A survey of Gnathostoma larvae in fresh water fish in the valley of the Yangtze River and morphological characteristics of the recovered larvae

Investigations of the prevalence of larval gnathostomes in fresh water fishes were carried out at the southeastern Yangtze Valley, People's Republic of China, in the periods of October 1989 and November 1990. Fishes were collected from Shanghai, Chenchiang, Nanching, Chiuchiang and Nanchang districts in 1989. Additional sampling in Shanghai district was done at Kunshan, Tien-shanfu, Chingpu and Nanhui. Species of fishes collected were Channa argus (110), Siniperca chuatsi (24) and Silurus asotus (2). Muscle tissue of the fishes was dissected into small pieces, sliced and then examined under a dissecting microscope. The viscera were pooled by species in groups of 4 or 5 individuals, homogenized, and were then digested overnight in artificial gastric-juice at 37 degrees C. Four encysted larvae were recovered from the muscle tissue of four C. argus. Thirty-four larvae were obtained from digestion of viscera. A total of 38 larvae were recovered. Eighteen of 38 larvae were examined morphologically and they were able to be divided into three types by their body length; 5 early third-stage larvae (0.58-0.86 mm), 12 third-stage larvae (1.12-2.61 mm), and one advanced third-stage larva of 4.86 mm. Light and scanning electron microscopy revealed that the former two types had characteristics of Gnathostoma hispidum and the last one had those of G. spinigerum. In 1990, we investigated fish near Hongtze-hu and Tai-hu lakes. A total of 553 fishes belonging to 12 genera and 12 species were examined. Seventeen larvae were recovered from the viscera of G. argus and Monopterus albus. These larvae were identified as G. hispidum.

Clinical manifestations of HBsAg and anti-HCV negative chronic liver disease in Nagasaki Prefecture, Japan

The discovery of hepatitis C virus (HCV) has enabled the diagnosis of type C chronic liver disease, which had in the past been diagnosed as part of non-A, non-B chronic liver disease. Although most cases with chronic liver disease are caused by hepatitis B virus (HBV) or HCV infection, there are still cases of non-B, non-C chronic liver disease. Forty patients with chronic liver disease, who were seronegative for hepatitis B surface antigen and antibody to HCV, were followed for a mean period of 72 months. The clinical manifestations in these patients were compared with those reported for type B and type C chronic liver disease. Of the 40 patients, 22 were diagnosed with chronic hepatitis, 14 with liver cirrhosis and 4 with hepatocellular carcinoma (HCC). Twenty-seven (67.5%) patients showed mild alanine aminotransferase activity profiles, and the natural clinical course of most patients showed a slow progression compared with that reported for type B and type C patients. The yearly incidence of HCC was 9.7% in patients with liver cirrhosis and 3.9% in chronic hepatitis. These rates were similar to those in type B or type C patients. This suggests that our population sample contained a number of patients with type B, type C or other etiologic agent(s), because 66.7% of the patients who developed HCC had some evidence of exposure to HBV or HCV. Our results suggest that more detailed and accurate tests for detecting HBV and HCV should be considered before making the diagnosis of non-B, non-C chronic liver disease, and that there is the need to reveal unknown etiologic agent(s).

Role of endogenous ouabain-like substance during graded exercise in hypertensive individuals

Changes in plasma endogenous ouabain-like substance (EOLS) and plasma noradrenaline, along with changes in blood pressure (BP), heart rate, and blood lactate concentration, were investigated in hypertensive individuals during strenuous exercise testing. Thirteen (4 men and 9 women) middle-aged (34-63 years, mean 50 +/- 2 years) patients with mild essential hypertension underwent graded multistage submaximal exercise testing on a cycle ergometer. The workload in each exercise test was increased depending on the individual's physical fitness until they reached 75-80% of the predicted age-adjusted maximal heart rate prescribed by the American College of Sports Medicine. Systolic (S) BP rose by 67 +/- 9 mm Hg (P < 0.001), mean (M) BP by 28 +/- 3 mm Hg (P < 0.001), diastolic (D) BP by 9 +/- 2 mm Hg (P < 0.005) and heart rate by 79 +/- 6 beats/min (P < 0.001) after submaximal graded exercise. The blood lactate concentration and plasma noradrenaline increased significantly (+3.40 +/- 0.34 mmol/l and +895 +/- 94 pg/ml respectively, P < 0.001). Although the change in EOLS was not significant, it showed a strong positive correlation with the change in plasma noradrenaline (R = 0.760, P < 0.001). These results suggest that EOLS may participate in modifying sympathetic vasoconstriction during submaximal graded exercise.

