Precore mutations and core clustering mutations in chronic hepatitis B virus infection

BACKGROUND

Mutant hepatitis B virus is often associated with severe liver damage. The purpose of this study is to elucidate the relationship between mutations in hepatitis B precore/core gene and the severity of liver damage.

METHODS

The hepatitis B precore/core gene from 20 patients with chronic hepatitis B virus infection was studied by polymerase chain reaction and direct sequencing.

RESULTS

Missense mutations in the core gene were only found in patients with chronic active hepatitis. Three mutation clustering regions of core gene, codons 48-60, 84-101, and 147-155, had higher substitution rates than other regions. All patients with chronic active hepatitis had missense mutation(s) either in codons 84-101 or in codons 48-60. There was a trend of increasing substitutions in the precore/core gene from e antigen-positive asymptomatic carriers to e antibody-positive patients with chronic active hepatitis.

CONCLUSIONS

These data suggest that (1) severe liver damage in chronic hepatitis B virus infection is related to the clustering missense mutations in codons 48-60 and 84-101 of core gene and that (2) the emergence of precore stop codon mutation and missense mutations around the carboxy-terminal processing site of precore/core protein (codons 147-155) may be the adaptive mechanisms of hepatitis B virus to decrease production and secretion of viral protein and retain the viral persistence.

Aflatoxin B1 DNA adducts in smeared tumor tissue from patients with hepatocellular carcinoma

Aflatoxins are well-known animal hepatocarcinogens, but the association between aflatoxins and human hepatocellular carcinoma remains to be elucidated. A study method consisting of indirect immunofluorescence assay combined with densitometry was developed to quantitate aflatoxin B1 DNA adducts in smeared liver tissue obtained at the time of biopsy for diagnosis in 50 hepatocellular carcinoma patients in Taiwan. Monoclonal antibody 6A10, generated against the persistent form of the major N7 guanine adduct of aflatoxin B1, was used for detection of adduct. Thirty-five (70%) of the hepatocellular carcinoma samples had detectable levels of aflatoxin B1 DNA adducts (> or = 1/10(6) nucleotides). The detection rate was slightly lower in men (69%) than in women (75%), and younger patients had a significantly higher rate of adducts (83%) than did older ones (58%). Carriers of both HBsAg and HBeAg, carriers of HBsAg only and noncarriers had different rates of detection: 29%, 74% and 82%, respectively. Patients with family histories of hepatocellular carcinoma had a higher detection rate (100%) than did those patients without such histories (67%). No association was found between aflatoxin B1 DNA adducts in liver tissue and Child's score for severity of liver disease. The results suggest that aflatoxin B1 may be involved in the pathogenesis of hepatocellular carcinoma in Taiwan. Our immunohistochemical method for analysis of adducts in small numbers of cells from the target organ should improve results of monitoring for the biologically effective dose of aflatoxin.

Alpha-fetoprotein in patients with hepatocellular carcinoma after transcatheter arterial embolization

To assess the usefulness of alpha-fetoprotein (AFP) in monitoring treatment effects of transcatheter arterial embolization (TAE) in hepatocellular carcinoma (HCC) patients, a total of 31 sets of AFP levels after TAE in 21 HCC patients were analysed by linear regression between logarithmic AFP levels and days. Eleven sets of AFP data with poor linear declination were accompanied with poor TAE results except in one patient who had chronic hepatitis with acute exacerbations. Twenty sets of data with good linear declination in the first month after TAE indicated good TAE results. Seven of them showed no evidence of tumour recurrence nor elevated AFP levels within a follow-up of 6 months. The mean, standard deviation and range of half-lives of AFP in the non-recurrent group were 5.0, 1.6 and 2.9-7.2 days, respectively. The others experienced late tumour recurrence that was detected by rebound of AFP levels except one who had another non-AFP-secreting HCC. Thus, the results might be used as a reference in monitoring the treatment effects of TAE and the timing selection of repeated TAE.

