Resolution of refractory hepatic hydrothorax after chemical pleurodesis with minocycline

Management of refractory hepatic hydrothorax is a challenge to physicians in clinical practice. We reported two patients with hepatic hydrothorax, non-alcoholic cirrhosis and rapidly recurring pleural effusion. They failed to improve with diuretics and repeated thoracentesis. Refractory hepatic hydrothorax was successfully treated by minocycline-induced pleural symphysis. After pleurodesis, ventilatory function returned to normal in both patients. No recurrence of pleural effusion was noted. We suggest that minocycline pleurodesis is an alternative treatment for refractory hepatic hydrothorax because it is simple, safe and effective.

Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers

BACKGROUND

After endoscopic treatment of bleeding peptic ulcers, bleeding recurs in 15 to 20 percent of patients.

METHODS

We assessed whether the use of a high dose of a proton-pump inhibitor would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Patients with actively bleeding ulcers or ulcers with nonbleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive omeprazole (given as a bolus intravenous injection of 80 mg followed by an infusion of 8 mg per hour for 72 hours) or placebo. After the infusion, all patients were given 20 mg of omeprazole orally per day for eight weeks. The primary end point was recurrent bleeding within 30 days after endoscopy.

RESULTS

We enrolled 240 patients, 120 in each group. Bleeding recurred within 30 days in 8 patients (6.7 percent) in the omeprazole group, as compared with 27 (22.5 percent) in the placebo group (hazard ratio, 3.9; 95 percent confidence interval, 1.7 to 9.0). Most episodes of recurrent bleeding occurred during the first three days, which made up the infusion period (5 in the omeprazole group and 24 in the placebo group, P<0.001). Three patients in the omeprazole group and nine in the placebo group underwent surgery (P=0.14). Five patients (4.2 percent) in the omeprazole group and 12 (10 percent) in the placebo group died within 30 days after endoscopy (P=0.13).

CONCLUSIONS

After endoscopic treatment of bleeding peptic ulcers, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding.

Correlation of neurological manifestations and MR images in a patient with Wilson's disease after liver transplantation

Orthotopic liver transplantation (OLT) has been applied to patients with Wilson's disease (WD) for correction of irreversible liver cirrhosis. However, the neurological outcome and the correlation between clinical manifestations and neuroimage findings after OLT remain uncertain. We present a WD patient who showed an improvement in both liver functions and neurological manifestations after OLT. Serum levels of ceruloplasmin and copper returned to normal rapidly after the operation. His ataxic gait was improved 5 months later and dysmetria and tremor disappeared 11 months later. The high signal intensities on T2-weighted brain magnetic resonance images regressed at bilateral thalami 5 months later and disappeared in bilateral thalami and red nuclei 16 months after OLT. We conclude that the neurological improvement could be expected in WD patients after OLT. The improvement was correlated with the MRI changes in red nuclei and bilateral thalami.

Quantitative PET scan findings in carbon monoxide poisoning: deficits seen in a matched pair

Quantitative positron emission tomography (PET) was utilized to establish the degree and localization of central nervous system dysfunction in 2 adult patients 3 years status postchronic carbon monoxide poisoning. The individual PET scans were compared against a composite scan made up of 32 normals using a z transformation statistical parametric map. Neuropsychological findings indicated marked anterior frontal lobe syndrome in the context of far-above-average intelligence, memory, and language. They also showed manifest frontal symptoms in activities of daily living that resulted in vocational disability in each case. PET analysis revealed substantially decreased metabolism in the orbitofrontal and dorsolateral prefrontal cortex as well as in areas of the temporal lobe for each individual. Individual scans were very similar and consistent with patient's presenting symptoms, and changed life circumstances. This report represents the first quantitative functional neuroimaging study relevant to carbon monoxide poisoning.

The genetic basis of cardiac function: dissection by zebrafish (Danio rerio) screens

The vertebrate heart differs from chordate ancestors both structurally and functionally. Genetic units of form, termed 'modules', are identifiable by mutation, both in zebrafish and mouse, and correspond to features recently acquired in evolution, such as the ventricular chamber or endothelial lining of the vessels and heart. Zebrafish (Danio rerio) genetic screens have provided a reasonably inclusive set of such genes. Normal cardiac function may also be disrupted by single-gene mutations in zebrafish. Individual mutations may perturb contractility or rhythm generation. The zebrafish mutations which principally disturb cardiac contractility fall into two broad phenotypic categories, 'dilated' and 'hypertrophic'. Interestingly, these correspond to the two primary types of heart failure in humans. These disorders of early cardiac function provide candidate genes to be examined in complex human heart diseases, including arrhythmias and heart failure.

