Effects of high-dose statin on the human hepatic expression of genes involved in carbohydrate and triglyceride metabolism.

OBJECTIVES: Atorvastatin, an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A reductase, the rate-limiting enzyme in cholesterol synthesis, lowers plasma cholesterol and triglyceride (TG) levels dose dependently. The aim of this study was to investigate the molecular mechanism(s) of this decrease in plasma TG levels in atorvastatin-treated subjects. RESEARCH DESIGN AND METHODS: Lipoprotein separation and plasma analysis of lipids, glucose and insulin were performed in subjects randomly assigned to placebo (n = 9) or atorvastatin (80 mg per day) (n = 10) for 4 weeks. Liver TG mass was determined in pooled samples. Hepatic expression of several genes involved in carbohydrate and TG metabolism was determined. RESULTS: Atorvastatin lowered plasma levels of very low-density lipoprotein (VLDL) TG (∼50%, P < 0.05) and liver TG mass compared to placebo. Except for cholesterol changes, there were no other significant differences in plasma lipids, glucose or insulin. However, atorvastatin reduced mRNA expression of sterol regulatory element-binding protein 1c (SREBP1c) (>30%, P < 0.05), glucokinase (∼50%, P < 0.05) and angiopoietin-like protein 3 (ANGPTL3) (∼25%, P < 0.01), and induced mRNA expression of acetyl-coenzyme A carboxylase 1 (∼45%, P < 0.05) and glucose-6-phosphatase (∼90%, P < 0.05) compared to placebo. CONCLUSIONS: Following treatment with atorvastatin, reduced ANGPTL3 mRNA expression may contribute to the reduced plasma levels of VLDL TG. The reduced liver TG mass induced by a high dosage of atorvastatin may be important for the treatment of patients with fatty liver.

Gene segment reassortment between American and Asian lineages of avian influenza virus from waterfowl in the Beringia area.

Since prehistoric times, the Bering Strait area (Beringia) has served as an avenue of dispersal between the Old and the New Worlds. On a field expedition to this area, we collected fecal samples from dabbling ducks, geese, shorebirds, and gulls on the Chukchi Peninsula, Siberia, and Pt. Barrow, Alaska, and characterized the subtypes of avian influenza virus present in them. Four of 202 samples (2%) from Alaska were positive for influenza A virus RNA in two independent polymerase chain reaction (PCR)-based screening assays, while all shorebird samples from the Chukchi Peninsula were negative. Subtypes H3N8 and H6N1 were recorded once, while subtype H8N4 was found in two samples. Full-length sequences were obtained from the three unique isolates, and phylogenetic analysis with representative sequences for the Eurasian and North American lineages of influenza A virus showed that one HA gene clustered with the Eurasian rather than the North American lineage. However, the closest relative to this sequence was a North American isolate from Delaware described in 2002, indicating that a H6 spillover from Asia has established itself in North America.

Patient satisfaction and results after evisceration with a split-sclera technique.

PURPOSE: A retrospective study of the postoperative results and patient satisfaction after evisceration with a split-sclera technique. MATERIAL AND METHODS: The medical records of 60 patients were reviewed. All patients were operated by evisceration with a split-sclera technique and placement of an orbital implant. The patients were operated by the same surgeon between 1995 and 2003. Multiple-choice questionnaires were sent to the patients, and the patients were also offered a clinical examination. RESULTS: Extrusion/exposure of the implant was seen in 3/62 (4.8%) orbits. Migration of the implant was seen in one patient. At the time of the study, 45/60 patients were still alive, 32 of these answered the questionnaire. In a question about the patient's psychological well-being after the operation, 9/32 (28%) answered that they had felt depressed; four of these had had a recent trauma to the eye resulting in the evisceration; 25/32 (78%) patients were pleased or very pleased with the operation. A clinical examination was performed in 31 patients. The motility of the prosthesis and implant was measured and found to be rather poor (mean between 2.5 to 4.1 mm in each direction); however, most patients judged their motility to be good or excellent. CONCLUSION: Evisceration with a scleral split modification has been used successfully in our clinic since 1995. The risk for exposure is low, 3/62 (4.8%). Postoperative depression was common (9/32). Recent trauma was a risk factor for postoperative depression.

