Secondary Structural Elements of the HCV X-region Involved in Viral Replication

BACKGROUND AND AIMS

The noncoding regions in the 3'-untranslated region (UTR) of the hepatitis C virus (HCV) genome contain secondary structures that are important for replication. The aim of this study was to identify detailed conformational elements of the X-region involved in HCV replication.

METHODS

Ribonucleic acid (RNA) structural analogs X94, X12, and X12c were constructed to have identical conformation but 94%, 12%, and 0% sequence identity, respectively, to the X region of HCV genotype 2a. Effects of structural analogs on replication of HCV genotypes 1b and 2a HCV RNA were studied by quantitative reverse transcriptase polymerase chain reaction.

RESULTS

In replicon BB7 cells, a constitutive replication model, HCV RNA levels decreased to 55%, 52%, 53%, and 54% after transfection with expression plasmids generating RNA structural analogs 5B-46, X-94, X-12, and X-12c, respectively (p<0.001 for all). In an HCV genotype 2a infection model, RNA analogs 5B-46, X-94, and X-12 in hepatic cells inhibited replication to 11%, 9%, and 12%, respectively. Because the X-12 analog was only 12% identical to the corresponding sequence of HCV genotype 2a, the sequence per se, or antisense effects were unlikely to be involved.

CONCLUSIONS

The data suggest that conformation of secondary structures in 3'-UTR of HCV RNA genome is required for HCV replication. Stable expression of RNA analogs predicted to have identical stem-loop structures might inhibit HCV infection of hepatocytes in liver and may represent a novel approach to design anti-HCV agents.

A review of methotrexate-associated hepatotoxicity

Methotrexate is effective not only in treating psoriasis and rheumatoid arthritis but also various other disorders. The use of methotrexate has been somewhat limited by concerns regarding its adverse effects, including its potential for hepatotoxicity. The purpose of this article is to provide an overview of methotrexate-associated hepatotoxicity, including risk factors, pathogenesis and recommendations for monitoring it by US, UK and European guidelines, as well as providing a brief overview of its mechanism of action and of high-dose methotrexate.

The Molecular and Structural Basis of HBV-resistance to Nucleos(t)ide Analogs

Infection with hepatitis B virus (HBV) is a worldwide health problem. Chronic hepatitis B can lead to fibrosis, liver cirrhosis, and hepatocellular carcinoma (HCC). Management of the latter two conditions often requires liver transplantation. Treatment with conventional interferon or pegylated interferon alpha can clear the virus, but the rates are very low. The likelihood, however, of viral resistance to interferon is minimal. The main problems with this therapy are the frequency and severity of side effects. In contrast, nucleos(t)ide analogs (NAs) have significantly lower side effects, but require long term treatment as sustained virological response rates are extremely low. However, long term treatment with NAs increases the risk for the development of anti-viral drug resistance. Only by understanding the molecular basis of resistance and using agents with multiple sites of action can drugs be designed to optimally prevent the occurrence of HBV antiviral resistance.

Portal serum constituents possible determinants for anatomical localization ofSchistosoma mansoni during maturation and reproduction

Coupled adult pairs ofSchistosoma mansoni were incubated in medium containing either peripheral or portal serum from rat, rabbit, hamster, or man, and egg production was measured daily. In all cases egg production was significantly increased for pairs in the presence of portal sera compared with that in the presence of peripheral sera. Fractionation of rabbit portal serum according to molecular weight demonstrated that the most active component(s) were in the range of 2000 to 50,000. Similarly, a rat portal serum fraction in the range of 2000 to 30,000 molecular weight was most stimulatory. These fractions were as effective in stimulating oviposition as whole portal serum.

CONCLUSIONS

(1) portal serum factor(s) exist that stimulateS. mansoni oviposition in vitro; (2) they are present in susceptible and nonsusceptible hosts; and (3) the molecular weight range for the active components is larger than would be expected for simple carbohydrates, amino acids, or free fatty acids absorbed from the gastrointestinal tract.