Correlation of intellectual impairment in Parkinson's disease with FDG PET scan

This study investigated the relationship between regional glucose metabolism with intellectual impairment in patients with Parkinson's disease using statistical parametric mapping. Regional cerebral glucose metabolism using [18F]deoxyglucose (FDG) PET scans were performed on 10 patients with Parkinson's disease. We used the intellectual impairment score from the UPDRS. PET scans were analyzed with SPM96. Patients showed significant positive correlations with left limbic structures such as the cingulate gyrus, parahippocampal gyrus, and medial frontal gyrus. Patients showed significant negative correlations with associative neocortical posterior structures such as bilateral parietal and occipital gyrus. There were significant relationships between regional glucose metabolism and intellectual impairment.

DNA-Based immunization produces Th1 immune responses to hepatitis delta virus in a mouse model

Hepatitis delta virus (HDV) superinfection is one of the major causes of fulminant hepatitis in endemic areas of hepatitis B virus (HBV) infection. Currently, there is no effective treatment or vaccine against HDV superinfection. DNA-based immunization is a promising antiviral strategy to prevent or treat persistent viral infections. In this study, we investigated the immunological effects of DNA vaccines against HDV in BALB/c mice. Plasmid (pD) encoding large hepatitis D antigen (L-HDAg), or plasmid (pS/pD) coexpressing hepatitis B surface antigen (HBsAg) and L-HDAg, were injected into mice intramuscularly. The seroconversion rate, anti-HBs levels, anti-HDV titers, T-cell proliferation responses, and T-helper (Th)-release cytokine profiles were analyzed. Mice immunized with plasmids, pS/pD or pD, produced low, but significant, titers of anti-HDV antibodies. In contrast, pS/pD induced much stronger anti-HBs titers in the immunized animals. Interestingly, splenic lymphocytes derived from pS/pD-inoculated mice demonstrated significant proliferation responses to recombinant HBsAg and HDAg, and resulted in a Th1-like immune response as suggested by the production of interferon gamma (INF-gamma) and interleukin-2 (IL-2), but not IL-4. The splenic lymphocyte derived from the pD-inoculated mice showed a similar Th1 response to the stimulation of HDAg, but not to HBsAg. In conclusion, our results suggest that DNA vaccines against HDV can induce significant cellular immune responses with a Th1 preference. HBV and HDV coimmunization can be performed by DNA vaccines. These results are promising for the future development of prophylactic and therapeutic HDV vaccines.

Clinical, virologic and pathologic significance of elevated serum gamma-glutamyl transpeptidase in patients with chronic hepatitis C

BACKGROUND

Elevated serum gamma-glutamyl transpeptidase (GGT) is often seen in patients with chronic hepatitis C virus (HCV) infection and is associated with a poor response to interferon treatment. The pathogenesis of these phenomena is unclear. Therefore, we assessed the prevalence of elevated serum GGT in Chinese patients with chronic hepatitis C and evaluated the clinical, biochemical, virologic and histologic features of this phenomenon.

METHODS

One hundred and twelve patients with biopsy-proven chronic hepatitis C were enrolled. Patients who were habitual alcohol drinkers, alcoholics or had diabetes mellitus were excluded.

RESULTS

Forty-three (38.4%) of 112 patients had elevated serum GGT (> 60 U/l). Patients with elevated serum GGT had significantly higher serum levels of alanine and aspartate aminotransferases, alkaline phosphatase and total bilirubin, significantly higher histologic scores of liver lobular necro-inflammation and fibrosis when compared to patients with normal serum GGT. Elevated serum GGT was not correlated to serum HCV RNA titer or HCV genotype. Multivariate logistic regression analysis showed that a histologic fibrotic score > or = 2 was the only significantly independent predictor associated with elevated serum GGT. Fifty-seven of 112 patients completed a six-month course of interferon treatment. Patients with elevated serum GGT had a significantly lower sustained response rate to interferon when compared to patients with normal serum GGT (8% vs 30%, p = 0.042).

