Review article: angiogenesis soluble factors as liver disease markers

Angiogenesis is the formation of new blood vessels from pre-existing ones; it has been studied at the molecular level in different pathologies and is currently considered a promising novel therapeutic target in cancer. Recently, the use of angiogenesis soluble factors as markers of tumour growth has been investigated. The knowledge gained has led to test their use as therapeutic agents. Additionally, angiogenesis soluble factors could be used for the follow-up of pathologies that currently require monitoring with invasive techniques, like chronic viral hepatitis or renal and haematological diseases. The different factors have been described in multiple studies. In some cases, such as hepatocellular carcinoma, a potential use as prognostic markers has been suggested.

Effects of herbicide on the kidneys of two Venezuelan cultured fish: Caquetaia kraussii and Colossoma macropomum (Pisces: Ciclidae and Characeae)

The use of chemical pesticides and herbicides has increased environmental pollution and affected ichthyofauna in the watersheds where they are used. We studied the effect of an herbicide, triazine, on the kidneys of two species (Caquetaia kraussii and Colossomna macropomum) widely found in Caribbean and South American rivers. In Venezuela, these species are abundant and have a high aquaculture potential because they may be cultured and reproduced in captivity. Four kidney samples from juveniles of each species exposed to the herbicide were examined by Transmission Electron Microscopy. Kidney tubule alterations included loss of plasmalemma and cell interdigitations, misshaped mitochondria, decrease in rough endoplasmic reticulum and free polysomes, and the presence of autophagic vacuoles and primary lysosomes. These alterations at the cellular level may explain fish behaviour in terms of kidney tubule pathology, and relative amounts and conditions of organelles within affected cells.

La technique de « pseudo-pollicisation » ulnaire dans les différences congénitales

In certain rare cases of thumb aplasia or hypoplasia, pollicisation of the second finger is not recommended or impossible. It happens when the most radial fingers are hypoplastic or abnormal or when an ulnar prehension pattern has already developed. In these cases, if functional, pollicisation of the most ulnar finger in not suitable because of the ugly cosmetic result. In order to combine the functional advantages of the ulnar pollicisation with a satisfactory cosmetic appearance, the authors describe pseudo-ulnar pollicisation by supination osteotomy. This operation combines rotation of the fifth ray with the establishment of a larger web space between the two most ulnar fingers. We have used this technique in five preliminary cases with a minimum follow-up of 18 months.

Déficiences longitudinales ulnaires : proposition d’une classification descriptive

Ulnar longitudinal deficiency is an extended malformation sometimes involving the whole upper extremity, even including sometimes the opposite side. The clinical and radiological aspects are variable and none of the existing classifications takes into account all the possible deformities. Multiple decisive factors in the surgical indications are missing such as shoulder stability, elbow position (extension or flexion with or without pterygium), orientation of the hand (internal rotation), wrist inclination and number of digits. Based on a review of our 46 clinical cases as well as the published cases in the literature we have developed a simple way to describe each level.

Hepatitis C virus-related extra-hepatic disease--aetiopathogenesis and management

Summary Hepatitis C virus infection is often associated with extra-hepatic manifestations, secondary to the elicitation of autoimmune reactions, generalized deposition of immune complexes and lymphoproliferative disorders. The most clearly established associations are those linking chronic hepatitis C with mixed cryoglobulinaemia (and the related glomerulonephritis and cutaneous vasculitis), as well as with the presence of autoantibodies. Less well-documented disorders include non-Hodgkin's lymphoma, thrombocytopenia, sialadenitis, thyroid disease, lichen planus, porphyria cutanea tarda, rheumatoid disorders and neurological disorders. Extra-hepatic manifestations are most frequent in patients of female sex, advanced age, long-lasting infection and cirrhosis. Optimal treatment strategies should be based on the predominant manifestation of the disease. In the case of autoimmune disorders not clearly attributable to the viral infection, corticosteroids may be the most effective option. Interferon-alpha alone or in combination with ribavirin may be indicated for those disorders related to immune complex deposition, such as mixed cryoglobulinaemia, although relapses of extra-hepatic signs often occur on discontinuation of treatment. In some cases, interferon-alpha may induce or exacerbate some extra-hepatic manifestations.

