Effect of fibrin glue occlusion of the hepatobiliary tract on thioacetamide-induced liver failure

BACKGROUND

Expression and activation of hepatocyte growth factor (HGF) is stimulated by a complex system of interacting proteins, with thrombin playing an initial role in this process. The impact of temporary occlusion of the hepatobiliary tract with fibrin glue (major component thrombin) on the HGF system in acute and chronic liver damage in a rat model was investigated.

METHODS

Chronic liver damage was induced in 40 rats by daily intraperitoneal application of thioacetamide (100 mg/kg) for 14 days. After 7 days half of them received an injection of 0.2 mL fibrin glue into the hepatobiliary system. Daily intraperitoneal administration of thioacetamide continued for 7 consecutive days. The rats were then sacrificed for blood and tissue analysis. Acute liver failure was induced in 12 rats by intraperitoneal administration of a lethal dose of thioacetamide (500 mg/kg per day for 3 days) after an injection with 0.2 mL fibrin glue into their hepatobiliary tract. Survival rates and histological outcome were investigated and compared with control animals.

RESULTS

Fibrin glue occluded rats showed significantly lower liver enzyme activities and serum levels of bilirubin, creatinine and urea nitrogen. Immunohistochemistry revealed a significant increase in c-met-, HGFalpha- and especially HGFbeta-positive cells. Rats subjected to a lethal dose of thioacetamide survived when fibrin glue was applied 24 hours prior to the toxic challenge. These animals showed normal liver structure and no clinical abnormalities.

CONCLUSION

Fibrin glue occlusion of the hepatobiliary tract induces therapeutic and prophylactic effects on chronic and acute liver failure by stimulating the HGF system. Therefore, fibrin glue occlusion might be useful in treating toxic liver failure.

Giant cell arteritis in a 19-year-old woman associated with vertebral artery aneurysm and subarachnoid hemorrhage

Giant cell arteritis (GCA) is a disease chiefly found in elderly patients. Intracranial vessels are rarely involved in GCA. Here we report the case of a 19-year-old woman with GCA in the basilar and vertebral arteries. Two weeks after the first symptoms, she developed an aneurysmatical dilatation of the right vertebral artery which ruptured leading to subarachnoid hemorrhage. Although the ruptured right vertebral artery was clipped neurosurgically, she died two days later. Autopsy revealed GCA with focal medial necrosis and intimal thickening of the vertebral arteries and the basilar artery. No other arteries were affected. In the involved vessels, the media exhibited C1q immunoreactivity. At the intimal site of the internal elastic lamina there were increased levels of elastase. Other arterial diseases showing the pattern of GCA were excluded. This case demonstrates that GCA is not necessarily restricted to elderly people. Moreover, this case shows that a GCA-induced aneurysm is a very rare reason for subarachnoid hemorrhage even in young adults.

Screening for specialized columnar epithelium with methylene blue: chromoendoscopy in patients with Barrett's esophagus and a normal control group

BACKGROUND

Barrett's esophagus is characterized by the presence of specialized columnar epithelium (SCE) in the distal esophagus and is a precursor for dysplasia and adenocarcinoma. Methylene blue is used to selectively stain this type of epithelium within the columnar lined distal esophagus (CLE). The goal of our prospective study was to investigate the staining pattern with methylene blue in patients with visible CLE and a control group with macroscopically normal gastroesophageal junction.

METHODS

Chromoendoscopy of the distal esophagus with 1% methylene blue was performed on a total of 73 patients (51 with visible CLE, 22 normal control subjects). Biopsies were targeted toward stained or macroscopically abnormal mucosal areas. Unstained CLE was sampled by obtaining 4-quadrant biopsy specimens at 2 cm intervals.

RESULTS

The targeted biopsy of stained areas provided histologic proof of SCE with a sensitivity of 98% and a specificity of 61%. The detection of SCE increased with this method in patients with visible CLE (75%), but SCE was also prevalent in the control group (73%). Areas that by their appearance raised a suspicion for dysplasia and adenocarcinoma were already endoscopically apparent in 3 of 4 cases before methylene blue staining and showed different staining patterns.

CONCLUSIONS

Methylene blue staining increases the rate of detection of SCE, both in patients with visible CLE and with normal gastroesophageal junction. For detection of dysplastic or malignant areas it is important to look for visible mucosal changes.

Severe adenovirus bronchiolitis in children

Severe adenoviral infections such as the necrotizing adenovirus bronchiolitis occur sporadically in infants. Ascertaining the etiologic role of adenovirus in cases of lung disease can pose a diagnostic problem. We present two cases of severe bronchiolitis in previously healthy children in which adenovirus could be shown to be the causing agent. Both children received immunosuppressive therapy with steroids and Cyclosporin for 3 mo and a course of intravenous Ribavirin for 10 d. The results were conflicting: despite therapy Patient 1 died due to respiratory failure, Patient 2 improved notably.

CONCLUSIONS

Adenovirus can cause severe bronchiolitis in previously healthy children. Diagnosis may be difficult to achieve. The role of antiviral therapy in the treatment of adenoviral infections remains to be cleared.

Isolation and identification of psoralen plus ultraviolet A (PUVA)-induced genes in human dermal fibroblasts by polymerase chain reaction-based subtractive hybridization

Premature aging of the skin is a prominent side-effect of psoralen photoactivation, a therapy used for a variety of skin disorders. Recently, we demonstrated that treatment of human dermal fibroblasts with 8-methoxypsoralen and ultraviolet A irradiation resulted in a permanent growth arrest with a switch of mitotic to postmitotic fibroblasts. Furthermore, an upregulation of matrix-degrading metalloproteinases and a high level of de novo expression of the senescence-associated beta-galactosidase was detected in the PUVA-treated postmitotic fibroblasts. The molecular basis for this PUVA-induced change in the functional and morphologic phenotype of fibroblasts resembling or mimicking replicative senescence is, however, unknown. Herein after, we have used a polymerase chain reaction-based subtractive hybridization protocol to identify human genes that are induced by PUVA treatment. Application of polymerase chain reaction-Select resulted in the cloning of four PUVA genes. Sequence analysis and homology searches identified three cDNA clones of known genes related to cell cycle regulation (p21waf1/cip1), stress response (ferritin H) and connective tissue metabolism (tissue inhibitor of metalloproteinases-3), whereas one cDNA clone represented a novel gene (no. 478). Northern blot analyses were performed to confirm a PUVA-dependent increase in specific mRNA levels in human dermal fibroblasts in vitro. This report on the identification of growth arrest related genes in PUVA-treated fibroblasts may stimulate further research addressing the causal role of these known and novel genes in extrinsic and intrinsic aging processes on a molecular and cellular level.

Severity of HCV-induced liver damage alters glucose homeostasis in noncirrhotic patients with chronic HCV infection

BACKGROUND/AIMS

To investigate the link between hepatitis C infection and glucose intolerance, we measured insulin sensitivity, glucose effectiveness and beta-cell secretion in noncirrhotic HCV-infected patients with normal glucose tolerance according to WHO criteria as assessed by oral glucose tolerance tests.

METHODS

Glucose, insulin and C-peptide data from frequently sampled intravenous glucose tolerance tests were analyzed using the minimal modeling technique for glucose and C-peptide to determine insulin sensitivity, glucose effectiveness, first and second phase insulin secretion in noncirrhotic HCV-infected patients (n = 10) and in healthy control subjects (n = 10). Histological activity index (HAI) as well as the extent of fibrosis were evaluated by scoring liver biopsies.

RESULTS

Insulin sensitivity (2.72 +/- 1.63 vs. 6.84 +/- 1. 20 10(-4) min(-1) per microU/ml, p < 0.01) and glucose effectiveness (2.29 +/- 0.45 vs. 2.89 +/- 0.39 10(-2) min(-1), p < 0.05) ere significantly lower in patients with HCV-induced liver disease. Insulin sensitivity was negatively related to serum alanine aminotransferase (r = -0.47, p < 0.05) and aspartate aminotransferase concentrations (r = -0.65, p < 0.05). Multiple linear regression analysis revealed a strong relation of insulin sensitivity with fibrosis score and HAI (r = -0.82, p < 0.02 for both). Second phase insulin secretion was significantly enhanced in HCV-infected patients (14.30 +/- 2.04 vs. 8.29 +/- 1.65 min(-1), p < 0.05).

CONCLUSIONS

HCV-infected patients with normal glucose tolerance are insulin and glucose resistant. The impairment of glucose tolerance appears to be closely related with the severity of HCV-induced liver damage.

Hepatocellular proliferation in patients with chronic hepatitis C and persistently normal or abnormal aminotransferase levels

BACKGROUND/AIMS

Some patients chronically infected with the hepatitis C virus (HCV) have persistently normal alanine aminotransferase (ALT) levels while progressive liver damage is observed histologically. In the present study, we compared the rate of proliferation, apoptosis, and necrosis in liver biopsy specimens of patients with persistently normal or elevated ALT levels.