CONCLUSIONS

Elevated serum GGT in chronic hepatitis C patients was frequently associated with more severe hepatic fibrosis or cirrhosis and may, in part, account for poor response to interferon therapy.

Overexpression of a Zebrafish ARNT2-like Factor Represses CYP1A Transcription in ZLE Cells

Aryl hydrocarbon receptor nuclear translocator (ARNT) factors belong to a novel basic-helix-loop-helix-PAS (bHLH-PAS) transcription factor family that controls a variety of physiological and developmental processes. In a previous study, we obtained a partial complementary DNA fragment of an ARNT2-like factor from zebrafish embryo, liver, and other tissues by reverse transcription-polymerase chain reaction. In an effort to characterize the function of this factor, we screened an embryonic complementary DNA library and obtained a complete cDNA of this ARNT2-like factor, zARNT2A. The deduced protein sequence of zARNT2A encompasses the basic-helix-loop-helix and PAS-A/B motifs and shares highest sequence similarity with the amino-terminal half of mouse ARNT2 factor. However, it lacks a carboxy-terminal transactivation motif following the PAS-A/B motifs. Transient expression of zARNT2A in cultured cells resulted in repression of TCDD-dependent CYP1A transcription. Whole-mount in situ hybridization revealed that zARNT2A is expressed in brain and pronephros at prime-5 stages. In adult fish, zARNT2A messenger RNA is transcribed in a wide range of tissues, which indicates that zARNT2A and its corresponding signal transduction mechanisms have important roles in fish development and other physiological aspects.

Shark cartilage extract interferes with cell adhesion and induces reorganization of focal adhesions in cultured endothelial cells

In this study, we examined the effects of shark cartilage extract on the attachment and spreading properties and the focal adhesion structure of cultured bovine pulmonary artery endothelial cells. Treatment with cartilage extract resulted in cell detachment from the substratum. Immunofluorescence staining of those treated cells that remained attached showed that, instead of being present in both central and peripheral focal adhesions as in control cells, both integrin alpha(v)beta(3) and vinculin were found only in peripheral focal adhesion and thinner actin filament bundles were seen. In addition to causing cell detachment, cartilage extract partially inhibited the initial adherence of the cells to the substratum in a dose-dependent manner. Integrin alpha(v)beta(3) and vinculin staining of these cells also showed a peripheral focal adhesion distribution pattern. Vitronectin induced cell spreading in the absence of serum, but was blocked by simultaneous incubation with cartilage extract, which was shown to inhibit both integrin alpha(v)beta(3) and vinculin recruitment to focal adhesion and the formation of stress fibers. Dot binding assays showed that these inhibitory effects on cell attachment and spreading were not due to direct binding of cartilage extract components to integrin alpha(v)beta(3) or vitronectin. Shark cartilage chondroitin sulfate had no inhibitory effect on either cell attachment or spreading of endothelial cells. These results show that the inhibitory effects of cartilage extract on cell attachment and spreading are mediated by modification of the organization of focal adhesion proteins.

Characterization of a strain-specific monoclonal antibody to hepatitis delta virus antigen

Sequences of the hepatitis delta virus (HDV) vary to different degrees among isolates. A monoclonal antibody, designated as HP6A1, against the antigen of HDV (HDAg) has been characterized for its specificity. HP6A1 bound to HDAg of isolate 25 (genotype I) that was used for immunization, but not to others of both genotypes I and II. The epitope recognized by HP6A1 was then determined by a phage library displaying various heptapeptides. A consensus peptide deduced has the best match with that of residues 4-10 of HDAg (isolate 25). To confirm the phage mapping result, Escherichia coli recombinant proteins containing different lengths and various segments of HDAg (isolate 25) were constructed. The shortest HDAg segment contained in the fusion protein that reacted with HP6A1 was residues 1-10. When this peptide was added to the N-terminus of a heterologous protein engineered for eucaryotic expression, the fusion protein was detected by HP6A1. It is concluded that HP6A1 recognizes an epitope located at the N-terminus of HDAg (isolate 25). Since viruses of quasi-species exist in natural infections, a question of how different viral strains interact in vivo remains to be explored. The highly specific MAb opens a possibility to examine the fate of one strain in the presence of other related species in a cell transfection system.

