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.

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.

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.

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.