Systematic review: pentoxifylline for the treatment of severe alcoholic hepatitis

BACKGROUND

Acute alcoholic hepatitis (AH) is a severe manifestation of alcoholic liver disease with a grave prognosis. Pentoxifylline, an oral antitumour necrosis factor agent, has been reported to reduce mortality and incidence of hepatorenal syndrome (HRS) in severe alcoholic hepatitis (SAH).

AIM

To summarise evidence for the use of pentoxifylline in SAH.

METHODS

A literature search was undertaken using MeSH terms 'hepatitis, alcoholic' and 'pentoxifylline' using the set operator AND. We included randomised controlled trials examining pentoxifylline in SAH, published as abstracts or full manuscripts. Risk ratios (RRs) were calculated for pooled data using random effects modelling. Risk of bias was assessed using Cochrane group criteria and quality of trials assessed using 'Consolidated Standards of Reporting Trials' CONSORT guidelines.

RESULTS

Ten trials including 884 participants were included, from six papers and four abstracts. There was significant heterogeneity between trials regarding control groups and trial end-points. Treatment was given for 28 days in all trials except one. Pooling of data showed a reduced incidence of fatal HRS with pentoxifylline compared with placebo (RR: 0.47, 0.26-0.86, P = 0.01), but no survival benefit at 1 month (RR: 0.58, 0.31-1.07, P = 0.06). There were no significant differences between treatment groups in trials of pentoxifylline vs. corticosteroid, or vs. combination therapy.

CONCLUSIONS

Pentoxifylline appears superior to placebo in prevention of fatal HRS and thus may be effective treatment of SAH when corticosteroids are contraindicated. However, multiple trials have failed to show conclusive superiority of either pentoxifylline or corticosteroids.

Esophageal cancer awareness in Bomet district, Kenya

BACKGROUND

Esophageal cancer is the most common malignancy in Western Kenya and patients present with advanced disease.

OBJECTIVE

To determine baseline level of knowledge of esophageal cancer in Bomet District in order to develop targeted and effective educational classes.

METHODS

A questionnaire with twelve questions testing knowledge about esophageal cancer and eight questions aimed at determining barriers to healthcare was conducted out of Tenwek Hospital from June to July 2010.

RESULTS

Eighty-one questionnaires were completed. 33% thought that cancer is a virus and 35% thought that it is contagious. 47% did not think that family history is a risk factor. 79% accurately claimed dysphagia as the most common symptom for esophageal cancer. 40% thought that herbal therapy is the optimal treatment for esophageal cancer. Cost and fear of diagnosis were cited as the most significant barriers to healthcare. Most participants had a monthly income of less than 3000 Kenyan schillings (37.5 US dollars); for 37% of participants, the cost of transport to the hospital represented a third of their monthly income.

CONCLUSION

The questionnaire provided population-specific information on cancer knowledge and aided in targeting barriers to healthcare access. These factors will be incorporated into the cancer education outreach program of Tenwek Hospital.

Expression of an alternatively spliced ercc1 messenger-RNA species, is related to reduced DNA-repair efficiency in human T-lymphocytes

We have previously shown that in non-drug-selected human T lymphocytes, DNA repair is the primary determinant of cellular resistance to cisplatin (1). In this system, we have assessed mRNA levels of expression of the nucleotide excision repair (NER) genes ERCC1 and XPA, as well as the alternatively spliced species of ERCC1 which lacks exon VIII. The focus of these studies, was to try to identify the possible relative roles of normal XPA, full-length ERCC1, and alternatively spliced ERCC1, in a system where DNA repair is a clear determinant of cisplatin resistance. ERCC1 expression was directly related to cisplatin-DNA adduct repair capability, as well as directly related to cisplatin resistance, suggesting a primary role for ERCC1 in effecting DNA repair. XPA expression was approximately equivalent in each cell line, regardless of the level of DNA repair activity, suggesting a helper role for the product of this gene. The mRNA levels of the alternatively spliced species of ERCC1 were strongly inversely related to DNA repair activity, suggesting a possible inhibitory influence on the DNA repair process. This interpretation is consistent with alternative splicing of several known oncogenes, where the alternatively spliced species has an inhibitory effect on the full-length gene product. The NER pathway appears to be vitally important in effecting cisplatin resistance in non-drug-selected T lymphocytes. Further, it appears that NER may have at least one inhibitory regulatory component.