Factors predictive of liver cirrhosis in patients with chronic hepatitis B: a multivariate analysis in a longitudinal study

OBJECTIVE AND DESIGN

Chronic hepatitis B virus (HBV) infection may lead to liver cirrhosis; however, factors associated with the development of cirrhosis have been incompletely studied. A total of 516 patients with chronic hepatitis B were followed up longitudinally to determine their outcome.

METHODS

The clinical and pathological features were compared between those with and without cirrhosis occurrence. The risk factors were analysed, and the probability of the development of cirrhosis was estimated.

RESULTS

During a mean follow-up period of 5.7 +/- 3.4 years (range 1-17 years), cirrhosis occurred in 71 patients, with a calculated annual incidence of 2.4%. Older age (> 45 years) at entry, male gender, persistent hepatitis (> 1.5-fold rise of serum alanine aminotransferase levels for at least one year) and diabetes mellitus were identified as independent risk factors of cirrhosis in a multivariate analysis (odds ratios 8.0, 19.3, 2.0 and 5.2, respectively; P values all < 0.05). A logistic regression equation was used to predict the probability of cirrhosis occurrence, which was as high as 76.6% when all risk factors were present. Acute exacerbation or super-infection by hepatitis C or D viruses were not significant predictors. Patients with subsequent cirrhosis had higher initial hepatic histological necro-inflammatory activities when compared to age- and sex-matched non-cirrhotic controls (Knodell's scores: 8.2 +/- 2.4 versus 6.0 +/- 4.1, P< 0.05).

CONCLUSIONS

Patients who were elderly, male, diabetic or had a history of persistent and histologically severe hepatitis were at increased risks of liver cirrhosis. Aggressive anti-viral therapy may be needed for these patients and they should be closely monitored for HBV-related late complications.

Prospective case-controlled trial of adjuvant chemotherapy after resection of hepatocellular carcinoma

Recurrence of hepatocellular carcinoma (HCC) after curative hepatic resection is frequent and is an important factor adversely influencing long-term survival. The role of postoperative chemotherapy in the reduction of tumor recurrence rate is still controversial. During the period of 1992-1995 a series of 49 patients who underwent curative resection of HCC and had at least one risk factor of tumor recurrence were followed in this prospective study. Patients were allocated to adjuvant chemotherapy and control groups. Twenty-four patients received a combination of low dose intravenous epirubicin (20 mg/m2) and mitomycin (5 mg) monthly for seven courses starting 5 to 6 weeks after surgery. Twenty-five patients had no adjuvant treatment. The disease-free and overall survivals were compared for the two groups. A total of 154 courses of chemotherapy were given to the 24 patients. The chemotherapy-related side effects were mild and tolerable with no mortality. At a median follow-up of 39 months (range 9-71 months), 9 patients in the adjuvant chemotherapy group and 16 patients in the control group developed tumor recurrence. The respective 1-, 2-, 3-, and 5-year disease-free survival rates were 75%, 67%, 63%, and 63% for patients in the adjuvant chemotherapy group and 68%, 42%, 37%, and 32% for patients in the control group (p = 0.0575). The 1-, 2-, 3-, and 5-year overall survival rates were 100%, 96%, 77%, and 72% in the adjuvant chemotherapy group and 92%, 67%, 63%, and 51% in the control group (p = 0.0746). In conclusion, postoperative adjuvant chemotherapy using the present regimen has a tendency to reduce tumor recurrence rate and may improve long-term survival for high risk patients.

Preferentially deleted chromosome region 9p21 in large hepatocellular carcinomas

The role of somatic deletions in chromosome 9 and chromosome 22 loci in hepatocellular carcinomas (HCC) was studied. Twenty-one paired HCC and adjacent tumor-free liver tissue samples were examined for loss of heterozygosity at six chromosome 9 and ten chromosome 22 loci. Among informative cases, the highest LOH rates were observed at 9p21 (40% or 4/10 at IFNA) and 9q23 (23% or 3/13 at D9S318). Our observed LOH rate at 9p21 was significantly higher than the background level previously reported for the same tumor type. Clinical data indicate that chromosome 9p21 deletions occurred preferentially in larger tumors (>5 cm diameter). However, a sequence analysis of the MTS1 gene coding region in cases of 9p21 LOH did not reveal any change, suggesting another tumor suppressor gene as the LOH target.

