 10 patients in each stage group, nighttime cough was analyzed for epoch frequency, epoch severity (epoch length and coughs per epoch), and pattern (productive or nonproductive).Results: Cough was found in all patients ranging from 1 to 294 events over the recording period. In 29 patients, cough epochs were monitored, ranging from 1 to 75 epochs. The highest amount of cough epochs was found in patients with COPD stage III. Active smokers had significantly more productive cough epochs (61%) than nonsmokers (24%).Conclusion: We found a high rate of nighttime cough epochs in patients with COPD, especially in those in stage III. Productive cough was predominantly found in patients with persistent smoking. LEOSound lung sound monitor offers a practical and valuable opportunity to evaluate cough objectively. Keywords: cough, COPD, nighttime, cough-monitor, lung sound, cough epochs&nbsp

Background Crepitus of the knee may mirror structural and functional changes in the joint during motion. Although the magnitude of these sounds increases with greater cartilage damage, it is unclear whether knee joint sounds also reflect joint loading. Methods Twelve healthy volunteers (mean 26 (SD 3.6) years, 7 females) participated in the randomized-balanced crossover study. Knee joint sounds were recorded (linear sampling, 5512 Hz) by means of two microphones, one placed on the medial tibial plateau and one on the patella. Two activities of daily living (standing up from/sitting down on a bench; descending stairs) and three open kinetic chain knee extension-flexion cycles (passive movement, 10% and 40% loading of the individual one repetition maximum) were performed. Each participant carried out three sets of five repetitions and three sets of 15 steps downwards (stairs), respectively. For data analysis, the mean sound amplitude and the median power frequency for each loading condition were determined. Friedman test and Bonferroni-Holm adjusted post-hoc test were performed to detect differences between conditions. Findings We obtained significant differences between joint sound amplitudes for all movements, both measured at the medial tibial plateau (Chi2 = 20.7, p Interpretation Overall, the larger the supposed knee joint loading was, the louder was the recorded knee crepitus. Consequently, vibroarthrographically assessed knee joint sounds can differ across knee joint loading conditions.

Night-time respiratory symptoms have a considerable impact on sleep and life quality in patients with chronic obstructive pulmonary disease (COPD). Lack of awareness of night-time symptoms can lead to worsened COPD control. Automated long-term monitoring of respiratory symptoms with LEOSound enables assessment of nocturnal wheezing and cough.In this observational study we investigated the prevalence and severity of cough and wheezing in patients with stable COPD [Global Initiative for Chronic Obstructive Lung Disease (GOLD) II-IV] disease for two consecutive nights with the LEOSound system. 48 patients (30 males, 63%) were eligible for inclusion, median age was 67 years, and body mass index (BMI) was 25.3 kg/mIn 15 out of 48 patients (31%), we found wheezing periods for at least 10-minute duration. Wheezing periods30 minutes were monitored in seven patients and wheezing periods60 minutes were monitored in three patients. The maximum duration of wheezing was 470 minutes in one patient with COPD II. The median wheezing rate differed between the COPD stages and between active and non-active smokers. Cough was found in 42 patients (87.5%) with a range of 1-326 events. The cough-period-index in night one was 0.83 n/hour (P25:0.33||P75: 2.04) and night two 0.97 n/hour (P25:0.25||P75: 1.9). Most of the cough events were non-productive with a median of 0.86.Night-time symptoms are common in COPD patients. LEOSound offers an opportunity to evaluate objectively night-time symptoms like wheezing and cough in patients with COPD which remain otherwise unnoticed. We found a high incidence of night-time wheezing in these patients, which was related to persistant smoking.

Changes in normal lung sounds are an important sign of pathophysiological processes in the bronchial system and lung tissue. For the diagnosis of bronchial asthma, coughing and wheezing are important symptoms that indicate the existence of obstruction. In particular, nocturnal long-term acoustic monitoring and assessment make sense for qualitative and quantitative detection and documentation. Previous methods used for lung function diagnosis require active patient cooperation that is not possible during sleep. We developed a mobile device based on the CORSA standard that allows the recording of respiratory sounds throughout the night. To date, we have recorded 133 patients with different diagnoses (80 male, 53 female), of whom 38 were children. In 68 of the patients we could detect cough events and in 87 we detected wheezing. The recording method was tolerated by all participating adults and children. Our mobile system allows non-invasive and cooperation-independent nocturnal monitoring of acoustic symptoms in the domestic environment, especially at night, when most ailments occur.

The respiratory flow is a good indicator of sleep-related breathing disorders. Common praxis is to use a pneumotachograph as the golden standard for flow measurement. However, it does not have to be necessarily the best possible test device for long-term condition, because the device is very uncomfortable and rarely suitable for measurement during sleep. A computer-based method to determine the respiratory flow, called ThorAKUSTIK, yielded a highly positive correlation between the calculated flow out of the tracheal breath sound and a measured flow signal. In order to avoid noise interference due to a breath-mask or a pneumotachograph, in this study we applied the ThorAKUSTIK-method to lung sound which was measured at the back of 18 subjects and investigated the correlation between the calculated flow and the measured flow by a pneumotachograph. The new method showed a highly positive correlation (r = 0.89 and 0.90). Additionally we examined the use of an accelerometer signal to distinguish between inspiration and expiration. In this case we got high correlation coefficients of r = 0.87 and 0.88 between the calculated and measured airflow as well.

Auscultation is one of the most important noninvasive and feasible methods for the detection of lung diseases. Systematic changes in breathing sounds with increasing age are of diagnostic importance. To investigate these changes, we recorded lung sounds taken from four locations in the posterior thorax of 162 subjects, together with airflow. The data were analyzed according to age, sex, and smoking habit. In order to describe the power spectrum of the lung sounds, we calculated mean and median frequency, frequency with the highest power, and a ratio (Q) of relative power of the two frequency bands of 330 to 600 Hz and 60 to 330 Hz. Linear regression analysis was used as a measurement of age-dependence of these variables. Significant differences in Q were found in men versus women (p0.05), but not in smokers versus nonsmokers. Within the groups, a small but significant correlation existed between Q and age (r(2)/= 0.1, p0.05). For both men and women, a slight increase of the relative power in the frequency band of 330 to 600 Hz was recorded with increasing age. However, on the basis of large individual variations, these small changes (DeltaQ approximately 5%, SD(Q)/= +/- 5%) have no clinical significance and need not to be considered in the automatic detection of lung diseases by analyzing lung sounds.