Platinum-DNA adduct in head and neck-cancer patients receiving Cisplatin and Carboplatin chemotherapy

Sixteen patients with squamous cell carcinoma of the head and neck region were studied for the formation of platinum-DNA adduct in leukocyte DNA. Every patient received carboplatin and cisplatin, each given intravenously on day 1 of 21-day treatment cycles. Blood was obtained for DNA isolation 24 hours after treatment on cycles 1 and 2; and on the morning before cycle 2 of therapy (21 days after cycle 1 drug delivery). Adduct was measured by atomic absorbance spectrometry with Zeeman background correction. As has been shown in previous studies, adduct persistence and accumulation could be demonstrated in a portion of the cohort. Adduct removal from blood cell DNA during the 21 days of cycle number 1, was determined for 12 patients. In these patients, adduct removal was directly i-elated to clinical resistance to the cisplatin/carboplatin treatment regimen; and adduct removal was inversely related to leukocyte toxicity. These data demonstrate that changes in adduct levels with time may provide valuable information, in the study of the human in vivo biology of platinum-DNA damage and repair.

An ORS-ICP-MS method for monitoring trace levels of cobalt and chromium in whole blood samples from hip arthroplasty patients with metal-on-metal prostheses

OBJECTIVE

To develop a rapid and reliable method, using an octopole reaction system (ORS) ICP-MS, capable of monitoring trace levels of Co and Cr in whole blood samples from hip arthroplasty patients with metal-on-metal prostheses.

DESIGN AND METHOD

Whole blood is diluted 10-fold with an alkaline diluent and analyzed using an Agilent 7500 CE ORS-ICP-MS.

RESULTS

Limit of quantification of 0.03 μg/L Co and 0.20 μg/L Cr in patient samples. <6% covariance obtained for quality control materials analyzed over 10 runs.

CONCLUSION

This method is capable of monitoring trace levels of Co and Cr in diluted whole blood samples with a vial to vial run time of approximately 2 min. Results are comparable to those obtained using high resolution (HR) ICP-MS with sample digestion.

Cardiovascular tissue banking in Europe

INTRODUCTION

In the past 50 years, human cardiovascular tissue allografts, also called homografts, have been implanted into patients with different valvular diseases. The use of these allografts and  the number of cardiovascular tissue banks and their respective techniques increased. We conducted a survey to establish the quantity of allografts processed, and issued by, European tissue banks. The survey also included the collection of other relevant statistics.

METHODS

In 2011, the Foundation of European Tissue Banks collected data from 19 different cardiovascular tissue banks in 11 European countries.

RESULTS

From  2007 to 2010 the  data show a decrease in the number of hearts received, from 1700 to 1640 in 18 tissue banks; the average number of hearts received for cardiovascular tissue processing decreased from 113 to 91. The number of heart valves issued for transplantation increased from 1272 in 2007 to 1486 in 2010. The average rate of discard because of microbiological contamination was 20.7%, while 4.2% of the grafts were not used because of positive serology. Half of the tissue banks issued arterial grafts, while 3 banks also issued veins and pericardium. An overview of decontamination methods shows considerable methodological differencesbetween 17 cardiovascular tissue banks.

CONCLUSIONS

From the experience in Europe, it can be concluded that cardiovascular tissue banks have an established place in the domain of cardiovascular surgery. The statistics show fluctuating data concerning the demand for human cardiovascular allografts and methodological questions. There is room for growth and improvement with respect to validation of decontamination methods.

Performance measures in three rounds of the English bowel cancer screening pilot

OBJECTIVES

To compare performance measures across all three rounds of the English bowel cancer screening faecal occult blood test pilot and their relation to social deprivation and ethnicity.

METHODS

In each round in three primary care trusts, data for a restricted population of over 48,500 aged 60-69 years were analysed. Individual-based data included postcode linked to area-based data on the Index of Multiple Deprivation (IMD) 2004, and ethnicity. Outcomes were the rates of screening and colonoscopy uptake, positivity and detection of neoplasia (adenomas or bowel cancer) and bowel cancer, and the positive predictive values (PPVs) of a positive test for neoplasia and bowel cancer. Sensitivity was calculated by the proportional incidence method using data on interval cancers identified from cancer registrations.

RESULTS

The overall uptake rate was 61.8%, 57.0% and 58.7% in the first, second and third rounds, respectively. Although the PPV for cancer decreased over the course of the three rounds (10.9% in the 1st round, 6.5% in 3rd round), the PPV for all neoplasia remained relatively constant (42.6% in 1st round, 36.9% in 3rd round). Deprivation and non-white ethnic background (principally Indian subcontinent in the pilot region) were associated with low screening and colonoscopy uptake rates, and this changed little over the three screening rounds. Uptake was lower in men, although differences in uptake between men and women decreased over time. Non-participation in previous rounds was a strong predictor of low uptake.

CONCLUSIONS

Performance measures are commensurate with expectations in a screening programme reaching its third round of screening, but a substantial ongoing effort is needed, particularly to address the effects of deprivation and ethnicity in relation to uptake.