Hepatic Sarcoidosis

Sarcoidosis is a multisystem disease characterized by the presence of non-caseating granulomas in affected organs. Pulmonary involvement is the most common site of disease activity. However, hepatic involvement is also common in sarcoidosis, occurring in up to 70% of patients. Most patients with liver involvement are asymptomatic. Therefore, the majority of cases are discovered incidentally, frequently by the finding of elevated liver enzymes. Pain in the right upper quadrant of the abdomen, fatigue, pruritus, and jaundice may be associated with liver involvement. Portal hypertension and cirrhosis are complications linked to long-standing hepatic sarcoidosis. Liver biopsy is usually required to confirm the diagnosis. It is important to differentiate hepatic sarcoidosis from other autoimmune and granulomatous liver diseases. Not all cases of hepatic sarcoidosis require treatment. For symptomatic patients, the first line treatment includes corticosteroids or ursodeoxycholic acid. Various immunosuppressant agents can be used as second line agents. Rarely, severe cases require liver transplantation.

An ironic case of liver infections: Yersinia enterocolitis in the setting of thalassemia

A 49 years old Vietnamese male with a history of thalassemia, presented with gastrointestinal symptoms and signs of hemolysis. He was diagnosed with yersinia enterocolitis. Yersinia is a gram-negative rod that most frequently occurs in children especially during the winter months. In the current case, the bone marrow biopsy showed hemophagocytosis along with positive cultures for Yersinia. The microorganism likely triggered hemophagocytosis. This syndrome, also known as, hemophagocytic lymphohistiocytosis, is defined by fever for more than 7 d, cytopenia of two or more cell lines, hemophagocytosis, hepatitis, serum ferritin greater than 500, jaundice, lymphadenopathy, and hepatosplenomegaly. This disorder can be either familial or secondary to a strong immunologic activation. Both have an overwhelming activation of T-cells and macrophages.

Update on the Development of Anti-Viral Agents Against Hepatitis C

Hepatitis C virus (HCV) infects nearly 170 million people worldwide and causes chronic hepatitis, cirrhosis, and hepatocellular carcinoma. The search for a drug regimen that maximizes efficacy and minimizes side effects is quickly evolving. This review will discuss a wide range of drug targets currently in all phases of development for the treatment of HCV. Direct data from agents in phase III/IV clinical trials will be presented, along with reported side-effect profiles. The mechanism of action of all treatments and resistance issues are highlighted. Special attention is given to available trial data supporting interferon-free treatment regimens. HCV has become an increasingly important public health concern, and it is important for physicians to stay up to date on the rapidly growing novel therapeutic options.

Sessile serrated adenomas in the proximal colon are likely to be flat, large and occur in smokers

AIM: To examine the epidemiology and the morphology of the proximal sessile serrated adenomas (SSAs).

METHODS: We conducted a retrospective study to identify patients with SSAs using a university-based hospital pathology database query from January 2007 to April 2011. Data collected included: age, gender, ethnicity, body mass index, diabetes, smoking, family history of colorectal cancer, aspirin, and statin use. We collected data on morphology of SSAs including site (proximal or distal), size, and endoscopic appearance (flat or protuberant). We also compared proximal SSAs to proximal tubular adenomas detected during same time period.

RESULTS: One hundred and twenty patients with SSAs were identified: 61% were distal and 39% were proximal SSAs. Proximal SSAs were more likely to be flat than distal (100% vs 78% respectively; P = 0.0001). Proximal SSAs were more likely to occur in smokers (OR = 2.63; 95%CI: 1.17-5.90; P = 0.02) and in patients with family history of colorectal cancer (OR = 4.72; 95%CI: 1.43-15.55; P = 0.01) compared to distal. Proximal SSAs were statistically more likely to be ≥ 6 mm in size (OR = 2.94; P = 0.008), and also more likely to be large (≥ 1 cm) (OR = 4.55; P = 0.0005) compared to the distal lesions. Smokers were more likely to have proximal (P = 0.02), flat (P = 0.01) and large (P = 0.007) SSAs compared to non-smokers. Compared to proximal tubular adenomas, proximal SSAs were more likely to be large and occur in smokers.

CONCLUSION: Proximal SSAs which accounted for two-fifths of all SSAs were more likely to present as flat lesions, larger SSAs, and were more likely to occur in smokers and in patients with family history of colorectal cancer. Our data has implications for colorectal cancer screening.

Sessile serrated adenomas in the proximal colon are likely to be flat, large and occur in smokers

AIM

To examine the epidemiology and the morphology of the proximal sessile serrated adenomas (SSAs).