Effect of triiodothyronine on graft function in a model of heart transplantation

BACKGROUND

Brain death is associated with neuroendocrine changes that result in impaired metabolism, reduced myocardial energy stores, and deteriorating cardiac function. As a result of these changes, a substantial number of normal human hearts are not considered suitable for transplantation. In the hope of preventing these complications and stabilizing the condition of cardiac donors, we compared the function of transplanted hearts from brain-dead rats that received triiodothyronine (T3) (n = 6) with that of hearts from a group that received a placebo (n = 5).

METHODS

This experiment was designed to be both blinded and randomized. Brain death was achieved by bilateral carotid ligation and inflation of an intracranial balloon. Triiodothyronine or placebo was administered in a blinded, randomized fashion. The brain-dead donors were then supported with conventional techniques for 2 hours after which time heterotopic transplantation was performed using hypothermic preservation and a working heart model. Hemodynamics of the transplanted hearts were assessed 48 hours postoperatively.

RESULTS

The hearts from donors that had been pretreated with T3 were found to have a significantly higher (p < 0.005) peak left ventricular pressure than the hearts from the placebo-treated group (137 +/- 17 mm Hg versus 115 +/- 15 mm Hg). Left ventricular end-diastolic pressure was significantly lower (p < 0.01) in the T3-treated group (5.2 +/- 2.2 mm Hg) compared with the placebo-treated group (6.9 +/- 0.5 mm Hg). There was also a significantly higher (p = 0.03) maximal first derivative of left ventricular pressure in the T3-treated group compared with the placebo-treated group (4,876 +/- 1,348 mm Hg/s versus 3,344 +/- 1,016 mm Hg/s). Finally, the cardiac output in the group given T3 was 93 +/- 16 mL/min compared with 61 +/- 22 mL/min in the group given the placebo (p < 0.01).

CONCLUSIONS

Hearts from brain-dead rats that had received T3 before transplantation showed improved postoperative function. The experimental design of predonation brain death, cold immersion storage, and transplantation in a working heart model should make these data more relevant clinically than those previously reported.

[Surgical results of valve replacement with the Björk-Shiley tilting disc valves]

We evaluated the Björk-Shiley tilting-disc (BS) valve replacement up to the longest duration for about 12 years. The study was started in November 1982 and ended in September 1991. There were total number of 206 with 117 males and 89 females aged between 18 and 71 with a mean of 51.6. Eighty three patients had isolated aortic valve replacement (AVR), 92 had isolated mitral valve replacement (MVR), and 31 had AVR plus MVR. One hundred and fourteen spherical-disc valves were replaced in the aortic, 112 spherical and 11 monostrut in the mitral position. The mean duration of follow up was 6.5 years for a total of 1330.6 patient years (PY). Forty-one patients (3.8%/PY) died later, and 14 out of 41 died of valve-related complications. Actuarial survival rates for all, AVR, MVR and DVR at 10 years after operation were 71.2%, 73.5%, 73.9% and 55.4%, respectively. The linearized rates of thromboembolism (TE), thrombosed valve (TV), anticoagulant-related hemorrhage (ACH), prosthetic valve endocarditis (PVE), hemolysis (H), and reoperation (RO) were 1.2%/PY, 0.2%/PY, 0.7%/PY, 0.2%/PY, 0.1%/PY, and 0.2%/PY, respectively. The rates of freedom from TE, TV, ACH, PVE, H, and RO and 10 years after operation were 83.5%, 98.5%, 94.0%, 98.4%, 99.0% and 95.6%, respectively. The major causes of postoperative mortality and morbidity were TE, TV, and ACH. One hundred and fifty-six out of 161 patients showed an improvement in NYHA functional class post operatively. The surgical results of valve replacement with the BS valve was excellent and acceptable one. Intensive management with a special reference of anticoagulant therapy is necessary for a long-term management of the patients with mechanical valve replacement.

