Elevated expression and polymorphisms of SOCS3 influence patient response to antiviral therapy in chronic hepatitis C

BACKGROUND

The response to antiviral therapy of chronic hepatitis C virus (HCV) infection is determined by virological, environmental and genetic factors.

OBJECTIVE

The hypothesis was tested that the expression of specific genes and their haplotype frequencies can differentiate between non-responders (NRs) and sustained virological responders (SVRs) to antiviral treatment.

METHODS

A methodological approach based on molecular marker discovery and validation was used to study the genes influencing the antiviral treatment in lymphoblastoid cell lines from 74 genotype 1b HCV patients (44 from Southern Italy and 30 from Northern Italy) treated with pegylated interferon (IFN) alpha and ribavirin. Furthermore, an association study was performed, testing three single nucleotide polymorphisms (SNPs) of suppressor of cytokine signalling 3 (SOCS3) in 162 NR and 184 SVR subjects (SOCS3 -8464 A/C (rs12952093), -4874 A/G (rs4969170) and 1383 A/G, (rs4969168)).

RESULTS

SOCS3 basal expression levels were significantly increased in two independent sets of NR groups (p<0.05). A highly significant association was found between NRs and both the positively associated haplotype (OR = 2.01, 95% CI 1.45 to 2.79, p = 0.0002) and the negatively associated haplotype (OR = 0.56, 95% CI 0.42 to 0.76, p = 0.0014). In particular, the SOCS3 -4874 AA genotype was strongly associated with failure of antiviral therapy (OR = 4.00, 95% CI 2.09 to 7.66, p = 0.0003) and the AA genotype carriers had significantly higher SOCS3 mRNA and protein levels (p<0.05).

CONCLUSIONS

Basal levels of SOCS3, an inhibitor of the IFN alpha-induced Janus kinase-signal transducer and activator of transcription pathways, and its genetic polymorphisms influence the outcome of antiviral treatment. SOCS3 thus represents a novel blood biomarker for the a priori prediction of treatment response.

Therapy expectations and physical comorbidity affect quality of life in chronic hepatitis C virus infection

Hepatitis C virus (HCV) infection is associated with a significant reduction of health related quality of life (QOL), the causes and mechanisms of which are still unknown. To explore whether treatment history could affect QOL, we examined patients with detectable HCV viraemia who had a different therapeutic background. Two hundred sixty-four consecutive subjects with chronic HCV infection and detectable viraemia were enrolled. Of these, 163 were untreated patients, 43 were relapsers, 58 were nonresponders (NR) to nonpegylated interferon (IFN) therapy. To assess QOL, three self-report instruments were employed: the Short Form-36 (SF-36), the Chronic Liver Disease Questionnaire (CLDQ-I) and the World Health Organization Quality of Life assessment (WHOQOL-BREF). Clinical and demographic data were collected, and the QOL scores of HCV-positive patients were compared with those of an Italian normative sample and healthy controls. Further antiviral treatment was offered to untreated and relapsed patients but not to NR. All patient groups displayed lower QOL scores compared with the normative sample and controls. NR displayed lower QOL scores in several areas compared with untreated patients and relapsers. In multivariate regression analyses, being NR and having a physical comorbidity were significantly associated with poorer QOL.

CONCLUSIONS

Treatment history and expectations and physical comorbidity may affect QOL in HCV-positive patients. Untreated and relapsed patients have comparable levels of QOL and higher scores than NR.

Steatohepatitis is associated with diabetes and fibrosis in genotype 1b HCV-related chronic liver disease

