Are there predictive factors of severe liver fibrosis in morbidly obese patients with non-alcoholic steatohepatitis?

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is a clinicopathological entity characterized by the presence of steatosis and lobular and/or portal inflammation with or without fibrosis. Patients with non-alcoholic fatty liver and fibrosis on liver biopsy have increased liver-related deaths.

METHODS

181 wedge liver biopsies, taken at the time of bariatric surgery from patients with a mean body mass index (BMI) of 47, were studied. In all cases, the liver biopsy was performed without knowledge of the patient's clinical and biochemical data, which were then examined with univariate and multivariate analysis.

RESULTS

Diagnosis of NASH was established in 105 patients (91%); 74 patients (70%) showed mild steatosis, 20 (19%) had moderate inflammation and fibrosis, and 11 (10%) had steatosis with severe fibrosis. None of the liver biopsies showed cirrhosis. Age was the only independent predictor of moderate and severe fibrosis (p = 0.001).

CONCLUSIONS

Since only age was a predictor of moderate or severe fibrosis, and no clinical or biochemical abnormalities detected slowly progressive hepatic fibrosis, liver biopsy is the only means of detecting progression to more advanced liver disease in a NASH patient.

Spontaneous retropharyngeal hematoma: diagnosis by mr imaging

Spontaneous retropharyngeal hematoma is an uncommon entity that is difficult to diagnose and may progress rapidly to airway obstruction. We report a case of a 53-year-old man with acute onset of retropharyngeal pain, dysphonia, and dysphagia after vomiting. On CT, a nonspecific retropharyngeal collection was seen. MR imaging demonstrated blood products, suggesting a diagnosis of retropharyngeal hematoma, and the patient was managed conservatively. MR imaging allowed specific diagnosis of a rare condition that is otherwise difficult to diagnose without surgical intervention.

Asialofetuin liposome-mediated human alpha1-antitrypsin gene transfer in vivo results in stationary long-term gene expression

The development of nonviral vectors for in vivo gene delivery to hepatocytes is an interesting topic in view of their safety and tremendous gene therapy potential. Since cationic liposomes and liposome uptake by receptor-mediated mechanisms could offer advantages in the efficacy of liposome-mediated gene transfer, we studied the effect of liposome charge (anionic vs. cationic) and the covalently coupled asialofetuin ligand on the liposome surface in mediating human alpha1-antitrypsin (hAAT) gene transfer to mice in vivo. The changes in liposome charge were made by adding the following lipids to the backbone liposomes: anionic phosphatidylserine, cationic N-[1-(2,3-dioleoyloxy)propyl]-N,N,N-trimethyl-ammonium methylsulfate or a lipopeptide synthesized from dipalmitoylphosphatidylethanolamine and covalently coupled to the cationic nuclear localization signal peptide. Two plasmids containing the hAAT gene were used: pTG7101, containing the complete genomic sequence of the human gene driven by the natural promoter, and p216, containing the human hAAT cDNA under the control of the CMV promoter. The results indicate that both untargeted anionic and cationic liposomes mediate plasma levels of hAAT that decline over time. However, asialofetuin liposomes increase the plasma levels of hAAT and can mediate long-term gene expression (>12 months) with stationary plasma levels of protein. Results from quantitative and qualitative reverse transcriptase polymerase chain reaction match those from protein plasma levels and confirm both the human origin of the message and the liver as source of the protein. The use of asialofetuin liposomes in hepatic gene therapy may both increase and prolong in vivo gene expression of hAAT and other clinically important genes.

[Why are not all patients with chronic liver disease associated with hepatitis C virus treated?]

AIMS

To analyze the prevalence of patients with chronic liver disease associated with hepatitis C virus (HCV) not undergoing antiviral treatment and the reasons for which this treatment was not indicated.

PATIENTS AND METHODS

718 patients with HCV infection referred for therapeutic evaluation between January 1990 and January 1998. Demographic, clinical, biological and histological variables were prospectively analyzed. The patients were divided into two groups: treated and untreated.

RESULTS

393 patients were treated and in 325 patients antiviral treatment was not considered to be indicated. The most frequent reasons for not starting therapy were advanced age, the presence of decompensated cirrhosis and the patients' refusal to undergo antiviral treatment.