Leukemia cutis in three children: clinical and immunohistochemical studies

We report 3 children with leukemia cutis observed at the initial diagnosis of systemic leukemia. Leukemia subtypes in the three children were congenital monocytic, acute undifferentiated, and acute monocytic, respectively. The patients were girls age 10 days, 14 years, and 11 months, respectively, at diagnosis. We describe the clinical features of the cases and the results of immunohistochemical studies on paraffin-embedded skin biopsy specimens. The skin lesions were tumors and areas of reddish purple erythema in the first child, pigmented erythema in the second, and bright red erythema in the first child, pigmented erythema in the second, and bright red erythema in the third. In the first two patients skin lesion biopsy specimens had dense leukemic infiltrates in the dermis with reactive T lymphocytes scattered among them. In the third patient, the infiltrating cells were almost all reactive T lymphocytes, with a few leukemic cells. A relationship between the leukemic-reactive cell ratio and the prognosis was suggested; dense leukemic cell infiltrates may be associated with a poor prognosis.

[Primary pulmonary cryptococcosis treated by thoracoscopic resection]

A 37-year-old man was admitted to the hospital because of an abnormal shadow in the right lower field on a chest roentgenogram. The lesion was calcified and was therefore suspected to be benign. Thoracoscopic resention was performed. The pathological diagnosis was cryptococcosis of the lung. The lesion was completely resected, so no antifungal drug was given. The patient was doing well as of 12 months after the operation.

Detection of HBV-DNA and HCV-RNA viral sequences by polymerase chain reaction in selected Kenyan samples and the relationship to HBV seromarkers

We undertook a study on selected samples from patients who had presented with viral hepatitis and conditions of the liver (liver cirrhosis, chronic hepatitis and hepatocellular carcinoma). Diagnosis, screening and confirmation for viral hepatitis was done using a battery of techniques: ultrasound, conventional serological methods (Hepatitis B surface Antigen [HBsAg] - Reverse Passive Haemagglutination [RPHA], Hepatitis B core Antibody [HBcAb] - Passive Haemagglutination [PHA], Alpha-feto Protein - RPHA), Hepatitis B e Antigen/Antibody [HBeAg/Ab] - Radioimmunoassay [RIA], Hepatitis C antibody [HCV-Ab] - Enzyme Immunosorbent Assay [EIA]. Due to the high specificity and sensitivity of the Polymerase Chain Reaction technique [PCR] in detecting the viral genomes, it was used to establish the presence of the HBV-DNA and HCV-RNA to correlate the serological diagnosis of their respective seromarkers. A total of 39 serum samples were tested comprising 11 blood donors, 8 chronic liver disease patients and 20 hepatocellular carcinoma cases. 4/19 (21%) HCV-antibody (C-l) reactive samples were found to be positive for HCV-RNA by PCR. 14 of the 19 (73.7%) including the 4 HCV-RNA positive cases tested positive for HBcAb. 6 of 11 (55%) HBsAg positive cases also tested positive for HBV-DNA by PCR, In 8 of 20 (40%) hepatocellular carcinoma cases, no aetiological role could be assigned to hepatitis B or C as only HBcAb was demonstrated in those cases.

Comparative surface ultrastructure of adults and eggs of Gnathostoma obtained in Japan

As limited studies have been done on surface morphology of Gnathostoma, adult specimens and eggs of four kinds of species in Japan were compared by scanning electron microscopy. Worms had a subglobular head-bulb which was armed with 7-10 rows of cephalic hooks. Mutidigitate cuticular spines were spaced unevenly on transverse cuticular striations on the anterior half of the body. The lengths of the spines were variable with tridentate spines longer than bidentate ones, These tridantate spines became one of the species specific characteristics. The posterior half of the bodies of G. doloresi and G. hispidum were covered densely with long unidentate spines which were gradually shorter towards the posterior ends. Ventral sides of male terminals had different shape of papillae which so called small and caudal ones in species. Eggs recovered from the uteri of female worms were covered with cuticular pits of different sizes, shapes and depths in species.