Liver steatosis, diabetes mellitus and hepatitis C virus (HCV) genotype have been implicated in liver fibrosis in HCV-related chronic active hepatitis (CAH). The aim of this study was to evaluate whether steatosis and diabetes were associated with more severe liver fibrosis in patients with genotype 1b HCV-related CAH. One-hundred and eighty patients (98 men, 82 women; age range 17-68 years; median 51) infected with genotype 1b HCV underwent ultrasound examination and liver biopsy because of elevated levels of serum alanine transaminase. Based on liver histology, patients were divided into three steatosis classes: 1 (involving <33% of hepatocytes), 2 (34-66%) and 3 (>66%). Fibrosis was graded with the Ishak score (range: 0-6). Virological and epidemiologic characteristics, biochemical data, body mass index, and apparent duration of disease were recorded. Diabetes was identified according to American Diabetes Association criteria. The median fibrosis grade was 2 (23 patients had liver cirrhosis) in the three steatosis classes, with no significant differences between classes. At multivariate analysis, fibrosis was significantly related to age, alanine transaminase, diabetes, hepatitis B core antibody, steatohepatitis and grading. At binary logistic regression analysis, only diabetes and fibrosis stage were significantly associated with steatohepatitis. Steatosis was not an independent risk factor for liver disease severity in our CAH/genotype 1b HCV-infected patients. Steatohepatitis was associated as well as diabetes and affected the severity of liver fibrosis.

The role of bright liver echo pattern on ultrasound B-mode examination in the diagnosis of liver steatosis

AIM

The observation of bright liver echo pattern on ultrasound is commonly considered a sign of hepatic steatosis. However, the interference of liver fibrosis on sensitivity and specificity of bright liver echo pattern has caused many to question its effectiveness as a diagnostic tool. The objective of this study was to evaluate the sensitivity, specificity and predictive values of bright liver echo pattern for liver steatosis.

PATIENTS AND METHODS

We studied 235 consecutive patients suspected of having liver disease of various aetiologies. Median age was 52 years (range, 17-72 years), and there was a male/female ratio of 1:18. All patients underwent ultrasound examination before liver biopsy and was performed by two operators. The presence or absence of bright liver echo pattern and posterior attenuation or areas with different patterns of fat infiltration were noted. Histologic evaluation was performed and graded by Ishak score. Steatosis was categorised as absent, 0-2%, 3-29% to 30-49% or >50%.

RESULTS

Interobserver concordance was high. Bright liver echo pattern was found in 67% of patients with steatosis of any degree and 89% of patients with steatosis of >or=30%. Only three patients without steatosis, who had a low Ishak score, demonstrated bright liver echo pattern on ultrasonography. The sensitivity, specificity, positive predictive value and negative predictive value of bright liver echo pattern for steatosis were 64%, 97%, 96.0% and 65%, respectively. Among the subgroup of patients who had steatosis of >or=30%, the sensitivity, specificity, positive predictive value and negative predictive value of bright liver echo pattern were 91%, 93%, 89% and 94%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of posterior attenuation and/or skip areas associated with bright liver echo pattern for steatosis were 89.7%, 100%, 100% and 92.3%, respectively. Univariate analysis showed bright liver echo pattern to be associated only with steatosis and not with fibrosis.

CONCLUSION

We concluded that the presence of bright liver echo pattern is a sign of liver steatosis and that liver fibrosis does not interfere with ultrasound measurements. Posterior attenuation and/or skip areas are closely related to steatosis of >or=30%.

Mean and long-term results of the surgical treatment of early gastric cancer

AIM

Interest in the diagnosis and treatment of early gastric cancer (EGC) has been steadily increasing due to the high 5-year survival rate which can reach 85-100% after curative resection. The aim of this retrospective study was to analyze the clinical and histologic characteristics as well as the results of 45 patients undergoing surgical resection for EGC.

METHODS

Between 1998 and 2004, 45 patients, 14 females and 31 males with a mean age of 60.2+/-15 years (range: 31-85) were recruited. Subtotal gastrectomy was performed in 28 (62.2%) patients and total gastrectomy in 17 (37.3%). D1 and D2 resections were performed in 36 and 9 patients, respectively. The carcinoma was limited to the mucosa in 26 (57.8%) patients and extended into the submucosa in 19 (42.2%). Lymph node invasion occurred in 4 (8.8%) patients. Mean follow-up was 36 months (range: 3-63). Survival was calculated using the Kaplan-Meier method. Multivariate analysis of clinic and histologic factors was performed to identify predictive factors for survival.