CONCLUSIONS

A broad subgroup of patients with chronic liver disease associated with HCV do not receive antiviral treatment. This is related with: a) patients' advanced age at diagnosis, b) diagnosis at the advanced stages of the disease, and c) patients' refusal to undergo such treatment after being informed of its potential risks and benefits.

Involvement of the fas system in hepatitis C virus recurrence after liver transplantation

To date, there have been no reports of the involvement of the Fas system in recurrent hepatitis C virus (HCV) infection after orthotopic liver transplantation (OLT). In 25 patients who underwent OLT for HCV-related liver cirrhosis, we evaluated the expression of the Fas antigen (FasAg) on hepatocytes, apoptic hepatocytes, and serum levels of soluble Fas (sFas). The level of HCV viremia and HCV genotype were determined by polymerase chain reaction. Serum sFas levels were determined by an enzyme immunoassay procedure. DNA fragmentation was determined by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) technique on deparaffinized liver samples. FasAg expression was evaluated by an immunoperoxidase method. Sixteen patients had evidence of recurrent HCV disease. The number of hepatocytes expressing FasAg and the percentage of apoptotic hepatocytes was greater among patients who developed recurrent hepatitis than among those who did not (P <.01 and P <.0001, respectively). There was a correlation between hepatic expression of FasAg, intensity of lobular inflammation (P =.007), and TUNEL index (P <.001). The levels of sFas were greater among the patients with recurrent HCV hepatitis than those without recurrent hepatitis (P <.04). We conclude that (1) Fas expression is up-regulated in recurrent HCV after OLT and is related to the grading of liver disease; likewise, levels of sFas were greater in the patients with recurrent HCV hepatitis; and (2) the demonstration of hepatocytes with FasAg expression and the labeling of the nuclei by TUNEL assay suggest that hepatic apoptosis mediated by the Fas system may have a role in the pathogenesis of recurrent HCV hepatitis after OLT.

Active recombinant human tyrosine kinase c-Yes: expression in baculovirus system, purification, comparison to c-Src, and inhibition by a c-Src inhibitor

C-Yes is a non-receptor-type tyrosine kinase of the Src family that is most closely related to c-Src. C-Yes has been implicated in development of some human cancers. Here we report on the expression, purification, and characterization of the active human recombinant c-Yes. A full-length human c-Yes clone has been generated and the protein was expressed in insect Sf9 cells. Active c-Yes was purified by liquid chromatography to yield a preparation with a high specific activity (160 nmol/min/mg using an optimal Src substrate peptide). In a comparison between human c-Yes and c-Src enzymes, relative phosphorylation efficiencies on nine protein and four peptide substrates were different. However, the recently described Src inhibitor CGP77675 inhibited human c-Yes with a potency similar to that of c-Src (IC(50) value of 6.5 nM). The purified preparation of active c-Yes provides a good basis for further enzymatic characterization and for the development of c-Yes-specific inhibitors.

[An unusual complication of esophageal foreign body]

Esophageal foreign bodies must be carefully managed because they carry a high risk of potentially severe complications. A case of a sharp foreign body located in a previously unsymptomatic pharyngoesophageal diverticulum is described. The management protocol for esophageal foreign bodies is reviewed. Fiberesophagoscopy is the therapeutic technique of choice, but it may be dangerous if patients are not selected properly.

[Soluble Fas in acute rejection in patients with liver transplantation. Response to treatment]

It has been suggested that in the cellular rejection of hepatic graft, the lesion provoked by cytotoxic T-lymphocytes might be mediated by the Fas antigen/Fas ligand system, producing cell death by apoptosis.

AIM

To determine whether soluble Fas (sFas) is increased during treatment and to evaluate response to treatment.

MATERIAL AND METHODS

Fourteen patients with orthotopic liver transplantation who presented an episode of acute cellular rejection were studied. Serum levels of sFas were detected by enzyme-immunoanalysis at diagnosis and again 5 days after treatment was completed. As control groups, sFas was analyzed in 12 patients with liver transplantation without rejection and in 10 healthy subjects.

