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Primary biliary cirrhosis is a chronic cholestatic disease of unknown aetiology which predominantly affects middle-aged women. It is thought to be autoimmune in nature, but unlike many autoimmune diseases no clear HLA association has been described. Several studies have suggested conflicting associations with HLA class II, although a DR8 association is most frequently described. To test the hypothesis that primary biliary cirrhosis is associated with a certain HLA class II locus we genotyped 130 patients with the disease from the north-east region of England and 363 local healthy controls. HLA-DRB1 and confirmatory DQA and DQB genotypes were determined by TaqI restriction fragment DNA length polymorphism analysis. In addition, a polymerase chain reaction technique (double ARMS) was used to investigate the DRB3 locus (DR52) in 98 primary biliary cirrhosis patients and 107 local controls. We found an increased frequency of HLA-DR8 (18.5% vs 9.2%, p < 0.005, relative risk of 2.0 [1.3-3.1]) in the primary biliary cirrhosis group. HLA-DR8-positive primary biliary cirrhosis patients had a higher serum bilirubin level (p = 0.03) than DR8-negative patients. There was no difference in the DR52 frequencies and no association with markers of disease severity. These results support earlier serological findings, although the association between primary biliary cirrhosis and DR8 is weaker than previously described. In addition, DR8-positivity may identify a clinical subgroup with a worse prognosis.

Background—Iron overload is common in the livers of alcoholics and may play a role in disease pathogenesis. An MHC like gene, HFE,has recently been identified that is mutated in most patients with hereditary haemochromatosis (C282Y in 90% and H63D in 45% of the remainder).Aim—To examine the hypothesis that these mutations determine hepatic iron status in alcoholics and play a role in predisposition to advanced alcoholic liver disease.Methods—TheHFE gene was genotyped in 257 patients with alcoholic liver disease and 117 locally matched healthy volunteers. In addition, iron staining was scored (0–4) on biopsy specimens from fibrotic/cirrhotic patients with and withoutHFE mutations matched for age and sex.Results—Some 15.7% of fibrotic/cirrhotic patients were C282Y heterozygotes compared with 13.7% of controls (p = 0.77). One control and three patients were C282Y homozygotes. Of chromosomes without the C282Y mutation, 68/442 (15.4%) of patients’ chromosomes carried the H63D mutation compared with 36/216 (16.6%) of control chromosomes (p = 0.91). Significant (>grade 1) hepatocyte iron staining was seen in 6/23 C282Y heterozygotes and 4/26 H63D heterozygotes compared with 4/23 controls.Conclusions—Possession of a single copy of either of the two HFEmutations influences neither liver iron content nor the risk of fibrotic disease in alcoholics.

The results of a 3-year, placebo-controlled trial of prednisolone treatment in primary biliary cirrhosis (PBC) are presented. The active (n = 19) and placebo (n = 17) arms were initially well matched for age, menopausal status and disease severity. At 3 years hepatic symptoms were relatively improved in the prednisolone group. Hepatic mortality was 3/19 (prednisolone), 5/17 (placebo) (p = n.s.). For all liver blood tests the trend favoured prednisolone treatment, though the differences were only significant for alkaline phosphatase and protein. All immunoglobulins fell significantly. Quantitative ELISA determination of antimitochondrial antibody showed a significant fall in the prednisolone group compared with placebo (p less than 0.001 at 1 year, p less than 0.05 at 3 years). Deterioration in histology (appearance of cirrhosis) was more common in the placebo group. Overall hepatic function (hepatic mortality, doubling in bilirubin, 6 milligrams fall in albumin, de novo appearance of cirrhosis or symptoms of portal hypertension) was significantly worse in the placebo group (p less than 0.01). After 3 years no significant differences could be detected in bone mineral content (single photon absorptiometry of radius and femur) between the two groups or in comparison with other PBC patients. Thus, after 3 years, prednisolone treatment was associated with a better overall hepatic outcome and little evidence of increased bone loss.

