Diagnosing coeliac disease by rectal gluten challenge: a prospective study based on immunopathology, computerized image analysis and logistic regression analysis.

The purpose of this study was to evaluate the use of rectal gluten challenge in the diagnosis of coeliac disease. A total of 103 patients with features suggestive of this diagnosis were prospectively enrolled into the study; a diagnosis of coeliac disease was based on strictly defined criteria used in judging the proximal jejunal biopsy. On that basis, 45 out of the 103 patients were deemed to have coeliac disease. A slurry of gluten powder in physiological saline was introduced into the rectum, and biopsies taken before and at 2 h or 4 h after the challenge were examined immunohistochemically by computerized image analysis. Cell counts were analysed by logistic regression, and the best equations were obtained for each challenge group. The 2 h challenge yielded diagnostic sensitivity and specificity of 69.6% and 78.6% respectively. The 4 h challenge provided sensitivity and specificity of 100% and 100% respectively. These results were compared with other clinical diagnostic predictors,including anti-endomysial antibodies, which yielded diagnostic sensitivity and specificity of 70% and 98% respectively. It is concluded that a 4 h rectal challenge is a highly sensitive means of identifying gluten-sensitized individuals, and would be of particular value in cases showing negative antibody screening or equivocal biopsy appearances.

Closed path integrals and the quantum action.

We suggest a closed form expression for the path integral of quantum transition amplitudes. We introduce a quantum action with parameters different from the classical action. We present numerical results for the harmonic oscillator with weak perturbation, the quartic potential, and the double well potential. The quantum action is relevant for quantum chaos and quantum instantons.

Morphometric analysis of intestinal mucosa : the measurement of volume compartments and cell volumes in human intestinal mucosa.

The widespread use of peroral (capsule) and, more recently, endoscopically obtained mucosal biopsies from jejunum and duodenum provides an easy source of material for diagnostic (clinical) and investigative scientific study. The basis of our understanding of small intestinal diseases has stemmed directly from these sources since, in addition to the purely morphological (and pathological/immunopathological) domain, these biopsies have helped to elucidate other types of mucosal disease (e.g., the "disaccharidase" deficiencies, defects in water and electrolyte transfer, and amino acid transport and lipid metabolism).

Benzofuran based PDE4 inhibitors.

Replacement of the 3,4-dialkoxyphenyl substructure common to a number of PDE4 inhibitors with a 2-alkyl-7-methoxybenzofuran unit is described. This substitution can result in either enhancement or substantial reductions in PDE4 inhibitory activity depending on the system to which it is applied. An in vitro SAR study of a potent series of 4-(2-heteroaryl-ethyl)-benzoiurans 26 is also presented.

Idiopathic bile acid malabsorption: qualitative and quantitative clinical features and response to cholestyramine.

BACKGROUND: Idiopathic bile acid malabsorption is a poorly recognized cause of chronic diarrhoea. The SeHCAT (75Selenium HomotauroCholic Acid Test) can accurately diagnose this condition. AIM: To identify patients with idiopathic bile acid malabsorption, to describe their clinical features, both qualitatively and quantitatively, and to assess the response to cholestyramine. METHOD: Idiopathic bile acid malabsorption was considered in all patients complaining of chronic diarrhoea. They were included in the study if their SeHCATs were positive (< 15% retention) and secondary causes of bile acid malabsorption were excluded. The response to therapy with cholestyramine was assessed. RESULTS: Nine patients were diagnosed with idiopathic bile acid malabsorption (median SeHCAT retention 8%, range 3-12.6). Their median daily faecal weight was 285 g (range 85-676) and median faecal fat output was 17 mmol/24 h (range 8.3-38.8). Six patients had an immediate response to cholestyramine. There was a marked reduction in stool frequency (median stool frequency pre-treatment 5/day vs. 2/day post-treatment, P = 0.03). Five patients had large volume diarrhoea (faecal weight > 200 g/day) and three had steatorrhoea. CONCLUSIONS: Idiopathic bile acid malabsorption, once suspected, especially by documenting true 'large volume' watery diarrhoea or steatorrhoea, is easily diagnosed and response to therapy is often very good. There is often a previous history of gastrointestinal infection and this condition should be considered in patients with chronic diarrhoea of undetermined origin, especially before they are labelled as having irritable bowel syndrome.

Studies in vivo of omega-gliadins in gluten sensitivity (coeliac sprue disease).