RESULTS

The 5-year actuarial survival rate was 85% and there was no postoperative mortality. Statistical analysis did not demonstrate any significant statistical relationship between survival and parietal penetration (P = 0.67) or superficial extension (P = 0.38) of the tumor. Survival was clearly influenced (P < 0.001) by lymph node involvement.

CONCLUSIONS

Prognosis of EGC is usually excellent but can be influenced by the presence of lymph node metastases.

Hepatitis C virus carriers with persistently normal ALT levels: biological peculiarities and update of the natural history of liver disease at 10 years

Some chronic hepatitis C (CHC) patients exhibit persistently normal alanine aminotransferase (ALT) levels (PNAL). Patients with PNAL experience significantly milder disease. In order to understand the differences between CHC patients with elevated ALT levels compared with those with PNAL better, we compared epidemiological, immunological and histological findings, in particular, the value of proliferating hepatocyte activity (PCNA) between the two groups of patients. We studied 40 chronic hepatitis C virus (HCV) carriers with increased ALT who underwent liver biopsy for histological diagnosis and determination of clinical prognosis, and 24 PNAL patients under follow-up for 10 years. Immunological response to different HCV genomic epitopes was tested in both the control group and in PNAL subjects. PCNA values from liver specimens of all patients as well as liver biopsies of PNAL patients at time points 0 and 5 years were calculated according to Hall et al.Age, sex and body mass index (BMI) were not significantly different between the two groups. The median liver histology stage was significantly higher in HCV carriers vs the PNAL group (2.5, range = 2-6 vs 1.5, range = 1-2; P < 0.01). Among PNAL patients, histological stage was not statistically different at the three time points considered. Interferon (IFN)-gamma production was comparable in the two groups. PCNA was significantly higher in the group with elevated ALT levels vs the PNAL group (8%, range = 4-15%vs 5% range = 3-8%; P < 0.05) and no statistically significant differences were found in PNAL patients at time points 0, 5 and 10 years. This study confirms that progression to cirrhosis is slow or absent in PNAL patients after 10 years of follow-up. Accordingly, the hepatic proliferative activity index is low and seems to be stable over time.

Simulation of the photodynamics of azobenzene on its first excited state: Comparison of full multiple spawning and surface hopping treatments

We have studied the cis-->trans and trans-->cis photoisomerization of azobenzene after n-->pi* excitation using the full multiple spawning (FMS) method for nonadiabatic wave-packet dynamics with potential-energy surfaces and couplings determined "on the fly" from a reparametrized multiconfigurational semiempirical method. We compare the FMS results with a previous direct dynamics treatment using the same potential-energy surfaces and couplings, but with the nonadiabatic dynamics modeled using a semiclassical surface hopping (SH) method. We concentrate on the dynamical effects that determine the photoisomerization quantum yields, namely, the rate of radiationless electronic relaxation and the character of motion along the reaction coordinate. The quantal and semiclassical results are in good general agreement, confirming our previous analysis of the photodynamics. The SH method slightly overestimates the rate of excited state decay, leading in this case to lower quantum yields.

Validity and reliability of the Italian version of the Chronic Liver Disease Questionnaire (CLDQ-I) for the assessment of health-related quality of life

BACKGROUND

The Chronic Liver Disease Questionnaire is a specific health-related quality of life assessment designed for patients with liver diseases.

AIM

The aim of this paper is to report on the validity, reliability and sensitivity to change of the Italian version (Chronic Liver Disease Questionnaire-I) in subjects with HCV infection.

SUBJECTS

The Chronic Liver Disease Questionnaire-I was administered to 350 subjects with HCV infection together with the World Health Organization Quality of Life Assessment, abbreviated version, a generic quality of life assessment.

METHODS

The instrument was translated from English, backtranslated and reviewed in focus groups in the framework of a large multicentre study. Exploratory factor analysis identified five factors accounting for 65% of the variance of Chronic Liver Disease Questionnaire-I items and only partially overlapping with those found in the original version.