METHODS

We conducted a retrospective study to identify patients with SSAs using a university-based hospital pathology database query from January 2007 to April 2011. Data collected included: age, gender, ethnicity, body mass index, diabetes, smoking, family history of colorectal cancer, aspirin, and statin use. We collected data on morphology of SSAs including site (proximal or distal), size, and endoscopic appearance (flat or protuberant). We also compared proximal SSAs to proximal tubular adenomas detected during same time period.

RESULTS

One hundred and twenty patients with SSAs were identified: 61% were distal and 39% were proximal SSAs. Proximal SSAs were more likely to be flat than distal (100% vs 78% respectively; P = 0.0001). Proximal SSAs were more likely to occur in smokers (OR = 2.63; 95%CI: 1.17-5.90; P = 0.02) and in patients with family history of colorectal cancer (OR = 4.72; 95%CI: 1.43-15.55; P = 0.01) compared to distal. Proximal SSAs were statistically more likely to be ≥ 6 mm in size (OR = 2.94; P = 0.008), and also more likely to be large (≥ 1 cm) (OR = 4.55; P = 0.0005) compared to the distal lesions. Smokers were more likely to have proximal (P = 0.02), flat (P = 0.01) and large (P = 0.007) SSAs compared to non-smokers. Compared to proximal tubular adenomas, proximal SSAs were more likely to be large and occur in smokers.

CONCLUSION

Proximal SSAs which accounted for two-fifths of all SSAs were more likely to present as flat lesions, larger SSAs, and were more likely to occur in smokers and in patients with family history of colorectal cancer. Our data has implications for colorectal cancer screening.

Pharmacogenetic selection of transplanted human hepatocytes in immunocompetent rats

OBJECTIVE

To introduce a genetic survival advantage for transplanted human hepatocytes over host cells in rats.

METHODS

Green fluorescent protein (GFP) was introduced into Huh-7 human hepatoma cells to create fluorescent GFP-Huh-7 cells. mRNA of CYP2E1, the enzyme that converts acetaminophen (APA) into hepatotoxic intermediates, was quantified by real-time polymerase chain reaction (PCR). The effects of APA on GFP-Huh-7 and control Huh-7 cells were determined in a cell culture. Immunological tolerance was induced by the injection of GFP-Huh-7 cells into fetal rats in utero. The GFP-Huh-7 cells were transplanted after birth of the rats into tolerant rats followed by APA treatment. Serum alanine aminotransferase (ALT) levels and liver histological data were obtained. GFP-Huh-7 cells were detected by quantitive PCR and microscopy.

RESULTS

CYP2E1 mRNA levels in the GFP-Huh-7 cells were 2.7% of parental Huh-7 cells. In 1 mmol/L APA, parental Huh-7 cells decreased by 60% while GFP-Huh-7 cells increased to within 95% of untreated controls after 5 days. In rats in which GFP-Huh-7 cells were transplanted and treated with APA, serum ALT increased to a peak of 200 U/L on day 1 and returned to normal levels by day 3. Fluorescence microscopy of liver specimens from rats transplanted with GFP-Huh-7 cells showed substantial increases in GFP-Huh-7, but not Huh-7 cells by day 7 after APA treatment. Real-time PCR confirmed a 10-fold increase of GFP mRNA in APA-treated rats, but not in those without APA treatment.

CONCLUSIONS

The difference in CYP2E1 gene expression between GFP-Huh-7 and rat hepatocytes provides a convenient means for the enrichment of transplanted human cells in rat liver.

Animal models for the study of hepatitis C virus infection and replication

Hepatitis C virus (HCV) hepatitis, initially termed non-A, non-B hepatitis, has become one of the leading causes of cirrhosis and hepatocellular carcinoma worldwide. With the help of animal models, our understanding of the virus has grown substantially from the time of initial discovery. There is a paucity of available animal models for the study of HCV, mainly because of the selective susceptibility limited to humans and primates. Recent work has focused modification of animals to permit HCV entry, replication and transmission. In this review, we highlight the currently available models for the study of HCV including chimpanzees, tupaia, mouse and rat models. Discussion will include methods of model design as well as the advantages and disadvantages of each model. Particular focus is dedicated to knowledge of pathophysiologic mechanisms of HCV infection that have been elucidated through animal studies. Research within animal models is critically important to establish a complete understanding of HCV infection, which will ultimately form the basis for future treatments and prevention of disease.