Bile acids and lipoprotein metabolism: effects of cholestyramine and chenodeoxycholic acid on human hepatic mRNA expression.

Modulation of bile acid synthesis in human by cholestyramine or by chenodeoxycholic acid (CDCA) treatment affects lipoprotein metabolism leading to altered plasma lipid levels. The molecular changes caused by these treatments, which in turn influence lipoprotein metabolism, are still not entirely known in humans. In this study, mRNA levels were analyzed using real time RT-PCR in liver tissue from patients undergoing cholecystectomy due to gallstone disease. The patients were treated with either CDCA (n=6) or cholestyramine (n=5) for three weeks prior to surgery, six patients received no treatment and served as controls. Cholestyramine increased the expression of the LDL receptor (LDLR) by about 65% and that of proprotein convertase subtilisin kexin 9 (PCSK9) by 70%. After CDCA the levels of both LDLR and hydroxy-methyl-glutaryl coenzyme A reductase mRNA decreased approximately by 50%. The expression of PCSK9 was not changed. The mRNA levels of PCSK9, LDLR, and HMGCoAR were significantly correlated to those of sterol regulatory element binding protein 2 (SREBP2), indicating that SREBP2 is of importance in the regulation of the expression of these genes also in human liver.

Effects of combined treatment with pravastatin and ursodeoxycholic acid on hepatic cholesterol metabolism.

BACKGROUND: Treatment with ursodeoxycholic acid and also, to some degree, statins reduces cholesterol saturation of bile. The present study aimed [1] to study the effects of combined treatment with ursodeoxycholic acid and pravastatin on hepatic cholesterol metabolism and [2] to evaluate if the addition of pravastatin to ursodeoxycholic acid treatment has beneficial effects on the lipid composition of gallbladder bile in gallstone patients. MATERIALS AND METHODS: Nineteen patients with cholesterol gallstones were subjected to combined treatment with ursodeoxycholic acid (500 mg bid) and pravastatin (20 mg bid) for three weeks before cholecystectomy. Eleven patients received ursodeoxycholic acid only and 20 untreated gallstone patients served as controls. Gallbladder bile was collected, and for both the patients receiving combined treatment and the controls a liver biopsy was also obtained peroperatively. RESULTS: The cholesterol saturation of bile averaged 59% in the patients on combined treatment, 60% in the ursodeoxycholic acid-treated patients, and 130% in the untreated controls. In the patients receiving ursodeoxycholic acid, this bile salt constituted approximately 60% of all bile salts. The patients receiving combined treatment had reduced cholesterol synthesis, as reflected by a 45% reduction in serum lathosterol. The activity and the mRNA levels of cholesterol 7 alpha-hydroxylase and the mRNA levels for the low density lipoprotein-receptor were not significantly affected. CONCLUSIONS: Pravastatin does not further reduce the cholesterol saturation of bile in gallstone patients treated with ursodeoxycholic acid, although hepatic cholesterol synthesis is inhibited. The study supports the important concept that de novo synthesized cholesterol is not particularly important for biliary cholesterol secretion in humans.

DNA ploidy and S-phase fraction in carcinoma of the gallbladder related to histopathology, number of gallstones and survival.

Gallstones are a risk factor for the development of gallbladder cancer. We studied DNA ploidy and cell cycle composition by flow cytometry in archival specimens from 52 gall bladder carcinomas in relation to histopathological grade, tumour stage, gallstone number and survival. 69% of the gallbladder carcinomas showed aneuploidy. All tumours with single stones (N=11) were aneuploid while only 61% of tumours with multiple stones (N=41) were aneuploid (p=0.002). DNA aneuploidy was related to increase in T-category (p=0.01), grade (p=0.02), and nuclear pleomorphism (p=0.0005). The distribution of DNA ploidy shifted from tetraploid in low stage towards triploid positions in high stage tumours (p=0.02) combined with higher S-phase values in triploid tumours (p=0.05). S-phase fraction increased during development from normal tissue to dysplasia, cancer in situ and cancer in diploid cases (p=0.0002), and further at the change from diploid to aneuploid (p=0.004). At a median cancer specific survival time of four months patients with diploid tumours had a better survival than those with aneuploid tumours (p=0.02). In multivariate analysis of the tumour characteristic, only T-category and tumour grade were independent prognostic factors. The shift from diploid to aneuploid and the further shift of ploidy within aneuploid tumours are in agreement with the concept of a clonal development of gallbladder cancer. These changes are combined with a stepwise increase in the fraction of S-phase cells. Low frequency of symptoms in single stone patients may be the reason for detection of malignancy at a late stage of tumour development.

