Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of a double-blind, placebo-controlled study.

BACKGROUND: Weight loss among older patients is a severe problem, associated with an increased incidence of infections, decubiti, and death. Megestrol acetate (MA) causes weight gain in cachectic cancer and AIDS patients, but its effects in older cachectic patients are unknown. OBJECTIVE: To compare the effects of MA oral suspension (O.S.), 800 mg/day, versus placebo on weight in geriatric nursing home patients with weight loss or low body weight. DESIGN: Twelve-week, randomized, double-blind, placebo-controlled trial with a 13-week follow-up period. SETTING: Veterans Administration Medical Center (VMAC) nursing home. PATIENTS: Nursing home patients with weight loss of > or =5% of usual body weight over the past 3 months, or body weight 20% below their ideal body weight. INTERVENTIONS: Patients were randomly assigned to receive placebo or MA 800 mg/day for 12 weeks and were then followed for 13 weeks off treatment. MEASUREMENTS: Primary outcome was measured by weight and appetite change. Secondary outcome measures included sense of well-being, enjoyment of life, change in depression scale, laboratory nutrition parameters, energy intake counts, body composition, and adverse events. RESULTS: At 12 weeks there were no significant differences in weight gain between treatment groups, whereas MA-treated patients reported significantly greater improvement in appetite, enjoyment of life, and well-being. Body composition was not statistically different between the two groups. At Week 25 (3 months after treatment), 61.9% of MA-treated patients had gained > or =1.82 kg (4 lbs) compared to 21.7% of placebo patients. CONCLUSIONS: In geriatric patients with weight loss or low body weight MA improves appetite and well-being after 12 weeks of treatment. During the 3 months of MA treatment, there was no statistically significant weight gain (> or =4 lbs). Three months after treatment, weight gain (> or =4 lbs) was significantly increased in MA-treated patients.

Increased levels of serum hepatocyte growth factor in patients with end-stage renal disease.

Blood levels of hepatocyte growth factor (HGF) have been found to be elevated in patients with chronic renal failure. The cause of the increase in this mitogen is unclear. We determined serum HGF levels in 34 patients on maintenance dialysis and ten healthy volunteers. Predialysis serum HGF levels were elevated in patients with end-stage renal disease as compared to control subjects (1.65 +/- 0.2 ng/mL vs 0.46 +/- 0.04 ng/mL, p<0.01). In addition, serum HGF levels were significantly higher in African-American dialysis patients compared to Caucasian patients (2.18 +/- 0.36ng/mL vs 1.18 +/- 0.12ng/mL, p<0.01). The observed differences could not be accounted for by variations in serum creatinine, serumalbumin, or blood pressure between the African-American and Caucasian patients. Serum HGF levels were elevated in patients with end-stage renal disease, and were higher in African-American than Caucasian patients, but the pathophysiology and significance of this finding remain unclear.

Chronic liver disease in central Harlem: the role of alcohol and viral hepatitis.

For reasons not yet determined, chronic liver disease (CLD) has been a leading cause of excess morbidity and mortality in central Harlem. We conducted a case series and case-control analysis of demographic, clinical, epidemiological, and alcohol-intake-related information from patients with CLD and age- and sex-matched hospitalized control patients. Patients' sera were tested for markers of viral hepatitis. The presumed etiology of CLD among case-patients was as follows: both alcohol abuse and hepatitis C virus (HCV) infection, 24 persons (46% of case-patients); alcohol abuse alone, 15 (29%); HCV infection alone, 6 (12%); both alcohol abuse and chronic hepatitis B virus (HBV) infection, 3 (6%); and 1 each (2%) from: 1) schistosomiasis, 2) sarcoidosis, 3) unknown causes, and 4) alcohol abuse, chronic HBV, and HCV combined. In the case-control analysis, patients who had both alcoholism and either HBV (odds ratio [OR]: 6.3; 95% CI: 0. 5-334) or HCV (OR: 2.9; 95% CI: 1.3-6.2) were at increased risk for CLD, whereas patients who had only one of these three factors were not at increased risk for CLD. Patients who tested positive for the hepatitis G virus (HGV) did not have a significantly increased risk of CLD, and neither severity of CLD nor mortality was greater among these patients. Most patients in central Harlem who had CLD had liver damage from a combination of alcohol abuse and chronic viral hepatitis. Alcohol and hepatitis viruses appear to be synergistically hepatotoxic; this synergy appears to explain both the high rate of CLD in central Harlem and the recent reductions in this rate. Persons at risk for chronic HBV and HCV infection should be counseled about their increased risk of CLD if they consume excessive alcohol. Morbidity and mortality from liver disease could be decreased further by a reduction in alcohol consumption among persons who have chronic HBV and HCV infection, avoidance of needle sharing, and hepatitis B vaccination.