1. In primary biliary cirrhosis, the major M2 autoantigen, reacting with antimitochondrial antibodies in sera from >90% of patients, has been identified as the E2 component of the pyruvate dehydrogenase complex. However, two recent reports suggest that alternative polypeptides may be major autoantigens. 2. The evidence that a 75 kDa subunit of complex I of the respiratory chain is a major autoantigen (Frostell, Mendel-Hartvig, Nelson, Totterman, Bjorkland & Ragan, Scand. J. Immunol. 1988; 28, 157–65) is refuted. The findings of Frostell et al. can be explained by contamination of complex I with the pyruvate dehydrogenase complex, evidence for which is presented here. 3. Inspection of the partial amino acid sequence of an unidentified mitochondrial autoantigen (Muno, Kominami, Ishii, Usui, Saituku, Sakakibara & Namihisa, Hepatology 1990; 11, 16–23) shows that it is the El β-subunit of the pyruvate dehydrogenase complex, previously identified as a major autoantigen, and not a ‘new’ alternative major autoantigen. 4. These findings substantiate previous work showing that the mitochondrial M2 autoantigens identified so far in primary biliary cirrhosis are all polypeptide components of the pyruvate dehydrogenase complex or the other related 2-oxo acid dehydrogenase complexes.

Six components of the mammalian 2-oxo acid dehydrogenase complexes have previously been identified as M2 autoantigens in primary biliary cirrhosis. In this report, we present data showing that both polypeptide-specific and cross-reacting antibodies are present in patients' sera. Antibodies reacting with E2 of the pyruvate dehydrogenase complex cross-react with protein X but not with any other mammalian antigen. The main immunogenic region on protein X has been localized to within its single lipoyl domain. Polypeptide-specific antibodies bind to E1 alpha and E1 beta of the pyruvate dehydrogenase complex. Antibodies reacting with the E2 polypeptides of the 2-oxoglutarate dehydrogenase complex and branched-chain 2-oxo acid dehydrogenase complex show some cross-reactivity but do not recognize any of the antigens of the pyruvate dehydrogenase complex. Antibodies against the E2 component of the mammalian pyruvate dehydrogenase complex cross-react effectively with the corresponding protein from yeast but not with E2 from Escherichia coli. Antibody titer against mammalian antigens is significantly higher than against the bacterial antigens, arguing against a bacterial origin for primary biliary cirrhosis.

The extent to which mitochondria are involved in the aging process is controversial; much of the reported decline in mitochondrial oxidations in human skeletal muscle may be due to disease and inactivity rather than age. To study true aging, mitochondrial respiratory chain function was studied in 9 young and 12 elderly athletes. No significant deterioration with age was observed. If mitochondria are involved in aging, it must be through a more subtle mechanism than a global decline in respiratory chain activity.

"Pure" alcoholic fatty liver has been widely assumed to be "benign" with very low risk of progression to cirrhosis. Studies thus far have included either patients with coexisting recognised precursor lesions of cirrhosis or have been restricted to short-term histological follow-up. We have followed 88 patients, first seen between 1978 and 1985, with a histological diagnosis of pure alcoholic fatty liver and no evidence of fibrosis or alcoholic hepatitis, for a median of 10.5 years, to determine any factors predictive of disease progression. Of the 88, at follow-up nine had developed cirrhosis and a further seven fibrosis. Eight of nine patients with cirrhosis had continuing alcohol consumption of more than 40 units per week at follow-up; in the other patients, consumption was unknown. Independent histological predictors of progression on index biopsy were: presence of mixed macro/microvesicular fat, and presence of giant mitochondria. We can no longer regard alcoholic fatty liver as benign. In the presence of continuing high alcohol consumption the above histological features identified those at high risk (47-61%) of disease progression. Therefore, patients with these features should be counselled intensively regarding their alcohol consumption.