BACKGROUND AND STUDY AIMS Endoscopic diagnosis of dysplastic lesions and early cancers in chronic ulcerative colitis is a major problem. Identification of suspicious lesions is influenced by the macroscopic appearance of the colon, but also by the endoscopist's experience. In this study we evaluated the identification of dysplastic lesions by the naked eye in an animal model of colitis after 5-aminoaevulinic acid-induced photosensitization. METHODS 80 male Wistar rats were examined. Acute and chronic colitis were induced by oral application of 5% dextrane sulfate sodium (DSS) in 1-7 cycles (1 cycle = seven days DSS and 10 days water). For sensitisation 5-aminolaevulinic acid (5-ALA) at different doses (0, 10, 25, 50, 75, 100, and 200 mg/kg) was used. The colonic fluorescence was examined under a blue light (390-436 nm) for excitation. Histological findings of fluorescent and non-fluorescent biopsy specimens were recorded. RESULTS Using 100 mg/kg 5-ALA intravenously for photosensitization, all dysplastic lesions (5/5) showed fluorescence (sensitivity 100%). However, at this concentration of 5-ALA, 60 false positive lesions were found out of 76 specimens taken from lesions that were not dysplastic--only 16 specimens of non-dysplastic lesions did not fluoresce (specificity 21%). Using 75 and 50 mg/kg 5-ALA intravenously sensitivity decreased to 92% (36/39) and 42% (5/12), respectively, while specificity increased to 35% (29/82) and 62% (45/73). Using 50 mg/kg 5-ALA intravenously, fluorescence-positive biopsy specimens showed inflammation of the colon in 31% whereas only 12% contained normal mucosa (p < 0.01). The distribution of fluorescence-positive biopsy specimens with histologically confirmed inflammation was similar for different grades of inflammation after sensitisation with 75 and 100 mg/kg 5-ALA, whereas with 50 mg/kg 5-ALA fluorescence-positive biopsy specimens contained significantly (p < 0.05) more moderate, massive, or ulcerative inflammation (79%) than mild inflammation (21%). CONCLUSION 5-ALA induced photosensitization gave a high sensitivity, but low specificity in identifying dysplastic lesions in DSS-induced colitis in rats. In this animal model inflammation is a major factor in disturbing the fluorescence localisation of dysplasia after sensitisation with 5-ALA.

The autonomic nervous system modulates gastrointestinal motility, secretion and mucosal immunity. Its dysfunction may be of pathogenetic importance in inflammatory bowel disease (IBD). This study aimed at investigating the autonomic nervous function in patients with IBD. Forty-seven patients with IBD, 28 with Crohn's disease (CD) and 19 with ulcerative colitis (UC), were investigated by means of 5 cardiovascular and 2 pupillary standardized autonomic nervous function tests. In CD and UC, cardiovascular autonomic neuropathy was very rare (0%, 5%), whereas pupillary autonomic neuropathy was more prevalent (21%, 21%). In contrast to autonomic neuropathy, overall cardiovascular (CD: 29%, UC: 26%) and pupillary autonomic hyperreflexia (46%, 37%) were found more often. Patients with CD and UC demonstrated elevated percentiles in the respiratory sinus arrhythmia test as compared to controls (RSA: 82.3 +/- 3.9%, 80.0 +/- 5.9%, controls: 50.0% +/- 1.5%, p < 0.0001). CD patients with, as compared to patients without, RSA hyperreflexia had significantly higher CDAIs (p < 0.001), increased erythrocyte sedimentation rates (p < 0.005) and more often extraintestinal disease manifestations (p < 0.001). UC patients with, as compared to patients without, pupillary latency time hyperreflexia had lower hemoglobin (p < 0.05), lower albumin (p < 0.01) and increased erythrocyte sedimentation rates (p < 0.05). Autonomic hyperreflexia was significantly associated with more severe inflammation and systemic disease in IBD. Hyperreflexia may be a response to inflammation or a pathogenetic element that drives mucosal inflammation.

Background and aims Budesonide may be an effective therapy for mild-to-moderately active ulcerative colitis (UC). This study aimed to demonstrate non-inferiority for oral 9mg budesonide once daily (OD) versus 3g mesalazine granules OD. Methods This was an eight-week randomised, double-blind, double-dummy, multicentre study in which patients with mild-to-moderately active UC, defined as Clinical Activity Index (CAI) ≥6 and Endoscopic Index (EI) ≥4, received budesonide (Budenofalk® 3mg capsules×3) or mesalazine (Salofalk® 1000mg granules×3). The primary endpoint was clinical remission at week 8 (CAI ≤4 with stool frequency and rectal bleeding subscores of "0"). Results 343 patients were randomised (177 budesonide, 166 mesalazine). Fewer patients achieved the primary endpoint with budesonide versus mesalazine (70/177 [39.5%] versus 91/166 [54.8%]) with a difference in proportions of −15.3% (95% CI [−25.7%, −4.8%]; p =0.520 for non-inferiority). The median time to first resolution of symptoms was 14.0 days (budesonide) and 11.0days (mesalazine) (hazard ratio 1.19; 95% CI [0.94, 1.51]). Mucosal healing was observed in 54/177 (30.5%) budesonide patients versus 65/166 (39.2%) mesalazine patients, a difference of −8.6% (95% CI [−18.7%, 1.4%]; p =0.093). The incidences of adverse events (budesonide 26.6%, mesalazine 25.3%) and serious adverse events (budesonide 1.7%, mesalazine 1.2%) were similar. Conclusions Once-daily 3g mesalazine administered as granules is superior to 9mg budesonide OD administered as capsules for achieving remission in mild-to-moderately active UC. However, it is noteworthy that remission of UC was attained in about 40% of budesonide-treated patients with a rapid onset of resolution.