Hepatotoxicity from isoniazid and rifampin in inner-city AIDS patients.

OBJECTIVE: To determine the incidence of hepatotoxicity due to isoniazid and rifampin in inner-city patients with active tuberculosis. DESIGN: A hospital-based review of 70 consecutive in-patients in a 770-bed, inner-city hospital. The patient population is primarily African-American and Hispanic. METHODS: Fifty-eight men and 12 women were followed from 2-12 wk (median 4 wk). Patients had to be treated for at least 2 wk to be eligible for the study. Patients were excluded if they had been on any anti-tuberculous or any other hepatotoxic drug during the 2-month period before their hospitalization. Aminotransferases, alkaline phosphatase, bilirubin, and albumin were obtained at least every 2 wk. RESULTS: Hepatocellular toxicity, defined as AST and/or ALT greater than 200 IU/L, occurred in eight out of 70 (11.4%) patients. The mean age of these patients was 38.9 yr (22-58 yr). Patients with AIDS were significantly more likely to develop hepatotoxicity than those with any other risk factor (p < 0.01). CONCLUSIONS: Baseline aminotransferases followed by monitoring may be necessary in AIDS patients.

Changes in glucose transport and transporter isoforms during the activation of human peripheral blood lymphocytes by phytohemagglutinin.

We have explored the mechanism of stimulation of glucose transport during PHA stimulation of human peripheral blood lymphocytes (HPBT) enriched in T cells. Equilibrium exchange flux of 3-O-methyl glucose (3-O-MG) was stimulated two- and fourfold at 24 and 48 h after PHA stimulation, respectively. The increase was transient in that the flux rate returned to control (unstimulated) levels by 96 h. Immunoblotting and immunoprecipitation using specific Abs revealed that resting HPBT expresses glucose transporter isoforms GLUT-2 and GLUT-3 but not GLUT-1. After PHA stimulation, GLUT-1 expression was induced predominantly in the plasma membrane, whereas GLUT-3 expression was simultaneously down-regulated. GLUT-1 expression was detectable at 24 h, peaked at 48 h, and disappeared at 96 h. The total number of glucose transporters per cell measured as the total capacity of D-glucose displaceable cytochalasin B binding did not change significantly at any time after PHA stimulation. PHA stimulation also caused expression of high affinity IL-2R and secretion of IL-2. The IL-2 secretion was transient, which peaked at 24 h, slightly preceding the GLUT-1 expression peak and disappeared at 72 h. In PHA-activated HPBT cells synchronized at G0-G1, GLUT-1 was not expressed but was rapidly induced by exposure to IL-2. This induction did not occur in the presence of cyclosporin A, which inhibits IL-2 secretion. Based on these observations, we conclude that PHA stimulation increases glucose transport partly by inducing the expression of GLUT-1 instead of GLUT-3 and that GLUT-1 expression is induced by signals generated by IL-2 binding to its high affinity receptors.

Calcium uptake during mitogenic stimulation of human lymphocytes: characterization of intracellular calcium compartments and demonstration of the presence of immunoreactive calrecticulin.

Phytohemagglutinin (PHA) stimulation of human peripheral blood lymphocytes (HPBL) rapidly increases 45Ca2+ uptake into intracellular pools. Detectable increase in 45Ca2+ uptake occurred only on exposure to mitogenic lectins but not with non-mitogenic lectins. However, intracellular free Ca2+ concentration [(Ca2+)i] increased comparably on exposure to either mitogenic or non-mitogenic lectins. Permeabilization of 45Ca2+ loaded cells revealed distinct pools of Ca2+ uptake. The highly digitonin sensitive pool #I (permeabilized by 0.02% digitonin) exchanged slowly and included a part that represented endoplasmic reticulum. Pool II was defined by lower digitonin sensitivity, had a much faster initial uptake. Pool III was digitonin-resistant and predominantly non-vesicular. During the first 120 min of PHA stimulation, significant increase in 45Ca2+ uptake occurred only into pool II. Progressive increase in uptake into pool I then occurred so that by 24 hours, this pool constituted the major fraction of PHA induced increment in total 45Ca2+ uptake. Using specific antibody to the calcium binding protein calreticulin, an analogous immunoreactive protein was detectable in resting HPBL. PHA stimulation led to a striking increase in abundance of immunoreactive calreticulin so that 24 hrs after PHA stimulation, there was a 28 and 3.4 fold increase in the amount of immunoreactive calreticulin present in the non-particulate fraction and the total particulate membrane fraction, respectively. A major part (72%) of the total cellular immunoreactive calreticulin in PHA stimulated cells at 24 hrs was released into the medium after permeabilization of lymphocytes with 0.02% digitonin, corresponding to the location of calcium uptake pool I.