Pollicization in Congenital Differences

Pollicization of the index finger is a well established procedure for some cases of thumb hypoplasia. We reviewed our experience of 27 "normal" index-finger pollicizations with a mean follow-up of seven years, excluding those cases with more extensive radial hypoplasia and abnormal fingers. Even in such an "ideal" situation, strength was deceptive and the frequently slender aspect of the new thumb with quite extensive dorsal scar formation and the "cleft" appearance of the first web disappointing. In a prospective series of 32 cases, we tried to improve both the function and appearance of the thumb by modifying the classical incision as well as the transferred muscles and tendons.

Percutaneous needle aponeurotomy: complications and results

Recently French rheumatologists have repopularized fasciotomy using a percutaneous needle technique. This blind approach has been claimed to be plagued by numerous complications. We reviewed the charts of 211 patients treated consecutively on 261 hands and 311 fingers to assess the rate of postoperative complications. The first 100 patients were evaluated with a mean follow up of 3.2 years to assess the rate of recurrences and extension of the disease. In the whole group the mean age was 65 years and delay between onset and treatment was 6 years. Division of the cords were performed only in the palm in 165 cases, in the palm and finger in 111 and purely in the finger in 35. Complications were scarce without infection or tendon injury but one digital nerve was found injured during a second procedure. Postoperative gain was prominent at metacarpophalangeal joint level (79% versus 65% at interphalangeal level). The reoperation rate was 24%. In the group assessed at 3.2 years follow up, the recurrence rate was 58% and disease "activity" 69%. Fifty nine hands need further surgery. The ideal indication for this simple and reliable technique is an elderly patient with a bowing cord and predominant MP contracture.

Therapeutic advantages of pegylation of interferon alpha in chronic hepatitis C

Modification of the pharmacokinetic profile of interferon-alfa (IFNalfa) through pegylation (addition of a polyethylenglicol molecul) has resulted in a marked improvement of drug efficacy for the treatment of infection due to hepatitis C virus. Two pegylated derivatives of IFNalfa are available: PEG-IFNalfa-2a, with a 40 kDa polyethylenglicol molecule of branched structure, and PEG- IFNalfa- 2b, with a 12kDa linear PEG. Both compounds have slower absorption, more reduced distribution and lower elimination rate than the respective non- pegylated IFNalfa, which assures that concentrations appropriate to inhibit viral replication are maintained during longer periods of time, thus a allowing administration once a week, In addition to archieving greater therapeutic efficacy, the adverse effects related to excessive Cmax are reduced, the risk of therapeutic failure is decreased by eliminating the intervals of inefficient plasma levels, and the uncomfortable thrice weekly injection regimens are avoided. The current recommendations include the use of a combination therapy with pegylated IFNalfa and ribavirin as the standard treatment. However, further research is required to archieve dosage optimization of pegylated IFN and rebavirin according to the patientś characteristics and to evaluate the efficacy and safety of this combined theraphy for difficult- to- treat patients.

Review article: immunopathogenetic and therapeutic aspects of autoimmune hepatitis

Autoimmune hepatitis is a chronic, progressive liver disease that responds well to immunosuppressive therapy, but has a poor prognosis if untreated. Possible triggering factors include viruses, other autoimmune disorders and drugs. The molecular mechanisms contributing to the pathogenesis include: reactions of autoantibodies against their corresponding autoantigens; aberrant expression of histocompatibility antigen class I and II molecules, cell adhesion molecules and cytokines; increased oxidative stress; and the occurrence of angiogenesis. The prevalence of the disease is highest in Caucasians, Europeans and women. The natural history of autoimmune hepatitis shows a poor prognosis, with frequent progression to cirrhosis and hepatic insufficiency in untreated patients. The occurrence of hepatocellular carcinoma is rare and is found only in long-standing cirrhosis. Corticosteroids as monotherapy or in combination with azathioprine are the treatments of choice; different therapeutic schedules and particularities of treatment for pregnant women and children have been established. To avoid treatment-associated adverse effects, alternative therapies have been proposed, including ciclosporin, budesonide, tacrolimus, mycophenolate mofetil, ursodeoxycholic acid, methotrexate, cyclophosphamide, mercaptopurine and free radical scavengers. Liver transplantation is indicated for patients refractory to or intolerant of immunosuppressive therapy.