Relationship between fatty liver, alanine aminotransferase, HBsAg and hepatitis C virus

A community health survey of 923 residents aged 30 years or more was performed in Putai Township of Taiwan. To elucidate the relationships between hepatitis C virus (HCV) and surrogate tests for non-A, non-B hepatitis in hyperendemic areas of hepatitis B virus (HBV) serum levels of alanine aminotransferase (ALT), triglycerides, cholesterol, hepatitis B surface antigen (HBsAg) and antibody to HCV (anti-HCV) were examined. Glucose tolerance tests and the history of diabetes treatment were used to define the diabetes status. Fatty liver was diagnosed by sonography. The prevalence of anti-HCV was 2.6% (95% confidence interval, 1.6-3.6%). Elevated ALT and fatty liver were significantly associated with anti-HCV in univariate analysis. Anti-HCV was not an associated factor for fatty liver after adjusting for serum triglycerides and cholesterol, sex, body mass index and diabetes status through multiple logistic regression. However elevated ALT was still associated with anti-HCV after adjusting for serum triglycerides, sex, body mass index, HBsAg and age through multiple linear regression. The anti-HCV prevalence was similar between HBsAg-positive and negative subjects. Aggregation of HCV infection was found among spouses. It was concluded that elevated ALT and intimate contact with HCV carriers might be associated factors for HCV infection, and that HBV infection and fatty liver were not related to HCV infection in Taiwan.

Clinical utility of pulsed Doppler in the detection of arterioportal shunting in patients with hepatocellular carcinoma

Ninety-seven patients with hepatocellular carcinoma had duplex scanning from the patent or residual portal lumen and comparative angiography. Duplex ultrasonography identified five of nine patients with angiographic evidence of arterioportal shunting. Furthermore, Doppler results indicated the presence of the shunt in one patient without angiographic evidence. Duplex scanning from the portal lumen may be useful in the detection of arterioportal shunting. This procedure can be used to evaluate the hemodynamic change of the recipient portal vein under natural physiologic conditions. However, small shunts without hepatofugal portal blood cannot be detected by this procedure.

The role of hepatitis B and C viruses in hepatocellular carcinoma in a hepatitis B endemic area. A case-control study

To investigate the role of hepatitis B (HBV) and C viruses (HCV) in hepatocellular carcinoma (HCC) in an HBV endemic area and elucidate the interaction of these two viruses, a case-control study of 128 patients with HCC and 384 age-matched and sex-matched control subjects was done. The positive rates of hepatitis B surface antigen (HBsAg, 77.3%, 99 of 128) and anti-HCV (19.5%, 25 of 128) in patients with HCC were significantly higher than in control subjects (P less than 0.001). Both HBsAg and anti-HCV were important risk factors for HCC (relative risks, 13.96 and 27.12, respectively), and the risk for HCC was elevated significantly to 40.05 (95% confidence interval, 12.57 to 127.6) when HBsAg and anti-HCV were considered simultaneously. These results suggested that HBV and HCV were associated highly with HCC in an HBV endemic area and that these two viruses might contribute independent but synergistic effects to the pathogenesis of HCC.

The role of hepatitis B and C viruses in hepatocellular carcinoma in a hepatitis B endemic area. A case-control study

To investigate the role of hepatitis B (HBV) and C viruses (HCV) in hepatocellular carcinoma (HCC) in an HBV endemic area and elucidate the interaction of these two viruses, a case-control study of 128 patients with HCC and 384 age-matched and sex-matched control subjects was done. The positive rates of hepatitis B surface antigen (HBsAg, 77.3%, 99 of 128) and anti-HCV (19.5%, 25 of 128) in patients with HCC were significantly higher than in control subjects (P less than 0.001). Both HBsAg and anti-HCV were important risk factors for HCC (relative risks, 13.96 and 27.12, respectively), and the risk for HCC was elevated significantly to 40.05 (95% confidence interval, 12.57 to 127.6) when HBsAg and anti-HCV were considered simultaneously. These results suggested that HBV and HCV were associated highly with HCC in an HBV endemic area and that these two viruses might contribute independent but synergistic effects to the pathogenesis of HCC.