Blood ethanol concentrations after separate oral dosing and intravenous infusion of ethanol (0.15 g/kg) were measured in 16 control subjects and 13 subjects treated with ranitidine. All subjects underwent routine upper gastrointestinal endoscopy. Peak blood ethanol concentrations, and area under the blood ethanol/time curve, were significantly higher in the ranitidine group after oral, but not intravenous, ethanol administration. The first pass metabolism, as calculated by the difference between the area under the curves, was significantly lower in the ranitidine group. In addition, all subjects withdrawn from ranitidine (n = 6) had a significant reduction in peak blood ethanol concentration and area under the curve after repeat dosing with oral ethanol. Both groups were well matched for age, sex, indications for endoscopy, findings at endoscopy, and gastric histology. These findings show that ranitidine increases the bioavailability of low dose ethanol and has possible short term forensic, and longterm physical implications for moderate drinkers who are taking the drug.

It has been claimed that the amino acid derivative carbocisteine is predominantly metabolized by sulfoxidation and that this pathway exhibits a genetic polymorphism. Moreover, those subjects with a 'poor metabolizer' phenotype have been thought to have a genetic predisposition to developing certain diseases. We have confirmed the observations of others that this marker drug does not undergo significant S-oxidation. Furthermore, a novel urinary metabolite, S-(carboxymethylthio)-L-cysteine (CMTC) has recently been identified. To determine if a genetic polymorphism for this biotransformation pathway exists, metabolic ratios (% urinary excretion carbocisteine/% urinary excretion CMTC) for 120 healthy volunteers were assessed using high-performance thin-layer chromatography. Urinary excretion of the parent drug ranged from 6% of the dose administered to 56% (mean +/- SD, 23.4 +/- 0.8%). No cysteinyl sulfoxide metabolites were identified in the urine samples. The amount excreted as CMTC exhibited a 12-fold variation but only accounted for mean of 4.4% (1-12%) of the dose given. Two individuals initially had high metabolic ratios (> 30), however, on rechallenge both their MRs were less than 5. Therefore, carbocisteine is not an appropriate probe drug for sulfoxidation. The formation of the novel metabolite CMTC appears to exhibit polymorphism, although the considerable intra-subject variation for its formation does not allow assignment of a phenotype.

Type 1 collagen is the predominant collagen in cirrhotic livers. Each type 1 collagen molecule contains three subunits, two are identical (the α 1 chains) and the sequence of the third ( α 2 ) is very similar. They are encoded at the non-synthenic loci, COL1A1 and COL1A2 and restriction site dimorphisms have been described at each locus. Genetic factors have been invoked as a basis for increased susceptibility to alcoholic cirrhosis. One hypothesis is that genetically determined differences in type 1 collagen may be involved in this predisposition. We have examined this by analysing restriction fragment length polymorphisms at each type 1 collagen locus in leucocyte DNA from 56 unrelated patients with alcoholic cirrhosis and 74 local unrelated healthy controls. Based on the presence or absence of these restriction site dimorphisms four possible haplotypes were generated at COL1A1 and COL1A2 . We found no significant difference in allele frequencies between alcoholic cirrhotics and controls and, unlike a previous small study, we found no particular haplotype of either gene was associated with alcoholic cirrhosis. Our study provides no evidence for involvement of type 1 collagen structural genes in a genetic predisposition to cirrhosis in alcoholics.

We studied the effects of potassium supplementation (60 mmol/day) and matching placebo on the postural blood-pressure fall in ten elderly patients with symptomatic idiopathic postural hypotension in a double-blind, randomized cross-over trial. There was a significant decrease in the orthostatic fall in systolic blood pressure (SBP 33 +/- 5 mmHg to 16 +/- 9 mmHg, p less than 0.01) and in supine SBP (162 +/- 7 to 150 +/- 7 mmHg, p less than 0.01) between placebo and potassium phases. Supine diastolic and erect blood pressures were unchanged, though pulse rate showed a greater orthostatic increase (7 +/- 3 beats/min to 14 +/- 2 beats/min, p less than 0.05) following potassium therapy. No significant changes were seen in intracellular electrolytes, plasma renin activity, aldosterone levels or body weight. Seven patients reported symptomatic improvement with potassium, but none during the placebo phase. Potassium therapy was well tolerated and may be a successful and safe method of treating idiopathic postural hypotension.