Genomic structure and 5' regulatory regions of the let-23 gene in the nematode C. elegans

The let-23 gene in the nematode Caenorhabditis elegans encodes a receptor tyrosine kinase and is necessary for the induction of a vulva, survival past the L1 stage, hermaphrodite fertility and for male spicule development. We sequenced the entire let-23 genomic region of over 12 kb. The 5' end of the let-23 mRNA was mapped by sequencing polymerase chain reaction products, and two mRNAs were found which had alternative exons and were probably initiated at different sites. One transcript was trans-spliced to SL1. Expression of either cDNA rescued a let-23 vulvaless mutation in germline transformation. These results suggest that the let-23 gene encodes two proteins of 1323 or 1335 amino acid residues. We prepared various 5' deletion constructs of the let-23 gene, and examined their rescue activities for a let-23 lethal or vulvaless mutation. The results revealed that two regions were required for let-23 expression, one for larval survival and the other for vulva formation. We also cloned and analyzed a let-23 homologue from Caenorhabditis vulgaris. It can encode two proteins of 77% amino acid residue identity with the Let-23 proteins. The 12 kb fragment carrying the C. vulgaris gene rescued the let-23 vulvaless mutation in C. elegans. Seventeen sequences highly conserved between the two species were identified in the 5' upstream region or within an intron. Three of these sequences are contained in the two regions required for let-23 expression, suggesting that they are cis-acting elements for let-23 expression.

Prevalence of hepatitis B or C virus infection in patients with fulminant viral hepatitis. An analysis using polymerase chain reaction

BACKGROUND/METHODS

The cause of fulminant hepatitis is still not fully understood. We studied 23 patients with fulminant hepatitis, using polymerase chain reaction to detect hepatitis virus genomes. Tests for HBsAg and IgM anti-HAV and IgM anti-HBc were performed in all patients. Serum samples were stored at -70 degrees C for later analysis of anti-HCV and hepatitis virus genomes such as hepatitis B virus, hepatitis C virus and hepatitis D virus.

RESULTS

Of 23 patients, 17 (74%) had HBV-DNA and two (9%) had HCV-RNA. No patient was positive for both viruses or positive for HDV-RNA. Serological tests indicated that two patients, negative for HBV-DNA and HCV-RNA, were positive for IgM anti-HAV. In contrast, 8 of 17 (47%) HBV-DNA positive patients were negative for both IgM anti-HBc and HBsAg in conjunction with low levels of viremia. Four patients were positive for anti-HCV, but only one was positive for HCV-RNA. One patient, positive for HCV-RNA, was negative for anti-HCV.

CONCLUSIONS

Our results indicate that analysis of hepatitis virus genomes using polymerase chain reaction allows accurate identification of the virus causing fulminant hepatitis.

Three-vessel study of cerebral blood flow using phase-contrast magnetic resonance imaging: effect of physical characteristics

The development of phase-contrast magnetic resonance imaging (P-C MRI) provides a noninvasive method for measurement of volumetric blood flow (VFR). We performed P-C MRI to study the effects of physical characteristics on cerebral blood flow. VFR of the left and right internal carotid arteries and basilar artery were measured using P-C MRI and total cerebral blood flow (tCBF) was calculated by summing up the VFR values in the three vessels. Moreover, we investigated the changes in these blood flows as influenced by age, head size, height, weight, body surface area, and handedness. The blood flows were 142 +/- 58 ml/min (mean +/- standard deviation) in the basilar artery; and 229 +/- 86 ml/min in the left, and 223 +/- 58 ml/min in the right internal carotid artery; and tCBF was 617 +/- 128 ml/min. Significant increases were observed in head size-related change of VFR in the basilar artery (p = .028) and height-related change of tCBF (p = .045). The other characteristics did not significantly influence any VFR. The results suggest that head size and height may reflect CBF, and that these effects should be considered when changes of CBF are diagnosed. Phase-contrast MRI is useful for a noninvasive and rapid analysis of cerebral VFR and has potential for clinical use.

Habitual and genetic factors that affect urinary background levels of biomarkers for organic solvent exposure