METHODS

Fourteen patients with persistently normal and 14 age- and sex-matched patients with elevated ALT levels were enrolled. Proliferation was detected using anti-Ki 67 in 10-microm liver biopsy specimens of the patients. Apoptosis was measured by TUNEL-assay and by monoclonal anti-M30 directed against caspase-cleaved cytokeratin 18 filaments.

RESULTS

The mean number of anti-Ki 67 positive hepatocytes was lower in patients with persistently normal aminotransferases (3.1 +/- 2.8/10(3) vs 10.8 +/- 8.8/10(3) hepatocytes, p<0.0011) and was correlated with serum ALT (r=0.86, p<0.01) and aspartate aminotransferase levels (r=0.83, p<0.01). The rate of apoptosis detected by TUNEL assay was low and not different between patients with persistently normal and elevated aminotransferases. Staining with anti-M30 revealed a granular staining pattern and showed a trend towards higher cell death rates in patients with elevated aminotransferase levels (apoptotic hepatocytes with >75% staining: 3.97 +/- 6.24/10(3) hepatocytes vs 13.65 +/- 19.41/10(3) hepatocytes; p=0.08).

CONCLUSIONS

Patients with chronic hepatitis C and normal aminotransferases have significantly lower hepatocyte proliferation rates and show a trend towards lower apoptosis rates compared with patients with elevated aminotransferases.

PCR-based subtractive hybridization identifies repressed genes in growth-arrested human dermal fibroblasts following combined treatment with 8-methoxypsoralen and UVA irradiation (PUVA)

To identify genes which are repressed in growth-arrested human dermal fibroblasts upon a single treatment with 8-methoxypsoralen and UVA irradiation (PUVA) we have used a PCR-based subtractive hybridization protocol resulting in cloning of four PUVA-repressed genes. Sequence analysis and homology searches identified three known genes related to growth control, lipid and connective tissue metabolism. One cDNA clone represented a novel gene. Northern blot analyses confirmed a PUVA-dependent reduction in mRNA expression in fibroblasts in vitro. The identification of growth arrest related repressed genes in PUVA-treated fibroblasts may stimulate further research addressing the causal role of these genes in the control and regulation of the postmitotic phenotype of fibroblasts on a molecular and cellular level.

[Insular carcinoma of the thyroid: a differentiated thyroid carcinoma with poor prognosis]

Insular carcinoma of the thyroid is a low differentiated type constituting about 5% of all thyroid cancers. Higher aggressiveness has been suggested as an important clinical feature. The value of preoperative fine-needle aspiration biopsy is not clearly proven for insular carcinoma. The criteria for histological diagnosis have been outlined by Carcangiu et al. Because of its aggressiveness, radical treatment at primary surgery appears advisable. Its clear distinction from undifferentiated (anaplastic) and medullary (C cell) cancers is important, as thyroglobulin is regularly synthesized by cancer cells. Enrichment of radioactive iodine makes such treatment feasible postoperatively and at relapse. Follow-up should be performed as in highly differentiated papillary and follicular thyroid cancer. A patient series of eight cases is presented. While all cancers were advanced at the initial diagnosis, the observed disease courses were in agreement with the assumption that insular carcinoma is a more aggressive form of differentiated thyroid cancer.

Oxaceprol is a well-tolerated therapy for osteoarthritis with efficacy equivalent to diclofenac

The therapeutic equivalence and safety of treatment for 21 days with 400 mg t.i.d. oxaceprol (n = 132) and 50 mg t.i.d. diclofenac (n = 131) were assessed in a multicentre, randomised, double-blind study of a mixed population of patients with osteoarthritis of the knee and/or hip. In a per-protocol analysis of efficacy, the mean Lequesne index decreased by 2.5 points in the oxaceprol group (n = 109) and by 2.8 points in the diclofenac group (n = 109). The 95% confidence interval for the end-point difference revealed therapeutic equivalence. This was confirmed by assessments (visual analogue scale) of pain at rest, weight-bearing pain, pain on standing and pain on movement, all of which decreased to a similar extent under both treatments. The pain-free walking time increased in both groups from 10 min to 25 min by the end of the treatment period. Mobility was also increased to a similar extent by both drugs. The physicians assessed treatment as good or very good in 45-46% of patients in both groups. In all patients who received treatment, 28 and 37 adverse events were reported by 25 out of 132 (18.9%) and 33 out of 131 (25.2%) patients treated with oxaceprol and diclofenac, respectively. In 15 patients (11.4%) with 15 adverse events in the oxaceprol group and 25 patients (19.1%) with 27 adverse events in the diclofenac group, a relation to the medication was considered probable. The difference between the groups was statistically significant (p = 0.04106) for the number of these adverse events. Oxaceprol is therapeutically equivalent to diclofenac, but better tolerated than diclofenac in the treatment of osteoarthritis.

Treatment of pruritus by capsaicin in a patient with pityriasis rubra pilaris receiving RE-PUVA therapy

Pityriasis rubra pilaris (PRP) is characterized by redness of the skin, scaling and a variable degree of pruritus. We present a patient with extremely itchy PRP successfully treated with oral retinoids and photochemotherapy with 8-methoxypsoralene (RE-PUVA) and topical capsaicin. The PRP-related pruritus which clearly preceded photochemotherapy and for which no other cause was apparent was relieved with capsaicin. This single case report provides evidence that topical capsaicin may be a useful therapeutic option in treating PRP-associated pruritus where antihistamines have been unsuccessful.

Photoaging of the skin from phenotype to mechanisms

The skin is increasingly exposed to ambient UV-irradiation thus increasing its risk for photooxidative damage with longterm detrimental effects like photoaging, which is characterized by wrinkles, loss of skin tone, and resilience. Photoaged skin displays prominent alterations in the cellular component and the extracellular matrix of the connective tissue with an accumulation of disorganized elastin and its microfibrillar component fibrillin in the deep dermis and a severe loss of interstitial collagens, the major structural proteins of the dermal connective tissue. The unifying pathogenic agents for these changes are UV-generated reactive oxygen species (ROS) that deplete and damage non-enzymatic and enzymatic antioxidant defense systems of the skin. As well as causing permanent genetic changes, ROS activate cytoplasmic signal transduction pathways in resident fibroblasts that are related to growth, differentiation, senescence, and connective tissue degradation. This review focuses on the role of UV-induced ROS in the photodamage of the skin resulting in biochemical and clinical characteristics of photoaging. In addition, the relationship of photoaging to intrinsic aging of the skin will be discussed. A decrease in the overall ROS load by efficient sunscreens or other protective agents may represent promising strategies to prevent or at least minimize ROS induced photoaging.

Evaluation of factors controlling glucose tolerance in patients with HCV infection before and after 4 months therapy with interferon-alpha

BACKGROUND

Epidemiological data suggest that chronic hepatitis C virus (HCV) infection may contribute to the development of diabetes mellitus. Therapy of HCV infection with recombinant interferon-alpha (r-IFN-alpha) can also impair of glucose metabolism.

METHODS

To investigate the impact of HCV infection and the therapy with r-IFN-alpha on glucose metabolism we measured insulin sensitivity, glucose effectiveness, and first and second phase insulin secretion, using the minimal modelling analysis of frequently sampled intravenous glucose tolerance tests in 13 nondiabetic patients with HCV-induced liver disease before and after therapy with r-INF-alpha (6 x 106 U, subcutaneously, three times a week over 4 months). Liver biopsy was performed to evaluate and score liver fibrosis as a marker of HCV-induced cell injury.

RESULTS

Insulin sensitivity (r = - 0.59, P < 0.05) and first phase insulin secretion (r = - 0.66, P < 0.03) were negatively related to the fibrosis score. Insulin sensitivity rose from 1.96 (SEM 0.37, n = 8) to 5.69 (SEM 0.99, n = 8) 10-4 min-1 per microU mL-1 (P < 0.01) in responders and from 2.51 (SEM 0.61, n = 5) to 6.95 (SEM 1.99, n = 5) in nonresponders after 4 months r-INF-alpha therapy. Fasting free fatty acids decreased significantly to about 50% (P < 0.01) in patients with and without therapy response after 4 months, whereas first phase insulin secretion did not change.

CONCLUSIONS

HCV-induced liver injury is related to the deterioration of insulin sensitivity and first phase insulin response, thus impairing glucose homeostasis in these HCV-infected patients. The administration of r-INF-alpha three times a week over 4 months is not associated with an impairment of glucose homeostasis.