We have studied the clinical histories and liver biopsy findings in 1951 consecutive adult patients with suspected chronic liver disease, and in four known PiZ-homozygous alpha 1-antitrypsin-deficient patients with emphysema (candidates for lung transplant) and no known liver disease, in order to assess the importance of periportal alpha 1-antitrypsin granules in the liver and their possible causal role in liver disease, and to assess the value of possible screening tests. Periportal granules were found in 30 (1.5 per cent) of the 1951 liver biopsies and in all four known PiZ-homozygous subjects. They were the sole putative aetiological agent in eight of 85 patients (9.4 per cent) with otherwise cryptogenic cirrhosis and present in 2.5 per cent of patients with cirrhosis of known aetiology (alcohol, autoimmune etc.). All but one were Z phenotype (seven homozygotes, 22 heterozygotes). alpha 1-Antitrypsin granules were seen in 12 patients (including three of four lung transplant candidates) with no histological chronic liver disease. Determination of serum alpha 1-antitrypsin levels was quite unhelpful in identifying these patients. This study does not support the concept that periportal alpha 1-antitrypsin granules are necessarily pathogenic, but in some cases they may be causally related to otherwise cryptogenic liver disease. The presence of granules gave no important diagnostic, therapeutic or prognostic information.

The genetic locus for alpha-1-antitrypsin (alpha-AT) is highly polymorphic, but all protein variants are encoded by a single locus on chromosome 14. Periportal hepatocyte granules are described in association with chronic liver disease and the Z variant. A Z-specific point mutation in exon V of the alpha-AT gene, converting amino acid 342 from Glu to Lys, is thought to be responsible for the hepatocyte accumulation. We describe the use of the polymerase chain reaction (PCR) to amplify exon V of the alpha-AT gene and subsequent detection of the wild-type M- and Z-specific sequences by hybridisation to 32P-labelled-allele-specific oligonucleotides. We applied this technique to leucocyte DNA from 37 patients with suspected chronic liver disease, 25 of whom had hepatocyte alpha-AT inclusion granules on liver biopsy. All 25 were homozygous or heterozygous for the Z allele. One patient, phenotyped as PiS, was found to be PiSZ and another phenotyped as PiZ (presumed homozygous), was found to be a Z heterozygote. No Z allele was detected in any of the twelve patients without alpha-AT inclusion granules. This sensitive PCR technique could be used to assess the relative risk of chronic liver disease in PiZ heterozygotes and to determine whether individuals without the Z amino acid 342 substitution can developed periportal alpha-AT granules.

Primary biliary cirrhosis (PBC) is characterised by the presence of antimitochondrial antibodies. The PBC-specific, immunoreactive, trypsin-sensitive antigens on the inner mitochondrial membrane (M2) have hitherto not been identified. A major 70 kD M2 autoantigen is the E2 component (lipoate acetyltransferase) of the pyruvate dehydrogenase enzyme complex located within mitochondria. This has been confirmed by immunoblotting of PBC patients' sera against purified E2 protein: sera from 38/40 (95%) patients with established clinical, biochemical, and histological features of PBC (18 stage II/III, 22 stage IV) reacted positively with E2; whilst no sera from 39 controls (27 non-PBC chronic liver disease, 12 healthy normal women) gave a positive response. Immunoblotting showed that a second subunit of the pyruvate dehydrogenase complex, a 50 kD polypeptide of unknown function (component X), is also an M2 autoantigen. Identification of these M2 mitochondrial antigens should facilitate the development of a specific serological test for PBC and the study of autoimmunising epitopes.