Urinary hippuric acid, phenol, and o-cresol, which are biomarkers for toluene, benzene, and phenol exposures, are usually present in a significant amount in urine collected from subjects who have not been occupationally exposed to the organic solvents. With the improvement of working environments, the urinary concentrations of the biomarkers have become lower and closer to the levels of urine from unexposed subjects. It is very useful to clarify the background levels of these biomarkers and the factors which effect the background levels of the biomarkers in order to make effective use of biological monitoring under low level exposure. In the present study, the effects of life habits and the genetic polymorphisms of the metabolizing enzymes on the background levels of urinary hippuric acid, phenol and o- and p-cresol were clarified, using 351 males (means age: 38.6, range: 19-71) who were not occupationally exposed to hazardous chemical materials. Their life habits, smoking, alcohol consumption, and dietary habits were examined by means of a questionnaire. The genotypes of five metabolizing enzymes, that is, low Km aldehyde dehydrogenase (ALDH2), polymorphic N-acetyl transferase (NAT2), cytochrome P-4501A1 (CYP1A1), cytochrome P-4502E1 (CYP2E1), and glutathione-S-transferase mu (GSTM1) were determined form peripheral blood samples. The urinary hippuric acid and creatinine were analyzed by HPLC and urinary phenol, o-, p- and m-cresol were determined by GC/MS. Recoveries and the coefficients of variance of phenol, o-cresol, and p-cresol ranged from 92.7 to 107.8% and 1.3% to 6.7%, respectively. Linear relationships between the concentrations of phenol, o- and p-cresol, and their peak area ratios were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chest wall reconstruction after the resection of primary chest wall tumors]

Between April 1983 and June 1994, we performed chest wall reconstructions on 9 patients (7 males and 2 females) out of 27 all of whom underwent the radical resection for the primary chest wall tumors. Histological diagnosis of tumors included 6 chondrosarcomas, 1 Ewing's sarcoma, 1 plasmacytoma and 1 giant cell tumor. Six lesions were located on the rib and 3 on the sternum. For the materials for reconstruction of the chest wall use a polyethylene plate in 2 patients, a Marlex mesh in 5 patients and a Marlex mesh with a methyl methacrylate utilizing the sandwich method in 2 patients. The polyethylene plate proved to be satisfactory for maintaining stability of the chest wall. However, our experience using this plate showed intensive foreign body reactions, and discovering these we have not use the polyethylene plate. Marlex mesh had an affinity with human tissue and was very easy to use and produced no complications. We use Marlex mesh for flat surfaces on the anterior or posterior chest wall. Marlex mesh and methyl methacrylate utilizing the sandwich method, combined the solidity and shaping of methyl methacrylate with the benefit such as easy fixation and excellent incorporation of the mesh.

Noninvasive analysis of water movement in rat testis using deuterium magnetic resonance imaging

To measure water movement in the testis without the effects from the blood-testis barrier, we performed in vivo deuterium magnetic resonance imaging (2H MRI) of rats administered with deuterated saline. Alcohol was injected into one testis of each animal and the other was administered with normal saline as a control. Dynamic 2H MRI was obtained at 2 T by FLASH pulse sequence (TR, 300 ms; TE, 10 ms; alpha = 90 degrees) using a surface coil (3 cm in diameter). The variation in 2H signal intensity between the two testes as a function of time after deuterated saline injection was examined every 1.1 min up to 20 min. The signal intensity in the testis receiving the alcohol treatment was lower than that in the normal control. Thus, deuterium MRI can be used to analyze functional disorders of the testis.

Desquamative interstitial pneumonia in sibs

We report on 2 sibs with desquamative interstitial pneumonia. The female died at age 1 7/12 years despite use of prednisolone and methylprednisolone, while the male, now age 3 years. is alive with oxygen support. The occurrence of desquamative interstitial pneumonia in sibs born to normal parents suggests that in some cases the disease is an autosomal-recessive trait.

[Management of patients with closing aortic dissection]

Acute aortic dissection is a catastrophic event requiring immediate diagnosis and definitive treatment, while the clinical characteristics of closing aortic dissection are not well known. From Jan. 1991 through Dec. 1994 a total of 24 patients with closing aortic dissection (CAD) was managed at our institution. There were 19 men and 5 women, ranging in age from 49 to 74 years with a mean of 65 years. All patients presented with a sudden onset of severe chest and back pain. Twenty patients had a history of hypertension with a wide mediastinal silhouette on chest X-ray. The diagnosis of CAD was established by contrast computed tomographic (CT) scans in all patients with no evidence of patent false lumen. The descending thoracic aorta was involved in 17 patients and the ascending in 5. Conservative medical management was initially attempted for all. Seven patients (Stanford type A/B: 2/5) ultimately required surgical intervention, and 2 patients died. The follow-up was 100% complete with a mean term of 14.6 months. The overall survival rate was 74% at 3 years after the initial presentation. Based on our clinical experience, all patients with CAD need careful antihypertensive therapy and frequent follow-up studies to assess the aorta.