Nocturnal worsening of respiration in patients with chronic sinusitis is most likely induced by creeping of mucus from the parasinuses down to the pharynx. The aim of this study was to document respiratory symptoms such as deglutition, wheezing and cough in patients with chronic sinusitis using long-term recording of respiratory sounds.According to the CORSA (computerized respiratory sound analysis) criteria, long-term recording of respiratory sounds was performed in 20 patients with chronic sinusitis.Wheezing was detected in 30%, (excessive) cough was found in 40%. Deglutition was measured with a frequency of ten per hour.Long-term recording of respiratory sounds is a practical and noninvasive method for the documentation of clinical symptoms like wheezing, coughing and deglutition during sleep.

Ascites and plasma concentrations of soluble tumor necrosis factor receptors p55 and p75 were measured in a prospective study in 34 patients (35 occasions of ascites) with hepatic (5 infected and 21 uninfected) and malignancy-related (9) ascites. All patients had high concentrations of both soluble tumor necrosis factor receptors in ascites and plasma; these were about 500 times higher than the corresponding tumor necrosis factor-α concentrations. Ascites levels of soluble tumor necrosis factor receptors p55 and soluble tumor necrosis factor receptors p75 were significantly elevated in patients with malignancy-related (p55: 26.0 ± 8.6 ng/ml; p75: 20.5 ± 17.4 ng/ml; mean S.D.) and infected ascites (p55: 25.1 ± 10.9 ng/ml, p75: 22.6 ± 11.0 ng/ml) compared with patients with uncomplicated hepatic ascites (p55: 10.1 ± 4.4 ng/ml; p75: 6.0 ± 2.6 ng/ml). Patients with infected or malignancy-related ascites also showed higher soluble tumor necrosis factor receptor concentrations in plasma than did patients with plain hepatic ascites. Successful antibiotic treatment of peritonitis reduced soluble tumor necrosis factor receptor p55 and p75 ascites levels in three patients from 24.2 ± 15.2 ng/ml to 10.7 ± 1.9 ng/ml and from 20.2 ± 14.4 ng/ml to 7.5 ± 1.8 ng/ml, respectively. Soluble tumor necrosis factor receptors p55 and p75 at cutoff levels of 16.5 ng/ml and 9.5 ng/ml, respectively, differentiated between infected or malignant and plain hepatic ascites with diagnostic accuracies of 94% and 89%, respectively. They did not differentiate between infected and malignant ascites. The concentrations of soluble tumor necrosis factor receptor p55 were usually higher in ascites than in plasma in all subgroups of patients. Levels of soluble tumor necrosis factor receptor p75 were also higher in ascites than in plasma in patients with malignant and infected ascites, but soluble tumor necrosis factor receptor p75 levels were usually higher in plasma than in ascites in patients with uncomplicated hepatic ascites. The concentrations of both tumor necrosis factor receptors correlated well in ascites (r = 0.83, p < 0.001) and plasma (r = 0.85, p < 0.001) but only weakly with tumor necrosis factor-α levels in ascites (p55: r = 0.32, p = 0.03; p75: r = 0.29, p = 0.047) and not with tumor necrosis factor-α in plasma. The high soluble tumor necrosis factor receptor concentrations found in ascites may influence the local bioavailability of tumor necrosis factor and might have an impact on the treatment of peritoneal carcinomatosis with recombinant tumor necrosis factor. Furthermore, the determination of soluble tumor necrosis factor receptors could be of value for the differential diagnosis of ascites. (HEPATOLOGY 1992;16:749–755.)

The ascites and serum concentrations of interleukin-6 (IL-6) and interleukin-1 (IL-1) were determined in 21 patients with hepatic ascites and in 9 patients with malignancy-associated ascites. There was no evidence for bacterial peritonitis in any patients. All ascites samples contained high amounts of immunoreactive IL-6 [hepatic ascites 1730 +/- 2130 pg/ml (mean +/- SD), 1160 pg/ml (median); malignant ascites 4020 +/- 1510 pg/ml (mean), 3820 pg/ml (median)] but no IL-1. The mean ascites to serum ratios of IL-6 were 96 (median 49) in patients with hepatic ascites and 587 (median 480) in patients with malignant ascites. Ascites IL-6 was biologically active as determined by the B9 cell bioassay. The results indicate that even in the absence of infection IL-6 is produced in high amounts in the peritoneal cavity of patients with hepatic or malignant ascites.

It has been suggested that leucocytes play an important role in the pathogenesis of complicated pancreatitis. Indeed, increased plasma concentrations of neutrophil elastase as a marker of neutrophil activation could be detected in patients with a severe course of the disease. Recently, interleukin-8 (IL-8) has been described as a novel neutrophil activating peptide. To determine the role of IL-8 in acute pancreatitis we measured its serum concentrations by a specific enzyme-linked immunosorbent assay in 10 patients with acute pancreatitis daily during the first week of hospitalization. IL-8 levels were compared with plasma concentrations of neutrophil elastase and the clinical course of the disease. Three of the patients had uncomplicated pancreatitis, while seven showed various extrapancreatic complications. Patients with complicated pancreatitis had statistically significant (P less than 0.05) higher mean values of IL-8 (121 +/- 41 pg/ml-1 vs. 13 +/- 6 pg ml-1, mean +/- SEM) and neutrophil elastase (547 +/- 35 ng ml-1 vs. 250 +/- 20 ng ml-1) than patients with uncomplicated disease. There was a positive correlation (r = 0.52, P less than 0.0001) between IL-8 and neutrophil elastase in the lower concentration range of IL-8 (less than 100 pg ml-1). At IL-8 levels greater than 100 pg ml-1 neutrophil elastase was always greatly elevated; however, under these conditions the relationship between IL-8 and elastase was no longer linear. No measurable IL-8 concentrations were found when plasma elastase was less than 200 ng ml-1. During follow-up, initially elevated IL-8 concentrations decreased in correlation with clinical improvement.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased serum concentrations of acute-phase proteins can be found in active inflammatory bowel disease. Because interleukin 6 (IL-6) is one of the main mediators of acute-phase protein synthesis by the liver, the serum concentrations of IL-6 and the acute-phase proteins C-reactive protein, alpha 1-antitrypsin, and alpha 1-acid glycoprotein were determined in 70 patients with Crohn's disease (CD) and 23 patients with ulcerative colitis (UC). Disease activities were determined by established clinical activity indices. Serum IL-6 concentrations were significantly (P less than 0.005) increased in patients with CD (mean +/- SEM, 6.8 +/- 0.9 U/mL) compared with patients with UC (mean, less than 4 U/mL) and healthy controls (mean, less than 4 U/mL). Of patients with CD, 68.5% had serum IL-6 concentrations of greater than or equal to 4 U/mL, compared with 21.7% of patients with UC and 0% of healthy controls. There was a tendency toward higher serum IL-6 concentrations in patients with active CD than in patients with inactive disease. However, these differences were not statistically significant. There was no correlation between IL-6 serum concentrations and clinical activity indices, possibly because of the short circulatory lifetime and rapid hepatic clearance of IL-6 from the portal venous blood. In contrast to serum IL-6, acute-phase proteins, which have a longer circulatory lifetime, were significantly correlated with clinical activity indices. Only the follow-up of individual patients with initially highly active disease showed a further increase in IL-6 levels during acute exacerbations of the inflammatory process. The results show that most patients with even moderately active CD have significantly increased serum concentrations of IL-6, most probably reflecting a continuous stimulation of IL-6-producing cells.

