Genotypes, nt 1858 variants, and geographic origin of hepatitis B virus--large-scale analysis using a new genotyping method

The nucleotide at position 1858 of hepatitis B virus has importance in chronic hepatitis B (HB) because a cytosine at nt 1858 effectively prevents virus escape through the precore TAG stop codon mutation. The relatedness between nt 1858 and genotypes was analyzed using a new genotyping method based on restriction fragment length polymorphism (RFLP) analysis of an S gene amplicon. Seventy-three gene bank sequences were analyzed by phylogenetic tree construction and RFLP prediction. A tree supporting the existence of 6 genotypes (A-F) was obtained, with C-1858 found in 9 of 9 A genotypes, 0 of 7 B, 0 of 19 C, 1 of 10 D, 0 of 2 E, and 3 of 3 F. Serum samples from 187 HB e antigen-positive chronic carriers were analyzed: Genotypes in northern Europeans were 60% A, 31% D; in southern Europeans and Middle Easterners 96% D; in Africans 53% A, 27% D, 20% E; and in East Asians 14% A, 43% B, 43% C. Cytosine at nt 1858 was found in 36 of 44 A, 0 of 32 B, 8 of 34 C, 0 of 59 D, 0 of 3 E, and 1 of 1 F genotype samples.

A randomized prospective study of vocational outcome in rehabilitation of patients with non-specific musculoskeletal pain: a multidisciplinary approach to patients identified after 90 days of sick-leave

This study was designed to evaluate the effectiveness of a multidisciplinary rehabilitation programme offered to a general population with 90 days of sick-leave due to non-specific musculoskeletal pain. The results concerning return to work and re-sick-listing during a follow-up period of five years were evaluated for Swedes and immigrants separately. Compared to a control group, the rehabilitation offer resulted in improved work stability after work return among the Swedes. The immigrants, as a group, did not benefit from the programme compared to the controls in primary care.

Changing aneurysmal morphology after endovascular grafting: relation to leakage or persistent perfusion

PURPOSE

To relate changing abdominal aortic aneurysm (AAA) morphology after endovascular grafting to the presence of leakage, collateral perfusion, and other factors.

METHODS

Thirty-five patients who underwent successful AAA endovascular grafting were evaluated. Self-expanding Z-stents and Dacron grafts were applied in bifurcated and aortomonoiliac systems. Postoperative diameter changes were calculated from repeated spiral computed tomographic scans, angiograms, and ultrasonic phase-locked echo-tracking scans during a median 6-month follow-up (interquartile range [IQR] 3 to 12).

RESULTS

At 12 months, the diameters of completely excluded aneurysms had decreased 6 mm (IQR 2 to 11; p = 0.006). The proximal graft-anchoring stents had dilated 2 mm (IQR 0.5 to 3.3; p = 0.01). The aortic diameters immediately below the renal arteries but above the stents had not changed. Endoleakage and collateral perfusion (n = 13) were each associated with preserved aneurysm size and a 12 times higher risk of aneurysm dilation. After the leakage or the collateral perfusion had been treated, the aneurysm size decreased. Aneurysms with extensive intraluminal thrombi presented a reduced risk of leakage or perfusion.

CONCLUSIONS

The diameters of endovascularly excluded AAAs decrease, except in cases of leakage or perfusion. Careful follow-up of patients with aortic endografts is necessary.

The effect of endovascular aortic stents placed across the renal arteries

OBJECTIVES

To investigate renal artery patency and renal function after deployment of aortic stents covering the orifices of renal arteries.

DESIGN

Prospective open animal study.

SETTING

Department of Experimental Surgery at a university hospital.

MATERIALS

Twenty-three pigs were used.

METHODS

Ten pigs were observed for 1 h after graft-anchoring aortic stents, Gianturco (5) and Palmaz (5), were placed so that the stents covered the renal arterial orifices. In 13 pigs, Gianturco (6) and Palmaz (7) stents without grafts were placed over the renal arteries and left in situ for 7 days. Renal function and blood flow were measured by renograms, iohexol clearance and ultrasonic blood flow meter and patency was verified by angiograms. The kidneys were microscopically examined for signs of ischaemia and microemboli.

RESULTS

One renal artery covered by a graft-anchoring Gianturco stent occluded. The remaining renal arteries remained patent without any significant decrease in renal blood flow after stent deployment. Normal renal function and histology was maintained.