Prevalence and risk factor analysis of TTV infection in prostitutes

TTV, a DNA virus, has been isolated from patients with non-A to non-E post-transfusion hepatitis. In the past it was assumed that TTV was transmitted parenterally. It is unclear whether sexual contact leads to transmission of this virus. In this study, two sets of TTV-specific polymerase chain reaction primers were used to detect serum TTV DNA in 140 prostitutes and 136 controls. The prevalence of TTV DNA in prostitutes was significantly higher than in the control group (46/140 [32.9%] vs. 29/136 [21.3%]; P = 0.043). There was no significant difference in the prevalence of positive antibody to hepatitis A virus (anti-HAV) in either group (87.8% for prostitutes, 85.3% for controls). No particular risk factor was significantly associated with positive TTV DNA in prostitutes. In summary, TTV is highly prevalent in prostitutes. Transmission of TTV via sexual contact is not as efficient as transmission of hepatitis C and D viruses and GB virus-C hepatitis G virus. The high prevalence of TTV in controls indicates that there are diverse routes of transmission of this virus.

Characterization of a highly glycopeptide-resistant Enterococcus gallinarum isolate

BACKGROUND AND PURPOSE

Adequate treatment of emergency infection involving antibiotic-resistant bacteria such as vancomycin-resistant Enterococcus requires a convergence of clinical and bacteriologic techniques. An isolate of Enterococcus gallinarum, designated as TSGH63, is known to be uncommonly vancomycin-resistant. This study investigated the genetic determinant for this unique characteristic.

METHODS

After completing the conventional identification and sensitivity tests, the genomic content of E. gallinarum TSGH63 was extracted and analyzed by pulse-field electrophoresis. A set of specific primers for vanA, vanB, vanC1, and vanC2/C3 genes was then applied in a multiplex polymerase chain reaction (PCR) to differentiate its genetic content. To locate the determinant for high vancomycin resistance, the electrophoresis profile was further analyzed by Southern blot using the digoxigenin (DIG)-labeled vanA gene probe. Finally, interspecies transfer of the vancomycin-resistance determinant of E. gallinarum TSGH63 was tested by a conjugation experiment in vitro.

RESULTS

A 50-kb plasmid was identified in the analysis of the genomic extract of E. gallinarum TSGH63 by pulse field electrophoresis. Using multiplex PCR, we demonstrated that E. gallinarum TSGH63 harbors a vanA gene in addition to a vanC1 gene. The DIG-labeled vanA gene-specific probe bound to the plasmid exclusively on the Southern blot. The plasmid-carried vanA gene, but not the vanC1 gene, was found to be transferable from TSGH63 to E. faecalis JH2-2 by conjugation in vitro.

CONCLUSIONS

This is the first report of isolation of E. gallinarum with a high level of resistance to glycopeptides in Taiwan. The demonstrated interspecies transfer of the vancomycin-resistance gene highlights the importance of stringent control of the use of vancomycin.

Diabetes mellitus as a risk factor of liver cirrhosis in patients with chronic hepatitis B virus infection

Liver cirrhosis may occur in chronic hepatitis B surface antigen (HBsAg) carriers. Diabetes mellitus (DM)-associated chronic hepatitis may also occasionally lead to cirrhosis; however, its role in the course of chronic HBsAg carriers has not been studied. A cohort of 500 HBsAg carriers (398 men; mean age at entry, 42 +/- 15 years) were followed up longitudinally. After a mean follow-up of 5.8 +/- 3.3 years, 71 (14.2%: 70 men) patients developed cirrhosis. Increased risks of cirrhosis were found among men and the elderly (p < 0.001). Fifteen (21.1%) cirrhotic patients were noted to have had DM for 2-15 years before the development of cirrhosis. By contrast, only eight (1.9%; p < 0.001 ) of the patients without cirrhosis developed DM. When cirrhotic patients were compared to 102 age- and sex-matched non-cirrhotic controls, DM and elevation of serum alanine transaminase levels were found to be independent factors associated with the advent of cirrhosis in multivariate analysis. Other factors, including acute exacerbation, bridging hepatic necrosis, and superinfection by hepatitis C or D viruses, were insignificant. Our results suggest that DM may play a role in the progression to liver cirrhosis in chronic HBsAg carriers. High-risk subjects should be closely monitored for late complications.