Treatment with DOTA-d-Phe(1)-Tyr(3)-octreotide (DOTATOC), labeled with beta-emitting radioisotope yttrium-90 ((90)Y-DOTATOC), has successfully been used for the palliative treatment of patients with advanced somatostatin receptor-expressing neuroendocrine tumors (NETs). However, controversy persists as to whether patients with metastatic NETs of the pancreas should undergo radical (salvage) surgery or receive palliative therapy. We proposed that (90)Y-DOTATOC could be used in a neoadjuvant intention for improving therapy of hepatic NET metastases.We investigated a novel therapy concept in a 49-year-old patient presenting with a neuroendocrine tumor of the pancreatic tail and synchronous multiple bilobular hepatic metastases. After surgical removal of the large primary tumor by extended left en bloc resection of the pancreatic tail, the patient received neoadjuvant (90)Y-DOTATOC for therapy of primarily non-resectable bilobular hepatic metastases.The (90)Y-DOTATOC therapy resulted in an impressive regression of hepatic lesions, thus facilitating surgical removal of all remaining liver metastases in a second operation (staged surgery). In addition, one lesion was ablated using radiofrequency ablation (RFA). At 1-year of follow-up after hepatic R0 resection/RFA, there was no evidence of tumor recurrence or extrahepatic metastasis.The neoadjuvant use of (90)Y-DOTATOC therapy could prove valuable for treatment of advanced pancreatic NETs metastatic to the liver in terms of facilitating R0 resection by applying staged surgery concepts.

Iodinated recombinant human interleukin-6(125I-rhIL-6) was intravenously injected into rats and its fate was studied during 24 h. Between 10–20 min after a single-dose injection, 125I-rhIL-6 accumulated in liver as previously reported [Castell et al. (1988) Eur. J. Biochem. 177, 357–361]. After 1 h. the radioactivity disappeared from the liver and accumulated in skin, reaching 35% of injected 125I-rhIL-6 5–8 h after injection. No comparable accumulation of radioactivity was found in skin when [125I]iodide or rat serum 125I-albumin was administered. Finally the radioactivity was detected as [125I]iodide in urine. Autoradiograhic analysis of skin sections 5 h after 125-I-rhIL-6 injection showed radioactivity in the interstitium. When the experiments were carried out with [35S]rhIL-6, essentially the same results were obtained: a decrease in radioactivity in the liver after 20 min, and a substantial increase in skin 7 h after injection. In vitro experiments showed that 125I-rhIL-6 is degraded by rat and human fibroblasts, whereas no degradation was observed with rat hepatoma cells (Fao) or human hepatocytes. These observations suggest the involvement of skin in the catabolism of IL-6.

Some patients with Crohn's disease (CD) do not respond to corticosteroid therapy. Furthermore, corticosteroids frequently cause side effects. Thus, predictive parameters for treatment refractoriness would be helpful for treatment decisions.A total of 300 patients with active CD (i.e., with a Crohn's Disease Activity Index [CDAI]200) entered the study. Treatment started with 60-100 mg/day prednisolone equivalent, which was then tapered to 10-15 mg/day within 6 wk and maintained at that dose for another 4 wk. After 10 wk of treatment, response to steroids was defined by a CDAI150, steroid resistance by a CDAI alwaysor =150 and steroid dependency by a relapse after dose reduction. Of 239 eligible patients, 196 were responders, 26 were steroid resistant, and 17 were steroid dependent.Prior bowel resections, a high initial CDAI, and perianal disease were associated with steroid resistance. Of the steroid resistant patients 53.9% were bowel-resected compared to 20.4% of the responders (relative risk = 3.63; 95% CI = 1.79-7.36). Perianal disease was observed in 42.3% of steroid resistant patients versus 21.9% of responders (relative risk = 2.28; 95% CI = 1.12-4.66) and initial CDAI was 347+/-91 in resistant patients versus 301+/-81 in responders (p0.05). Parameters for steroid dependent patients were not significantly different from those of responders.In this study (thus far the largest study for the evaluation of predictive factors for treatment refractoriness to corticosteroids in CD), only prior bowel resection, perianal disease, and a high initial CDAI were found to be predictive of resistance to steroid treatment.