RESULTS

sFas levels were found to be significantly higher in patients with rejection than in those without rejection and in healthy subjects (24.2 +/- 39.1 vs. 2.8 +/- 4.0 vs. 0.6 +/- 1.5 UI/ml; p = 0.03). In patients with acute cellular rejection, immunosuppressive treatment significantly decreased sFas levels compared with basal values (24.2 +/- 39.1 vs. 9.9 +/- 30.2 UI/ml; p = 0.005). A clear correlation between the serum levels of sFas, glutamate oxaloacetate transaminase (GOT), glutamate-pyruvate transaminase/glutamic-pyruvic transaminase (GPT) and gamma-glutamyl transferase (GGT).

CONCLUSIONS

a) The increase of sFas during rejection and the decrease in patients with a good evolution suggests that the Fas system may play an important role in the hepatocyte lesion produced by an apoptosis mechanism in these patients. b) Monitoring sFas could be useful in diagnosing rejection and in evaluating response to treatment.

Different time course of circulating adhesion molecules and hyaluran during hepatic allograft rejection

BACKGROUND

Inducible adhesion molecules are involved in cell-mediated allograft rejection. In addition, the endothelium is the main target of this process. This study investigated, whether soluble (s) forms of vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1) are elevated during cellular rejection and whether hyaluran is a useful marker of endothelial function in liver transplantation.

METHODS

Serum levels of sICAM-1, sVCAM-1, and hyaluran were determined in 24 controls and 27 hepatic transplant recipients. These patients were divided in two groups: group I, 14 patients without rejection; and group II, 13 patients with rejection. Samples were collected on day 1 and 7 after transplantation, on the day of liver biopsy, and after treatment of the rejection.

RESULTS

We found a significant increase in sICAM-1 levels in the postoperative period in the rejection group compared with the non rejection group. It persisted significantly elevated until the diagnosis of rejection was made. In contrast, sVCAM-1 was only significantly elevated in the rejection group when diagnosis of rejection was evident. Hyaluran levels were also significantly elevated in the rejection group at diagnosis of rejection. We noticed a significant decline in sICAM-1, sVCAM-1, and hyaluran levels after successful treatment of rejection. In addition, we observed in the non-rejection group a stable lower levels of hyaluran during the entire postoperative period.

CONCLUSIONS

The release of circulating adhesion molecules is a prominent feature coinciding with the first episode of hepatic rejection. Differential patterns of sICAM-1 and sVCAM-1 exist during rejection. In addition, hyaluran levels may be a sensitive marker of liver endothelial cell function in the postoperative period of liver transplantation.

Pharmacokinetics of oligodeoxynucleotides encapsulated in liposomes: effect of lipid composition and preparation method

1. The effect of the method employed to prepare liposomes and their lipid composition were evaluated in terms of the encapsulation efficiency and pharmacokinetic features of two oligodeoxynucleotides of a 21 mer: the normal (N-Odn) and the phosphorothioate (S-Odn) oligodeoxynucleotide. 2. Liposomes were prepared by the classical method of multilamellar vesicles (MV) and by the dehydration-rehydration method (DR). Two lipid mixtures were used to prepare liposomes--the predominant lipid being phosphatidylcholine (PC) and sphingomyelin (SM) respectively. 3. The DR method for liposome preparation provided the highest encapsulation efficiency, regardless of liposome lipid composition and the type of oligodeoxynucleotide involved (N-Odn or S-Odn). 4. The pharmacokinetics of free and liposome encapsulated oligodeoxynucleotides was studied in mouse following i.v. administration. Liposome encapsulated oligodeoxynucleotides exhibited a significantly lower plasma clearance and longer half-life and residence time than free oligodeoxynucleotides. The method used to obtain the liposomes affected plasma clearance, which was lower for liposomes elaborated by the DR method than for liposomes prepared with the MV method. The use of S-Odn in place of N-Odn decreased the plasma clearance of oligodeoxynucleotide when administered encapsulated in liposomes, regardless of the lipid composition and method used to obtain the liposomes.