1. Highly purified omega-gliadins from wheat were used to challenge gluten-sensitized individuals. Characteristic responses by mucosal CD3(+) and gamma delta+ lymphocytes were demonstrated. Each lymphocyte subset showed an increase within 8-12 h post-challenge, indicating a specific response by the rectal mucosa to this gliadin species.2. Available sequence data for the omega-gliadins and homologous proteins from barley and rye indicate a common repeating octapeptide motif (consensus PQQPFPQQ). The results indicate, therefore, that the octapeptide repeat, or a contained sequence such as PQQP, plays an important role in the mucosal immunopathology of gluten sensitivity.

Novel cytokine release inhibitors. Part I: Triterpenes.

Tripterine and closely related triterpenoid derivatives as IL-1 beta release inhibitors are discussed.

A novel series of [2-[methyl(2-phenethyl)amino]-2-oxoethyl] benzene-containing leukotriene B4 antagonists: initial structure-activity relationships.

This report describes the synthesis of a new class of LTB4 receptor antagonists containing [2-[methyl(2-phenethyl)amino]-2-oxoethyl]benzene as a key binding domain for interaction with high-affinity LTB4 receptors. In addition to this binding domain, two other structural features, an acid function and a lipophilic group, are also required by these compounds for high binding affinity. Our studies indicate that maximal binding affinity in this series is controlled by the spatial relationship of these groups relative to one another. The structure-activity relationships are discussed. The most potent compound in this chemical series, (E)-5-[2-[methyl(2-phenethyl)-amino]-2-oxoethyl]-2-(benzyloxy)cinn amic acid (32), has an IC50 of 2 nM in a guinea pig spleen cell membrane assay. In the whole-cell human neutrophils binding assay, (Z)-5-[2-[methyl-(2-phenethyl)amino]-2-oxoethyl]-2-(benzyloxy)cinn amic acid (30) was the most potent compound with an IC50 of 50 nM.

Structure-activity relationships study of two series of leukotriene B4 antagonists: novel indolyl and naphthyl compounds substituted with a 2-[methyl(2-phenethyl)amino]-2-oxoethyl side chain.

N-Methyl-N-phenethylphenylacetamide has been reported to be a key binding domain to LTB4 receptors. Here we describe the synthesis and structure-activity relationship (SAR) studies of two new series of LTB4 receptor antagonists in which the phenyl ring of this receptor binding domain is replaced with indole and naphthalene, respectively. Results of these studies indicate that, in addition to the 2-[methyl(2-phenethyl)amino]-2-oxoethyl moiety, the presence of an acid group and a lipophilic side chain, as well as the spatial relationship of these three functions, is crucial for high binding affinity with LTB4 receptors. Our SAR studies also reveal that an arenecarboxylic acid, or an enoic acid in which the carboxyl group is conjugated with the central ring, is the preferred polar group. The lipophilic side chain of the naphthyl series was found to tolerate minor variations, ranging from a phenylmethoxy group to phenyl and alkyloxy groups. The most active compounds are 2-ethyl-3-[1-[2-[methyl(2-phenethyl) amino]-2-oxoethyl]-5-(phenylmethoxy)indol-3-yl]propenoic+ ++ acid (4g) of the indolyl series and 4-[2-[methyl(2-phenethyl)amino]-2-oxoethyl]-8-(phenylmethoxy )-2-naphthalenecarboxylic acid (2a) or the naphthyl series, with IC50 of 8 and 4.7 nM respectively, in the receptor binding assay using intact human neutrophils.

Time-course of adhesion molecule expression in rectal mucosa of gluten-sensitive subjects after gluten challenge.

Adhesive interactions between endothelium and circulating cells, such as monocytes, neutrophils and lymphocytes, are crucial for localizing the inflammatory response. We investigated the inflammatory response of rectal mucosa to local gluten challenge as a dynamic model of antigen-induced tissue injury, during which the expression of adhesion molecules on leucocytes and endothelial cells could be sequentially observed. Expression of ELAM-1, ICAM-1 and VCAM-1 was monitored in 10 treated and eight untreated patients with gluten sensitivity (coeliac disease), and in five disease controls for up to 4 h (short challenge), while a further seven treated coeliacs were monitored for up to 24 h (long challenge) following rectal gluten challenge. In the former, the expression of VCAM-1 and ELAM-1 was significantly raised 4 h after gluten challenge compared with controls. VCAM-1 and ELAM-1 expression was also increased in mucosae of treated patients, but to a lesser extent. VCAM-1 expression continued to increase for up to 24 h after gluten, while ELAM-1 had begun to wane by 4 h, reaching basal levels by 24 h. In contrast, the expression of ICAM-1 did not change in any of the disease groups studied. These findings relate to significant increases in lymphocytes (CD3+ cells) after 8 h, and neutrophils (CD15+ cells) after 4 h in the lamina propria. This approach has permitted novel studies of the inflammatory response to a defined antigen in sensitized (gluten-sensitive) human patients.