OBJECTIVE Associations between HLA-DR genotypes and susceptibility to Crohn's disease (CD) have been reported. However, it is not known whether certain HLA-DR genotypes or IL-1ra gene polymorphism are associated with responsiveness to treatment or different clinical patterns of disease. DESIGN/SETTING In a large, randomized, controlled multicentre trial, 318 patients with CD were treated with daily doses of 6, 9 or 18 mg budesonide. Patients were stratified into two groups: patients without steroid pretreatment and with active CD (CDAI > 150) and patients with conventional steroid pretreatment of < or= 30 mg prednisolone per day, which was replaced by oral budesonide within 3 weeks. MAIN OUTCOME MEASURES The HLA-DRB1 genotypes 1-16 and the IL-1ra gene polymorphism were examined for an association with budesonide treatment failure. RESULTS Only HLA-DR 8 was associated with treatment failure of budesonide. HLA-DR 8 is not very common. Only 17/243 patients who could be evaluated expressed this genotype, and 13 of these 17 patients did not respond to budesonide (P < 0.00067). Neither the other HLA-DR genotypes nor the IL-1ra gene polymorphism had an influence on treatment outcome of budesonide therapy. No significant association of fistulas, perianal disease, need for bowel resections, and disease localization with certain HLA-DRB1 genotypes or the IL-1ra gene polymorphism were found. CONCLUSIONS This is the first description of an association of a certain HLA-DR genotype (HLA-DR 8) with treatment failure in inflammatory bowel disease (IBD).

Background & Aims: Transcription factors of the nuclear factor κB (NF-κB) family play an important role in the regulation of genes involved in inflammation. In inflammatory bowel diseases, proinflammatory cytokines known to be regulated by NF-κB are involved. The aim of this study was to investigate the role of NF-κB activation during mucosal inflammation in situ. Methods: A monoclonal antibody, α-p65mAb, was applied for immunofluorescence and immunohistochemical analysis that recognizes activated NF-κB. Electrophoretic mobility shift assay was used to directly demonstrate the presence of active DNA-binding NF-κB. Results: Using the α-p65mAb antibody, activated NF-κB could be found in biopsy specimens from inflamed mucosa but was almost absent in uninflamed mucosa. The number of cells showing NF-κB activation correlated with the degree of mucosal inflammation but was not significantly different between inflamed mucosa from patients with Crohn's disease, ulcerative colitis, and nonspecific colitis or diverticulitis. NF-κB activation was localized in macrophages and in epithelial cells as identified by double-labeling techniques. Electrophoretic mobility shift assay with isolated lamina propria mononuclear cells and epithelial cells confirmed these results. Conclusions: This study shows for the first time the activation of NF-κB during human mucosal inflammation in situ. In addition to macrophages, epithelial cells contained activated NF-κB, indicating an involvement in the inflammatory process. GASTROENTEROLOGY 1998;115:357-369

Background and study aims A second-look endoscopy is often performed to evaluate the efficacy of a prior injection therapy in patients with bleeding peptic gastric or duodenal ulcers. Although this strategy is widely established, it does not rely on unequivocal data from controlled studies. In a prospective, randomized, controlled multicenter trial we assessed the effect of programmed endoscopic follow-up examinations with eventual retreatment on the outcome of bleeding ulcers in these patients. Patients and methods One hundred and five patients with gastric or duodenal peptic ulcers presenting with active (Forrest type I) or recent (Forrest type IIa and IIb) bleeding upon endoscopy within four hours after admission were included in the study. Emergency treatment consisted of the sequential injection of both epinephrine (1:10,000 v/v) and up to 2 ml of fibrin/thrombin around the ulcer base. Fifty-two patients were randomized to receive programmed endoscopic monitoring with eventual retreatment in cases of Forrest type I, IIa, or IIb ulcers beginning within 16-24 hours after the index bleed. Follow-up endoscopies were continued until the macroscopic appearance revealed a Forrest type IIc or III ulcer. Fifty-three patients in the control group were closely monitored, and only received a second endoscopy when there was clinical or biochemical evidence of recurrent bleeding. The groups did not differ with respect to age, sex, site and severity of bleeding. Results The numbers of patients with recurrent bleeding were similar whether they were endoscopically monitored or not (21% versus 17%, P=0.80 chi-squared test). In addition, there was no statistically significant difference between the two groups with respect to the number of blood units transfused, need for surgical intervention, hospital stay or number of deaths (Mann-Whitney U-test). Improving local ulcer stigmata was not related to a better outcome. Conclusions Programmed endoscopic follow-up examinations with eventual retreatment in patients locally injected for an acute or recent hemorrhage from a gastric or duodenal ulcer did not influence their outcome when compared to patients receiving only a second endoscopic intervention upon evidence for recurrent hemorrhage. Scheduled control endoscopies cannot be recommended after an initial successful endoscopic treatment of peptic ulcer bleeding when selection of the patients for second-look endoscopy is directed by the Forrest criteria.

Objective : The pathophysiological significance of autoantibodies in inflammatory bowel diseases (IBD) is still unclear. To assess specific immunological abnormalities we examined the distribution and restriction of immunoglobulin classes and subclasses of anti-neutrophil cytoplasmic antibodies (ANCAs) in ulcerative colitis and of antibodies to pancreatic juice (APJs) in Crohn's disease. Methods : We tested 62 sera of patients with ulcerative colitis and 184 sera of patients with Crohn's disease for their immunoglobulin class and IgG subclass distribution of ANCAs (in ulcerative colitis patients) and APJs (in Crohn's disease patients) by fluorescence isothiocyanate (FITC)-labelled anti-human antibodies in an immunofluorescence assay with human granulocytes or pancreas as substrate. Twenty-five patients with Wegener's granulomatosis were used for comparison. Results : In ulcerative colitis ANCAs were found in 74% of the patients. They were predominantly of the IgG (96%) and IgA class (37%). In Crohn's disease APJs (present in 28% of the cases) were of the IgG (98%) and IgA class (71%). ANCAs in ulcerative colitis were of the IgG1 (73%) and lgG3 (5%) subclasses, APJs in Crohn's disease of the IgG1 (94%), lgG2 (20%) and IgG3 (2%) subclasses. The immunoglobulin class and IgG subclass distributions of ANCAs and APJs resembled the changes in total immunoglobulin classes and IgG subclasses in ulcerative colitis or Crohn's disease. Conclusion : The immunoglobulin classes and IgG subclasses of autoantibodies in ulcerative colitis and Crohn's disease differ from each other and from the distribution of autoantibodies in vasculitic diseases (Wegener's granulomatosis, microscopic vasculitis, systemic lupus erythematosus). These alterations reflect specific pathophysiological features of ulcerative colitis and Crohn's disease.