Thirty seven patients with established cirrhosis of the liver were subjected to measurement of body protein metabolism using L-(1-14C) labelled leucine as a tracer. The effects of disease severity and those of solutions containing 0%, 16%, 35%, 53%, and 100% branched chain amino acids were evaluated. Significant increases in protein synthesis were noted with solutions containing 35%, 53%, and 100% branched chain amino acids, but in patients receiving 100% branched chain amino acids without additional essential amino acid supplement the increase in synthesis was matched by a significant increase in protein breakdown. Protein balance was thus improved only in patients receiving 35% and 53% branched chain amino acids. It was concluded that the high increase in protein breakdown in patients receiving 100% branched chain amino acids was undesirable, and such a solution should not be recommended for clinical use.

Summary In a Phase II clinical trial, 14 consecutive, unselected patients with primary hepatocellular carcinoma were treated with a new inhibitor of thymidylate synthase, CB3717. On the basis of previously reported criteria, 6 patients were considered to have a good prognosis (Grade A) and 8 a poor prognosis (Grade B). Three Grade B patients died after only one treatment. Six patients responded (4 Grade A and 2 Grade B) with a decrease in tumour size and greater than 50% fall in serum alphafetoprotein levels; 3 of these had a greater than 1 log fall in alphafetoprotein. A further patient (Grade B) showed static disease during treatment. Thus, of 11 patients receiving two or more treatments 7 showed clinical benefit, with a median survival from start of CB3717 therapy of 46 weeks (2 still alive at 33 and 67 weeks). Our results suggest that CB3717 will be a useful new therapeutic agent in hepatocellular carcinoma. Further controlled trials are indicated to confirm these preliminary findings, using the drug both as a single agent and in combination with inhibitors of thymidine uptake by cells, which may further increase efficacy.

Two human primary liver cancer cell-lines, PLC/PRF/5 and Hep 3B, grown both in vitro and as xenografts in nude mice were used to evaluate the chemotherapeutic potential of a new quinazoline antifolate CB3717. Xenograft growth rate was followed both by serial serum alphafoetoprotein (AFP) measurement and direct volume estimation. A dose regime of 200 mg CB3717 kg-1 body wt day-1 for 5 days caused a significant reduction in growth rate, as measured by relative serum AFP, of both xenografts; PLC/PRF/5 derived xenograft growth was also inhibited by 125 mg CB 3717 kg-1 day-1 for 5 days. Cell culture experiments showed that the ID50 for the cell lines fell within the range of serum CB3717 concentration achieved by a dose of 300 mg m-2 given to patients. Treatment with CB3717 stimulated the incorporation of exogenous thymidine into DNA by the tumour cells, presumably because of inhibition of the de novo pathway and reduction of endogenous thymidine triphosphate pools. These results suggest that CB3717 may be a useful new therapeutic agent in human primary liver cell carcinoma and that blocking the salvage pathway may further increase efficacy.

In vivo insulin sensitivity and adipocyte insulin binding and action were assessed in 16 patients with histologically proven hepatic cirrhosis and 11 age-, weight- and sex-matched normal control subjects. The cirrhotic group displayed impaired oral glucose tolerance, despite an exaggerated serum immunoreactive insulin response, and in vivo insulin resistance as assessed both by the euglycemic hyperinsulinemic clamp and the glucose-insulin infusion techniques. Adipocytes of the cirrhotic patients bound significantly less insulin than those of the control subjects (2.21 +/- 0.12% vs. 2.64 +/- 0.13%; p less than 0.05). Although the adipocytes from the cirrhotic patients were less sensitive to insulin stimulation in vitro (half-maximal stimulation at 60.0 +/- 8.0 vs. 21.8 +/- 3.3 pM; p less than 0.001), they exhibited higher maximum rates of lipogenesis. Comparison of the responses of the alcoholic, primary biliary cirrhosis and cryptogenic subgroups suggested pronounced differences in the maximum rates of lipogenesis. There were significant negative correlations between specific binding to adipocytes and both fasting serum immunoreactive insulin and in vivo insulin resistance as assessed by glucose-insulin infusion. Monocyte insulin binding was normal in the cirrhotic group and did not correlate with in vivo insulin resistance. It is concluded that both binding and postbinding defects in insulin target organ cells contribute to the marked in vivo insulin resistance of hepatic cirrhosis.