CONCLUSIONS

Aortic stents placed at the level of the renal arteries do not affect renal blood flow within 1 week in this experimental model. This may prove valuable in endovascular treatment of aortic aneurysms and in other procedures involving stents.

A telescopic stent-graft for aortoiliac implantation

OBJECTIVES

To test a new delivery system for a telescopic stent-graft.

MATERIALS

Variable overlap between the components of this stent-graft combination allows length adjustment. This device differs from other multi-component stent-grafts in that both components are contained within a single delivery system.

METHODS

The stent-graft was implanted in the distal thoracic to suprarenal aorta of five pigs (35-50 kg), where the arterial diameter falls by almost 50%. The proximal and distal components of the stent-graft were targeted to bony landmarks in the vertebral column.

RESULTS

Inspection of completion angiograms showed both proximal and distal stent-grafts to be within 1 mm of their target locations in all five experiments. Overall combined stent-graft length varied from 13.5 cm to 16.1 cm depending on the location of the bony landmark chosen as the distal target, and on the size of the pig.

CONCLUSIONS

This system may be useful for the repair of abdominal aortic aneurysm whenever preoperative sizing is difficult due to aortic tortuosity, or precluded due to the urgency of the procedure.

Are self-expanding stents superior to balloon-expanded in dilating aortas? An experimental study in pigs

OBJECTIVE

To study the stent/vessel interaction and distensibility following the natural increase in vascular diameter using self-expanding and balloon-expanded stents.

DESIGN

Open experimental study.

SETTING

Animal laboratory, university hospital.

MATERIALS AND METHODS

Eight Palmaz (P) and eight Gianturco (G) stents were transluminally placed in the infrarenal aortas of 16 pigs. Pulsatile diameter changes above, at and below the stents were non-invasively monitored with an ultrasound phase-locked echo-tracking system before and immediately after stenting and at 4 and 18 weeks. Blood pressure was registered intra-arterially and stiffness (beta) was calculated. Intravascular ultrasound (IVUS) was performed at 18 weeks.

RESULTS

Median weight increased from 20 kg (19-26) to 93 kg (62-130). Diameter of the aorta increased 60%. In group P no pulsatile diameter change could be measured at the stent (beta = infinity). In group G stenting increased stiffness from beta 20.7 (9.2) to 43.2 (8.0) (p < 0.05). After 18 weeks stiffness returned to beta 20.1 (12.4). Expanded, median diameter of the P stents was 7.4 (0.8) mm, not increasing after 18 weeks. Initial diameter of the G stents was 7.8 (1.0) mm, increasing 56% to 12.2 (2.3) mm (p < 0.05). IVUS revealed the G stents to be well attached to the vascular wall, but five P stents were detached within half of the circumference.

CONCLUSION

Self-expanding stents follow the pulsatile diameter change of the vessel wall, not adversely affecting distensibility after 18 weeks. They show good attachment despite 56% dilation. In contrast, the balloon-expanded stents do not show pulsatile movement and may detach during vessel diameter increase. This may be of importance when choosing stents for endovascular treatment of abdominal aortic aneurysms.

Accuracy of duplex sonography before carotid endarterectomy--a comparison with angiography

OBJECTIVES

The aim of this prospective study was to contribute to the evaluation of the reliability of Duplex sonography (DS) before carotid endarterectomy (CEA).

DESIGN

The study was performed prospectively in a university hospital setting.

METHODS

Eighty-one consecutive patients aged 49-83 years were examined with DS and carotid angiography (CAG) before CEA. The results of the DS were judged as either confident, or CAG was assessed to be necessary preoperatively. The results from the DS and the CAG were then compared.

RESULTS

DS was judged as confident in 148 of the 162 arteries examined. In none of these 148 arteries did CAG change patient management in any way, and the agreement between DS and CAG was good. In the remaining 14 arteries CAG was judged necessary, in 11 arteries because DS assessed the internal carotid artery (ICA) as occluded, which was confirmed by CAG in 10 arteries. In three arteries the reason was poor quality of the DS, however these three arteries were correctly assessed as severely diseased.

CONCLUSIONS

This study confirms that DS alone is sufficient in the preoperative evaluation before CEA, provided that CAG is performed whenever DS shows occlusion of the ICA, or when the quality of the DS is poor.