We have recently shown that ERCP is the most useful technique for detecting a biliary origin of acute pancreatitis and can be done without side effects. We now report on a second series of 50 patients with acute pancreatitis in whom ERCP, computed tomography (CT), ultrasound (US), and clinical and laboratory assessment were performed within the first 24 to 48 hours of hospitalization. A score for ERCP, CT and US was used to assess the severity of the disease. Patients were followed up until discharge or death and their condition classified according to outcome as mild (less than or equal to 1 complication), severe (greater than 1 complication) or fatal. ERCP was superior in detecting choledochal stones (ERCP 100%, US 25%, CT 50%) and dilated intrahepatic ducts (ERCP 75%, US 75%, CT 37%) but not gallbladder stones (ERCP 70%, US 100%, CT 60%). When the ERCP severity score was calculated there was no relevant difference between patients thereafter having a mild course (0.66 +/- 0.91, range 0-3), a severe course (1.3 +/- 0.80, range 0-3), or a fatal outcome (1.0 +/- 1.1, range 0-3). In contrast, the CT score was different in all three groups (mild: 3.0 +/- 1.9; severe: 5.3 +/- 3.2; lethal: 6.3 +/- 3.1) as was the US score (mild: 1.5 +/- 1.3; severe: 3.2 +/- 2.3; lethal: 4.4 +/- 1.4). It is concluded from these results that ERCP is of value in defining the origin of acute pancreatitis. When a biliary origin is detected this can lead to immediate treatment using endoscopic sphincterotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

The infiltration of leukocytes has been linked to the pathophysiology of complicated or severe pancreatitis. We have tested the ability of leukocyte scintigraphy using technetium-99m-hexamethyl propylene amine oxine (HM-PAO) as label to demonstrate the localization of leukocytes in the pancreas during acute pancreatitis. Twenty-eight patients with acute pancreatitis (eight with biliary, 13 with alcoholic, and seven with unknown origin) were studied with leukocyte scintigraphy using planar imaging and single photon emission computed tomography (SPECT). Fourteen patients had a mild (group I), 11 a severe (group II), and three a lethal outcome (group III) of pancreatitis. All patients of group III, six of group II, and two of group I had a positive leukocyte scan. Thus, the sensitivity of leukocyte scintigraphy for the detection of a lethal course, of acute pancreatitis was 100%, of a severe course 54%, and of a severe or lethal course 64%. The specificity of a negative scan for a mild pancreatitis was 86%. Comparison of the results of leukocyte scintigraphy with those of contrast enhanced CT showed that six of eight patients with pancreatic necrosis in CT had a positive leukocyte scan, but only five of 20 patients without detectable pancreatic necrosis in CT. In summary, leukocyte infiltration into the pancreas during pancreatitis can be demonstrated by noninvasive leukocyte scintigraphy using technetium-99m-HM-PAO as label. A correlation between the severity of the disease and leukocyte infiltration exists.

Sera of 64 patients with chronic inflammatory bowel disease (IBD) were screened for antibodies against neutrophil cytoplasmic antigens (ANCA) using an indirect immunofluorescence technique on ethanol-fixed human neutrophil granulocytes. 20 of 34 sera (59%) from patients with ulcerative colitis (UC) produced a fine-granular and perinuclear ANCA staining pattern (p-ANCA) clearly different from the typical diffuse and granular cytoplasmic ANCA fluorescence (c-ANCA, synonym ACPA) seen in active Wegener's granulomatosis (WG). The majority of the 20 p-ANCA positive UC patients had a high inflammatory disease activity. Among the 14 p-ANCA negative UC patients nine were without steroids; five of them had active disease, two were inactive and two had previously undergone colectomy. The remaining five patients still had active disease but received steroids for more than 4 weeks. Only 3 of the 30 sera from patients with Crohn's disease (CD) showed positive p-ANCA reactions. To narrow the specificity of the p-ANCA reaction all 64 sera were tested by ELISA for antibodies against anti-proteinase-3 (WG specific) and on HEp-2 cells for antinuclear (ANA) and anticytoplasmic antibodies. Ten p-ANCA positive UC sera were also tested in a myeloperoxidase ELISA. Only one UC serum reacted positively in the proteinase-3-ELISA and another one produced a weakly positive anti-nucleolar ANA fluorescence on HEp-2 cells. None of the tested sera reacted with myeloperoxidase suggesting that the p-ANCA staining pattern of granulocytes is not restricted to anti-myeloperoxidase antibodies as reported in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)

The biosynthesis of α1-antitrypsin, a secretory glycoprotein, has been studied in vitro in a cell-free translation system from wheat germ and in vivo with hepatocytes. When messenger RNA from rat liver polysomes was translated in a heterologous cell-free system a translation product was immunoprecipitated by anti-(α1-antitrypsin) which had a smaller molecular weight (42000) on sodium dodecyl sulfate/polyacrylamide gel electrophoresis than the authentic glycoprotein (54000) isolated from rat serum. An intact amino terminus of the α1-antitrypsin synthesized in vitro could be demonstrated by repetitive Edman degradation. When hepatocytes, labeled with [35S]methionine, were analyzed with respect to newly synthesized α1-antitrypsin, a protein with a molecular weight of 49000 was immunoprecipitated from a high-speed supernatant. When the hepatocytes were treated with tunicamycin, an inhibitor of protein glycosylation, a protein of a molecular weight of 40000 was immunoprecipitated from the cells as well as from the medium. Interestingly, an α1-antitrypsin form of an even higher molecular weight (54000) was immunoprecipitated from the hepatocyte monolayer medium. Several conclusions can be drawn from these findings. First, α1-antitrypsin is synthesized as a larger-molecular-weight precursor with an extra amino-terminal sequence of about 20 amino acids. Second, the liver form of α1-antitrypsin is different from the α1-antitrypsin which has been secreted, and third, the carbohydrate moieties of rat liver α1-antitrypsin do not appear to represent an absolute requirement for the secretion process. A length of 1930 ± 170 nucleotides was estimated for the poly(A)-rich mRNA of the precursor of rat liver α1-antitrypsin; a non-coding region of about 700 nucleotides must exist. Furthermore, it is shown that the major part of the poly(A)-rich RNA for α1-antitrypsin is found in loosely and tightly membrane-bound polyribosomes. This finding is in agreement with the current ideas on the site of synthesis of secretory proteins.