Biliary lipid composition in patients with cholesterol and pigment gallstones and gallstone-free subjects: deoxycholic acid does not contribute to formation of cholesterol gallstones.

BACKGROUND: Four main disturbances have been attributed to cholesterol gallstone disease: hypersecretion of cholesterol from the liver with cholesterol supersaturation in bile; disturbed motility with defective absorption and secretion by the gallbladder; increased crystallisation of cholesterol in the gallbladder bile; and slow intestinal transit with increased amount of deoxycholic acid in the bile acid pool. We aimed to evaluate the biliary lipid composition in a large series of gallstone patients, with emphasis on the amount of deoxycholic acid and with respect to number of stones, compared to gallstone free subjects. MATERIALS AND METHODS: Bile was sampled during operations through puncture of the gallbladder from 145 cholesterol gallstone patients, 23 patients with pigment stones and 87 gallstone free patients undergoing cholecystectomy. Biliary lipid composition, cholesterol saturation, bile acid composition, nucleation time and cholesterol crystals were analysed. RESULTS: The patients with cholesterol gallstones showed higher molar percentage of cholesterol, lower total biliary lipid concentration, higher cholesterol saturation, shorter nucleation time and higher proportion of crystals in bile than the other groups. The nucleation time was significantly shorter in multiple cholesterol gallstone patients, but this was not due to higher cholesterol saturation. Male cholesterol gallstone patients showed higher cholesterol levels, lower total biliary lipid concentration, and higher cholesterol saturation in bile than female patients. There was no difference in biliary content of deoxycholic acid, but significantly lower content of cholic acid in gallstone patients compared to gallstone free patients. CONCLUSIONS: We conclude that deoxycholic acid does not contribute to gallstone formation in cholesterol gallstone patients. The short nucleation time in patients with multiple cholesterol stones is not due to higher cholesterol saturation.

Effect of eyelid botulinum toxin injection on lacrimal drainage.

PURPOSE: To determine the effect of eyelid botulinum toxin injection on the lacrimal drainage and to assess the use of botulinum toxin in dry eye conditions. METHODS: Prospectively, three test groups were examined and one lacrimal system investigated in each person in each group. Botulinum toxin A (3.75 IU) was injected into the medial part of 13 lower eyelids of 13 normal test subjects and the medial part of nine lower eyelids in nine patients with dry eyes. A dose of 2.5 IU was injected into the medial part of 10 lower eyelids and the medial part of 10 upper eyelids of 10 patients with dry eyes. The drop test was used to determine the lacrimal drainage capacity and the blink output, before and after the injection. The subjective effect of the botulinum toxin injection on eye comfort was investigated. RESULTS: Three weeks after lower eyelid botulinum toxin injection, the mean blink output was reduced to 64% (1.19 of 1.87; P <.001) and 70% (0.94 of 1.35; P <.001) of the baseline values in the groups of normal subjects and patients, respectively. After injection in both the upper and lower eyelid, the mean blink output was reduced to 38% (0.54 of 1.41; P <.001) of the baseline value. The patients with dry eyes reported an improved eye comfort in six of nine cases after injection in the lower eyelid and in seven of 10 cases after injection in both the upper and lower eyelid. Adverse effects included one case of increased discomfort for 3 weeks after injection. CONCLUSION: Injection of botulinum toxin into the medial part of the eyelids decreased the lacrimal drainage, suggesting a new way to treat dry eye conditions. Further studies are required to assess the clinical value of this treatment.

Reliability of the drop test for the lacrimal drainage function.

PURPOSE: The purpose of this study was to investigate the reliability of the drop test. METHODS: The repeatability of the test was studied with the same and three different examiners. The influence of the blink rate was investigated by recording the blink frequency in 63 subjects. The degree of reflex lacrimation during the test was assessed in ten patients. The effect of different test solutions was investigated in ten test subjects. RESULTS: There was no significant difference when the test was repeated either by the same or different examiners. The reflex lacrimation during the drop test was not significant. There was no correlation between drop test result and blink rate. A moderate increase in the viscosity of the test solution affected the lacrimal drainage. CONCLUSION: The drop test is a reliable test for the lacrimal drainage function.