Hepatitis B virus carriers without precore mutations in hepatitis B e antigen-negative stage show more severe liver damage

Hepatitis B e antigen (HBeAg) is considered to be a major target for the immune response in chronic hepatitis B. The G-->A mutation at nucleotide 1896 may mediate viral escape by creating a TAG stop codon in the precore region, thus preventing HBeAg production. This mutation frequently evolves during HBe seroconversion if thymine, but rarely if cytosine, is present in position 1858. Applying a combination of polymerase chain reaction (PCR) and restriction enzyme action, we have studied the relation of the TAG mutation and the nucleotide (nt) 1858 variants to liver damage assessed by histology activity index (HAI) scoring in 175 chronic hepatitis B virus (HBV) carriers. A TAG mutation was found in 68 of 71 (96%) of HBeAg-negative carriers infected with a T-1858 strain, but not in any of 33 carriers infected exclusively with a C-1858 strain. Four patients showed a mutation of the precore start codon, and 2 had a TAA stop mutation at codon 2. HBeAg-positive infection with a mixture of wild-type and TAG mutant virus indicated active liver damage, because 8 of 9 (89%) of such patients had a Knodell HAI greater than or equal to 8. In HBeAg-negative stage, both inflammation and fibrosis were more pronounced in carriers infected with wild-type HBV compared with precore mutants. C-1858 strains were associated with more inflammation and fibrosis compared with T-1858 strains. C-1858 strains were found in 71% of northern European, 17% of southern European, 31% of African, 2% of Middle Eastern, and 10% of Far Eastern carriers. Analysis of these variants and mutants may prove useful for clinical evaluation and choice of therapy, and may be facilitated by the methods described.

Endovascular stent-anchored aortic grafts: a comparison between self-expanding and balloon-expandable stents in minipigs

PURPOSE

To study endovascular graft attachment with self-expanding Gianturco Z-stents and balloon-expanded Palmaz stents and the effect of these devices on the renal ostia.

METHODS

Ten stent-grafts were constructed, 5 with Gianturco Z-stents and 5 with Palmaz stents. The endografts were implanted under fluoroscopic guidance into the abdominal aorta of 10 pigs so that the uncovered portion of the proximal stent extended over the renal artery orifices. Distal aortic blood pressure and flow were measured before and after graft placement and 1 hour postprocedure. The aorta was then exposed surgically, and the central portion of the stent-graft was inspected through an aortotomy to assess perigraft leakage.

RESULTS

Stent-graft implantation was accurate and hemostatic in all cases, despite longitudinal folding of the graft due to oversizing. However, transverse folds produced pressure gradients (> 15 mmHg) between the ends of the graft in two cases. In another case, a pressure gradient resulted from partial thrombosis of the graft. In two cases, renal artery occlusion and thrombosis occurred due to coverage by the graft material. In two other animals, one of the renal arteries was entirely uncovered by a stent. The remaining 16 renal arteries were covered by the proximal stent but not the graft, as intended. One (6.25%) of these arteries thrombosed, but the remainder were grossly patent when the animals were sacrificed at 1 hour.

CONCLUSIONS

Both Palmaz and Gianturco Z-stents produced hemostatic endovascular graft attachment, even in the presence of moderate graft oversizing. The risk of acute renal artery occlusion from juxtarenal stenting does not appear to be prohibitive, but longer term observations are needed.

Options for treatment of persistent aneurysm perfusion after endovascular repair

Persistent aneurysm perfusion represents failure of endovascular repair. The leak may occur around either end of the prosthesis or through a collateral route. Most cases can be treated by endovascular means. Stents can be rotated, the prosthesis can be lengthened at either end, and collateral pathways can be occluded, all without recourse to open repair. This report describes the management of persistent aneurysm perfusion in five patients from a total experience of 32 cases of endovascular aneurysm repair.

Emergence of precore TAG mutation during hepatitis B e seroconversion and its dependence on pregenomic base pairing between nucleotides 1858 of 1896

The G-->A mutation of nucleotide (nt) 1896 in the precore region of hepatitis B virus (HBV) prevents production of hepatitis B e antigen (HBeAg) by creating a TAG stop codon. This mutation is often found in anti-HBe-positive patients with productive HBV infection and has been associated with severe chronic and fulminant hepatitis in some geographic areas. Emergence of the TAG mutation during HBe seroconversion was studied as was its relationship with nt 1858, which forms a base pair with nt 1896 in the pregenomic RNA loop. A TAG mutant evolved in 18 (72%) of 25 patients with a T-1858 strain but in only 1 (8%) of 13 with a C-1858 strain. Viremia with C-1858 strains was, despite their limited ability to develop the TAG mutation, as persistent as with T-1858 strains. Generally, T-1858-infected patients in whom a TAG mutant did not emerge were HBV DNA-negative by polymerase chain reaction on follow-up, whereas patients who developed the TAG mutation had prolonged viremia.