Hepatic amyloidosis in intravenous drug abusers and AIDS patients.

The clinical and pathological features of four liver biopsies and 12 autopsies from 1981-1990 with hepatic amyloidosis were reviewed. All of the patients had a history of both intravenous and subcutaneous cocaine and heroin use with chronic suppurative skin ulcers. Five patients were proven to have the acquired immunodeficiency syndrome at autopsy. Systemic amyloidosis was diagnosed in only five out of the 16 patients prior to death. Hepatomegaly was present in 12 patients. The amyloid protein was AA in 14 and AL in one case. Definitive characterization of the amyloid substance was not possible in one case. There was no evidence of multiple myeloma or a plasma cell dyscrasia in the one patient with AL amyloid. The amyloid distribution in the liver was both parenchymal and vascular in 12 cases. Cholestasis, which appeared to occur preterminally, was the only histological finding that correlated with the patient's clinical condition. The histological pattern of amyloid in the liver could not predict the type of amyloid protein that was identified. Amyloidosis should be considered in the differential diagnosis of unexplained hepatomegaly in the acquired immunodeficiency syndrome with chronic suppurative infections.

Analysis of cost-effectiveness of different strategies for hepatocellular carcinoma screening in hepatitis B virus carriers.

A mathematical model was used to calculate the efficacy of screening to detect hepatocellular carcinoma at a resectable stage in hepatitis B virus carriers. Data relating to tumour incidence, efficacy of screening tests and tumour growth times were obtained from a literature review. Various tests were costed according to charges currently prevailing at the authors' institution. The cost per early tumour detected is inversely proportional to tumour incidence. It is relatively low for populations with high incidences of hepatocellular carcinoma for example, male carriers over the age of 30. Both the costs and the proportions of early tumour detected increase with increasing frequency of screening. However, the use of ultrasonography at 10 monthly intervals or both ultrasonography and alpha-fetoprotein estimation at yearly intervals will detect 90% of tumours early at a cost of S$20,000 (US$11,800) per early tumour detected. The results would be significantly altered if tumour growth times were markedly different from those reported in the literature.

Transfusion-related chronic liver disease in sickle cell anemia.

The medical records and liver biopsies of nine sickle cell patients with chronically elevated liver function tests were retrospectively reviewed to determine the etiology of chronic liver disease. There were eight women and one man with a mean age of 30 yr. All patients had hemoglobin SS. Eight patients were referred for elevated aminotransferases and one for an elevated alkaline phosphatase. Hemosiderosis was present in all of the biopsies. Two patients had cirrhosis. Chronic hepatitis was noted in two patients, and five patients had cholestasis. Two patients had serologic markers demonstrating HBV exposure but no patients were HBsAg positive. Erythrophagocytosis, sinusoidal dilatation, and Kupffer cell hyperplasia were present in all of the liver biopsies. Transfusion-related causes were the most common significant pathologic findings in our patients, and appeared to be the etiologies of chronic liver disease in sickle cell patients.

Cluster of fulminant hepatitis B in crack users.

Fulminant hepatitis occurs in only 1% of acute hepatitis B patients, requiring hospitalization, but coinfection with delta virus increases the incidence. Hepatitis B and D infection are commonly associated with intravenous drug abuse, but there have been no previous reports of an association with nonparenteral cocaine. Crack use, via sexual promiscuity, is associated with an increased risk for human immunodeficiency virus infection, but has never been associated with viral hepatitis. We report four fatal cases of fulminant hepatitis B including, one with delta virus coinfection and one with human immunodeficiency virus (HIV) infection, in young, sexually active, heterosexual crack users. These patients denied a history of intravenous drug abuse. Our patients probably contracted hepatitis B infection via heterosexual contact. Chronic cocaine exposure may or may not have contributed to the fulminant outcome. Crack users may be at increased risk of developing hepatitis B and D infection. Epidemiological studies are needed to evaluate their risk of viral hepatitis and the effect of cocaine on its outcome.