Poly(A)-rich RNA was isolated from the livers of acutely inflamed rats by extraction with guanidinium HCl and oligo(dT)-cellulose chromatography. After translation in a recticulocyte lysate and immunoprecipitation with a specific antiserum to alpha 2-macroglobulin a polypeptide with an apparent molecular weight of 162000 could be detected. The cell-free synthesis of alpha 2-macroglobulin was stimulated 8-fold by the addition of RNase inhibitor. Full-length alpha 2-macroglobulin polypeptide chains appeared after 35 min in the presence of 1.85 mM Mg2+ and 100 mM K+. A nucleotide number of about 5100 was estimated for alpha 2-macroglobulin by means of sucrose gradient centrifugation of poly(A)-rich RNA followed by translation in vitro and immunoprecipitation of alpha 2-macroglobulin. In normal liver alpha 2-macroglobulin mRNA represented about 0.0007% of total translatable RNA. Acute inflammation generated by intramuscular injection of turpentine led to a 66-fold increase in translatable alpha 2-macroglobulin mRNA after 18 h, followed by a rapid decrease. In accordance to the induction of alpha 2-macroglobulin mRNA serum concentrations of alpha 2-macroglobulin increased to about 2 mg/ml. Unlike alpha 2-macroglobulin mRNA serum alpha 2-macroglobulin levels remained unchanged up to 60 h.

Purified rat alpha 1-proteinase inhibitor (Mr 54 000) and porcine pancreatic elastase (Mr 26 000) formed a complex (Mr 82 000) resistant to heat treatment under denaturing and reducing conditions. A similar alpha 1-proteinase-inhibitor-elastase complex was detected by immunoprecipitation of alpha 1-proteinase inhibitor from the medium of [35S]methionine-labeled hepatocyte primary cultures after incubation with elastase. Treatment of hepatocytes with tunicamycin led to the secretion of an unglycosylated alpha 1-proteinase inhibitor (Mr 41 000) which also formed a complex with elastase (Mr 66 000). Complex formation (Mr 68 000) could also be observed between cell-free synthesized pre-alpha 1-proteinase inhibitor (Mr 43 000) and elastase (Mr 26 000). The results suggest that neither glycosylation nor removal of the signal peptide are required for the formation of a biologically active conformation of alpha 1-proteinase inhibitor.

Ribonucleoprotein particles of 38 S were extracted from rat liver nuclei with isotonic salt buffer under concomitant sonication. The fate of the endogeneous nuclear RNAases assayed with poly(A), high molecular weight yeast RNA and rapidly labeled hnRNA was followed during the preparation of 38-S nuclear ribonucleoprotein (nRNP) particles. Essentially all the RNAase activity could be removed from the particle preparation. The effect of synthetic RNAase inhibitors on the nRNP particles was studied. Upon extraction of nuclei with 0.14 M NaCl, approximately 38% of the total nuclear radioactivity was found in the 38-S nRNP particles. By two successive extractions of the remaining chromatin with either isotonic or 0.22 and 0.3 M NaCl, an additional 25 and 9% of rapidly labeled hnRNA of 38 S particles were dissociated from chromatin, respectively. The chromatin components, DNA, nonhistone proteins, histones and RNA were determined after successive salt extractions. Particularly alterations in the nonhistone proteins and RNA were found. The protein patterns upon SDS-acrylamide gel electrophoresis of the salt-extracted chromatin preparations were compared with those of the 38-S nRNP particles. Particularly proteins in the molecular weight range of 32 000–43 000 were dissociated from chromatin after treatment with 0.22 or 0.3 M NaCl.

Fifty consecutive patients with acute pancreatitis were assessed with respect to a biliary origin of the disease. Endoscopic retrograde cholangiopancreaticography, surgery, and autopsy were used to define biliary pancreatitis. Ultrasound, computed tomography, and several laboratory tests (SGOT, SGPT, alkaline phosphatase, and bilirubin) were analyzed for their ability to detect a biliary origin of the disease. Ultrasound and computed tomography could not reliably make the diagnosis in the 10 patients found to have biliary disease. Receiver-operator-characteristic curves revealed that none of the laboratory tests assessed had sufficient sensitivity and specificity to determine the diagnosis, although all tests showed higher mean values in biliary pancreatitis. SGPT gave the best discrimination (positive predictive value 53%, negative predictive value 94%, cut off 40 units/liter). Therefore, initial ERCP is suggested for a reliable diagnosis of biliary origin of acute pancreatitis.

The biosynthesis and secretion of alpha 2-macroglobulin was studied in rat hepatocyte primary cultures. After immunoprecipitation of alpha 2-macroglobulin from a cell homogenate and the hepatocyte medium, two forms of alpha 2-macroglobulin with app. Mr of 176000 and 182000, respectively, were identified. A precursor-product relationship for the two alpha 2-macroglobulin forms was demonstrated by a pulse-chase experiment. The cellular form of alpha 2-macroglobulin could be deglycosylated by endoglucosaminidase H, whereas the medium form of alpha 2-macroglobulin remained unaffected. On the other hand, only the medium form of alpha 2-macroglobulin was found to be susceptible to neuraminidase. In vitro translation of rat liver poly(A)+ RNA resulted in a translation product of an app. Mr of 162000.