Characterisation of patients with primary biliary cirrhosis responding to long term ursodeoxycholic acid treatment

BACKGROUND

In some patients with primary biliary cirrhosis, ursodeoxycholic acid causes full biochemical normalisation of laboratory data; in others, indexes improve but do not become normal.

AIMS

To characterise complete and incomplete responders.

METHODS

Seventy patients with primary biliary cirrhosis were treated with ursodeoxycholic acid 10-15 mg/kg/day and followed up for 6-13 years.

RESULTS

In 23 patients (33%) with mainly stage I or II disease, cholestasis indexes and aminotransferases normalised within 1-5 years, except for antimitochondrial antibodies. Histological findings improved. Indexes were not normalised in 47 patients (67%) although the improvement of their biochemical functions parallelled the trend in the first group. In these incomplete responders histological findings improved to a lesser extent. The only difference between the two groups before treatment was higher levels of alkaline phosphatase and gamma glutamyl transpeptidase in the incomplete responders. At onset of treatment the discriminant value separating responders from incomplete responders was 660 U/l for alkaline phosphatase and 131 U/l for gamma glutamyl transpeptidase. One year later it was 239 and 27 U/l (overall predictive value for responders 92%, for incomplete responders 81%). There were no differences between the two groups concerning immune status, antimitochondrial antibody subtypes, liver histology, or any other data. HLA-B39, DRB1*08, DQB1*04 dominated in both groups.

CONCLUSIONS

In patients with mainly early stages of primary biliary cirrhosis, higher values of alkaline phosphatase and gamma glutamyl transpeptidase are the only biochemical indexes which allow discrimination between patients who will completely or incompletely respond to ursodeoxycholic acid treatment.

Exercise-induced myocardial ischemia in isolated coronary artery ectasias and aneurysms ("dilated coronopathy")

OBJECTIVES

The purpose of our study was to evaluate the clinical significance of isolated coronary artery ectasias or aneurysms (CEA).

BACKGROUND

It has been postulated that altered coronary blood flow in CEA predisposes patients to the development of myocardial ischemia (CI) and infarction.

METHODS

Sixty-seven patients with bilateral nonobstructive CEA without associated cardiac defects ("dilated coronaropathy") were derived from 16,341 cardiac catheterizations between 1986 and 1997. Ectasias were defined as luminal dilation of 1.5- to 2.0-fold, aneurysms of >2.0-fold of normal limits. Eleven of 25 patients presented with myocardial infarction due to an occlusion of the infarct vessel. In 42 patients without infarction (study group), exercise-induced CI was investigated.

RESULTS

A corresponding CI was documented in 32 of 42 patients in a coronary sinus lactate study (reduced lactate extraction 5.6 +/- 4.1%) and in 29 of 40 patients in an ergometry (0.25 +/- 0.06 mV ST depressions). The results differed significantly from a control group of 29 patients without heart disease (p < 0.001). Nitroglycerin (0.8 mg) provoked a further significant deterioration of CI in the 32 of 42 developing a frank cardiac lactate production (-2.6 +/- 6.8%, p < 0.001). The metabolic extent of CI was significantly correlated to the coronary diameters of the proximal and middle segments of left anterior descending artery and the middle segment of left circumflex artery (r = 0.87, p < 0.001). Stigmata of an impaired coronary blood flow such as delayed antegrade filling, segmental backflow phenomenon and local deposition of dye were found significantly more often with increasing coronary diameters (p < 0.04).

CONCLUSIONS

"Dilated coronaropathy" is an entity of nonobstructive, ischemic coronary artery disease. Nitroglycerin is of no therapeutic benefit but leads to an aggravation of exercise-induced CI.

Fluorine-18 FDG positron emission tomography for imaging of hepatocellular carcinoma

OBJECTIVE

The detection of increased fluorine-18 fluorodeoxyglucose (18F-FDG) uptake by positron emission tomography (PET) is based on the enhanced glucose metabolism of tumor cells. Because the detection and staging of hepatocellular carcinoma (HCC) in patients with liver cirrhosis can be difficult, we prospectively evaluated the sensitivity of 18F-FDG PET in 14 consecutive patients with HCC.

METHODS

Whole body and regional 18F-FDG PET of the liver were obtained. The results were compared with ultrasonography, contrast-enhanced, helical CT, histological grading, p53 protein expression of HCC, and serum alpha-fetoprotein (AFP) level.

RESULTS

In 7 patients PET demonstrated increased tumor 18F-FDG uptake, whereas HCC was not distinguishable from nonmalignant liver tissue in 7 other patients. Hepatic lesions were detected by ultrasonography in all patients, whereas only 11 of 14 HCCs could be identified by CT. In 3 patients extrahepatic spread was demonstrated by 18F-FDG PET. Patients with increased tumor 18F-FDG uptake had significantly larger hepatic lesions and higher serum AFP levels than those with normal 18F-FDG uptake. Lesions could be visualized by 18F-FDG PET in 7 of 8 patients with moderately or poorly differentiated HCC, whereas none of the six well-differentiated tumors was detected. Two patients with strong p53 expression demonstrated increased tumor 18F-FDG uptake and extrahepatic metastases.

CONCLUSIONS

The sensitivity of 18F-FDG PET for the imaging of HCC is low. Nevertheless, in patients with moderately or poorly differentiated HCC, tumors >5 cm, or with markedly elevated AFP levels 18F-FDG PET may contribute to an effective noninvasive staging.

Interferon-alpha improves glucose tolerance in diabetic and non-diabetic patients with HCV-induced liver disease

This pilot study was initiated to evaluate factors controlling glucose tolerance in patients with hepatitis C virus-induced liver disease before and after therapy with recombinant interferon-alpha (r-INF-alpha). Fifteen patients with histologically and serologically proven hepatitis C infection underwent oral and frequently sampled intravenous glucose tolerance tests (FSIGTT) before and after four months of therapy (6 x 106 U r-INF-alpha, subcutaneously, three times a week). Glucose, insulin and C-peptide data from FSIGTT were analysed using the minimal modeling technique to determine insulin sensitivity, glucose effectiveness and first and second phase insulin secretion. According to the WHO criteria 13 patients, had normal glucose tolerance; diabetes mellitus was diagnosed in 2 patients. In the morning following the last r-INF-alpha injection four months later, insulin sensitivity improved significantly in hepatitis C virus-infected patients with normal glucose tolerance (2.17 +/- 0.37 vs. 6.18 +/- 0.94 10(-4) min(-1) per microU/ml, p < 0.001) and with diabetes mellitus (0.86 to 2.61; 0.46 to 1.06 10(-4) min(-1) per microU/ml). This effect was independent of the extent of fibrosis, virus load before treatment and therapy response. First phase insulin secretion increased in non-diabetic (139.2 +/- 17.1 vs. 200.0 +/- 32.7, p < 0.05) and diabetic patients with HCV infection (55.24 to 118.5; 84.23 to 261.1). Moreover, free fatty acid concentrations in all HCV-infected patients were significantly reduced (0.48 +/- 0.01 vs 0.21 +/- 0.03 mmol/l, p < 0.01). Therapy with recombinant interferon-alpha is associated with an amelioration of glucose tolerance in non-diabetic and diabetic HCV-infected patients.

Oral budesonide and ursodeoxycholic acid for treatment of primary biliary cirrhosis: results of a prospective double-blind trial

BACKGROUND & AIMS

Ursodeoxycholic acid (UDCA) is used for treatment of primary biliary cirrhosis. Previous studies showed that, compared with UDCA monotherapy, bile salts plus prednisolone had no further effect on laboratory data but improved liver histology. Thirty percent of these patients had prednisolone-related side effects. Budesonide is a glucocorticoid with a high receptor affinity and a high first-pass metabolism. In this study we investigated whether budesonide and UDCA are superior to UDCA monotherapy.

METHODS

A 2-year prospective, controlled double-blind trial was performed. Twenty patients (mainly with early-stage disease) were treated with UDCA at a dose of 10-15 mg/kg daily in addition to 3 mg budesonide 3 times daily (group A), and 19 patients (1 dropped out for personal reasons) were treated with UDCA plus placebo (group B). Liver biopsy specimens were taken before, after 12 months, and at the end of study. Glucose tolerance tests, serum cortisol levels, and adrenocorticotropin-stimulated cortisol secretion were assessed at regular intervals. Bone mass density was measured by dual-energy photon absorptiometry.

RESULTS

Compared with pretreatment values, liver enzyme and immunoglobulin M and G levels decreased significantly in both groups. Improvement in group A was significantly more pronounced (P < 0.05) than in group B. Titers of antimitochondrial antibodies did not change. In group A, the point score of liver histology improved by 30.3%; in group B, it deteriorated by 3.5% (P < 0.001). Changes in bone mineral density after 2 years were -1.747% in group A and -0.983% in group B (P = 0.43). Budesonide had little influence on the hypothalamic-pituitary-adrenal axis. One patient in group A had budesonide-related side effects; in 3 patients in group B, complications of liver disease developed.