Adrenomedullin in liver transplantation and its relationship with vascular complications

Adrenomedullin (AM) is a potent vasodilating peptide that increases rat platelet cyclic adenosine monophosphate levels and acts on endothelial cells to stimulate nitric oxide release. Both mechanisms inhibit platelet function. Considering these effects, AM may have a role in cardiovascular regulation after orthotopic liver transplantation (OLT) and could have an antithrombotic effect. The aim of the present study is to investigate plasma AM levels in the early postoperative period after OLT and their relationship with vascular complications in OLT. We measured plasma AM levels in 35 patients with cirrhosis who underwent OLT at baseline and 1, 7, and 15 days postoperatively. We found that AM levels were significantly greater in patients with cirrhosis compared with healthy subjects. Of the 35 patients, 10 had vascular complications. In these 10 patients, AM concentrations were significantly greater than those observed in the nonthrombotic group in the early postoperative period. In addition, we also noticed in the nonthrombotic group a significant increase in AM levels from baseline to day 1, then a decrease to baseline levels in the early postoperative period. Our study shows that AM might act as a new humoral factor involved in the response to surgery in OLT and is significantly associated with vascular thrombosis in OLT.

Granulocyte elastase in cirrhotic patients with spontaneous bacterial peritonitis

Granulocyte elastase (GE) is a powerful proteolytic enzyme that is released by PMNs when degranulated in infectious processes. The aim of this study was to measure GE in ascites and plasma of cirrhotic patients with spontaneous bacterial peritonitis (SBP). We studied 29 cirrhotic patients, 17 of them having SBP (group A). Twelve patients with noninfected ascites formed the control group (group B). At the time of diagnosis of SBP, GE levels in ascites (183.17 +/- 86.11 microg/liter) and plasma (114.6 +/- 35.99 microg/liter) were higher in group A than in group B (27.41 +/- 11.54 microg/liter, P < 0.00001 and 82.54 +/- 20.52 microg/liter, P = 0.01, respectively). Levels of GE in ascites had a high value for discriminating between patients with and without SBP. In the patients who responded to the initial antibiotic treatment, these values significantly decreased in ascites (67.69 +/- 54.22 microg/liter, P = 0.003) and plasma (67 +/- 22.39 microg/liter, P = 0.01) 48 hr after therapy was started, in parallel with the decrease of PMN in ascites. In patients who did not respond, the production of GE remained elevated. Patients who developed renal insufficiency following SBP had more marked elevation of GE in plasma (144.8 +/- 33.43 microg/liter) than those with normal renal function (99.5 +/- 27.53 microg/liter, P = 0.02). These results suggest that the measurement of GE may be helpful for the diagnosis of SBP in patients with cirrhosis and for assessing the efficacy of therapy. In addition, the release of GE into plasma may contribute to the impairment of renal function that follows SBP in some patients.

Exposure to MDI during the process of insulating buildings with sprayed polyurethane foam

Buildings are often insulated with sprayed-in-place polyurethane foam in spite of the fact that few studies have been carried out on exposure levels to isocyanates during the spraying process. This paper is meant to provide new data on personal exposure to methylene-bis (4-phenylisocyanate) (MDI) while dwellings and office buildings are being insulated with polyurethane foam. An impinger using a 1-(2-methoxyphenyl)piperazine toluene solution as absorbent was used to take personal samples for the sprayer and helper during indoor and outdoor applications. The analytical results show that the levels of exposure were significant, especially for the sprayer, with values of up to 0.077 mg m-3 and 0.400 mg m-3 during outdoor and indoor applications, respectively. The helper's exposure was always lower.

A concept model for the automatic maintenance of controlled medical vocabularies

A controlled medical vocabulary is a fundamental requirement in a range of medical informatics applications. Large vocabularies development and maintenance is labor intensive and costly. Maintainers of medical vocabularies need appropriate tools to do their work correctly. In this paper, we describe our concept model for a controlled medical vocabulary. We present how this model can check vocabulary consistency. We propose a set of tools in a distributed environment, which permits edition, visualization and maintenance of medical terminologies.