Anti-HCV antibody in Chinese cirrhotic patients with or without hepatocellular carcinoma: relation to multitransfusion

To investigate the positive rates of antibodies to hepatitis C virus (anti-HCV) in Chinese cirrhotic patients with or without hepatocellular carcinoma and to evaluate the influence of blood transfusion on the prevalence of anti-HCV in such patients, a longitudinal study in 30 cirrhotic patients (17 combined with hepatocellular carcinoma) was carried out. Five patients (16.7%) were anti-HCV positive before transfusion. The positive rate of anti-HCV in HBsAg-positive patients and HBsAg-negative patients was 9.5% (2/21) and 33.3% (3/9), respectively. The positive rates in cirrhotic patients with or without hepatocellular carcinoma were 23.5% (4/17) and 7.7% (1/13), respectively. The positive rate of anti-HCV increased significantly after multitransfusion, and the estimated infectivity of blood products was 6.1 patients per 1000 units of blood products. It was concluded that the aetiological role of hepatitis C virus on liver cirrhosis and hepatocellular carcinoma in the endemic area of hepatitis B virus is not so important as in Western countries, and transfusion might result in an overestimated pathogenic effect of hepatitis C virus in cirrhotic patients and patients with hepatocellular carcinoma.

Treatment of hepatocellular carcinoma by transcatheter arterial chemoembolization and analysis of prognostic factors

A total of 100 patients with histologically proven hepatocellular carcinoma (HCC) underwent transcatheter arterial chemoembolization (TACE) and were followed for more than 1 year and 10 months. Portal vein branch thrombosis was diagnosed in 14 patients, and extrahepatic metastasis was noted in 11 subjects. The embolization material used was iodized oil (0.1-0.2 ml/cm tumor area at its maximal diameter), which was prepared by pumping with contrast agent and then mixed with anticancer drugs; Gelfoam particles measuring 1-2 mm in size were subsequently injected. The overall cumulative 0.5- 1-, 2-, and 3-year survival rates were 81%, 57%, 31%, and 21%, respectively. Patients with an intact capsule and those with solitary lesions, especially when the tumor diameter was < 5 cm, achieved a higher survival rate. In contrast, incomplete TACE, extrahepatic metastasis, and portal vein thrombosis were associated with the worst outcome. Patients with positive HBsAG and diffuse or multiple tumors also showed a poor outcome. Early diagnosis and early treatment of HCC are the keys for the achievement of better clinical results.

Hepatitis B virus e antigen and primary hepatocellular carcinoma

Serum samples from 243 cases of primary hepatocellular carcinoma (PHC) and 302 non-PHC hospital controls were tested for hepatitis B virus (HBV) surface antigen (HBsAg), antibody to HBsAg (anti-HBs), antibody to HBV core antigen (anti-HBc), HBV e antigen (HBeAg) and antibody to HBeAg (anti-HBe) with radioimmunoassays using commercial kits. A total of 236 (97%) PHC cases and 302 (100%) hospital controls were positive for one or more HBV markers. While 188 (77%) PHC cases and 57 (19%) controls were positive for HBsAg, 44 (18%) PHC cases and 5 (2%) controls were positive for both BHsAg and HBeAg. Statistically significant associations with PHC were observed for HBsAg and HBeAg with an odds ratio (OR) of 10.0 and 3.2, respectively, when age, sex and other markers were adjusted. The stratification analysis of interactive effects of HBV infection markers on the development of PHC showed that HBeAg carrier status may increase PHC risk associated with HBsAg status.