CONCLUSIONS

Combination therapy with UDCA and budesonide is superior to UDCA and placebo.

Laser angioplasty of restenosed coronary stents: results of a multicenter surveillance trial. The Laser Angioplasty of Restenosed Stents (LARS) Investigators

OBJECTIVES

This study evaluated safety and efficacy of excimer laser angioplasty for treatment of restenosed or occluded coronary stents.

BACKGROUND

Balloon angioplasty of in-stent restenosis is limited by a high recurrence rate. Debulking by laser angioplasty is a novel concept to treat in-stent restenosis.

METHODS

A total of 440 patients with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjunctive balloon angioplasty.

RESULTS

Laser angioplasty success (< or =50% diameter stenosis after laser treatment or successful passage with a 2.0-mm or 1.7-mm eccentric laser catheter) was achieved in 92% of patients. Adjunctive balloon angioplasty was performed in 99%. Procedural success (laser angioplasty success followed by < or =30% stenosis with or without balloon angioplasty) was 91%. There was neither a significant difference in success with respect to lesion length, nor were there differences between small and large vessels or native vessels and vein grafts. Success was higher and residual stenosis lower using large or eccentric catheters. Serious adverse events included death (1.6%, not directly laser catheter related), Q-wave myocardial infarction (0.5%), non-Q-wave infarction (2.7%), cardiac tamponade (0.5%) and stent damage (0.5%). Perforations after laser treatment occurred in 0.9% of patients and after balloon angioplasty in 0.2%. Dissections were visible in 4.8% of patients after laser treatment and in 9.3% after balloon angioplasty. Reinterventions during hospitalization were necessary in 0.9% of patients; bypass surgery was performed in 0.2%.

CONCLUSIONS

Excimer laser angioplasty with adjunctive balloon angioplasty is a safe and efficient technology to treat in-stent restenoses. These data justify a randomized comparison with balloon angioplasty.

Peri-hepatic lymphadenopathy in primary biliary cirrhosis reflects progression of the disease

OBJECTIVE

We prospectively investigated the peri-hepatic lymph node volume in patients with primary biliary cirrhosis (PBC) and healthy controls to evaluate the correlation with histology, biochemical and immunological features.

MATERIALS AND METHODS

The total peri-hepatic lymph node volume in the liver hilus was evaluated by high-resolution ultrasound in 67 consecutive patients with PBC and in 43 healthy controls. Stages I-IV of PBC were biochemically, immunologically and histologically proven in all patients.

RESULTS

Adequate visualization of the liver hilus was achieved in 59/67 patients (88%) with PBC and in 39/43 healthy controls (91%). Lymph nodes in the liver hilus were sonographically detected in all 59 patients with PBC and in 26/39 healthy controls (67%) with adequate visualization of the liver hilus. The mean peri-hepatic lymph node volumes were: stage I (n = 9): 0.8 +/- 0.5 ml; stage II (n = 28): 2.4 +/- 1.5 ml; stage III (n = 21): 4.2 +/- 2.3 ml; stage IV (n = 9): 3.2 +/- 1.0 ml. The peri-hepatic lymph node volume did not significantly correlate with cholestasis, liver function tests or the immunological status.

CONCLUSIONS

Enlarged lymph nodes in the liver hilus are sonographically detectable in almost all patients with PBC. The total peri-hepatic lymph node volume in patients with PBC reflects histological stage, i.e. larger lymph nodes are observed in more advanced disease.

Endothelin-induced contraction of the portal vein in cirrhosis

Endothelin (ET) is one of the most potent vasoconstrictors known so far. It has been proposed that the ET-induced contraction of hepatic stellate cells (Ito, endothelial cells) is an important mechanism for the development of portal hypertension. The purpose of this study was to investigate in an in vitro model whether ET causes a contraction of the portal vein which can contribute to portal hypertension in cirrhosis. Portal veins from normal and cirrhotic rats were used for experiments. Measurements were performed in vitro for cumulative concentrations of ET-1 and ET-3 (1, 5, 10, 50 and 100 nM). Both ETs caused a dose-dependent increase in portal venous tension; the maximal tension (Tmax) was measured at 50 nM. The measured Tmax was higher for cirrhotic (ET-1: Tmax = 189%; ET-3: Tmax = 175%) than for normal rats (ET-1: Tmax = 130%; ET-3: Tmax = 151%). ET-3 produced a higher tension of portal veins in normal rats than ET-1. In conclusion, this study shows that portal veins from cirrhotic rats react more sensitively to ET than those from normal rats. Besides the ET-induced contraction of hepatic stellate cells, contraction of the portal vein and its intrahepatic branches, especially in cirrhotic individuals, has to be considered as a further mechanism of ET contributing to portal hypertension.

Immunohistochemical study of HBV antigens in 338 liver cell carcinomas

Tumor tissue (n = 338) and liver parenchyma (n = 276) from patients of Asian (n = 31) and European descent (n = 307) with hepatocellular carcinoma (HCC, n = 299), cholangiocellular carcinoma (CCC, n = 16) and combined HCC/CCC (n = 23) were screened with immunohistochemical methods for HBV antigens (HBs, preS1, preS2, HBc, HBe and HBx). Of the HCC cases nine were of the fibrolamellar type (FLC). All cases of HCC/CCC and CCC were from Western European patients. HBV antigens could be demonstrated more frequently in HCC cases of Asian descent (59.09% in liver parenchyma and 66.67% in tumor tissue) compared to Western European HCC cases (23.11% and 30.77%; chi-square test, p = 0.0003 and p = 0.0001, respectively), HCC/CCC (26.32% and 30.43%), CCC (7.14% and 20%) and FLC (0% and 25%). Results for HBx were not considered here due to questionnable HBV specificity of the antibodies employed. Immunohistochemical detection mainly HBs, whereas HBc, HBe and preS antigens played only a minor part. Comparing the results obtained with a rabbit and a goat polyclonal HBs antibody and a cocktail of seven monoclonal HBs antibodies showed statistically significant superior sensitivity for the goat antibody. Reactivity of tumor tissue for HBc and/or HBe as observed in twelve cases is suggestive of virus replication within tumor tissue. These data plus the demonstration of HBV antigens within so-called proliferated bile ducts, which represent metaplastic hepatocytes, underscore the nature of CCC as malignant counterpart of proliferated bile ducts. Consequently, it is proposed to divide the entity liver cell carcinoma (LCC) into the subcategories HCC and CCC in contrast to adenocarcinomas arising from bile ducts or peribiliary glands. In conclusion, HBV seems to play a part in the pathogenesis of LCC in Asian and in Western European patients. Further factors like HCV and other chronic inflammatory processes may be employed here.

Evaluation of rapid microsatellite analysis of paraffin-embedded specimens in screening for hereditary nonpolyposis colorectal cancer

Length alterations in short repetitive DNA sequences, termed microsatellite instability (MSI), are used as a diagnostic criterion of replication errors caused by various mutations in at least five mismatch repair genes. Therefore, MSI analysis is useful in clinical practice to identify patients with hereditary nonpolyposis colorectal cancer (HNPCC). MSI can be detected by amplification of microsatellite loci in DNA extracted from paraffin-embedded tumor and corresponding peritumoral specimens after numerous time consuming steps limiting the clinical utilities. Rapid microsatellite analysis, a efficient and rapid DNA extraction technique based on Triton X-100 preincubation, was compared with the conventional DNA extraction for HNPCC screening in colorectal tumor specimens from 12 patients. Five complex and two noncomplex (CA)n microsatellite loci were tested, with use of multicolor fluorescent analysis. MSI and loss of heterozygosity in colorectal tumor samples could equally be assessed with the two DNA preparation methods, whereas the number of initially unsuccessful DNA extractions from paraffin-embedded tissue specimens and overall duration for MSI analysis were significantly reduced when rapid microsatellite analysis was used. A replication error-positive phenotype was detected in 2 of 10 patients with a positive family history for colorectal cancer, and diagnosis of HNPCC was finally confirmed by detection of a specific germline mutation. The described rapid microsatellite analysis is less time consuming and more efficient, and, in general, it reduces the risk of contamination by limiting the number of steps required. Therefore, it might replace current DNA extraction procedures. Furthermore, techniques using fluorescent polymerase chain reaction and semiautomated DNA sequencer allow for precise, observer-independent, and rapid scoring in MSI and loss of heterozygosity assessment. A combination of our rapid DNA extraction method and the use of a highly specific microsatellite marker might improve replication error analysis in HNPCC screening.