Disseminating multimedia protocols over Internet for emergency and catastrophe management

Over the last years we have developed various computing methods to assist specialized personnel on various aspects of catastrophe and emergency management. New models can address tasks such as patient triage; stabilization, resource coordination and hospital alertness and techniques based on information technologies. In this paper we present various tools (written on Java and C+2) that we created to store, represent, and disseminate practice guidelines and protocols over the World Wide Web. Guidelines and protocols are stored using a standard database program (e.g., Microsoft Access), and represented in a flowchart format linked to multimedia information such as text, pictures, sound, video or external sources of data. Using our JAVA tool, protocols can be disseminated over the Web and viewed with any browser with JAVA compliance. We have implemented 15 emergency protocols that we developed in collaboration with specialized military personnel from the Ministry of Defense, Spain. Users can access remotely those electronic protocols comparing their procedures and methods. Our goal is to enhance agreement and consensus among remote medical centers regarding emergency and catastrophe management, establishing discussions over the network. Our tools have also a potential for training medical and paramedical personnel for emergency situations.

Implications of sperm chromosome abnormalities in recurrent miscarriage

PURPOSE

Our purpose was to assess the existence of sperm chromosome abnormalities in recurrent pregnancy loss in an assisted reproduction program.

METHODS

In this prospective study, 12 sperm samples from couples undergoing in vitro fertilization with two or more first-trimester spontaneous abortions were analyzed. Diploidy and disomy in decondensed sperm nuclei were assessed for chromosomes 13, 18, 21, X, and Y using two- and three-color fluorescence in situ hybridization.

RESULTS

Sex chromosome disomy in sperm samples from recurrent abortion couples was significantly increased compared to that from internal controls (0.84% vs 0.37%). In a subpopulation of seven couples who underwent oocyte donation, mean frequencies for sex chromosome disomy (1%) were even higher and diploidy (0.43%) was also significantly increased.

CONCLUSIONS

These results suggest an implication of sperm chromosome abnormalities in some cases of recurrent pregnancy loss.

Severe clinical course of de novo hepatitis B infection after liver transplantation

The aim of this study is to determine the origin, clinical outcome, allograft histological characteristics, and virological outcome of de novo hepatitis B virus (HBV) infection after orthotopic liver transplantation (OLT). We studied 136 hepatitis B surface antigen (HBsAg)-negative liver transplant recipients. HBV DNA was detected by dot-blot hybridization and polymerase chain reaction (PCR). The S gene was sequenced. Hepatitis C virus (HCV) RNA was assessed by PCR. The long-term clinical and histological outcome was determined. Six of 136 HBsAg-negative patients (4.4%) became HBsAg positive after transplantation. The source of HBV infection was reactivation of latent HBV infection in 2 patients and was not identified in 4 patients. Two donors had isolated core antibody. Two of these 6 patients developed acute liver failure related to hepatitis B. The 4 other patients had severe chronic hepatitis related to hepatitis B. All patients had high-level HBV replication. No significant mutations in the S gene were found. These data suggest that de novo hepatitis B infection is not a mild disease and might represent a significant cause of graft dysfunction. This is the first report of fulminant hepatitis caused by de novo hepatitis B infection after OLT.

Variceal ligation compared with endoscopic sclerotherapy for variceal hemorrhage: prospective randomized trial

BACKGROUND

To evaluate the safety and efficiency of variceal ligation compared with endoscopic sclerotherapy, 88 patients with cirrhosis with recent variceal bleeding were randomized to undergo either treatment.

METHODS

Sclerotherapy was performed using ethanolamine and polidocanol injection at 1, 2, and 3 weeks and every 3 weeks thereafter. The Stiegmann-Goff device was used for variceal ligation at the same intervals.

RESULTS

The rate of variceal eradication was the same for both groups, but eradication was accomplished sooner in patients undergoing variceal ligation (5.3+/-1.6 vs. 6.6+/-2.4 endoscopic sessions, p < 0.05) and with fewer complications (19 vs. 6, p < 0.005). The rate of recurrent bleeding was lower in patients treated by ligation (31% vs. 50%, p < 0.05). After eradication, variceal recurrence was more frequent in patients treated by variceal ligation at 1 and 3 years (47% and 92% vs. 23% and 55%, p < 0.01). Portal hypertensive gastropathy was significantly worse in the patients who had variceal ligation (17 patients vs. 6, p < 0.01). Survival and treatment failure were similar in both groups.