Rare synchronous primary large B-cell gastric lymphoma and huge retroperitoneal liposarcoma with inguinal hernia in chronic hepatitis B patient

Multiple primary neoplasms with synchronous or metachronous presentation are rare, although the incidence has recently increased because of several factors. We present the case of a 53-year-old patient with chronic hepatitis B who presented with abdominal mass, mild abdominal pain, and inguinal hernia. Computed tomography imaging demonstrated diffuse thickening of the gastric antral wall, together with a huge heterogeneous abdominal mass with predominant fat attenuation with septa that showed mild enhancement on contrast-enhanced scans. Distal gastrectomy and wide resection of the retroperitoneal mass was performed. Pathology exam led to a diagnosis of diffuse large B-cell gastric lymphoma with retroperitoneal liposarcoma. This is a rare case of a primary gastric lymphoma with another primary (sarcomatous) malignancy occurring synchronously in same patient.

The presence and expression of the hepatitis B virus in human oocytes and embryos

BACKGROUND

The objective of this study was to explore the potential for vertical transmission of hepatitis B virus (HBV) from parents to offspring via human germ cells.

METHODS

For study samples, 250 oocytes from hepatitis B surface antigen (HBsAg) seropositive women and 578 embryos from couples with at least one HBsAg seropositive partner were collected. HBV DNA in the nuclei of oocytes and embryos was detected by fluorescence in situ hybridization; HBsAg expression was analysed using immunofluorescence; and serum HBV DNA levels were measured by real-time PCR. The HBV infection duration of the women and the serum HBsAg status of their mothers were also examined.

RESULTS

HBV DNA was present in 9.6% (24/250) of oocytes and 14.4% (83/578) of embryos. Rates of HBV DNA positive embryos were similar among couples in which the woman, man or both partners were HBsAg seropositive, 13.1% (57/436), 21.3% (16/75) and 14.9% (10/67), respectively. Rates of positivity in oocytes and embryos were significantly higher in a group with high serum levels HBV DNA than in a group with lower serum levels (P= 0.004 and P= 0.002, respectively). Higher rates of oocyte positivity were found for women whose mothers were HBV infected compared with those with uninfected mothers. Expression of HBsAg was observed in 8.7% (2/28) oocytes and 14.1% (10/71) embryos (P= 0.34).

CONCLUSIONS

The presence of HBV DNA in human oocytes or embryos was related to the women's serum levels of HBV DNA and the infection status of their mothers. The HBV positive embryos were either maternally or paternally dependent. HBV infection may result in vertical transmission to the offspring via germ cells.

Soybean-derived beta-conglycinin affects proteome expression in pig intestinal cells in vivo and in vitro

It is well known that β-conglycinin, a soybean allergen, induces allergies and causes intestinal damage in fetuses and neonates. However, the underlying mechanisms responsible for the adverse effects of β-conglycinin remain elusive. In particular, it is unknown whether or not this dietary substance causes direct damage affecting the proliferation and integrity of intestinal cells. This study evaluated the effect of different concentrations of β-conglycinin (0 to 1,500 µg/mL) and the duration of culture (48 or 72 h) on the proliferation and proteome of porcine intestinal epithelial cells. Eight individually housed piglets (10 d old; initial BW, 3.79 ± 0.07 kg) were randomly divided into 2 groups (n = 4) and challenged with or without β-conglycinin via oral administration d 10 through 28. After the last administration of β-conglycinin or PBS, piglets were killed and jejuna mucosal samples were collected for proteomic analysis. Supplementing β-conglycinin to either culture medium or weanling pigs increased (P < 0.05) the expression of proteins related to apoptosis, stress, and inflammation, but decreased (P < 0.05) the expression of proteins related to cytoskeleton and nucleus replication in intestinal cells. Further analysis confirmed an increase in caspase-3 expression in the cells exposed to β-conglycinin in vivo and in vitro. Collectively, these novel results indicate that β-conglycinin directly induces intestinal damage by depressing intestinal-cell growth, damaging the cytoskeleton, and causing apoptosis in the piglet intestine.