[Parotid swelling with night sweat, fever and weight loss symptoms. A rare differential diagnosis]

HISTORY AND CLINICAL FINDINGS

A 29-year-old patient complained of recurrent swelling of the eyelids and cheeks, fever, diffuse headaches, night sweat and weight loss (8 kg during 8 weeks). Both parotid glands showed swelling which were solid, plain and non-painful to pressure. Palpation did not reveal enlarged lymph nodes. There were no other pathological findings except for anisocoria and disturbed motoric function of the right eye's pupil.

INVESTIGATIONS

Laboratory findings, chest X-ray, abdominal sonography and ilium crest biopsy showed no signs of lymphoma or other tumour. MRT showed enlarged parotid glands and hypointensity of a few small (up to 2 cm) areas. Because of these findings Heerfordt syndrome with involvement of the third cranial nerve and the lacrimal glands was suspected and verified by parotid biopsy.

TREATMENT AND COURSE

Under corticosteroid therapy started with 80 mg/d symptoms rapidly ceased. Therapy was continued for one year. 8 months after therapy had been stopped the patient had no complaints and investigations showed no signs of recurrence nor pulmonary or any other organ manifestation.

CONCLUSION

If swelling of the parotid glands with night sweat, fever and weight loss occur, parotid biopsy should be performed early to exclude malignancy. With parotid gland biopsy also diagnosis of other diseases which have similar signs, such as Sjögren syndrome and parotid gland sarcoidosis, can be established early.

[Metastatic breast carcinoma with neuroendocrine differentiation--its combined therapy with tamoxifen and the somatostatin analog octreotide]

HISTORY AND ADMISSION FINDINGS

A 75-year-old woman with histologically confirmed liver metastases from an undiagnosed primary tumor was admitted for further diagnosis and treatment. She had no symptoms and was in a very good general condition. The physical examination was unremarkable.

INVESTIGATIONS

The liver enzymes GOT and GPT were slightly elevated. The carcinoembryonic antigen (CEA) and the erythrocyte sedimentation rate (ESR) were markedly raised. Repeat analysis of the liver biopsies revealed a carcinoma with neuroendocrine differentiation (carcinoid).

TREATMENT AND COURSE

Chemoembolization of the advanced liver metastases was undertaken. Subsequently the breast tumor was resected. Histological analysis revealed a mammary carcinoma with neuroendocrine differentiation. Postoperative radiotherapy to the breast was instituted and she was started on tamoxifen (30 mg daily). But despite repeat chemoembolization the liver metastases continued to grow. Administration of octreotide, a somatostatin analogue, was begun (200 micrograms twice daily). There were no side effects; the tumor markers showed definite reduction and scintigraphy demonstrated almost complete regression. Computed tomography indicated a dissociated response of the liver metastases to the treatment (some got smaller, one had grown and several new ones had appeared).

CONCLUSION

Combined tamoxifen and octreotide treatment of a metastasizing carcinoma of the breast with neuroendocrine differentiation may give effective palliation.

[Segmental anatomy of the liver--a sonomorphological viewpoint]

The liver is an ideal organ for ultrasonography. In this context, intrahepatic structures allow the identification of segments according to Couinaud by ultrasonography. This article describes, step by step, the ultrasonographic segmental anatomy of the liver.

Tracing cellular and molecular mechanisms involved in endometriosis

The aetiology and pathogenesis of endometriosis, defined as the presence of endometrium-like tissue outside the uterine cavity, is largely unknown. In this paper we present and discuss possibilities to study the putative pathogenic properties of endometriotic cells in vitro. The current focus of our investigations is on the invasive phenotype of the disease, assuming that this might contribute to the pathogenesis of endometriosis. So far, we have shown that: (i) cytokeratin-positive and E-cadherin-negative endometriotic cells have an invasive phenotype in a collagen invasion assay in vitro similar to metastatic carcinoma cells; (ii) the invasiveness of endometriotic but not of eutopic endometrial cells can be stimulated by a heat-stable protein present in peritoneal fluid; and (iii) the endometriotic cell line EEC145T, which we established, may be a useful tool for the identification of gene products which are, positively or negatively, invasion-related. Finally, our studies suggest that the invasive phenotype in endometriosis shares aspects with tumour metastasis, but might also have unique mechanisms.

Invasive pulmonary aspergillosis in a critically ill neonate: case report and review of invasive aspergillosis during the first 3 months of life

We report a fatal case of invasive pulmonary aspergillosis in a severely ill neonate and review 43 additional cases of invasive aspergillosis reported from 1955 through 1996 that occurred during the first 3 months of life. Eleven of the 44 patients had primary cutaneous aspergillosis, 10 had invasive pulmonary aspergillosis, and 14 had disseminated disease. Most infections were nosocomial in origin. Prematurity (43%); proven chronic granulomatous disease (14%); and a complex of diarrhea, dehydration, malnutrition, and invasive bacterial infections (23%) accounted for the majority of underlying conditions. At least 41% of the patients had received corticosteroid therapy before diagnosis, but only one patient had been neutropenic. Among patients who received medical and/or surgical treatment, outcome was relatively favorable, with an overall survival rate of 73%. Invasive aspergillosis may occur in neonates and young infants and warrants consideration under certain circumstances. Current therapeutic approaches consist of high-dose amphotericin B and appropriate surgical interventions.

Hepatic and portal vein flow pattern in correlation with intrahepatic fat deposition and liver histology in patients with chronic hepatitis C

OBJECTIVE

The flow pattern in hepatic veins depends on cardiac physiology and liver histology. The aim of our study was to determine the dependence of the flow pattern of hepatic and portal veins in relation to histologic features in patients with chronic hepatitis C.

SUBJECTS AND METHODS

In 135 patients with chronic hepatitis C, the Doppler sonography spectrum of the right hepatic vein was classified as triphasic, biphasic, or monophasic. The flow of the portal vein was characterized according to the undulation (velocity(max,min)). A liver biopsy was performed during sonography, and biopsy specimens were semiquantitatively evaluated on a histologic activity index and a score of the hepatic fat content. Multiple logistic regression analysis was used to identify the histologic features that might contribute to the type of flow pattern.

RESULTS

The hepatocyte fat content was the only variable associated with an independent effect on the type of flow pattern (monophasic versus triphasic; odds ratio, 16.26; 95% confidence interval, 6.38-41.45; p < .0001). A pronounced undulation in the portal vein was associated with portal inflammation but not with other parameters of the histologic activity index or the intrahepatic fat deposition.

CONCLUSION

On sonography, the normal flow pattern in the right hepatic vein is triphasic. The monophasic flow pattern in the right hepatic vein is mainly caused by intrahepatic fat deposition and occasionally by inflammatory or fibrotic changes. Conversely, the flow pattern of the portal vein is mainly influenced by portal inflammation.

Rapid microsatellite analysis of paraffin embedded tumour specimens from patients with hereditary non-polyposis colorectal cancer

In screening for hereditary non-polyposis colorectal cancer (HNPCC)--an autosomal dominant disorder characterised by mutations in mismatch repair genes--detection of microsatellite instability is an important diagnostic criterion. The mono- or dinucleotide repeat DNA sequences are usually amplified from formalin fixed, paraffin embedded tissue by polymerase chain reaction after numerous time consuming steps including deparaffinisation, DNA extraction, and purification. A rapid single step method for direct DNA analysis is described, based on preincubation of paraffin embedded tissue with Triton X-100 followed by DNA amplification with fluorescence labelled primers and electrophoresis in an automated sequencer. This procedure allows precise allele sizing and analysis of genetic instability, is more efficient and time saving, reduces the risk of contamination, and is therefore of particular interest in screening for HNPCC.

Saccharomyces cerevisiae LIF1: a function involved in DNA double-strand break repair related to mammalian XRCC4

Saccharomyces cerevisiae DNA ligase IV (LIG4) has been shown previously to be involved in non-homologous DNA end joining and meiosis. The homologous mammalian DNA ligase IV interacts with XRCC4, a protein implicated in V(D)J recombination and double-strand break repair. Here, we report the discovery of LIF1, a S.cerevisiae protein that strongly interacts with the C-terminal BRCT domain of yeast LIG4. LIG4 and LIF1 apparently occur as a heterodimer in vivo. LIF1 shares limited sequence homology with mammalian XRCC4. Disruption of the LIF1 gene abolishes the capacity of cells to recircularize transformed linearized plasmids correctly by non-homologous DNA end joining. Loss of LIF1 is also associated with conditional hypersensitivity of cells to ionizing irradiation and with reduced sporulation efficiency. Thus, with respect to their phenotype, lif1 strains are similar to the previously described lig4 mutants. One function of LIF1 is the stabilization of the LIG4 enzyme. The finding of a XRCC4 homologue in S.cerevisiae now allows for mutational analyses of structure-function relationships in XRCC4-like proteins to define their role in DNA double-strand break repair.