Antibody to herpes simplex virus type 1 in peptic ulcer patients.

It has been postulated that herpes simplex virus type 1 may be a causative factor of duodenal ulcer. Serum antibody titres to herpes simplex virus type 1 in duodenal and gastric ulcer patients were compared with race-, sex- and age-matched controls. No differences in antibody titres could be demonstrated between duodenal ulcer and gastric ulcer patients and their respective controls, between gastric ulcer and duodenal ulcer patients or between acute and convalescent sera in either gastric or duodenal ulcer. Although Chinese are more susceptible to ulcer disease than Malays and Indians, antibody titres were comparable between subjects of different races. The results of this study do not support a causal role for herpes simplex virus in peptic ulcer disease.

Mechanism of mitogen-induced stimulation of glucose transport in human peripheral blood mononuclear cells. Evidence of an intracellular reserve pool of glucose carriers and their recruitment.

The present study examines the effects of phytohemagglutinin stimulation of a population of human (h) PBMC enriched in lymphocytes (hPBMC) on D-glucose displaceable cytochalasin B binding sites or medium-affinity sites (M-sites) in relation to glucose transport. Previously we have shown that M-sites are glucose transporters in hPBMC (Mookerjee, B.K., et al. 1981. J. Biol. Chem. 256:1290-1300). Equilibrium exchange of 3-O-methyl D-glucose in unstimulated cells revealed two populations with fast and slow flux rates. Phytohemagglutinin stimulates flux rates by converting part of the slow flux population to the fast flux population. M-sites occur in two distinct pools, one in plasma membrane and the other in microsomal fraction. Phytohemagglutinin treatment increases the plasma membrane pool size of M-sites with a concomitant reduction in the microsomal pool size without affecting the binding affinities or the total number of M-sites/cell. Data presented in this paper demonstrate that there are two pools of glucose transporters in these cells and phytohemagglutinin stimulation induces an energy-dependent net translocation of glucose transporters from an intracellular reserve pool to the plasma membrane, which accounts for greater than 60% of the increment in glucose transport.

A simple radioimmunoassay of human interleukin-2.

We have developed a liquid phase radioimmunoassay of human interleukin-2 which uses inexpensive commercially available reagents exclusively. The assay is simple, reproducible and specific in detecting different batches of human interleukin-2 of natural as well as recombinant origin, but not detecting recombinant murine interleukin-2. The assay is sensitive to a concentration of approximately 0.05 ng/ml and can be used in measurement of IL-2 in serum containing culture media.

Modal coupling in tilted-mirror waveguide lasers and amplifiers.

Tilted-mirror facets have been introduced as a design alternative to antireflection coating for waveguide structures that require low facet reflectivity. We show that tilted-mirror facets with finite reflectivity can induce significant intermode coupling in semiconductor lasers and optical amplifiers. We describe the effect of tilt-induced intermode coupling on the cavity modes using a simple model and discuss the implications of our results on the design of tilted-mirror integrated-optical lasers and amplifiers.

Characteristics of calmodulin binding to purified human lymphocyte plasma membranes.

We have explored the role of calmodulin in plasma membrane-related phenomena in lymphocyte activation by measurement of [125I]calmodulin binding to highly purified plasma membrane of human peripheral blood lymphocytes. Calcium-dependent calmodulin binding to lymphocyte membrane was found to reach equilibrium within 5 min of incubation at 37 degrees C and to be saturable and specific. A single class of high affinity-binding sites was identified, with a dissociation constant (Kd) of 1 to 3 X 10(-8) M and a total binding capacity (Bt) of 1 to 2 pmol/mg membrane protein. The free calcium concentration necessary for half-maximal binding was 100 to 300 nM. This was strikingly similar to the cytoplasmic-free calcium activity [Ca2+]i measured by the Quin-2 fluorescence technique, particularly after stimulation with phytomitogens. Calmodulin binding was inhibitable by trifluoperazine (TFP), W-7, and chloropramazine, all of which are calmodulin antagonists. The concentration of TFP that caused 50% inhibition of lymphocyte proliferative responses to phytomitogens was found to be identical to the concentration of TFP which causes 50% inhibition of calmodulin binding to lymphocyte plasma membrane. SDS-polyacrylamide gel electrophoresis followed by gel overlay and autoradiography with iodinated calmodulin revealed five calcium-dependent, TFP-inhibitable, calmodulin-binding polypeptides.