Association between hepatitis C virus antibodies and hepatocellular carcinoma in Taiwan

In order to assess the association between antibodies to hepatitis C virus (anti-HCV) and hepatocellular carcinoma (HCC), as well as the interaction of anti-HCV with other HCC risk factors in Taiwan, a total of 127 pairs of newly diagnosed HCC patients and healthy community controls were studied. Case-control pairs were individually matched for age (+/- 3 years), sex, residence, and ethnicity. Serum samples from study subjects were examined for anti-HCV by enzyme immunoassays as well as hepatitis B surface antigen (HBsAg) and e antigen (HBeAg) by radioimmunoassays using commercial kits. The habits of cigarette smoking, alcohol drinking, and peanut consumption were obtained through standardized interviews according to a structured questionnaire. Both the anti-HCV as well as the carrier status of HBsAg and HBeAg were significantly associated with HCC showing a multivariate-adjusted odds ratio of 24.8 for carriers of HBsAg alone, 33.5 for carriers of both HBsAg and HBeAg, and 23.7 for those who were positive for anti-HCV. The population-attributable risk percentage was estimated as 3% for anti-HCV alone, 69% for HBsAg carrier status alone, and 6% for both anti-HCV and HBsAg in Taiwan. There were also synergistic effects on HCC development for anti-HCV with HBsAg carrier status, cigarette smoking, and habitual alcohol drinking.

[Primary treatment of contaminated syringes and needles in a ward]

Body fluid transmitted viruses become the major enemies of human health. These viruses have been reported as occupational hazards for health care personnel, and they may become environmental hazards as well. We conducted this study to examine the primary treatment of used syringes and needles in a ward, and to evaluate the effects of re-education. For questions such as "The used syringes with bloody contamination should isolated from those without" and "The cover of used needles should not be put back on", we recorded error rates during the 1st one-week observation. A lecture about the standard treatment methods of discarding instruments was given to all nurses in this ward after the 1st observation. The 2nd and 3rd one-week observations were repeated one day and one month after the lecture, respectively. The misclassification rates of discarded syringes were 4.4% (33/758), 1.4% (9/661) and 3.9% (18/616). There was a significant decrease between the 1st and 2nd observations (p less than 0.05), but no significant difference between the 1st and 3rd observations (p greater than 0.05). The rates of covered discarded needles were 50.4% (287/569), 44.3% (198/447) and 38.5% (269/699), respectively. These rates showed a trend to decrease (p less than 0.05). The misclassification rates of discarded syringes were low. Although re-education achieved only temporary effects, self-protective education on not re-covering used needles was effective. However, about 40% of all discarded syringes were still being covered after use. Based on our finding, some improvements have been made in this ward.

Aqueous acupuncture for postoperative pain--a matched controlled trial

The analgesic effects of acupuncture are well-documented. Aqueous acupuncture, or point injection, is a conveniently modified modern acupuncture method. This matched controlled trial was carried out to evaluate the effects of aqueous acupuncture in postoperative pain control. A total of 12 patients were selected as age-, sex- and operative-style-matched controls. In treating group, 2 to 5 ml of 20% glucose solution was injected into Ho-Ku (LI 4) and Yang-Ling-Chuan (GB 34) when patients had regained conciousness from operation anesthesia. The pain intensity were recorded as score system included verbal, sleep disturbance and use of narcotics. In comparisons with the control group, the intensity of postoperative pain, and the amounts and frequency of narcotics used were significantly lower in the study group, especially for the first 12 postoperative hours. Aqueous acupuncture is a convenient and effective procedure in postoperative pain control.

Effects of hepatitis B virus, alcohol drinking, cigarette smoking and familial tendency on hepatocellular carcinoma

Independent and interactive effects related to the development of hepatocellular carcinoma were assessed using a community-based case-control study for hepatitis B virus, habitual alcohol drinking, cigarette smoking, peanut consumption and history of hepatocellular carcinoma among the immediate family. All 200 male newly diagnosed hepatocellular carcinoma patients were recruited consecutively through the period of study as the case group from two teaching medical centers in northern and southern Taiwan. Healthy community residents matched one-to-one with cases on age, sex, ethnic group and residential area were selected as the control group. The carrier status of HBsAg and HBeAg was determined by blind radioimmunoassays, and other risk factors were obtained through standardized interviews according to a structured questionnaire. Conditional logistic regression analysis showed a significant association between hepatocellular carcinoma and the carrier status of HBsAg and HBeAg with an odds ratio of 16.7 and 56.5, respectively, for carriers of HBsAg alone and for carriers of both HBsAg and HBeAg. There was a dose-response relationship between cigarette smoking and hepatocellular carcinoma with an odds ratio of 1.1, 1.5 and 2.6, respectively, for those who smoked 1 to 10, 11 to 20 and more than 20 cigarettes a day. A significant association with hepatocellular carcinoma was also observed for the habitual alcohol consumer with an odds ratio of 3.4. Those whose immediate family had a history of hepatocellular carcinoma were more likely to have the disease develop, with an odds ratio of 4.6. However, the frequency of peanut consumption was not significantly associated with hepatocellular carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal sonographic screening in a single community