Intraoperative gamma probe detection of neuroendocrine tumors

Previous studies of the intraoperative use of a handheld gamma probe to localize metastases and primary tumors of colorectal cancer have shown improved assessment of tumor spread and changes in surgical management based on added information gained by radioimmunoguided surgery. We conducted a prospective study to determine whether intraoperative radiodetection is able to reveal microscopic and occult disease of neuroendocrine tumors [medullary thyroid carcinomas (MTCs), gastroenteropancreatic (GEP) tumors].

METHODS

After the injection of 180 MBq [111In-diethylenetriaminepentaacetic acid (DTPA)-D-Phe1]pentetreotide and/or 500 MBq 99mTc-dimercaptosuccinic acid (DMSA) (both for double-nuclide scintigraphy), preoperative somatostatin receptor imaging (12 patients with GEP tumors) and double-nuclide scintigraphy (10 patients with relapsing MTCs were performed. The results were combined with the information obtained from conventional imaging modalities (CT and sonography). Intraoperative radiodetection was performed 24 hr after administration of [111In-DTPA-D-Phe1]pentetreotide or 4 hr after the injection of 99mTc-DMSA using a handheld gamma probe.

RESULTS

Intraoperative gamma counting localized 70 somatostatin receptor-positive lesions of GEP tumors, whereas preoperative receptor imaging visualized 74%, surgical palpation visualized 44% and radiological imaging modalities localized only 43%. In 10 patients with recurrent MTCs, the surgeon was successful in localizing and removing 30 tumor lesions using the gamma probe. Twenty-seven of 30 lesions demonstrated tumor involvement, whereas 3 lesions were false-positive (lymphadenitis). Double-nuclide scintigraphy revealed 67% (Octreoscan, 7 of 20; 99mTc-DMSA, 13 of 20), surgical palpation revealed 60% and conventional imaging methods (CT, sonography) revealed only 50% of all lesions detected intraoperatively by the handheld gamma probe. The smallest lesion identified by the handheld probe (not palpated by the surgeon) was a lymph node metastasis (5-mm diameter).

CONCLUSION

The preliminary data show that intraoperative handheld gamma probe detection of microscopic and occult endocrine tumors is feasible and more sensitive than external scintigraphy and conventional imaging.

Estimation and filtering of potential protein-protein docking positions

MOTIVATION

Software systems predicting automatically whether and how two proteins may interact are highly desirable, both for understanding biological processes and for the rational design of new proteins. As a part of a future complete solution to this problem, a bundle of programs is presented designed (i) to estimate initial docking positions for a given pair of docking candidates, (ii) to adjust them, and (iii) to filter them, thus preparing more detailed computations of free energies.

RESULTS

The system is evaluated on a test set of 51 co-crystallized complexes aiming at redocking the subunits. It works completely automatically and the evaluation is performed using one single set of parameters for all complexes in the test set. The number of solutions is fixed to 50 positions with a median CPU time of 26 min. For 30 complexes, these contain a near-correct solution with root mean square deviation ( RMSD ) </=5.0 A, which is ranked first in five cases. For all complexes, the best solution is scored on rank 16 as the worst case, and has a median RMSD of 4.3 A. Alternatively to this initial estimation of docking positions, a global sampling of rotations was tested. Whereas this yields top-ranked solutions with RMSD </=3.0 A for all 51 complexes, the median CPU time increases to 11 h. This shows that this blind sampling is not feasible for most applications.

AVAILABILITY

The system and its components are available on request from the authors.

CONTACT

friedric@techfak.uni-bielefeld or posch@techfak.uni-bielefeld.de

A sparsely vascularised zone in the cortex of the bovine ovary

We consider that the microvascular bed may play a role in the initiation and maintenance of growth from primordial to primary follicles. Therefore, using immunochemistry, we examined microvessels in calf and cow ovaries to identify the presence of factor VIII-related antigen endothelial cells. A vessel-poor zone was observed in the cortex of immature and mature cow ovaries. Primordial and primary follicles were assembled in this zone. It is concluded that follicular dormancy is likely to be maintained by the scarcity of microvessels and thus by the consequent poverty of the blood supply.

Quantification of the initial decline of serum hepatitis C virus RNA and response to interferon alfa

Although several virus- and host-related predictive factors for the response to interferon alfa (IFN-alpha) have been defined in patients with chronic hepatitis C, no pretreatment parameter can definitely predict the response to antiviral treatment. Assessment of the initial response by quantification of serum hepatitis C virus RNA before and 4 weeks after initiation of therapy may be a clinically applicable and reliable parameter to predict long-term response. Therefore, the aims of the present study were to test the predictive value of a decline in HCV RNA of at least 3 log in the first 4 weeks of treatment (deltaHCV RNA) in patients treated with 3 x 10(6) units of recombinant IFN-alpha2a (rIFN-alpha2a) three times per week subcutaneously and to compare deltaHCV RNA with other established predictive factors, such as HCV genotype and pretreatment viremia. Serum HCV RNA was measured by a validated quantitative reverse transcription-polymerase chain reaction (RT-PCR). Geno/subtyping of HCV was performed by direct sequencing of the nonstructural (NS) 5B region of PCR-amplified isolates and subsequent phylogenetic analysis. Stable HCV RNA levels (deltaHCV RNA < or = 1 log) within the first 4 weeks of IFN-alpha treatment were present in 42 of 70 patients. A decline in HCV RNA levels between 1 to 3 log and more than 3 log was observed in 9 (13%) and 19 patients (27%), respectively. In 21 of 70 patients (30%), HCV RNA was not detectable at the end of 12 months' treatment. Three of 26 patients (11%) with a pretreatment viremia of < or = 10(6) copies/mL (all HCV subtype 3a) and 6 of 44 patients (14%) with a pretreatment viremia of > 10(6) copies/mL (HCV subtypes 1b, 2a, 2c, 3a [two patients], and 4) achieved a virological sustained response to interferon-alpha2a treatment. All patients with a virological sustained response had an initial deltaHCV RNA of more than 3 log. In a stepwise discriminant-function analysis, the initial deltaHCV RNA was confirmed as the strongest predictor of virological sustained response (P < .0001). In conclusion, the data of the present study suggest that IFN-alpha treatment can be terminated after 4 weeks in patients with a decrease in HCV RNA levels of less than 3 log, when apparent HCV eradication is considered the therapeutic target. The predictive value of deltaHCV RNA clearly exceeds the significance of HCV genotype and pretreatment viremia as predictors of successful IFN-alpha treatment.

Psoralen photoactivation promotes morphological and functional changes in fibroblasts in vitro reminiscent of cellular senescence

Premature aging of the skin is a prominent side effect of psoralen photoactivation, a treatment used widely for various skin disorders. The molecular mechanisms underlying premature aging upon psoralen photoactivation are as yet unknown. Here we show that treatment of fibroblasts with 8-methoxypsoralen (8-MOP) and subsequent ultraviolet A (UVA) irradiation resulted in a permanent switch of mitotic to stably postmitotic fibroblasts which acquired a high level of de novo expression of SA-beta-galactosidase, a marker for fibroblast senescence in vitro and in vivo. A single exposure of fibroblasts to 8-MOP/UVA resulted in a 5.8-fold up-regulation of two matrix-degrading enzymes, interstitial collagenase (MMP-1) and stromelysin-1 (MMP-3), over a period of &gt;120 days, while TIMP-1, the major inhibitor of MMP-1 and MMP-3, was only slightly induced. This imbalance between matrix-degrading metalloproteases and their inhibitor may lead to connective tissue damage, a hallmark of premature aging. Superoxide anion and hydrogen peroxide, but not singlet oxygen, were identified as important intermediates in the downstream signaling pathway leading to these complex fibroblast responses upon psoralen photoactivation. Collectively, the end phenotype induced upon psoralen photoactivation shares several criteria of senescent cells. In the absence of detailed molecular data on what constitutes normal aging, it is difficult to decide whether the changes reported here reflect mechanisms underlying normal cellular aging/senescence or rather produce a mimic of cellular aging/senescence by quite different pathways.

Composition of ibotenic acid-induced calcifications in rat substantia nigra

Agonists of the excitatory neurotransmitter glutamate have neurotoxic properties and are, therefore, frequently used to place locally circumscript brain lesions. In certain vulnerable brain areas, especially the substantia nigra and globus pallidus, the ensuing neurodegeneration is accompanied by the formation of calcium deposits. In the present study, we investigated the structure and chemical composition of calcium deposits formed in rat substantia nigra upon local application of ibotenic acid. Using scanning and transmission electron microscopy in combination with X-ray analysis and analysis of the electron diffraction patterns, we demonstrate that the inorganic components of the calcifications consist of calcium and phosphate. The calcium phosphate is deposited in a polycrystalline manner in degenerating neurons and in a matrix surrounding the degenerated complexes. New matrix is continuously added around the enlarging calcium deposits. Content of inorganic material is always higher in the center of the deposits than in the margin, but in every case the diffraction pattern reveals that the calcium phosphates are present in the form of hydroxyapatite. Thus, organic and inorganic components of the calcifications are subject to a continuous process of growth and maturation. The ibotenic acid-induced calcium deposits in rat substantia nigra provide a reliable model system to study the pathogenesis of non-arteriosclerotic calcifications.