Aneurysms of the pancreaticoduodenal artery associated with occlusion of the celiac artery

Aneurysms of the pancreaticoduodenal artery are rare and may be associated with celiac artery stenosis or occlusion. Twenty-eight patients are reported in the literature. The diagnostic findings and therapeutic alternatives of four additional patients form the basis of this report. One patient with ruptured pancreaticoduodenal aneurysm was successfully treated by transcatheter embolization, and one patient was treated surgically; both patients had an uneventful recovery. In the remaining two patients, the aneurysms were left untreated. One patient died 1 year later of an unrelated cause, and the other patient is symptom-free after 2 years.

Detection of hepatitis B virus precore TAG mutant by an amplification-created restriction site method

A new method for detecting the hepatitis B virus (HBV) precore 1896 G-->A mutation is described. This mutation prevents hepatitis B e antigen production by introducing a TAG stop codon and has been associated with severe chronic and fulminant hepatitis. The method is based on a polymerase chain reaction (PCR) that creates a restriction enzyme (Bsu36I) cleavage site if the mutation is present. After incubation of the PCR product with Bsu36I and a subsequent agarose gel electrophoresis, the presence of the TAG mutant is revealed by an altered position of the DNA band. The method was compared with direct sequencing on 36 serum samples and correctly identified all samples containing mutant HBV. The TAG mutant was present in 17 cases (as mixed wild type and mutant virus in 4). Twelve of 18 patients with advanced liver disease confirmed by biopsy carried mutant HBV. This method of detecting HBV precore 1896 G-->A should be useful for evaluation and follow-up of patients and for prevalence studies.

Muscle fiber characteristics, capillaries and enzymes in patients with fibromyalgia and controls

In 11 female patients with Fibromyalgia Syndrome (FS), biopsies from the m. vastus lateralis were analyzed, in order to reveal any possible changes which might explain muscular weakness and fatigue. Nineteen healthy subjects served as a control group. Light microscopy did not show any gross histopathological findings. Fiber composition and fiber areas did not differ between the two groups, except for a greater coefficient of variation of the area of type II A fibers and of the mean fiber area in the FS group. The number of capillaries per square millimeter and also the fiber area in relation to the capillaries, was lower in the FS patients. Analyses of enzymes showed decreased levels of 3-hydroxy-CoA-dehydrogenase and citrate synthase in the patient group. The reduced oxidative enzyme levels and capillarization indicate reduced physical activity, although this does not associate with muscle fiber hypotrophy.

Differential regulation of C-CAM isoforms in epithelial cells

C-CAM is a Ca(2+)-independent cell adhesion molecule (CAM) that mediates intercellular adhesion of isolated rat hepatocytes. It is widely distributed in epithelia, where its presence both at lateral cell borders and on apical cell surfaces suggests that it may have diverse biological functions. Two major isoforms, C-CAM1 and C-CAM2, which differ in the lengths of their cytoplasmic domains, have been identified. The lack of suitable in vitro systems has so far prevented a detailed study of the physiological role of C-CAM in epithelia. We now report on the identification, biochemical characterization and functional analysis of C-CAM isoforms in the established epithelial cell line NBT II, derived from a chemically induced carcinoma of rat bladder. C-CAM in NBT II cells is a 110–115 kDa cell surface glycoprotein located predominantly at sites of cell-cell contact but also present on the apical cell surface. Northern blotting analysis revealed the presence of both C-CAM1 and C-CAM2, with the major transcripts for both isoforms present within the 4.0 kb size range. The dissociation of NBT II cell colonies by anti-C-CAM antibodies indicated that at least one function of C-CAM in these cells is to mediate intercellular adhesion. The maintenance of extensive cell-cell contacts and the expression of C-CAM at the contact sites in cells grown in low Ca2+ medium suggested that, like its counterpart in hepatocytes, C-CAM in NBT II cells may be a Ca(2+)-independent cell-cell adhesion molecule. The co-localization and coordinate reorganization of both C-CAM and actin by anti-C-CAM antibodies indicated that these two proteins were associated and suggested that interactions with the cytoskeleton may be important for the regulation of C-CAM function. The specific upregulation of C-CAM1 in cells induced to undergo epithelial to mesenchymal-like transitions (EMT) by the serum substitute Ultroser G suggested that C-CAM isoforms are important modulators of the adhesive properties of these cells.