RESULTS

The Chronic Liver Disease Questionnaire-I proved to discriminate between subjects with and without comorbid diseases at baseline (t-test = 3.59, p < 0.001). Test-retest reliability was moderate (ICC = 0.60). The Chronic Liver Disease Questionnaire-I was sensitive to change in patients who deteriorated after one month of treatment. Change in the overall Chronic Liver Disease Questionnaire-I score in deteriorated patients was correlated with changes in World Health Organization Quality of Life Assessment, abbreviated version scores in the physical, psychological and environment, but not in the social area.

CONCLUSIONS

The Italian version of Chronic Liver Disease Questionnaire is a valid and reliable instrument to be used in cross-sectional and longitudinal studies.

A randomized controlled trial of pegylated interferon alpha-2a (40 KD) or interferon alpha-2a plus ribavirin and amantadine vs interferon alpha-2a and ribavirin in treatment-naïve patients with chronic hepatitis C

We determined whether triple therapy comprising amantadine (AMA), ribavirin (RBV) and either peginterferon (PEG-IFN) alpha-2a or conventional IFN alpha-2a would improve sustained virological response (SVR) rates over dual therapy with IFN alpha-2a and RBV in patients with chronic HCV infection. A total of 362 treatment-naïve patients were randomized to 48 weeks of treatment with: PEG-IFN alpha-2a 180 microg/week (group A) or IFN alpha-2a 3 MU tiw (groups B and C). All patients received RBV 1000 or 1200 mg/day and those in groups A and B received AMA 200 mg/day. SVR was defined as an undetectable HCV RNA after 24 weeks of untreated follow-up. At the end of therapy, 74.4% (95% CI 0.66-0.82) of patients in group A were HCV RNA-negative compared with 42.5% (95% CI 0.33-0.50) of those in group B (P = 0.0001) and 48.8% (95% CI 0.40-0.56) of those in group C. SVR was achieved in a significantly greater proportion of patients in group A compared with groups B and C: 65.3% (95% CI 0.53-0.56), 33.3% (95% CI 0.25-0.41) and 44.6% (95% CI 0.36-0.53; P = 0.0001) respectively. In patients with genotype 1, SVR rates were 55.2, 22.8 and 28.8% with the three regimens respectively. Factors independently associated with SVR were HCV genotype 2 or 3, therapy with PEG-IFN, female gender and age. In treatment-naive patients with chronic hepatitis C, triple therapy with PEG-IFN alpha-2a, RBV and AMA produces higher SVR than dual or triple therapy with conventional IFN alpha-2a.

Photodissociation Dynamics of Chlorine Peroxide Adsorbed on Ice

Chlorine peroxide plays an important role in the chlorine-ozone chemistry in the antarctic stratosphere. Adsorption by ice crystals may alter its photochemistry in different ways. We have simulated the photodissociation of a ClOOCl molecule adsorbed on ice by means of a semiclassical representation of the excited state dynamics. Electronic energies and wave functions of ClOOCl are computed by an ad hoc reparametrized semiempirical method, and the interaction with ice is taken into account by a QM/MM strategy. The reaction mechanism is similar to what was previously found for the isolated molecule: sequential or almost simultaneous breaking of both Cl-O bonds leads to the 2Cl + O2 reaction products in most cases. The Cl atoms remain temporarily adsorbed on the ice surface, whereas O2 is ejected. The main effect for the overall chlorine chemistry is probably an increase of the photodissociation rates at long wavelengths, due to the change of adsorption cross sections induced by the interaction with ice.