[The "candlestick" technique for the correction of certain types of congenital metacarpal synotosis]

Metacarpal synostosis is a rare congenital hand malformation requiring only occasionally a surgical correction. However in case of divergent epiphyses there is a progressive accentuation of the deformity. In the "Y" type of symmetrical synostosis, the authors propose a trapezoidal osteotomy with upside down relocation allowing realignement of the epiphyses without distant bone donor site.

Assessment of the phototoxic potential of compounds and finished topical products using a human reconstructed epidermis

The goal of this study was to design a model system for the assessment of phototoxic potential using a human reconstructed epidermis (HRE, SkinEthic Laboratories, Nice, France), by testing some representative phototoxic (P) and non-phototoxic (NP) compounds and finished topical products. The tissue response to 24-h application of 5-5000 microg/mL of the test agents in the presence and absence of UVA light was analyzed in terms of viability (Lactate Dehydrogenase release), pro-inflammatory activity (IL-8 release and mRNA expression) and morphology (histopathology). 8-Methoxypsoralen (P) and promethazin (P), but not sodium lauryl sulfate (NP) produced cytotoxicity concentration-response curves significantly different between irradiated and nonirradiated tissues. Only irradiated tissues showed morphological damage. Application of tetracyclin (P) in the culture medium, but not topically, induced similar signs of phototoxicity. 6-Methylcoumarine (weak P) was not cytotoxic, yet it increased IL-8 release and mRNA expression only following UVA irradiation. PUVA therapy creams containing 1% 8-Methoxy-psoralen (P) or coal tar (P) decreased viability and induced histologic damage in UVA-exposed tissues. In conclusion, the phototoxic potential of the tested agents was correctly predicted by using a tiered strategy that involves determining cytotoxicity, production of IL-8, and morphological damage following exposure of the HRE to the compounds and UVA light.

[Secondary treatment of digital mutilations: reconstruction or amputation]

Decision for stump improvement, shortening or reconstruction after finger mutilation is based on multiple factors. Some of them belong to the patient, age, psychological background, job and leisure activities and cosmetic expectation. Others belong to the injury, its mechanism and the anatomical lesions. Abstention, prostheses and rehabilitation are among the options. Conventional techniques are not to be forgotten as age remains an ultimate frontier in microsurgical reconstruction to obtain a good sensory result. Function and appearance are closely linked for a useful and a used hand.

[Recurrence of finger tendon giant cell tumors after excision through a "shark teeth" approach. Report of 25 cases]

Local recurrences after excision of a giant cell tumor of the tendon sheath are classically related to incomplete excision. We have review a special group of circumferential tumors excised through a huge approach. Twenty-six circumferential tumors were excised between 1985 and 1998, through a special incision described by the senior author. It is composed of four triangular flaps drawn around the finger, one dorsal, one palmar (both proximally based) and two lateral (distally based). Six presented already with a recurrence of previous operations (mean 2.5 interventions). Some anatomical neighboring structure was "invaded" in all except one case. However the approach allows for a macroscopically satisfactory excision. Twenty-five patients were reviewed by an independent observator after a mean follow-up of six years. Six patients (24%) presented a recurrence after a mean postoperative delay of 17 months. Among them five have been already operated (83%) and five had multiple tumors. Satisfactory excision does not prevent recurrence and two types of distinct tumors exist. Recent immunohistological studies give support to this view and such examination is recommended.

Metacarpal synostosis: a simple classification and a new treatment technique

The current classification of metacarpal synostosis is based on the extent of the synostosis. The authors propose a new classification that takes into account the shape of the metacarpal bones, the curvature of the epiphysis, and the discrepancy in length between the two bones. This classification provides better guidelines for the correction of all components of the deformity. The classification is based on the authors' observations of and experience with 36 cases of metacarpal synostosis; 13 of the deformities were surgically corrected. The I-shaped deformity, whether with distinct (type d) or fused (type f) metacarpophalangeal joints, does not require surgical correction. The U-shaped deformity has parallel epiphysis and does not require surgery unless the two metacarpals are asymmetrical in length (type a) or tightly fused (type t); in these cases, simple lengthening or widening of the space with a bone graft is sufficient. Y-shaped synostosis should be separated whether the branches are symmetrical or asymmetrical, the latter having one branch shorter than the other. Because the epiphyses are already divergent, simple separation does not effectively correct Y-shaped synostosis. The authors propose an osteotomy to isolate a trapezoidal segment of bone from the bifurcation. The isolated bone segment is then reversed in the proximal-distal direction to provide a "plateau" upon which the two distal metacarpals can be realigned. Two cases of Ys (symmetrical) synostosis were successfully treated with this technique; one case of Ya (asymmetrical) synostosis also required distraction lengthening of the shorter metacarpal to achieve an excellent result. One of the most difficult types of metacarpal synostosis to treat is k-shaped synostosis, observed only between the fourth and fifth metacarpals; in this type, the head of the short fifth metacarpal abuts the metaphysis of the fourth. Osteotomy and distraction lengthening provide predictable results for correction of this deformity. The authors suggest that k-shaped synostosis might represent a late evolution of untreated Ua synostosis.