CONCLUSIONS

Variceal ligation was superior to sclerotherapy in terms of the rate of recurrent bleeding and the occurrence of complications but worse with respect to recurrence of varices and the evolution of portal hypertensive gastropathy. Long-term follow-up studies are required to find out whether there are deleterious effects of variceal ligation.

Hepatitis G virus infection as a possible causative agent of community-acquired hepatitis and associated aplastic anaemia

Aplastic anaemia complicating hepatitis is a rare but well-documented phenomenon; however in many patients the cause remains unknown. We present a 24-year-old man with a well-defined community-acquired hepatitis, probably due to hepatitis G virus (HGV), who developed severe aplastic anaemia. In this case, the absence of other agents likely to cause the clinical manifestations, and the detection of HGV RNA at the time of illness, clearly point to this agent as being responsible for both the hepatitis and the aplastic anaemia. Further studies in serial serum samples and meticulous evaluation of the disorders associated with the infection will be needed to prove or dispute a causal association of HGV and aplastic anaemia.

P2Y receptor subtypes differentially couple to inwardly-rectifying potassium channels

Subtypes of P2Y receptors are well characterized with respect to their agonist profile but little is known about differences in their intracellular signalling properties. When expressed in Xenopus oocytes, both P2Y2 and P2Y6 receptors effectively couple to endogenous Ca2+-dependent Cl--channels. However, only P2Y2 receptors increased currents mediated by inward-rectifier K+ channels of the Kir3.0 subfamily. This increase in Kir-current was sensitive to pertussis toxin, while activation of Ca2+-dependent Cl--channels was not. In contrast, suramin, a P2 receptor antagonist, inhibited activation of both channels. These observations suggest that, in contrast to P2Y6, P2Y2 receptors couple to two different classes of G proteins.

Effect of the protein kinase inhibitors, 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine H-7 and N-(2-[methylamino]ethyl)-5-isoquinoline-sulfonamide H-8 on Lewis lung carcinoma tumor progression

The effects of 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine H-7 (a cAMP-dependent protein kinase and protein kinase C inhibitor), n-(2-[methylamino]ethyl)-5-isoquinoline-sulfonamide H-8 (a cAMP- and cGMP-dependent protein kinase inhibitor) and indomethacin (IND, a cyclooxygenase inhibitor) on both the spontaneous metastatic ability of 3LL (Lewis lung carcinoma) tumor cells and anti-tumor host response were studied. The study of tumor progression showed that H-7 and H-8 (2 mg kg(-1) day(-1) , i.p., for 8 days) significantly reduced the mean number of metastases (0.8 +/- 0.2 and 1.0 +/- 0.7, respectively, P < 0.05) with respect to the number of lung metastases (4.2 +/- 2.1) observed in the control group. In turn, the highest tumor-specific cytotoxicity response (50% increase vs. non-treated target cells) was observed when both animal and tumor cells were treated with H-8. This suggests that the protein kinase inhibitors could inhibit tumor progression toward lung metastases formation by blocking the immunosuppressor mechanism triggered by agents that increase intracellular cAMP.

Alcoholic recidivism after liver transplantation for alcoholic cirrhosis

Liver transplantation (LT) for alcoholic cirrhosis remains controversial. This controversy surrounding LT in alcoholics focuses on the risk of alcohol recidivism and on potential noncompliance with the immunosuppressive regimen, both of which result in graft failure. Our study examined alcohol recidivism after LT by measuring alcohol in urine and its repercussion on the allograft. Forty-four consecutive alcoholic patients and a comparison group of 17 patients receiving LT were included in this study and followed up for a mean of 39.5 +/- 19.6 months. Seven percent (3 of 44) of patients with alcoholic liver disease and 0% of patients in the comparison group admitted to having used alcohol after LT. Alcohol in urine, however, was detected in 18% (8 of 44) of the alcoholic group; therefore the true recidivism rate was higher than the rate admitted. All patients in both groups were compliant with the medications, because the cyclosporine levels were within the therapeutic range in all. On histologic examination the only alcohol-induced lesion found in three of the eight recidivistic patients was steatosis. Therefore, although alcoholic recidivism occurs, it does not seem to affect compliance to treatment profoundly or to compromise graft function. Therefore, LT seems justified for end-stage alcoholic cirrhosis.