Arthroscopic subacromial decompression versus open acromioplasty. A two-year follow-up study

In a prospective study, 20 patients were randomly selected for either open acromioplasty according to Neer or for arthroscopic subacromial + decompression (ASD). All suffered from shoulder impingement for which conservative treatment had been unsuccessful. Functional results after two years were assessed. All patients were assessed radiographically to visualize recurrence of subacromial osteophytes. Functional results in the arthroscopic group are good and similar to those after open surgery. Both methods seem to result in adequate subacromial decompression, including bone resection. The arthroscopic method also has in its favor less operating time, earlier restoration of active range of motion, and reduction in time away from work.

Natural history of patients with unoperated atherosclerotic carotid artery disease--results from a retrospective study

The natural history of carotid artery disease was studied in a retrospective study of 609 angiograms performed during 1969-1979 on patients who had subsequently not been operated on. The indication for angiography differed, but was aimed at clarifying suspected cerebrovascular events. 578 patients could be followed-up after a median time of 10.4 years (0-22). The median survival time after angiography was 9.7 years for the 355 men and 12.8 years for the 223 women (p = 0.0099). Internal carotid stenosis of > 50% was seen in 9.0% (bilaterally in 2.2%), a stenosis > 75% in 4.5% (bilaterally in 0.9%) and occlusion in 9% (bilaterally in 0.7%). Ulceration was present in 10.7% (bilaterally in 1.6%). 26.5% of the patients had a cerebrovascular event during follow-up, of which 31.4% had transient ischaemic attack or amaurosis fugax. Survival was not influenced by the degree of stenosis, but presence of arteriosclerotic carotid artery disease significantly reduced the median survival time from 11 to 3 years. The main cause of death for men was myocardial infarction (27.7%) and for women a cerebrovascular event (27.8%), a significant difference. From this study, in selected patients it can be concluded that the annual frequency of cerebrovascular events was low, approaching frequencies reported in asymptomatic patients. The cause of death differed between men and women, with more cardiac deaths among men and more cerebrovascular deaths among women.

Subcutaneous sterile water injections for chronic neck and shoulder pain following whiplash injuries

In many cases of whiplash injury symptoms persist and do not respond to treatment. There is uncontrolled evidence to suggest that intracutaneous injections of sterile water might help. Since that route may be unacceptable to patients the subcutaneous route is used in the randomised trial reported here. 40 patients with whiplash syndrome, mean age 46 years (24-73) were given subcutaneous injections of 0.3-0.5 ml sterile water or saline over tender and trigger points in the neck and shoulder. A maximum of three treatments were given during the first two months of the study and the patients were followed up for 8 months. The accidents had occurred 4-6 years previously. X-ray examinations revealed no traumatic spinal lesions. Neck mobility and pain levels were evaluated by a physiotherapist immediately before and after the first treatment and after 1, 3, and 8 months. After 3 months, the mean total mobility of the cervical spine had increased by 39 degrees in the sterile water group and 6 degrees in the saline group (p < 0.05). Minimum and maximum levels of pain in the weeks just before treatment were evaluated by a visual analogue scale from 0 to 10. After 3 months the minimum pain level had fallen from 2.2 to 1.4 in the sterile water group but was not reduced in the saline group (p < 0.02); the maximum had fallen from 8.1 to 3.8 in the sterile water group and from 8.3 to 7.5 in the saline group (p < 0.001). After 3 months, 19 of 20 patients in the sterile water group assessed their condition as generally improved but only 6 in the saline group felt that they had got better. After 8 months there were still significant differences for minimum pain score and for mobility but not for maximum pain or for self-assessment of improvement.

Hepatitis B carriers in Sweden--effects of immigration

The number of hepatitis B carriers in Gothenburg, the second largest city in Sweden, has gradually increased between 1980 and 1990. Altogether 525 chronic carriers (35% females) were found, corresponding to a prevalence of 0.11%. 401 (76%) were immigrants from high or medium prevalence regions, mainly the Middle East and Southeast Asia. 102 were native Swedes (19%). In 1988-90 the immigrants constituted 85% (154/182) of all new cases. 93% (245/264) of the carriers born in 1960-89 were immigrants, whereof 53% (130/245) were HBeAg positive. The increasing number of hepatitis B carriers in Sweden places demands on the public health service to undertake measures to prevent new cases of hepatitis B, as well as to discover and treat chronic liver disease induced by hepatitis B virus.