Prevalence and risk factor analysis of TTV infection in prostitutes

TTV, a DNA virus, has been isolated from patients with non-A to non-E post-transfusion hepatitis. In the past it was assumed that TTV was transmitted parenterally. It is unclear whether sexual contact leads to transmission of this virus. In this study, two sets of TTV-specific polymerase chain reaction primers were used to detect serum TTV DNA in 140 prostitutes and 136 controls. The prevalence of TTV DNA in prostitutes was significantly higher than in the control group (46/140 [32.9%] vs. 29/136 [21.3%]; P = 0.043). There was no significant difference in the prevalence of positive antibody to hepatitis A virus (anti-HAV) in either group (87.8% for prostitutes, 85.3% for controls). No particular risk factor was significantly associated with positive TTV DNA in prostitutes. In summary, TTV is highly prevalent in prostitutes. Transmission of TTV via sexual contact is not as efficient as transmission of hepatitis C and D viruses and GB virus-C hepatitis G virus. The high prevalence of TTV in controls indicates that there are diverse routes of transmission of this virus.

Role of desmin filaments in chicken cardiac myofibrillogenesis

Desmin filaments are muscle-specific intermediate filaments located at the periphery of the Z-discs, and they have been postulated to play a critical role in the lateral registration of myofibrils. Previous studies suggest that intermediate filaments may be involved in titin assembly during the early stages of myofibrillogenesis. In order to investigate the putative function of desmin filaments in myofibrillogenesis, rabbit anti-desmin antibodies were introduced into cultured cardiomyocytes by electroporation to perturb the normal function of desmin filaments. Changes in the assembly of several sarcomeric proteins were examined by immunofluorescence. In cardiomyocytes incorporated with normal rabbit serum, staining for alpha-actinin and muscle actin displayed the typical Z-line and I-band patterns, respectively, while staining for titin with monoclonal anti-titin A12 antibody, which labels a titin epitope at the A-I junction, showed the periodic doublet staining pattern. Staining for C-protein gave an amorphous pattern in early cultures and identified A-band doublets in older cultures. In contrast, in cardiomyocytes incorporated with anti-desmin antibodies, alpha-actinin was found in disoriented Z-discs and the myofibrils became fragmented, forming mini-sarcomeres. In addition, titin was not organized into the typical A-band doublet, but appeared to be aggregated. Muscle actin staining was especially weak and appeared in tiny clusters. Moreover, in all ages of cardiomyocytes tested, C-protein remained in the disassembled form. The present data suggest the essential role of desmin in myofibril assembly.

Helicobacter pylori infection is associated with milder gastro-oesophageal reflux disease

BACKGROUND

We have previously demonstrated a negative relationship between the prevalence of Helicobacter pylori and gastro-oesophageal reflux disease (GERD).

AIM

To study the effects of H. pylori infection on the severity of GERD.

METHODS

Ethnic Chinese patients with frequent heartburn and/or endoscopic oesophagitis were studied. Endoscopic examination was performed to assess the severity of oesophagitis (modified Savary-Miller grading) and the presence of hiatus hernia. Biopsies were taken for rapid urease testing and confirmation of Barrett's oesophagus. Risk factors which may affect the severity of oesophagitis (age, sex, smoking, drinking, diabetes mellitus, hiatus hernia, H. pylori status and body mass index) were evaluated by a multiple regression model. The cagA status of H. pylori infected GERD and age-and-sex matched controls were determined by Western blot. Age-and-sex matched non-reflux patients were recruited as controls for comparison.

RESULTS

Two hundred and twenty-five patients with GERD were studied, of whom 77 (34%) were infected with H. pylori. Oesophagitis and Barrett's oesophagus were found in 140 patients (62%) and six patients (3%), respectively. H. pylori infected patients had significantly less severe oesophagitis compared to the uninfected group (P=0.022). All patients with Barrett's oesophagus were uninfected. Factors that predicted severe oesophagitis included age over 60 years (P < 0.001) and hiatus hernia (P < 0.001). H. pylori infection was the only factor that showed a negative correlation with severe oesophagitis (P=0.011). The prevalence of the cagA positive strain in endoscopy-negative GERD, erosive oesophagitis and control subjects was 70, 76 and 78%, respectively (P=0.75).