Is pancreatoscopy of any benefit in clarifying the diagnosis of pancreatic duct lesions?

BACKGROUND AND STUDY AIMS

Modern fine-caliber endoscopes enable clinicians to directly visualize the pancreatic duct. They allow intraductal manipulation under optical control. We tried to evaluate the additional diagnostic potential of pancreatoscopy in assessing inconclusive intraductal pancreatic changes.

PATIENTS AND METHODS

We prospectively performed 20 pancreatoscopies in 18 patients with inconclusive ductal abnormalities that had been previously investigated by computed tomography (CT) scan, abdominal ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). The CHF-BP 30 (Olympus Optical Co., Japan) endoscope with an outer diameter of 3.1 mm and an instrumentation channel of 1.2 mm was used. Biopsies, cytological brushing and fluid collection were carried out, and the site of ductal abnormality was visualized. Endoscopic sphincterotomy (EST) was carried out in every patient prior to insertion of the pancreatoscope.

RESULTS

Seven intraductal tumors were histologically confirmed, i.e. five intraductal papillary mucinous tumors and two adenocarcinomas. Benign appearance of the intraductal lesion plus negative histopathological examinations were confirmed by a follow-up of two years in eight patients. Five had chronic pancreatitis, and a further three had pancreatitis with strictures, blood clot obstruction, and idiopathic benign stricture, respectively. There were no complications with the exception of one bleeding episode after EST; no pancreatitis occurred.

CONCLUSIONS

Pancreatoscopy is of diagnostic value in addition to CT, transabdominal ultrasound and ERCP in the differential diagnosis of poorly defined pancreatic lesions, particularly when assessing alterations of the ductal caliber without parenchymatous lesions.

Sonographic detection of focal changes in the liver hilus in patients receiving corticosteroid therapy

OBJECTIVE

While diffuse deposition of fat may occur with corticosteroid (CS) administration both in the liver and in other organs, comparatively little is known about focal changes in the liver under corticosteroid medication. Therefore, we evaluated pattern and extent of focal hepatic steatosis by ultrasound (US) in patients receiving corticosteroids.

SUBJECTS AND METHODS

93 patients with known inflammatory bowel disease (IBD) received corticosteroids during a period of at least six weeks prior to the ultrasound examination and 28 IBD-patients had no corticosteroids within the last three years. 13 additional patients received corticosteroids for other reasons than IBD for > 1 year. 80 healthy volunteers served as controls. Focal changes of the liver as assessed by high resolution ultrasound (Acuson 128, 3.5 and 5 MHz) were defined as areas of brighter echogenicity compared to the general aspect of the liver. The size of the hyperechoic areas was documented (photoprint).

RESULTS

40/93 IBD-patients with corticosteroids (43%) had definite areas of brighter echos in the hilus region of the liver. In IBD-patients without corticosteroids only one patient showed a focal brighter echogenicity, whereas in the non-IBD group with corticosteroids 8/13 had focal lesions (62%). In the control group only four healthy subjects showed brighter areas (5%).

CONCLUSION

Bright focal areas in the liver hilus occur in > 40% of IBD-patients during corticosteroid medication. This phenomenon occurs in IBD-patients as frequently and as intense as in other patients with longstanding corticosteroid therapy. There is a hilar area of the liver with typical size and location which reacts to corticosteroid administration with hyperechoic reflexes at ultrasound investigation. This is important to know when it comes to the differential diagnosis of focal changes.

Evidence for the development of macrophage-like cells in long-term culture of bovine aortic endothelial cells

Macrophages are known to be derived from monocytes which proliferate in the bone marrow. The proliferation of monocytes may occur in other places as well. In the present study, we describe the morphological behaviour of macrophage-like cells in endothelial cell cultures obtained from bovine aorta. These cells resembled hemopoietic clones containing progenitor-like cells. Immature and mature macrophage-like cells were rich in acid phosphatase activity, and expressed the CD18 molecule using immunolocalisation. Mature cells contained intracellular lipid droplets. "Actin" globules were apparent only in the peripheral cell areas without lamellipodia or filipodia. At the ultrastructural level, the mature cells were crowded with granules which could be lysosomes, phagolysosomes, or endocytotic vesicles. Multinuclear giant cells which behaved in a different way to the macrophage-like cells were observed. The development and maintenance of macrophage-like cells appears to be dependent on the coculture with endothelial cells. It may signify that endothelial cells are involved in the proliferation of monocytes outside the bone marrow.

Detection of normal mediastinal lymph nodes by ultrasonography

PURPOSE

The detection by US (in contrast to CT) of lymph nodes of any size in the mediastinum is usually considered to be a pathological finding. The aim of this study was to find out whether it was possible to detect normal lymph nodes by high-resolution mediastinal US.

MATERIAL AND METHODS

Six different mediastinal regions in 80 healthy asymptomatic volunteers and in 20 human cadavers were examined by means of US (with colour Doppler imaging) to assess US access to the respective regions and to demonstrate the number and size of detectable lymph nodes. All the cadaveric lymph nodes that were detected were examined histologically to exclude inflammatory or malignant infiltration.

RESULTS

In almost all subjects, we obtained US access to the supra-aortic (100%), paratracheal (95%), prevascular (99%), and pericardial (98%) regions, and to the aorticopulmonary window (98%). US access to the subcarinal region was more difficult (75%). In the healthy subjects, lymph nodes were detected in the paratracheal region (in 35% of these subjects, mean lymph-node diameter 12 x 7 mm), in the aorticopulmonary window (45%, 14 x 8 mm), and in the subcarinal region (13%, 13 x 7 mm). In the cadavers, histologically normal lymph nodes were detected frequently in the paratracheal region (85%, mean size 11 x 6 mm) and in the aorticopulmonary window (90%, 11 x 5 mm).

CONCLUSION

These results indicate that normal lymph nodes (and not only pathological lymph nodes) can be demonstrated by high-resolution mediastinal US.

Detection of the adrenal glands by endoscopic or transabdominal ultrasound

BACKGROUND AND STUDY AIMS

The value of transabdominal and endoscopic ultrasound (EUS) in detecting normal adrenal glands is not yet established. The aim of our study was to evaluate whether these techniques can be routinely used to visualize the adrenal glands in patients without suspected adrenal pathology.

PATIENTS AND METHODS

Transabdominal ultrasound was validated by examination of 10 corpses and was performed in 80 healthy volunteers (3.5 and 5 MHz). EUS of the left adrenal gland was performed in 154 consecutive patients referred for various other reasons. In 20 patients we attempted to visualize the right adrenal gland as well.

RESULTS

Both adrenal glands were correctly identified in all of the 10 corpses once they were opened. In healthy volunteers, the right adrenal gland was visualized by transabdominal ultrasound in 79/80 patients (99 %) and the left adrenal gland in 55/80 patients (69 %). EUS allowed detection of the left adrenal gland in 151/154 patients (98%). In three patients EUS failed because of grossly distorted anatomy. In 6/20 patients we were also able to detect the right adrenal gland by EUS, which was obvious in two cases because of incidentalomas.

CONCLUSION

Visualization of the right adrenal gland is almost always possible by transabdominal ultrasound, while its detection by EUS is successful only in some cases. The left gland is more difficult to detect by transabdominal ultrasound, while it can nearly always be seen using EUS. Therefore, a combined transabdominal and endoscopic ultrasonographic approach is useful for visualization of the adrenal glands and may enable diagnosis of even small adrenal masses.

[Sonographic detection of lymph nodes in the hepatoduodenal ligament]

BACKGROUND AND OBJECTIVE

In patients with chronic inflammatory liver disease modern methods of ultrasound can visualize enlarged lymph nodes in the porta hepatis. Number, size and total volume of lymph nodes in the hepatoduodenal ligament in healthy subjects and in patients with chronic viral hepatitis without cirrhotic changes were investigated.

PATIENTS AND METHODS

Sonographic localization of the perihepatic lymph nodes was validated at post-mortem and intraoperatively. Following this, 92 healthy persons (57 men, 35 women; average age 33 +/- 9 years) and 48 patients (30 men, 18 women; average age 35 +/- 8 years) with serologically and histologically confirmed chronic viral hepatitis (30 with hepatitis C, 18 with hepatitis B) were investigated by abdominal ultrasound (Acuson 128, 3.5 and 5 MHz). The hepatoduodenal ligament was assessed according to a standardized procedure with demonstration of the lymph node positions ventral to the portal vein and between the portal vein and the inferior vena cava.