Altered vitamin E status in Niemann-Pick type C disease

Vitamin E (α-tocopherol) is the major lipid-soluble antioxidant in many species. Niemann-Pick type C (NPC) disease is a lysosomal storage disorder caused by mutations in the NPC1 or NPC2 gene, which regulates lipid transport through the endocytic pathway. NPC disease is characterized by massive intracellular accumulation of unesterified cholesterol and other lipids in lysosomal vesicles. We examined the roles that NPC1/2 proteins play in the intracellular trafficking of tocopherol. Reduction of NPC1 or NPC2 expression or function in cultured cells caused a marked lysosomal accumulation of vitamin E in cultured cells. In vivo, tocopherol significantly accumulated in murine Npc1-null and Npc2-null livers, Npc2-null cerebella, and Npc1-null cerebral cortices. Plasma tocopherol levels were within the normal range in Npc1-null and Npc2-null mice, and in plasma samples from human NPC patients. The binding affinity of tocopherol to the purified sterol-binding domain of NPC1 and to purified NPC2 was significantly weaker than that of cholesterol (measurements kindly performed by R. Infante, University of Texas Southwestern Medical Center, Dallas, TX). Taken together, our observations indicate that functionality of NPC1/2 proteins is necessary for proper bioavailability of vitamin E and that the NPC pathology might involve tissue-specific perturbations of vitamin E status.

In vitro steroid resistance correlates with outcome in severe alcoholic hepatitis

Steroids improve the outcome in alcoholic hepatitis (AH), but up to 40% of patients fail to respond adequately. Interleukin-2 (IL-2) exacerbates steroid resistance in vitro. We performed a prospective study to determine if intrinsic steroid sensitivity correlates with response to steroids in individuals with severe AH and if IL-2 receptor blockade can reverse this. Peripheral blood mononuclear cells (PBMCs) were isolated from 20 patients with AH and a Maddrey's score >32. Patients were treated with oral prednisolone plus full supportive measures. Clinical resistance to oral steroid treatment was defined as a drop in serum bilirubin of <25% within 7 days or death within 6 months. In vitro steroid resistance was measured in PBMC using the dexamethasone suppression of lymphocyte proliferation assay and repeated after the addition of the anti-IL-2 receptor (anti-CD25) monoclonal antibody, basiliximab. Suppression of lymphocyte proliferation <60% was considered to indicate steroid resistance. In all, 82% (9/11) of in vitro steroid-resistant patients were dead at 6 months as compared to 21% (2/9) of steroid-sensitive patients (P = 0.03). Similarly, 91% (10/11) of in vitro steroid-resistant patients failed to show a significant fall in bilirubin at day 7 as compared to 44% (4/9) of steroid-sensitive patients (P < 0.05). Basiliximab improved the maximal proliferation count in 91% (10/11) of in vitro steroid-resistant patients (P = 0.003).

CONCLUSION

Clinical outcome of steroid therapy in this patient cohort correlated with in vitro steroid resistance. IL-2 blockade improved in vitro steroid sensitivity. This suggests that intrinsic lack of steroid sensitivity may contribute to poor clinical response to steroids in severe AH. IL-2 receptor blockade represents a possible mechanism to overcome this.

Rehabilitation as a conservation tool: a case studyusing the common wombat

Wildlife rehabilitation seeks to return healthy animals back to their natural habitat with good survival prospects,and hence contribute to the persistence of their populations. However, the effectiveness of rehabilitation remains largelyundocumented, and its utility as a conservation tool is unclear. In this paper, we document the rehabilitation successof a large, herbivorous marsupial, the common wombat (Vombatus ursinus), and use the findings as a case study toevaluate the contribution that rehabilitation can make to wildlife conservation. Using a database of 54 orphaned wombatsmonitored for up to eight years, we found that 81.5% of young survived to release and, of those, 77.3% were alivein the wild by the end of the study. Survival during rehabilitation was greater for larger, older animals, but influencedalso by problems during care, reaction to human contact following weaning and, in particular, the responses ofindividuals to treatment. No factors associated with rescue condition, rehabilitation or release affected survival of animalsonce returned to the wild, suggesting that wombats were not disadvantaged by their progression through rehabilitation.We provide brief recommendations to improve rehabilitation success for wombats. We conclude that rehabilitation isan under-recognized but potentially valuable conservation tool, and suggest that it is timely to consider its contributionto wildlife management more generally.

Direct detection of lower hybrid wave using a reflectometer on Alcator C-Mod

The possibility of directly detecting a density perturbation produced by lower hybrid (LH) waves using a reflectometer is presented. We investigate the microwave scattering of reflectometer probe beams by a model density fluctuation produced by short wavelength LH waves in an Alcator C-Mod experimental condition. In the O-mode case, the maximum response of phase measurement is found to occur when the density perturbation is approximately centimeters in front of the antenna, where Bragg scattering condition is satisfied. In the X-mode case, the phase measurement is predicted to be more sensitive to the density fluctuation close to the cut-off layer. A feasibility test was carried out using a 50 GHz O-mode reflectometer on the Alcator C-Mod tokamak, and positive results including the detection of 4.6 GHz pump wave and parametric decay instabilities were obtained.