Effects of PEG-interferon-alpha-2A on Schistosoma mansoni infection in mice

In some regions of the world, co-existence of schistosomiasis and hepatitis C (HCV) infection is common. Because the morbidity in human schistosomiasis is primarily due to host cell-mediated immune response, it was of interest to determine the effects on Schistosoma mansoni infection of an immune stimulator used in the standard treatment of HCV infection. Schistosoma mansoni -infected mice were treated with PEG-interferon-alpha-2a (PEG-IFN-alpha) by subcutaneous injection. Groups 1, 2, and 3 received 0.2 microg, 0.6 microg, and 1 microg PEG-IFN-alpha/wk, respectively, while group 4 received saline. The total worm burden was lower in all treated groups, with a maximal reduction of 35% after 9 wk of treatment with 1 microg PEG-IFN-alpha. Interferon treatment also increased the proportion of single worms over pairs. Ova counts in intestine and liver, as well as the number of liver granulomas, were greatly decreased at all time points for all treated groups. PEG-IFN-alpha also had inhibitory effects on the size of granulomas after 4 wk of treatment. The results suggest that PEG-IFN-alpha may be worth investigating for the treatment of human schistosomiasis when standard oral agents cannot be used, or when rapid inhibition of granuloma formation may be a priority.

Gene therapy for metabolic diseases of the liver

Significant advances have been made in the field of liver-directed gene therapy. Many diseases are potential targets for gene therapy, including diseases that have exclusive liver involvement and those with systemic manifestations as a result of defective protein synthesis from the liver. Examples are Crigler-Najjar syndrome type 1, alpha(1)-antitrypsin deficiency and haemophilia A and B. Strategies for gene delivery include the use of viral and nonviral vectors. In addition to previously developed viral vectors, such as retroviruses, adenoviruses and adeno-associated viruses, new viral vectors such as lentiviruses are being investigated extensively. Nonviral vectors for gene delivery include liposomes and receptor-mediated gene therapy. A strategy to correct gene defects has been developed using chimaeric RNA/DNA oligonucleotides, and methods to inhibit aberrant or deleterious gene expression using ribozymes, antisense oligonucleotides and dominant-negative gene products are being developed. However, more research focusing on more efficient gene expression and safety will be required before gene therapy can be routinely applicable.

Inhibition of hepatitis C virus replication by single-stranded RNA structural mimics

AIM: To examine the effect of hepatitis C virus (HCV) structural mimics of regulatory regions of the genome on HCV replication.

METHODS: HCV RNA structural mimics were constructed and tested in a HCV genotype 1b aBB7 replicon, and a Japanese fulminant hepatitis-1 (JFH-1) HCV genotype 2a infection model. All sequences were computer-predicted to adopt stem-loop structures identical to the corresponding elements in full-length viral RNA. Huh7.5 cells bearing the BB7 replicon or infected with JFH-1 virus were transfected with expression vectors generating HCV mimics and controls. Cellular HCV RNA and protein levels were quantified by real-time polymerase chain reaction and Western blotting, respectively. To evaluate possible antisense effects, complementary RNAs spanning a mimic were prepared.

RESULTS: In the BB7 genotype 1b replicon system, mimics of the polymerase (NS-5B), X and BA regions inhibited replication by more than 90%, 50%, and 60%, respectively. In the JFH-1 genotype 2 infection system, mimics that were only 74% and 46% identical in sequence relative to the corresponding region in JFH-1 inhibited HCV replication by 91.5% and 91.2%, respectively, as effectively as a mimic with complete identity to HCV genotype 2a. The inhibitory effects were confirmed by NS3 protein levels. Antisense RNA molecules spanning the 74% identical mimic had no significant effects.

CONCLUSION: HCV RNA structural mimics can inhibit HCV RNA replication in replicon and infectious HCV systems and do so independent of close sequence identity with the target.

Differential composition of proteomes in sow colostrum and milk from anterior and posterior mammary glands

Piglets obtaining milk from anterior and middle mammary glands (MG) grow faster than those suckling posterior MG, but the underlying mechanisms are not clear. The purpose of this study was to investigate the differential proteomes of colostrum and milk secreted by anterior and posterior MG. Six healthy primiparous sows with 7 pairs of MG were used; the first and the second pairs were defined as anterior MG and the sixth and seventh pairs as posterior MG. Colostrum and milk were collected at d 1 and 14 after parturition, respectively. Comparative proteomics analysis was performed to identify the differentially expressed proteins in colostrum and milk secreted by anterior and posterior MG. Results show that protein composition in colostrum and milk varied markedly with the anatomical location of MG. Immunoglobulins, lactadherin, and haptoglobin were upregulated (P < 0.05) in colostrum from anterior MG compared with posterior MG. Concentrations of immunoglobulins and lactoferrin in milk from anterior MG were greater (P < 0.05) than milk from posterior MG. Moreover, concentration of proteins from somatic cells was greater (P < 0.05) in milk from posterior MG compared with anterior MG. Most proteins, in which abundance was upregulated in colostrum and milk from anterior MG, contribute to passive immunity, intestinal development of suckling piglets and epithelial integrity, and the health of MG. Collectively, these results indicate that in comparison with posterior MG, anterior MG are more active in protein synthesis and produce more immunoglobulins and lactoferrin in colostrum and milk.