RESULTS

Satisfactory imaging of the hepatoduodenal ligament was achieved in 83 of the 92 healthy persons (90.2%) and in 44 of the 48 patients with chronic viral hepatitis (91.7%). Lymph nodes were demonstrated in 60 of the 83 healthy subjects (72.3%) and in 43 of 44 patients with chronic hepatitis (97.7%). The mean perihepatic lymph node volume was 2.8 +/- 2.6 cm3 (0-9.7 cm3) and was thus significantly smaller (P = 10(-9)) than in the patients with chronic viral hepatitis (19.8 +/- 15.7 cm3 [0-62.4 cm3]). There was no significant difference in lymph node volume between patients with hepatitis B and those with hepatitis C (23.1 +/- 14.9 cm3 vs 18.9 +/- 15.6 cm3; P = 0.16).

CONCLUSIONS

With adequate ultrasound technique enlarged lymph nodes can be demonstrated in the porta hepatis of almost all patients with chronic hepatitis B or C. Lymph nodes of normal size can often be imaged also in healthy persons if their localization is known. The demonstration of lymph nodes in the hepatoduodenal ligament in the area of the porta hepatis and the determination of their volume can be helpful in the diagnosis of chronic inflammatory liver disease.

Local immunosuppression with budesonide after liver transplantation in the rat: a preliminary histomorphological analysis

BACKGROUND

In this study we have analyzed the local immunosuppression with budesonide, a topically selective glucocorticosteroid, in rats after orthotopic liver transplantation. Because of its high first-pass hepatic clearance budesonide can be given orally, achieving high intrahepatic and low systemic concentrations.

METHODS

Using an acute rejection model from Dark Agouti (DA) to Lewis rats, the histomorphological degree of rejection was assessed on histological sections at the ninth postoperative day.

RESULTS

Livers of the DA to Lewis study group without immunosuppression revealed severe allograft rejection with vast cellular infiltrates, massive endothelialitis, and hepatocyte necrosis. In the three budesonide study groups (250 microg, 500 microg, and 1 mg/kg/day) a moderate to mild liver allograft rejection was seen. Rejection was most prominent in the 250 microg group, whereas the 1 g group showed almost no signs of rejection, similar to the Lewis to Lewis control group. Aspartate and alanine transaminase (sGOT, sGPT) as well as alkaline phosphatase serum levels correlated with the degree of rejection, achieving highest levels in the DA to Lewis group without immunosuppression. Animals treated with 1 g of budesonide had serum levels similar to Lewis to Lewis control animals.

CONCLUSIONS

These results implicate a beneficial effect of local immunosuppression with budesonide in rats based on the histomorphological degree of liver allograft rejection.

Prevalence and clinical and histological manifestation of hepatitis G/GBV-C infections in patients with elevated aminotransferases of unknown etiology

BACKGROUND/AIMS

Hepatitis G virus (HGV) and hepatitis GB virus-C (GBV-C) are recently identified non-A-E hepatitis-associated viruses. The prevalence of HGV/GBV-C in the general population is high (1.0-1.7%), but data on the clinical and histological manifestations of the new viruses are sparse. In the present study we investigated the prevalence and clinical and histological manifestation of HGV/GBV-C infections in patients with elevated aminotransferase levels of unknown etiology.

METHODS

In 52 of 630 consecutive patients referred for evaluation of elevated aminotransferases the underlying liver disease remained unknown. Serum samples of these 52 patients with elevated aminotransferase levels of unknown etiology were tested for HGV/GBV-C RNA by reverse transcription-polymerase chain reaction (RT-PCR) using primers deduced from nonstructural regions. Cloned PCR products were sequenced and compared by phylogenetic analysis.

RESULTS

HGV/GBV-C RNA was consistently detected in 7 of the 52 patients (13%). Sequence and phylogenetic analysis revealed the presence of only one subtype, with nucleotide sequence homologies between 86 and 91%. All seven patients had persistent viremia for at least 9 months. In six patients liver function test results normalized, and alanine aminotransferase levels remained persistently elevated in only one patient. Four HGV/GBV-C positive and ten HGV/GBV-C negative patients consented to a liver biopsy, which revealed similar results with minimal to mild chronic hepatitis and mild portal fibrosis.

CONCLUSIONS

The prevalence of HGV/GBV-C infections in patients with elevated aminotransferases of unknown etiology is low. Since clinical, biochemical and histomorphologic features of patients with elevated aminotransferases of unknown etiology with and without HGV/GBV-C infection are indistinguishable, the role of HGV/GBV-C in the pathogenesis of chronic liver disease appears insignificant.

Enlargement of perihepatic lymph nodes in relation to liver histology and viremia in patients with chronic hepatitis C

Inflammatory processes in organs frequently lead to hyperplasia of regional lymph nodes. In the present study, we investigated whether lymph node enlargement within the hepatoduodenal ligament may reflect the inflammatory activity within the liver of patients chronically infected with the hepatitis C virus (HCV). In 114 patients with chronic hepatitis C and 49 healthy controls, the total lymph node volume within the hepatoduodenal ligament was prospectively investigated by ultrasound. In patients with chronic hepatitis C, a liver biopsy was taken at the same occasion, and specimens were semiquantitatively evaluated by the histological activity index (HAI). Hepatitis C viremia was assessed by quantitative reverse transcription-polymerase chain reaction (RT-PCR). Genotyping was performed by a reverse hybridization assay. In 104 of 114 patients (91.2%) and in 45 of 49 healthy controls (91.8%), adequate visualization of the region of the hepatoduodenal ligament was achieved by ultrasound. Lymph nodes were detected in all patients with chronic hepatitis C and in 33 of 45 controls. The mean perihepatic lymph node volume in healthy controls (2.2 +/- 1.8 mL) was lower than in HCV-infected patients with mild to moderate inflammatory activity, severe inflammatory activity, and patients with cirrhosis (5.8 +/- 2.2 mL, 18.1 +/- 10.4 mL, and 22.8 +/- 18.8 mL, respectively). In patients with HCV-RNA levels of less than 10(6) copies/mL, the total lymph node volume was 5.8 +/- 1.6 mL and was significantly increased in patients with higher viremia (20.3 +/- 13.8 mL; P < 10(-6)). No correlation was found between the total lymph node volume within the hepatoduodenal ligament, HCV genotypes, and liver function test results. In conclusion, enlargement of perihepatic lymph nodes in patients with chronic hepatitis C is predictive for the presence of severe inflammatory activity. The mechanism of portal lymphadenopathy in patients with chronic hepatitis is unknown but appears to be related to viral replication within the liver and the immune-mediated inflammatory response of the host.

A newly identified DNA ligase of Saccharomyces cerevisiae involved in RAD52-independent repair of DNA double-strand breaks

Eukaryotic DNA ligases are ATP-dependent DNA strand-joining enzymes that participate in DNA replication, repair, and recombination. Whereas mammalian cells contain several different DNA ligases, encoded by at least three distinct genes, only one DNA ligase has been detected previously in either budding yeast or fission yeast. Here, we describe a newly identified nonessential Saccharomyces cerevisiae gene that encodes a DNA ligase distinct from the CDC9 gene product. This DNA ligase shares significant amino acid sequence homology with human DNA ligase IV; accordingly, we designate the yeast gene LIG4. Recombinant LIG4 protein forms a covalent enzyme-AMP complex and can join a DNA single-strand break in a DNA/RNA hybrid duplex, the preferred substrate in vitro. Disruption of the LIG4 gene causes only marginally increased cellular sensitivity to several DNA damaging agents, and does not further sensitize cdc9 or rad52 mutant cells. In contrast, lig4 mutant cells have a 1000-fold reduced capacity for correct recircularization of linearized plasmids by illegitimate end-joining after transformation. Moreover, homozygous lig4 mutant diploids sporulate less efficiently than isogenic wild-type cells, and show retarded progression through meiotic prophase I. Spore viability is normal, but lig4 mutants appear to produce a higher proportion of tetrads with only three viable spores. The mutant phenotypes are consistent with functions of LIG4 in an illegitimate DNA end-joining pathway and ensuring efficient meiosis.

Multiple coronary artery-left ventricular fistulae: haemodynamic quantification by intracoronary Doppler ultrasound

Multiple coronary artery-left ventricular fistulae involving all three major coronary arteries are extremely rare. Clinical findings are heterogeneous but include a history of typical or atypical angina pectoris in most cases. Coronary arteriography in a 65 year old woman who presented with chest pain at rest revealed multiple fine fistulae arising from the left anterior descending, left circumflex, and right coronary arteries. Left-to-left shunt was estimated by measurements of coronary artery flow velocity with intravascular Doppler ultrasound.