Panorama of orbital space-occupying lesions. The 24-year experience of a referral centre.

PURPOSE: The aim of this survey was to study the frequency and management of orbital lesions requiring incisional or excisional biopsy for diagnostic or therapeutic purposes. METHODS: A histopathological review of specimens from 300 consecutive patients with space-occupying orbital lesions managed over a period of 24 years at a tertiary referral centre. RESULTS: The lesions could be attributed to 73 different entities with low-grade, non-Hodgkin lymphoma being the most common. More than half (54.3%) of lesions were neoplastic and malignant disease was present in 29.0% of patients. The majority of lesions were biopsied using the anterior transseptal or transconjunctival approach. CONCLUSION: Most orbital space-occupying lesions requiring biopsy are benign and easily accessible. However, the diversity of these rare lesions and complexity of management suggest that patient care is best provided by a team of experienced subspecialists at a designated orbital centre.

Gravity, blink rate, and lacrimal drainage capacity.

PURPOSE: To investigate the influence of gravity and blink rate on lacrimal drainage capacity and to learn whether lacrimal pump function can be measured with the drop test. METHODS: The drop test for lacrimal drainage capacity was performed in 20 test subjects, aged 12 to 30 years. Drops of a known volume of lukewarm saline solution were repeatedly instilled in the tear film for 3 minutes. Excessive saline solution was then removed, and the volume drained by the lacrimal passages was calculated. The drop test was performed both with the nasolacrimal duct in a 45-degree position and with the nasolacrimal duct in a horizontal position. The drop test was performed two times in each position, with the individual reading and not reading. A lower blink rate was induced by reading. RESULTS: There was a high correlation between blink rate and lacrimal drainage when the nasolacrimal duct was in a horizontal position. The volume drained with each blink was approximately 2 microliters. However, when gravity acted upon the fluid in the lacrimal sac-nasolacrimal duct in the direction of the tear flow, the lacrimal drainage capacity showed a significant but variable increase, and there was no significant correlation between blink rate and lacrimal drainage capacity. CONCLUSIONS: Lacrimal drainage capacity in young individuals was significantly affected by both blink rate and gravity. Lacrimal pump function can be measured quantitatively with the drop test.

The effect of vitamin C in high doses on plasma and biliary lipid composition in patients with cholesterol gallstones: prolongation of the nucleation time.

Vitamin C deficiency in guinea pigs leads to cholesterol supersaturation of bile and formation of cholesterol gallstones. It has been suggested that there may also exist an association between vitamin C and cholesterol gallstones in man, but such a relationship has not been studied in gallstone patients. In order to study the possible effects of vitamin C on gallstone disease in humans, plasma lipid levels, hepatic cholesterol metabolism, biliary lipid composition, cholesterol saturation and nucleation time of gallbladder bile were analysed in 16 consecutive gallstone patients, who were planned for laparoscopic cholecystectomy and were treated with vitamin C (500 mg, four times a day) for 2 weeks before surgery. The plasma concentration of vitamin C increased by 42% in the treatment group. The concentrations of plasma lipids did not differ before and after vitamin C treatment; nor did the plasma levels of lathosterol and 7 alpha-hydroxy-4-cholesten-3-one, reflecting cholesterol and bile acid synthesis respectively. The relative concentrations of cholesterol, bile acids and cholesterol concentration of bile did not differ significantly between the two groups, but the relative concentration of phospholipids was slightly higher in the treated group. The bile acid composition was changed; the percentage of cholic acid being lower and those of deoxycholic acid, ursodeoxycholic acid and lithocholic acid higher in the vitamin C-treated patients compared with the untreated group. The nucleation time was significantly longer in the treatment group (7 days) compared with the untreated group (2 days). Our findings indicate that vitamin C supplementation may also influence the conditions for cholesterol gallstone formation in humans.

Lysosomal enzyme activities in gallbladder mucosa of gallstone-free subjects and patients with gallstones.