We have examined the value of serum type III procollagen amino propeptide (PIIINP) measurement both in evaluation of disease activity and in estimation of prognosis in primary biliary cirrhosis (PBC). 55 paired sera from 32 PBC patients not receiving treatment known to affect PIIINP levels not with non-hepatic inflammatory conditions were used to estimate serum PIIINP by radioimmunoassay. Significant correlations were found between serum PIIINP and serum albumin (P less than 0.001), bilirubin (P less than 0.002) and aspartate transaminase (P = 0.01). The mean serum PIIINP level rose with advancing histological stage (P less than 0.001). In 18 patients in whom more than 1 serum was assayed (mean follow-up 42 months) PIIINP often fell, particularly in patients with established cirrhosis and advanced disease. The independent prognostic value of PIIINP was examined using Cox's proportional hazards model with three other prognostic co-variables (bilirubin, albumin, patient age). Stepwise regression analysis selected albumin (P less than 0.001) and bilirubin (P = 0.002) as the most important prognostic factors. PIIINP did not give independent prognostic information. We conclude that PIIINP is another marker of disease activity in PBC which confers no benefit over existing conventional measurements in routine management of this disease.

Three patients are described with recurrent jaundice, upper abdominal pain and rigors attributable to dextropropoxyphene hepatotoxicity. The diagnosis was established in each patient by rechallenge; post challenge hepatic histology is reported in two. Twelve previous patients with probable dextropropoxyphene hepatic toxicity have been described and are reviewed. In 10 of the 15 patients, a clinical diagnosis of gall stone disease was made. Liver function tests are usually hepatitic shortly after challenge, but more cholestatic after a few days. No fatalities have been described, but as dextropropoxyphene is widely available in many different analgesic preparations possible toxicity should be considered in patients with relapsing jaundice mimicking biliary disease, in whom gall stones have been excluded.

In 1863, Landois showed that infusion of bile into animals could produce a negative chronotropic effect [1]. This has since been attributed to raised concentrations of bile acids [2.3], however, recent reports of «digoxin-like activity» in both normal bile [4] and the serum of patients with liver disease [5-11] suggest an alternative explanation

The activity of the major drug-metabolizing enzymes, the mono-oxygenases, can be inhibited by an acute dose of ethanol. We set out to determine whether age has any relation to the degree of inhibition produced by ethanol, using acetanilide as a model substrate. Eight healthy young subjects (mean age 26 years) and eight healthy elderly subjects (mean age 72 years) were studied on two occasions, once receiving acetanilide alone and once acetanilide with 75 ml vodka (30 g ethanol). The clearance of acetanilide was significantly lower (p less than 0.05) in the elderly subjects at 27 +/- 3 l/h compared to 38 +/- 2 l/h in young subjects. No age-related differences in peak blood ethanol concentrations or ethanol elimination rates were noted. After ethanol, acetanilide clearance fell 18% to 31 +/- 3 l/h in young subjects (p = 0.05) and by 15% to 23 +/- 2 l/h in elderly subjects (p = 0.08). This suggests that the elderly do not suffer greater impairment of drug oxidation after acute ethanol ingestion than do the young.

A recent WHO estimate suggests that ca. 20% of the population in developed countries are 'elderly' and that 50% of all drugs are prescribed to individuals over age 65 years. It is now well recognised that the elderly are particularly susceptible to drug adverse reactions in general [1-3], and there are increasing suggestions that 'a number of hepatic adverse reactions to drugs may be age-related [4,5]. It is therefore appropriate to examine the changes which occur in human hepatic drug metabolism in advanced age and to assess the evidence for increased sensitivity to hepatic .adverse drug reactions in the elderly. The important liver-related physiological changes which may affect hepatic disposition of drugs which advanced age include reduced liver blood flow, and progressive decrease in liver size and weight both absolutely and relative to total body weight [6]. Other age-related changes which may affect drug pharmacokinetics include decrease in lean body mass with a proportionate increase in fat; glomerular filtration rate declines by 1-2% per year over age 65.