CONCLUSIONS

H. pylori infection is associated with milder GERD.

TT virus infection among hemodialysis patients at a medical center in Taiwan

Although the association between TT virus (TTV) infection and hepatitis is controversial, the high prevalence of TTV infection in healthy blood donors and even higher rate among frequently transfused patients poses a potential threat to public health and clinical care. In addition, there is a lack of data concerning the prevalence and mode of transmission of TTV infection in different subpopulations in Taiwan. In the present study, we investigated the prevalence of TTV infection in 111 uremic patients receiving regular hemodialysis in a single hospital in Taiwan. Blood samples were collected and analyzed using a seminested polymerase chain reaction (PCR) designed to amplify a 271 base-pair DNA fragment. The results show that the overall TTV positive rate in uremic patients in our hospital was 61% (68/111), which was much higher than the reported TTV prevalence rate among the normal population (ranging from 1%-12%). The results of analysis of the demographic and clinical characteristics of the patients indicate that blood transfusion may play an important role in TTV transmission (p < 0.05). In addition, the hepatitis B positive rate was significantly lower in TTV positive patients. However, liver function tests were not significantly different between TTV positive and TTV negative patients. The results of the present study suggest that blood transfusion plays an important role in TTV transmission in uremic patients.

Impact of hepatitis B and C virus infection on the outcome of kidney transplantation in Chinese patients

BACKGROUND

There has been improvement in kidney transplantation over the years; however, the impact of hepatitis B and C virus (HBV, HCV) infection on the long-term outcome of kidney transplant is still controversial.

METHODS

A total of 113 patients who received renal allografts from 1986 to 1998 were analyzed. Nine were positive for both hepatitis B surface antigen (HBsAg) and antibody to HCV (anti-HCV) (Group 1), 20 were HBsAg-positive and anti-HCV-negative (Group 2), 30 were HBsAg-negative and anti-HCV-positive (Group 3) and 54 were negative for both markers (Group 4). The outcome and survival were compared among the four groups of patients.

RESULTS

The mean follow-up period was 5.1 +/- 3.2 years (range, 0.5-13 years) for all patients. Group 2 patients had significantly higher liver-related complications (35% vs 0%, p < 0.0001) and liver-related deaths (20% vs 0%, p = 0.004) than did Group 4 patients. Among all, four HBsAg-positive patients had fulminant hepatitis and died within two years of transplantation. Three (Group 2) of the patients who died were seropositive for hepatitis B e antigen and/or HBV DNA and none had a history of or positive serologic marker to indicate hepatitis of other etiologies. The remaining patient (Group 1) had evidence of superinfection of HCV. Liver cirrhosis occurred in one, two and one patient in Groups 1, 2 and 3, respectively, and hepatocellular carcinoma occurred in two and one patient in Groups 2 and 3, respectively. Despite high liver-related mortality in HBV-infected patients, paradoxically, no significant differences among the four groups in the long-term graft and patient survivals were demonstrated. The presence of HBsAg or anti-HCV was not associated with a poor prognosis of survival as determined by Cox regression analysis.

CONCLUSIONS

HBV or HCV infection is not a contraindication to kidney transplantation in Chinese patients. However, it should be noted that serious liver-related complications may occur and limit survival in HBV- and/or HCV-infected patients after kidney transplantation.

Clinical and epidemiological implications of swine hepatitis E virus infection

In nonendemic areas, most patients with acute hepatitis E were infected through traveling to endemic areas. However, some patients did not have a history of foreign travel before infection. Furthermore, high seroprevalence rates of antibody to hepatitis E virus (anti-HEV) were found in the general adult population in some countries without any recorded outbreak of hepatitis E. The significance of anti-HEV assay in these subjects remains obscure. To study if swine might be a source of HEV infection, HEV was tested in sera of 235 pigs in Taiwan, and from 5 patients with acute HEV infection who either denied or did not provide any foreign travel history. Three (1.3%) pigs had detectable swine HEV RNA. The swine and human HEV strains from Taiwan formed a monophyletic group, distinct from three previously reported groups: the United States human and swine HEV strains, the Mexico strain, and the largest group composed of the Asian and the African strains. The identity of nucleotide sequences was 84-95% between swine and human HEV strains in Taiwan, and 72-79% between Taiwan strains and those from different areas. The predicted amino acid sequence of a Taiwan swine HEV strain within the peptide 3-2 used in commercial anti-HEV assay showed a high identity (91-94%) with those of other human and swine HEV strains. Swine may be a reservoir of HEV and subclinical swine HEV infection may occur. Cross-reactivity of current anti-HEV assay may account for the high prevalence rate of anti-HEV in the general population in nonendemic areas.