BACKGROUND/AIMS: Gallstone patients have a reduced cellular lysosome content in the gallbladder mucosa cells compared with gallstone-free subjects. The purpose of the study was to further evaluate the possible role of lysosomes in the pathogenesis of cholesterol gallstone formation in humans. METHODS: Lysosomal enzyme activities were assayed in gallbladder mucosa and for comparison in liver specimens of 19 gallstone-free subjects and 24 gallstone patients undergoing cholecystectomy. RESULTS: Gallstone patients had 25-50% lower activities of the lysosomal proteases cathepsin B, D and L in their gallbladder mucosa compared with gallstone-free subjects. The activity of acid phosphatase also tended to be decreased in gallstone patients. The liver lysosomal enzyme activities were not significantly different between the two groups. CONCLUSIONS: The results show that gallstone patients have diminished lysosomal enzyme activities in the gallbladder mucosa, a finding which may be related to decreased intracellular degradation of proteins and/or mucin in the mucosal cells. This may lead to a higher concentration of mucin in gallbladder bile and thus an increased risk of precipitation of cholesterol crystals and gallstone formation.

Immunochemical and functional properties of biliary alpha-1-antitrypsin.

Alpha-1-antitrypsin (AAT), the archetype of the serpin (serine proteinase inhibitor) superfamily, is synthesized by hepatocytes and excreted to some extent into bile. The role of intact biliary AAT in gallstone pathogenesis is unsettled, but its 36-residue C-terminal peptide was found to promote cholesterol crystallization in a bile model. The present study showed biliary AAT to have specific properties that differ from serum AAT regarding immunoreactivity, heat stability and antiproteolytical activity. Electrophoretical and immunochemical methods were used to characterize biliary AAT. The level of its inhibitory activity was determined spectrophotometrically. In 18 samples from common bile duct and 12 samples from gallbladder bile, AAT was found to be heat-stable and functionally inactive. Added to the untreated, temperature-inactivated or protease inhibitors containing bile, native AAT became functionally inactive, heat-stable and lost its immunoreactivity. In contrast, heat-inactivated AAT, native albumin, transferrin, alpha-1-antichymotrypsin and IgG were unaffected on being added to bile. AAT in human bile manifests specific biochemical properties, such as functional inactivity and heat stability, that may be consistent with a conformational transition of the serpin molecule induced by the hydrophobic environment, and which must be considered when evaluating its role in gallstone pathogenesis.

Evaluation of the lacrimal drainage function by the drop test.

PURPOSE: To compare the fluorescein dye disappearance test with a new test for lacrimal drainage capacity, the drop test. METHODS: In the fluorescein dye disappearance test, 1 microliter of fluorescein solution was instilled into the conjunctival sac of normal subjects and of patients with epiphora. Fluorescence from the tear film was measured, and the rate of dye disappearance was calculated as a measure of tear drainage. In the drop test, drops of 10 microliters of lukewarm saline solution were repeatedly instilled into the conjunctival sac for 3 minutes. Excessive saline solution was then removed from the tear film and measured. The volume of saline solution drained by the lacrimal passage could thus be calculated. RESULTS: The fluorescein dye disappearance test showed, in normal subjects, a tear turnover rate of 10.9 +/- 3.1% (95% confidence interval) per minute, which was nor age dependent. The drop test showed a decreased lacrimal drainage capacity with increasing age in normal subjects, with a mean capacity of 150 +/- 38.5 microliters/3 min for those 41 to 80 years old. In patients with indoor epiphora, the fluorescein dye disappearance test values were significantly reduced. However, the fluorescein dye disappearance test could not differentiate among normal eyes, eyes with minor epiphora, or eyes with moderate epiphora. The drop test showed a significant decrease even in patients with minor epiphora and was further decreased with increasing severity of symptoms. CONCLUSION: The drop test provides a quantitative measurement for lacrimal drainage function and is more sensitive than the fluorescein dye disappearance test.

Total protein content of human gallbladder bile: relation to cholesterol gallstone disease and effects of treatment with bile acids and aspirin.