A health survey, on adults aged 30 years or more, was carried out at 3 villages on the southwest coast of Taiwan. A total of 923 cases (42.6%) of the 2,166 population participated in the survey. The estimated total population prevalence rates were as follows: no gross lesion (60.5%), fatty liver (25.2%), biliary stone (5.2%), gall bladder polyp (1.9%), hepatic hemangioma (1.4%), liver cyst (0.9%) and renal cyst (2.9%). The prevalence rates of gall bladder polyp and renal cyst were higher in men, while that of fatty liver was higher in women. There was an increase in the prevalence with age for fatty liver in females. The results might be a reference about the above findings among Chinese in Taiwan.

The effect of pitressin and glypressin in variceal bleeding--a preliminary clinical trial

Effects of hemostatic and various side effects were compared between glypressin and pitressin. Fifty-five episodes of esophageal variceal bleeding in 29 patients were studied. Although the glypressin group included more patients in Pugh's classification C than the pitressin group, the result of hemostasis was not influenced. The effect of hemostasis was evaluated in 24 episodes receiving either glypressin or pitressin. The hemostatic effects of glypressin and pitressin were 6/11, 54.5% and 7/13, 53.8% respectively. Eighteen episodes in six patients, with multiple episodes, were used to observe the effect of these two drugs in the same person. No difference was observed. The number of side effects in the glypressin group and the pitressin group were 5 and 10 respectively. Although the side effects of glypressin might be fewer than those of pitressin, chest pain was observed in patients receiving glypressin treatment. The use of glypressin in the patients with cardiac diseases should be studied further. Glypressin is more convenient in clinical use. However, pitressin doses is easily modified. Both drugs might be selected in the control of variceal bleeding.

Risk factors for gallstones among Chinese in Taiwan. A community sonographic survey

A health survey of adults aged 30 years or more was carried out in southwest Taiwan to determine the prevalence of gallstones and to study risk factors associated with gallstones. Blood samples were collected and abdominal sonographic examination and anthropometric measurements were performed on a total of 923 people. The 40 gallstone cases detected resulted in a prevalence of 4.3%. The risk factors explored included age, sex, hepatitis, obesity, hyperlipidemia, and diabetes mellitus (DM). Age and DM were the only significant factors associated with gallstones in our study. With a reference group of 30-39-year-olds as a comparison, multiple logistic regression analysis showed a trend effect with odds ratios of 1.73, 3.74, and 6.32 for age groups of 40-49, 50-59, and 60 or above, respectively. The odds ratio for DM was as high as 2.59. However, sex, body weight index, chronic hepatitis B, and hyperlipidemia were not significantly associated with gallstones.

Time spent and satisfaction of new out-patients in Department of Internal Medicine. Kaohsiung Medical College Hospital

To assess the time spent and the degree of satisfaction of new clinic patients, one hundred and nine new out-patients from the Internal Medicine Clinic of Kaohsiung Medical College Hospital were studied from January 30th to February 6th, 1985. Both accurate field recording and telephone interviews concerning the time spent for each procedure and satisfaction with the medical personnel and expense in their first visits were carried out. The total time spent was 152 +/- 65 minutes (mean +/- SD) from questionnaire and 126 +/- 56 minutes from field recording. According to field recording, time spent in waiting for registration was 39.8 +/- 42.9 minutes. Most (55%) of study patients spent more than one hour in waiting for consultation. The time spent in waiting for filling prescription was 17 +/- 6 minutes. The accessibility of the paramedical examination units was good. The degree of satisfaction was measured by a five point rating scale for series of questions. The response were "very satisfied" or "satisfied" with professional services but not medical expense and cashier attitude. According to our results, some of our attempts to innovate service have been done including an appointment system, colored directional arrowheads, and changing our schedule to opening 30 minutes earlier.