Eosinophilic digestive diseases: eosinophilic esophagitis, gastroenteritis, and colitis

Eosinophilic digestive diseases (EDD) are relatively rare disorders associated with increased gastrointestinal eosinophilic infiltrates without any underlying primary etiology. The pathophysiology of EDD is unclear, but is suspected to be related to a hypersensitivity reaction given its correlation with other atopic disorders and clinical response to corticosteroid therapy. Given the overall relative increase of various atopic conditions, it is important for clinicians to understand the presentation and diagnosis and treatment options available. We present here a review of EDD, including the proposed pathophysiology, diagnosis and current treatment options for these disorders.

Nonalcoholic fatty liver disease and low-carbohydrate diets

Nonalcoholic fatty liver disease (NAFLD) is associated with insulin resistance, obesity, and other features of metabolic syndrome and is known to be the most common cause for abnormal liver enzymes. The recent surge in the number of patients with NAFLD has been accompanied by an increase in research on potential treatment options, particularly weight loss and dietary interventions. Given the growing interest on the role of carbohydrates in the prevention and treatment of NAFLD, this review discusses the relationship between the amount of carbohydrates in the diet and effects on NAFLD, with special emphasis on a low-carbohydrate diet. We discuss the role of insulin resistance in the pathophysiology of NAFLD and provide an overview of various popular diets and their role as a treatment option for NAFLD. Additional large, longer-duration trials studying the efficacy of a low-carbohydrate diet in the treatment and prevention of NAFLD are eagerly awaited.

Prospects for future therapy of HCV infection

Worldwide, HCV infection is a major cause of chronic liver disease and hepatocellular carcinoma and is often refractory to current antiviral treatments. The most effective therapy, pegylated interferon plus ribavirin, unfortunately eliminates virus only in approximately half of patients treated and is frequently poorly tolerated. The recent development of in vitro and in vivo HCV infection and replication models has resulted in breakthroughs in basic research toward the development of new antiviral agents. Currently, many therapeutic agents with different mechanisms of action are under development, and several are in late-phase clinical trials. Some of these drugs have shown promise when used in combination with the standard peginterferon and ribavirin, and others could constitute tablet-based combination therapies without standard therapy. This article reviews the current status of drug development, ongoing clinical trials and future perspectives in the field of HCV therapeutics.

Non-alcoholic steatohepatitis: an overview

Non-alcoholic fatty liver disease (NAFLD) includes a broad spectrum of fat-induced liver injury, ranging from mild steatosis to cirrhosis and liver failure. The presence of obesity and insulin resistance is strongly associated with non-alcoholic fatty liver and a greater risk of advanced disease. We present here a review of the mechanisms involved in the pathogenesis of NAFLD, advances in the diagnosis, and options for treatment.

The use of surrogate vascular markers in youth at risk for premature cardiovascular disease

Premature cardiovascular disease (CVD) begins in youth--a crucial period when modification of the disease may have the greatest impact. Failure to diagnose preclinical CVD at this stage misses a major opportunity to prevent the long-term consequences of this disease. An array of surrogate vascular markers (SVMs) are now available that can determine the extent of preclinical vascular injury in the pediatric population. These SVMs include flow-mediated vasodilatation, carotid intima media thickness, arterial stiffness, and biomarkers including high sensitivity C-reactive protein, cell adhesion molecules and methylarginines. We believe that the use of these SVMs will help to develop a better understanding of early pathological vascular changes in youth, facilitate earlier diagnosis of preclinical atherosclerosis and provide an objective measure of the vascular effects of any therapeutic intervention aimed at risk factor modification. Ultimately, our future health will depend on carefully balancing the benefits of early diagnosis and treatment in high-risk youth with the long-term risk of CVD. The application of SVMs in the pediatric population will help us achieve this balance.