Biochemical diagnosis of phaeochromocytoma: two instructive case reports.

The biochemical features of two patients with phaeochromocytomas illustrate the inadvisability of depending on a single group of analytes for the diagnosis. The first case presented as a surgical emergency with retroperitoneal haemorrhage. Biochemical diagnosis was difficult since total 24 hour urinary free catecholamine excretion was within normal limits in two out of three samples, and only marginally raised in the third with an atypical preponderance of adrenaline. Plasma catecholamine concentrations were also normal. But urinary excretion of the catecholamine metabolites, metadrenaline and 4-hydroxy-3-methoxy mandelic acid (HMMA), was consistently raised. In contrast, the second patient presenting with headache and labile hypertension showed normal metabolite excretion in the face of grossly increased free noradrenaline excretion and raised plasma noradrenaline concentrations. It is therefore recommend that, as well as urinary free catecholamines, one group of their main metabolites, the 3-methoxy amines (normetadrenaline and metadrenaline) or HMMA, should routinely be measured whenever a phaeochromocytoma is suspected.

Difficulties in localization and treatment of insulinomas in type 1 multiple endocrine adenomatosis (MEA).

A 15 year old girl with a family history of type 1 multiple endocrine adenomatosis presented with reversible neurological disturbances, hypoglycaemia and hyperinsulinaemia. Initial radiology was normal, but portal venous sampling suggested an insulinoma in the tail of the pancreas which was removed with conservation of the spleen. Hypoglycaemia persisted despite high doses of diazoxide and intravenous dextrose. A second laparotomy revealed a pancreatic endocrine tumour and sub-total pancreatectomy was performed. Histology revealed islet cell microadenomatosis. Hypoglycaemia persisted despite treatment with somatostatin analogues and 40% intravenous dextrose was required to maintain normoglycaemia. A possible lesion near the splenic hilum on computed tomographic scan was reported as a splenunculus although further peripheral, hepatic and portal venous sampling suggested hepatic or systemic lesions. A positron emission scan and selective visceral angiography suggested a lesion in the left upper quadrant. Acute lactic acidosis, rhabdomyolysis and renal failure supervened. Post mortem revealed the putative 'splenunculus' to be a residual insulinoma, whilst the splenic vein was thrombosed, accounting in part for discrepant venous sampling data. Hyperinsulinaemia in type 1 multiple endocrine adenomatosis may require more aggressive surgical and hormonal intervention than when dealing with solitary insulinomas. Insulinomas may mimic developmental abnormalities on computed tomographic scanning.

Influence of atrial natriuretic peptide on mammalian large intestine.

Atrial natriuretic peptide is distributed in a number of organs including the large intestine. Atrial natriuretic peptide has potent diuretic and natriuretic properties and appears to play a central role in fluid and electrolyte homeostasis by an action on the kidney. We examined the influence of atrial natriuretic peptide on mammalian colon because this organ is also intimately involved in homeostasis. Segments of the distal colons of male Sprague-Dawley rats were stripped of muscle layers and mounted in flux chambers. Atrial natriuretic peptide, when added to the serosal side of the mucosa, in concentrations ranging from 10(-8)-10(-5) M, caused a rapid, concentration-dependent increase in short-circuit current, transmucosal electrical potential difference, and conductance. The response to atrial natriuretic peptide was inhibited by (a) chloride-free solution on the serosal surface; (b) pretreatment of the tissues with the chloride channel blocker, diphenylamine-2-carboxylate (10(-3) M mucosally); (c) pretreatment with d,l-verapamil (10(-4) M mucosally and serosally); (d) calcium-free solution on the serosal surface; (e) pretreatment with tetrodotoxin (10(-7) M to serosal surface); and (f) pretreatment with atropine (10(-5) M serosally). However, the response to atrial natriuretic peptide was not influenced by pretreatment with amiloride (10(-4) M to mucosal and serosal surfaces) or piroxicam (10(-5) M serosally). Atrial natriuretic peptide did not elicit an increase in short-circuit current and potential difference across T84 cells derived from a human colonic carcinoma cell line, suggesting that the response to atrial natriuretic peptide is not due to a direct effect on colonocytes. These findings suggest that atrial natriuretic peptide acts by a calcium-mediated secretory mechanism involving cholinergic nerves and is likely to be involved in the endogenous neurohumoral regulation of ion transport in the mammalian colon.