Severe regional ischemia alters coronary flow reserve in the remote perfusion area

BACKGROUND

Clinical and experimental studies suggest that coronary flow reserve (CFR) may be abnormal in regions remote from myocardial infarction. We sought to determine the possible relation among stenosis severity, ischemic dysfunction, and impairment of CFR in remote regions.

METHODS AND RESULTS

In 7 open-chest dogs, acute graded left circumflex (LCX) ischemia was created and maintained based on measurement of the transstenotic (aortic-distal LCX) pressure gradient (measured in millimeters of mercury). Regional thickening was assessed with sonomicrometers. Regional myocardial flow was assessed at rest with radiolabeled microspheres. Doppler flow probes were placed on proximal LCX and left anterior descending (LAD) arteries to measure resting flow and CFR in response to intracoronary injection of adenosine (36 microg). These parameters were assessed under baseline conditions and during transstenotic gradients of 10, 20, 30, and 40 mm Hg. Increasing LCX stenosis severity caused progressive impairment of LCX CFR: baseline (2.22+/-0.10), stenosis 10 (1.80+/-0.06), stenosis 20 (1.56+/-0.08), stenosis 30 (1.30+/-0.04), and stenosis 40 (1.17+/-0.06) (P<.01 vs. baseline). Remote LAD CFR was not altered by mild to moderate LCX stenosis (baseline [2.33+/-0.19]; stenosis 10 [2.30+/-0.25]; stenosis 20 [2.15+/-0.26]). However, critical LCX stenosis producing mild to moderate reduction in thickening in the ischemic region was associated with a significant impairment of LAD CFR: stenosis 30 (1.90+/-0.26) and stenosis 40 (1.80+/-0.22) (P<.01 vs. baseline). These changes in remote CFR persisted after correction for changes in the rate-pressure product.

CONCLUSION

In an acute canine model of progressive LCX coronary stenosis, CFR was impaired in both ischemic and remote nonischemic regions in association with mild to moderate ischemic-induced regional myocardial dysfunction. Thus pharmacologic vasodilation provoked only mild heterogeneity in CFR in the presence of a critical LCX stenosis as a result of concurrent reduction of LAD CFR. This phenomenon warrants further clinical and experimental investigation because it may affect detection of flow heterogeneity during acute ischemia (which induced myocardial dysfunction).

Clinical significance of changes in serum hepatitis B virus DNA titer in patients with chronic hepatitis B treated with interferon

BACKGROUND

Interferon (IFN) has been used in the treatment of patients with chronic hepatitis B virus (HBV) infection. Nonetheless, the changes in serum HBV DNA titer during IFN treatment and the effect of these changes on the therapeutic results have not been well studied.

METHODS

Twenty patients with chronic hepatitis B who were positive for serum hepatitis B e antigen (HBeAg) and HBV DNA received IFN-alpha 2a 4.5 million units by subcutaneous injection three times a week for 24 weeks. Twenty age- and sex-matched patients with chronic hepatitis B were selected as a control group. Treatment response was defined as the normalization of serum alanine aminotransferase (ALT) and the seroconversion of serum HBeAg 24 weeks after discontinuation of the IFN treatment. Serum HBV DNA was measured using the branched DNA (bDNA) signal amplification assay.

RESULTS

There was no significant difference in pretreatment mean serum ALT and HBV DNA titer in either the IFN-treated or the control group. Treatment response was found in six (30%) of 20 IFN-treated patients and in four (20%) of 20 control patients (p > 0.05). Serum HBV DNA titer fell after IFN treatment and remained undetectable only in patients with final treatment response. Serum HBV DNA was negative at week 12 of the IFN treatment in four (67%) of six patients with treatment responses, significantly higher than in none (0%) of 14 patients without a treatment response (p = 0.001). Multivariate logistic regression revealed that the negativity of serum HBV DNA at week 12 of the IFN treatment successfully predicted treatment response.

CONCLUSIONS

Thirty percent of the patients with chronic hepatitis B responded to IFN-alpha 2a 4.5 million units subcutaneously injected three times a week for 24 weeks. Negativity of serum HBV DNA measured by bDNA assay at week 12 of the IFN treatment may suggest a beneficial treatment outcome.