A new type of advanced third-stage larvae of the genus Gnathostoma in freshwater eels, Fluta alba, from Nakhon Nayok, central Thailand

Five advanced third-stage larvae of a newly identified type of genus Gnathostoma were collected from freshwater eels, Fluta alba, which were purchased at a market in Nakhon Nayok, central Thailand. The most remarkable characteristic of the newly identified larvae was the larger body size compared with any other larva of Gnathostoma spp. They were also distinguishable from other species by the shape of their hooklets, which branched in a complex manner at the base: this had not been previously observed in any other larval Gnathostoma. The newly described larvae had an average number of 44.5, 45.0, 49.0 and 55.1 hooklets on the head-bulb from the first to the fourth rows, respectively, which were comparable to those of larval G. spinigerum. However, the average number of nuclei in each intestinal cell was 2.21 and fewer than those of the larvae of G. spinigerum. These results suggest that the new type of larvae belong to either G. vietnamicum, G. malaysiae, or constitute a new species of the genus Gnathostoma.

[Farber's lipogranulomatosis]

Farber's lipogranulomatosis is a disorder of lipid metabolism due to deficiency of lysosomal acid ceramidase. Since Farber described the first case in 1947, at least 50 cases have been reported. Clinical manifestations include progressive arthropathies with periarticular swelling, hoarse voice, multiple subcutaneous nodules and growth and developmental retardation. The histological findings indicate granuloma formation with infiltrated lipid-laden macrophages and fibroblasts. Curvilinear tubular structures, so-called "Farber bodies", are observed on electron microscopy. The specific diagnosis can be made by demonstration of a deficiency of acid ceramidase, ceramide accumulation in tissue or characteristic morphological features on biopsy or postmortem specimens. Bone marrow transplantation may be effective during the early stage of this disease.

A case of drug eruption caused by the crude drug Boi (Sinomenium stem/Sinomeni caulis et Rhizoma)

We report a case of drug eruption caused by the crude drug Boi. A 41-year-old female patient had been diagnosed with chronic rheumatoid arthritis in the department of internal medicine. After ingestion of a decoction of the crude drug Boi for the alleviation of arthralgia, a slight fever developed, which was followed by systemic edematous erythema with itching. HPLC showed that the main components of the crude drug Boi are sinomenine and magnoflorine. The results of patch tests were negative for all oral drugs that the patient had been taking. Oral ingestion tests showed that the patient showed positive reactions to the as-is Boi boiling-water decoction and 1/10-volume sinomenine. Based on this, the drug eruption was judged to be caused by sinomenine. It is considered the first time that the causative component of a drug eruption was confirmed by oral ingestion tests with components of a crude drug of Kampo medicine (Sino-Japanese traditional medicine).

Analysis of wild-type and e antigen-defective hepatitis B viruses during the course of a short-term corticosteroid therapy in chronic hepatitis B

Hepatitis B virus (HBV), with a G-to-a point mutation at nucleotide 83 in the precore region (mutant HBV83), accounts for most cases of hepatitis B e antigen (HBeAg)-defective HBV. However, it is still not clear how mutant HBV83 is associated with HBe seroconversion. Twenty-six HBeAg-positive patients with chronic hepatitis B who received oral prednisolone (30 mg/day) for 3 weeks were studied to clarify the prevalence of mutant HBV83 during the treatment using polymerase chain reaction with a restriction fragment length polymorphism assay. Twelve (46%) patients seroconverted to anti-HBe 1 year after treatment, whereas 14 (54%) did not. The proportion of mutant HBV83 to whole HBV remained unchanged in both groups during an acute exacerbation induced by withdrawal of corticosteroids. Among 12 anti-HBe-seroconverted patients, five (56%) of nine patients with only wild-type HBV at baseline developed detectable levels of mutant HBV83 while all three patients with a mixed viral population of wild-type HBV and mutant HBV83 at baseline developed a higher proportion of mutant HBV83 one year after treatment. In contrast, these changes were observed in only one (14%) of seven who failed to seroconvert. The results indicate that a flare-up of hepatitis precedes emergence or selection of mutant HBV83, followed by HBe seroconversion in patients with chronic hepatitis B.