Sequential changes of serum transaminase and abdominal sonography in patients with suspected dengue fever

Southern Taiwan experienced a dengue (type 1) outbreak in the autumn of 1988. One hundred and thirteen febrile patients suspected as having dengue infection were seen in the emergency room of the Kaohsiung Medical College Hospital. These patients were recruited for this study. Two hundred and eighty-six sequential serum aspartate transaminase (AST) and alanine transaminase (ALT) data from these patients were analyzed. Data analysis showed serum AST had increased daily and all data were out of normal range from day 6 of the illness. Compared to the AST level on the first day of the illness, the AST level was noted to elevate to an average of 9.25 folds on day 6. The sequential changes of AST were as follows: AST had elevated since the third ill-day in most cases and reached a peak on the 7th or 8th ill-day. It then declined gradually from the 8th ill-day and became normal about 3 weeks later. The changes of ALT level were about the same as AST but had later onset and lower peak. Abdominal sonographic examinations showed thickening of the gall bladder wall, splenomegaly and ascites in some patients during acute stage of the illness and recovered completely after patients recovered from the dengue attack. The sequential change of serum transaminase levels and sonographic findings were compatible. These findings may be used as a reference for the differential diagnosis among dengue fever, acute hepatitis and acute cholecystitis.

Prediction of fatty liver from serum triglyceride levels and body weight indexes

Fatty liver is a common disease in Taiwan. In this study, we tried to evaluate the validity of predicting the presence of fatty liver from clinical data instead of liver biopsy or sonography. From a community survey in Putai, a total of 873 adults older than 30 years and quantified as to triglyceride level, body height, body weight, and the results of the oral glucose tolerance test and upper abdominal sonography were recruited for analysis. Using a receiver operating characteristic (ROC) curve, the best 'cutoff values' for determination of fatty liver were predicted from body weight index and serum triglyceride level in 8 clusters grouped by sex, age and presence or absence of diabetes mellitus. The best cutoff values of triglyceride in the 8 clusters varied from 100 to 170 mg/dl with worse validity. Most of the values were 130 and 140 mg/dl. The cutoff values of body weight index were constant in all clusters and showed greater validity than those for triglyceride. They were 115% or 120%. Their accuracy for the prediction of fatty liver was positively correlated with its prevalence. However, their accuracy was lower than 70% in non-diabetic females. We conclude that body weight index is a good parameter for prediction of fatty liver especially in the high risk groups and we recommend that health-determining cutoff values of serum triglyceride and body weight index should be set at 130 mg/dl and 115%, respectively.

A case-control study of primary hepatocellular carcinoma in Taiwan

A case-control study was carried out to explore possible risk factors of primary hepatocellular carcinoma (PHC) in Taiwan. One hundred thirty-one PHC patients and 207 hospital control patients were interviewed and blood samples were collected for blood type and hepatitis B virus (HBV) infection marker tests. Eighty-three percent of the PHC patients were found to be hepatitis B surface antigen (HBsAg) positive as compared with 21.0% of the control patients with an odds ratio (OR) of 21.5. Hepatitis B e antigen (HBeAg) positive status increased the risk of PHC. No significant association was observed between erythrocyte genetic markers and PHC, except c of the Rh system, which was significantly lower in the PHC cases. As compared with the control patients, the PHC patients had a higher proportion with a history of liver diseases and more siblings affected with liver diseases. However, the variables such as cigarette smoking, alcohol drinking, peanut consumption, frequent intake of raw fish, heart diseases, peptic ulcer, malaria, hypertension, diabetes, color blindness, G-6-PD deficiency, surgical operation, blood transfusion, and liver diseases of parents and children were not found to be associated with PHC.