The administration of D-galactosamine*HCl (GalN) to rats induces a biochemical and morphological liver cell injury similar to viral hepatitis [ 1 ] . The formation of GalN metabolites followed by a trapping of uridine phosphate is considered to be essential for the development of liver cell damage. The decrease in the concentration of UTP has been suggested as the cause for the observed inhibition of RNA synthesis [2] . In addition, a decrease in the rate of [14 C] leucine incorporation into protein has been found after GalN administration [3]. It has been shown that the hepatic UTP deficiency must persist for a minimum time period of 2.5 h in order to generate a hepatitis [4]. After this minimum metabolite deficit period liver cell damage is irreversible. The mechanism for the switch towards cell death is presently unknown. A different gene expression could be responsible for the pathogenesis of the liver cell injury. The mechanisms of the regulation of gene expression in eucaryotes are still largely unknown. However, it is now generally accepted that non-histone chromosomal proteins (NHP) play an important role in gene regulation [5]. In the present paper it is demonstrated that changes in chromosomal proteins after GalN administration have been found.

Poly(A)+ RNA isolated from the livers of normal rats and of rats suffering from an acute inflammation was translated in a cell-free translation system from rabbit reticulocytes. The translation products were immunoprecipitated with specific antisera against alpha 1-acid glycoprotein, alpha 2-macroglobulin, transferrin, alpha 1-proteinase inhibitor and albumin. 15 to 21 h after intramuscular injection of turpentine 73-, 66-, 2.8-, and 2-fold increases in translatable mRNAs for alpha 1-acid glycoprotein, alpha 2-macroglobulin, transferrin and alpha 1-proteinase inhibitor, respectively, were observed. For albumin a decrease in translatable mRNA to about 30% of controls was measured.

The biosynthesis and secretion of alpha 2-macroglobulin, transferrin, alpha 1-acid glycoprotein and alpha 1-proteinase inhibitor were studied in rat hepatocyte primary cultures. After labeling with [35S]methionine, two forms, which can be separated electrophoretically differing by molecular weight, were found for each of the four glycoproteins. The following molecular weights were estimated for the intracellular precursors and the secreted forms: alpha 2-macroglobulin, 176 000 and 182 000; transferrin, 84 000 and 86 000; alpha 1-acid glycoprotein, 39 000 and 43 000-60 000; alpha 1-proteinase inhibitor, 49 000 and 54 000. Carbohydrate moieties could be removed from intracellular forms by treatment with endoglucosaminidase H indicating that their oligosaccharide chains were of the high-mannose type. The extracellular forms were sensitive to sialidase. They incorporated [3H]galactose and [3H]fucose showing that their oligosaccharide chains were of the complex type. Pulse-chase experiments revealed a precursor-product relationship for the high-mannose and the complex type glycoproteins. In the hepatocyte medium newly synthesized albumin was detected after 30 min and newly synthesized glycoproteins after 60 min. Unglycosylated alpha 2-macroglobulin (162 000), transferrin (79 000), alpha 1-acid glycoprotein (23 000), and alpha 1-proteinase inhibitor (41 000) were found in the cells as well as in the medium, when the transfer of oligosaccharide chains onto the polypeptide chains was blocked by tunicamycin. Tunicamycin led to a marked reduction of the secretion of alpha 2-macroglobulin, alpha 1-acid glycoprotein and alpha 1-proteinase inhibitor, whereas the secretion of transferrin was less affected.

The clearance of total rat liver secretory glycoproteins and of alpha 1-acid glycoprotein carrying no or different types of oligosaccharide side chains was studied in vivo and in the isolated perfused rat liver. In order to obtain unglycosylated or differently glycosylated forms of secreted glycoproteins, rat hepatocyte primary cultures were incubated with various inhibitors of N-glycosylation. Tunicamycin was used for the synthesis of unglycosylated (glyco)proteins, the mannosidase I inhibitor 1-deoxymannojirimycin for the synthesis of high-mannose type and the mannosidase II inhibitor swainsonine for the synthesis of hybrid-type glycoproteins. Glycoproteins carrying carbohydrate side chains of the complex type were synthesized by control hepatocytes. In vivo and in the perfused rat liver, high-mannose-type glycoproteins were cleared at the highest rate, followed by unglycosylated and hybrid-type glycoproteins. The lowest clearance rate was found for the glycoproteins with carbohydrate side chains of the complex type. For the highly glycosylated alpha 1-acid glycoprotein the differences in clearance rates were more pronounced. The following plasma half-lives were determined in vivo: complex type, 100 min; hybrid type, 15 min; unglycosylated form, 5 min; and high-mannose type less than 1 min. In the recirculating perfused liver 28% of complex-type alpha 1-acid glycoprotein, 40% of hybrid type, 47% of unglycosylated and 93% of high-mannose-type alpha 1-acid glycoprotein were removed from the perfusate within 2 h. It is concluded that N-glycosylation and processing to complex-type oligosaccharides seems to be of great importance for the circulatory life time of plasma glycoproteins.

The plasma half-life of recombinant human interleukin-6 (rhIL-6) was determined in rats by measuring the disappearance of the biological activity as well as of the radioactivity of 125I-rhIL-6 from the circulation. The kinetics of clearance were biphasic. It consisted of a rapid initial disappearance corresponding to a half-life of 3 min, and of a second slow one corresponding to a half-life of about 55 min. By cellulose-acetate electrophoresis it was shown that rhIL-6 binds to a plasma protein resulting in a complex migrating in the beta-gamma region; 20 min after intravenous injection, about 80% of the 125I-rhIL-6 that had disappeared from the circulation was found in the liver. 125I-rhIL-6 was exclusively localized on the surface of parenchymal cells suggesting the existence of an interleukin-6 receptor on the hepatocytes.

The plasma half-lives of glycosylated and unglycosylated alpha 1-proteinase inhibitor-radioactively labeled with [35S]methionine in rat hepatocyte primary cultures - were determined in the rat. Unglycosylated alpha 1-proteinase inhibitor was synthesized by hepatocytes in the presence of tunicamycin. Media from hepatocytes containing 35S-labeled glycosylated or unglycosylated alpha 1-proteinase inhibitor were injected into the tail veins of rats. At different times after injection alpha 1-proteinase inhibitor was isolated from plasma by affinity chromatography with anti-alpha 1-proteinase inhibitor Sepharose. Radioactivity measurements revealed a plasma half-life of 170 min for glycosylated alpha 1-proteinase inhibitor and of 30 min for the unglycosylated form of the inhibitor.