Treatment of patients with HCV infection with or without liver biopsy

Expert consensus recommends liver biopsy before therapy for chronic hepatitis C. A cost effectiveness analysis suggested that the best strategy in the management of patients was to treat without biopsy. We compared therapy in patients who did, or did not undergo biopsy. Hepatitis C virus (HCV)-positive patients (78) who did not agree to (n = 57) or with contraindications to liver biopsy (n = 21) (group A) were matched for age, sex and genotype with those who consented (group B). Before therapy (interferon/ribavirin for 12 months), a clinical diagnosis of chronic hepatitis, on the basis of standard biochemical and ultrasonographic parameters. The two groups showed similar baseline characteristics. A noninvasive, diagnosis of chronic hepatitis was made in 75.6% of group A, and in 83.3% of group B (P = 0.26). Concordance between clinical and histological diagnosis in group B amounted to 91%. End-of-therapy virological response was 52.6% in group A, and 57.7% in group B (P = 0.63). Sustained virological response was 41.0% [95% confidence interval (CI) 30.1-51.9] and 43.6% (95% CI 32.6-54.6) in the two groups (P = 0.87). Predictors of sustained response were noninvasive diagnosis of chronic hepatitis (P = 0.006), lack of portal hypertension (P = 0.037), platelets >10(5)/mm3 (P = 0.007), prothrombin >70% (P = 0.02), and genotype 2 or 3 (P < 0.0001). At multivariate analysis, genotype (P < 0.0001) and platelets (P = 0.004) maintained their predictive power. In most patients with HCV infection, virological clearance after therapy can be achieved irrespective of whatever a liver biopsy might show.

[Ultrasound-guided endoscopic drainage, without radiological examination, in patients with neoplastic biliary obstruction. Preliminary results]

AIM

Endoscopic stent insertion has become the preferred method for palliation of malignant biliary obstruction. Currently, endoscopic stent placement involves the use of contrast media and radiological equipment to achieve direct opacification of the biliary duct systems, and to determine the location and the extension of biliary obstruction. This report proposes a new combination of ultrasonography and biliary endoscopy, with endoscopic stent placement entirely performed under US-guidance.

METHODS

US-guided stent placement was carried out in 8 patients. A guide-wire and a guiding-catheter were endoscopically introduced and identified, by US, the common bile duct across the stricture. Hydromer-coated polyurethane angled stents (10F) were finally inserted over the guide-wire/guiding-catheter by a pusher tube system.

RESULTS

Successful stent insertion was achieved in all patients. There were no complications. Successful drainage, with substantial reduction in bilirubin level, was achieved in all patients (14.2+/-9.5 vs 4.2+/-2.9 mg/dl at 1 week).

CONCLUSION

Endoscopic stent placement performed under US-guidance, is safe and effective. Further studies in a larger series, including more proximal strictures are suggested.

[Endoscopic palliation of inoperable hilar biliary carcinoma with self-expanding metal stents]

AIM

Prosthetic palliation of patients with malignant hilar stenoses shows particular difficulties, especially in advanced lesions. This is a prospective report of the efficacy of endoscopically inserted single metal stent for complex malignant biliary hilar obstruction.

METHODS

Sixty-one consecutive patients were recruited. Contrast injection was deliberately limited to the distal end of the malignant tumor stenosis. A single metal stent was inserted across the stricture into the duct that was technically easiest for the drainage.

RESULTS

Successful stent insertion was achieved in 59 of 61 (96.7%) patients. In 3 (4.9%) cases stent malfunction occurred. Successful drainage was achieved in 59 (96.7%) patients and complete resolution of jaundice was achieved in 86% of cases. Early complications included 3 (4.9%) cases of cholangitis and 2 (3.2%) cases of stent occlusion. Late occlusion of the stent occurred in 14 patients (22.9%), including 10 (16.3%) cases of cholangitis and 1 case of liver abscess. Median stent patency was 169 days. Median patient survival was 140 days.

CONCLUSION

Metal stent insertion is safe, feasible, and achieves adequate drainage in the great majority of patients with non-resectable hilar cholangiocarcinoma.

Clinical management of HCV carriers with normal aminotransferase levels

An ad hoc committee appointed by the Italian Association for the Study of the Liver (AISF) proposed these Practice Guidelines for the management of HCV carriers with persistently normal aminotransferase levels. Only stringent ALT determinations will make it possible to distinguish these subjects from those in temporary biochemical remission. The overall prevalence in Italy has been estimated between 1.5 and 10.6%. HCV RNA quantitation and genotype determination are not predictors of the presence and severity of liver damage nor correlate with the outcome of the disease, and should not be used in clinical practice for the management and surveillance of HCV carriers with normal ALT. Only a minority of HCV carriers with normal ALT levels show a normal morphological picture (true 'healthy carriers'). Disease activity is mild in most cases; fibrosis is generally mild and cirrhosis is very rare. Histological activity, as monitored by sequential liver biopsies, seems to have very slow evolution. HCV carriers should not undergo liver biopsy on a routine basis. Liver biopsy can be reasonably proposed only in selected cases. Until the results of studies with PEG interferon plus ribavirin are available, HCV carriers should not receive antiviral treatment outside controlled experimental studies.