160 consecutive patients with primary biliary cirrhosis (PBC) (M:F, 13:147; total samples 286), 140 patients with other chronic liver disease (CLD) (M:F, 75:65; total samples 200), and 28 patients with primary Sjögren's syndrome (all F; total samples 37), were examined for bacteriuria over 6 months by midstream urine (MSU) examination. The overall prevalence of bacteriuria in PBC was 11.2% (7.5% on first MSU), in CLD 12.1% (10.7% on first MSU), 18.4% in the 65 female CLD patients, 10.7% in Sjögren's syndrome patients (3.5% on first MSU). The prevalence of bacteriuria was related to the age of the patient (P less than 0.02) in PBC and to the presence or absence of cirrhosis in both PBC and CLD (P less than 0.02). There was no difference in the prevalence of bacteriuria between PBC and CLD patients taken as a whole or among females alone, cirrhotic or non-cirrhotic groups. In a second prospective study of the cumulative incidence of bacteriuria in PBC versus CLD and Sjögren's no significant differences between groups was observed but among 29 PBC patients the cumulative proportion of positive tests for bacteriuria after 5 months (monthly testing) was 34%. We conclude that there is no specific association between PBC and bacteriuria compared with the prevalence of bacteriuria in other CLD.

Metabolic bone disease, particularly osteoporosis, is a complication of advanced primary biliary cirrhosis, but the extent of the problem is unclear. We present 33 patients who were investigated for bone disease at the time of diagnosis of their liver disease and who had received no prior treatment likely to influence their bones. Iliac crest bone biopsy showed no patient with osteoporosis, and mild osteomalacic changes in 1 patient. Slight elevations in appositional rate, osteoid volume, and resorption surface were compatible with a state of high bone turnover. Photon absorptiometry revealed a low forearm bone mineral content in 3 of 25 patients, calcium absorption was below normal in 14 of 24 patients, and there was evidence of fat malabsorption in 11 of 25 patients. Five patients also had low serum levels of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D. Thus, little evidence of significant metabolic bone disease was found in this group by these methods, but abnormalities were seen, such as poor calcium absorption, that may predispose to its later development.

Over a four-year period 40 patients of local origin, with primary hepatocellular carcinoma were seen at a regional referral centre. Twenty-nine patients had histological evidence of underlying cirrhosis and these patients were predominantly male (25/29) and elderly (mean age 66 years). Serological evidence of hepatitis B virus (HBV) infection was found in 11 (38 per cent) of the cirrhotic group. Of the 25 males with cirrhosis, 13 (52 per cent) were known to have seen military service in the tropics and of these eight had serum HBV markers. The non-cirrhotic group was younger (mean age 55 years) and the sex distribution was nearly equal (six male, five female). Two patients (19 per cent) had hepatitis B markers including one of the two men in this group who had served in the tropics. One patient with no serum HBV markers had integrated HIBV-DNA sequences in the cellular DNA of her tumour. These observations confirm the association of primary hepatocellular carcinoma with hepatitis B virus and suggest that a significant proportion of patients of United Kingdom origin acquired their susceptibility as a result of military service in the tropics. There is presumably a substantial cohort of ex-service men at risk of developing primary hepatocellular carcinoma.