OBJECTIVE: To measure the total protein content of gallbladder bile, and assess how treatment with aspirin and the gallstone solvents chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA) affects the biliary protein concentration. DESIGN: Prospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 102 Consecutive patients undergoing cholecystectomy for cholesterol gallstones (n = 73) or adenomyomas or cholesterolosis in the gallbladder wall (n = 29). Thirty of the patients with gallstones were treated with CDCA, UDCA or aspirin. INTERVENTIONS: Aspiration of bile from the gallbladder during operation. MAIN OUTCOME MEASURES: Protein content, and correlations between protein content and biliary lipids, cholesterol saturation and crystals, and concentrations of individual bile acids. RESULTS: There were no differences in total protein content among the groups except for the UDCA treated group, which had significantly less protein 2.1 (0.5) g/l compared with 6.1 (0.5) for untreated gallstones, 5.8 (0.9) for those treated with CDCA, 6.8 (1.2) for those treated with aspirin and 7.3 (0.7) for those with no gallstones). There were no differences between bile with and without crystals. There was a positive correlation between the protein content and biliary cholesterol concentration and saturation. Aspirin did not influence the total protein content in the bile. CONCLUSIONS: The total protein concentration in gallbladder bile was similar in patients with and without cholesterol crystals, which might indicate that the total protein content in bile does not influence formation of cholesterol crystals and consequently not the formation of gallstones. Patients treated with UDCA were the only group that had significantly less protein than the other groups, which indicates that the mode of action of UDCA is different from that of CDCA.

Rise and fall in the number of cholecystectomies: Stockholm 1932-1993.

OBJECTIVE: To assess the annual rates of cholecystectomy 1932-1993 in Stockholm and compare them with the rates for other common surgical procedures. DESIGN: Retrospective collection of data from annual hospital records. SETTING: Teaching hospital, Sweden. SUBJECTS: All subjects in Stockholm county who underwent cholecystectomy, herniorrhaphy, appendicectomy, colonic resection for cancer and mastectomy for cancer or who were admitted to hospital with acute cholecystitis and not operated on. MAIN OUTCOME MEASURES: Annual rates from 1932-1993. RESULTS: The rate of cholecystectomies/100000 inhabitants increased slowly from 1932 and peaked in 1957 at 315. It then decreased to 67 in 1990 after which the introduction of laparoscopic technique caused an increase to the present rate of 90. CONCLUSION: There has been a rise and a fall of the cholecystectomy rate during the last 60 years in Stockholm county which are probably explained by changes in the indications for the operation. There was no association with health care facilities or with changes in the rates of other operations.

Cholesterol metabolism in liver and gallbladder mucosa of patients with cholesterolosis.

The objective of this study was to investigate possible pathogenetic factors for cholesterolosis. Liver tissue, gallbladder mucosa, and gallbladder bile were collected in patients with cholesterol gallstones (GS) (14 patients with and 14 patients without cholesterolosis) and gallstone-free (GSF) subjects (11 with and 21 without cholesterolosis) undergoing cholecystectomy. In cholesterolosis, the gallbladder mucosa was characterized by a fivefold increase in esterified cholesterol and normal content of free cholesterol. The hepatic levels of 3-hydroxy-3-methylglutaryl coenzyme A reductase activity, governing cholesterol synthesis, and acyl coenzyme A: acyltransferase activity, catalyzing the esterification of cholesterol, were similar in patients with and without cholesterolosis. Also in the gallbladder mucosa, the 3-hydroxy-3-methylglutaryl coenzyme A reductase activity was similar in patients with and without cholesterolosis. The acyl coenzyme A: acyltransferase activity of the gallbladder mucosa was increased in the GSF subjects with cholesterolosis. The nucleation time of gallbladder bile was shorter in the GSF subjects with cholesterolosis compared with the time of those without cholesterolosis. Occurrence of cholesterol crystals, lipid composition, and cholesterol saturation of gallbladder bile were not significantly influenced by the absence or presence of cholesterolosis. The study has confirmed that cholesterolosis is associated with a several-fold increased level of esterified cholesterol. The data suggest that patients with cholesterolosis have normal hepatic cholesterol formation and esterification. The local synthesis of cholesterol in the gallbladder mucosa seems to be normal. A positive correlation was obtained between the cholesterol saturation of bile and the content of esterified cholesterol in the gallbladder mucosa in the whole series of patients.(ABSTRACT TRUNCATED AT 250 WORDS)