[Long-term results of endoscopic treatment of biliary stenosis from laparoscopic cholecystectomy]

BACKGROUND

The outcome of endoscopic biliary stent insertion for postoperative bile duct stenosis was retrospectively evaluated.

METHODS

Fifty-seven patients with biliary stenosis from laparoscopic cholecystectomy were included from February 1992 to January 2000. One to three stents were inserted for an average of 12.4 months, with stent exchange every three months to avoid cholangitis caused by obstruction.

RESULTS

Successful stent insertion was achieved in 43/57 (75.4%) patients. Stent insertion failed in 10 patients with complete and four patients with incomplete biliary obstruction. Early complications occurred in four patients. Late complications occurred in 5/43 patients. Five patients experienced recurrence of stenosis.

CONCLUSIONS

Endoscopic treatment should be the initial management of choice for postoperative bile duct stetiosis.

Tamoxifen in the treatment of hepatocellular carcinoma: 5-year results of the CLIP-1 multicentre randomised controlled trial

BACKGROUND

In 1998, when data of a meta-analysis on tamoxifen in the treatment of hepatocellular carcinoma (HCC) had suggested a little advantage for this treatment, we published the results of a multicenter randomised controlled trial, that showed no survival benefit for tamoxifen vs. control. Here we report an updated analysis of the study results 4.5 years after the closure of enrollment.

METHODS

The study had a planned sample size of 480 patients. Patients with any stage HCC were eligible, irrespective of locoregional treatment. Tamoxifen was given orally, 40 mg/die, from randomisation until death.

RESULTS

496 patients were randomised by 30 Institutions from January 1995 to January 1997. Information was available for 477 patients. As of July 2001, 374 deaths (78%) were recorded, and median survival times were 16 and 15 months (p=0.54), in the control and tamoxifen arm. Data were further analysed separately for advanced patients and for those eligible to potentially curative locoregional treatments: relative hazard of death for patients receiving tamoxifen was equal to 0.98 (95% CI 0.76-1.25) for the former group and 1.38 (95% CI 0.95-2.01) for the latter. The prognostic score recently devised by our group (CLIP score) was, as expected, strictly correlated (p<0.0001) to the locoregional treatment received and strongly correlated with prognosis.

CONCLUSIONS

the update of the present study confirms that tamoxifen is not effective in prolonging survivals, both in advanced patients and in those potentially curable and that the CLIP score is able to predict prognosis.

Reduction in psychopathology following bariatric surgery for morbid obesity

BACKGROUND

Although there has been some disagreement, there is growing evidence now that psychopathology is a comorbidity of morbid obesity among patients seeking bariatric surgery. The aim of this study was to determine whether psychopathology decreases following this surgery.

METHODS

Utilizing a national sample, this study focused on pre- and post-surgery scores on the Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2). The MMPI-2 was administered first during the pre-surgery medical examination, and again between 6 months and 1 year following surgery.

RESULTS

Validity scale scores on the pre- and post-surgery MMPI-2s indicated that there was no impediment to interpreting the clinical scale scores of these tests. There was a pervasive pattern of statistically significant decreases in pre- to post-surgery clinical scale scores. Further, comparison of MMPI-2 clinical scale scores to available test norms showed that the number of participants showing signs of mental disorders was unusually high before surgery, and at or below the test norms following surgery.

CONCLUSIONS

There is clear evidence in this study that psychopathology declines following bariatric surgery. The unusually high levels of psychopathology before surgery may be a joint function of the factors producing the morbid obesity, and a reaction to the obesity itself. That psychopathology declines following surgery to levels expected in the general population indicates that the patients were becoming more positive about their lives.