Many factors contribute to the altered responsiveness of the elderly to drug therapy [1]. Of these, particular attention has been given to investigating the effect of age upon the rate of drug elimination since, unless appropriate reductions in dosage are made, significant age-related reductions in clearance will tend to lead to higher blood levels, and hence a greater risk of toxicity [2]. The effects of age on renal drug clearance are now well-documented [3-5], and parallel the decline in renal function which occurs in the elderly. Physicians are thus accustomed to matching the dosages of drugs which undergo renal excretion to elderly patients' renal function. In many instances, serum creatinine levels alone provide sufficient guide to appropriate doses although, for drugs with low therapeutic ratio, it may be necessary to measure plasma drug levels to avoid toxicity. Age-related changes in the rates of drug metabolism have also been reported for many common therapeutic agents. Unfortunately, no clear pattern has emerged, and those changes that do occur are superimposed on .the wide range of genetic and environmental factors known to influence rates of drug metabolism. Two general trends have emerged: first, and with some notable exceptions, drugs undergoing hepatic microsomal oxidation are likely to be metabolised more slowly in the elderly, whilst those that are conjugated are usually uninfluenced by age; second, drugs with high hepatic clearances and extraction ratios (such as chlormethiazole and labetalol), and which undergo extensive 'first-pass', metabolism during oral absorption, may show substantially increased bioavailability in the elderly [2].

Summary Four patients are described with serologically proven hepatitis A (HAV) infection. In each patient there was a bimodal course to the illness — clinically and biochemically — with complete remission between the two phases of the illness. Other possible causes except NANB for a second hepatitic illness were excluded.

The signs, symptoms, alcohol history, and histological findings together with prognosis of 208 consecutive patients with alcoholic liver disease (ALD) are presented in respect of age. 200 were followed for at least 1 year. 28% of patients first presented over age 60, 6% over 70 years. Signs and symptoms were more severe at presentation in the 70+-year-old age group than in the young patients though the elderly more often presented with symptoms not directly related to liver disease. Prognosis was age-related, 1 year mortality was 50% among cirrhotics over the age of 60 versus 7% under 60 years. Alcohol consumption at presentation was similar in all age groups with no evidence of a significant reduction in the elderly. The care of older patients with ALD will become an increasing problem in developed countries where alcohol consumption has continued to rise.

Adverse hepatic reactions to nitrofurantoin therapy are well reported and range from acute cholestatic or hepatitic injury to chronic active hepatitis [R. G. Penn & J. P. Griffin (1982) Br. Med. J., 284, 1440-1442]. Neurological side-effects, predominantly sensorimotor peripheral poly-neuropathy, have also been documented [R. G. Penn & J. P. Griffin (1982)]. We report the first case of combined neurological and hepatic reaction to nitrofurantoin; this occurred during repeated treatment with the drug.

We examined the presenting features, clinical course and prognosis in relation to age in 121 patients with primary biliary cirrhosis (PBC) for a mean follow-up of 4.6 years. 35 patients (29%) were over age 65 years at presentation/detection. There was a higher proportion of patients asymptomatic of liver disease in the older (over 65 years old) than younger (under 65 years old) group. The clinical features of PBC were less marked in the older patients both in number of symptoms (p less than 0.05) and in progression of serum bilirubin, a marker of prognosis (p less than 0.001). There was no difference in liver-related mortality between old and young patients during the follow-up period. Overall mortality in patients with PBC presenting over age 65 was no different from age- and sex-matched controls.

To even the most casual observer, the elderly are a very heterogeneous population. Some individuals remain fit and active into their ninth or tenth decades, whilst others show evidence of infirmity during their early sixties in the absence of an acute physical illness. This dissociation of biological and chronological age represents a continuum bounded by, in the parlance of contemporary gerontology, the terms 'fit' and 'frail' [1]. The lack of an agreed operational definition, however, has resulted in conflict and confusion in the gerontological literature. We propose a definition which, we believe, describes these extremes.

Erythrocyte water content, micro-haematocrit (micro-Hct) and haematocrit (Hct) as derived by Coulter Counter were determined on 41 subjects. Significant discrepancies were observed between manual and automated Hct which could not be explained by abnormal red cell morphology and abnormal plasma osmolality, but appeared to be related to high erythrocyte water content (r = 0.54, p less than 0.001). As human ageing is associated with increased erythrocyte water content, these results question the reliability of Hct readings in the elderly. Further studies need to be performed to evaluate which estimation of Hct should be applied for subjects with high erythrocyte cell water.