[Progressive bone lengthening of the hand in congenital malformations. 41 cases]

PURPOSE OF THE STUDY

We retrospectively reviewed the experience of two Hand Units with progressive bone distraction lengthening, collecting 41 cases of hand skeleton lengthening for congenital malformations.

MATERIAL AND METHODS

The Ilizarov callostasis method was used in 31 cases and in 10 cases bone union was reestablished at a second stage with an iliac graft (2 cases), vascularized metacarpal bone graft (one case), and vascularized (one case) or nonvascularized (3 cases) toe epiphysis. In the last three cases of index lengthening, the distal part was translocated to the tip of the third, deepening at the same stage the first web. The most frequently treated malformation was symbrachydactyly (22 cases).

RESULTS

Mean lengthening was 2.3 cm (0.9 to 3.5) with a mean treatment duration of 3.8 months (1.5 - 8.2). The "lengthening index" was 0.59. There was a significant difference between phalanx and metacarpal lengthening, but the amount of lengthening or treatment duration were not affected by technique (Ilizarov vs bone grafting) or age. The complication rate was 32%. There were two complete failures, one extensor tendon tear, 3 pin tract infections (one requiring interruption of the lengthening), 2 cases of relevant pain, 2 delayed unions, 2 angulations and 1 callus fracture, 1 metacarpophalangeal dislocation and 1 joint stiffness.

DISCUSSION

Despite advances in micorsurgical toe transfer, there are still indications for bone lengthening in congenital malformations. The apparent simplicity of the technique can mask a certain number of complications, emphasizing the need for surgical experience. Progressive bone lengthening in congenital deformity has the advantage of preserving sensitivity and avoiding bone resorption. Callostasis does not increase the duration of treatment compared to bone graft.

Ductular morphogenesis and functional polarization of normal human biliary epithelial cells in three-dimensional culture

BACKGROUND/AIMS

The understanding of the physiology and function of human biliary epithelial cells (hBEC) has been improved by studies in monolayer culture systems. The aim was to develop a polarized model to elucidate the mechanisms of ductular morphogenesis and functional differentiation of hBEC.

METHODS

The morphological, phenotypic and functional properties of hBEC cultured as three-dimensional aggregates in collagen gel were assessed in medium supplemented with (or without) human hepatocyte growth factor (hHGF) and foetal bovine serum.

RESULTS

In the absence of added mitogens and serum, cells maintained as morphologically polarized aggregates, organized around a central lumen, were positive for phenotypic markers of biliary epithelium and negative for markers of other cell types. Functional markers, gamma-glutamyl-transferase, anion exchanger-2, responses to gamma interferon and forskolin induced secretion, were preserved. hHGF increased both the size and number of aggregates and induced hBEC to invade the gel and lumena forming anastomosing networks of cells.

CONCLUSIONS

Collagen gel culture in the absence of added growth factors and serum provides a model for analysis of the polarized functions of hBEC. The formation of poorly organized cords of cells in response to hHGF suggests that collagen gel culture may provide a model for the investigation of atypical ductular morphogenesis of the human biliary tract.

[Pollicization, remains of the past or current operation]

Pollicization is a long time honored operation but more recent introduction of microsurgical techniques allowing toe to thumb transfers has changed the indications in trauma and congenital malformations. We reviewed two series of patients to assess the long-term result in both traumatized and malformed hands. Twenty-seven pollicized mutilated fingers were reviewed with a mean follow up of 9.5 years; the longest follow up published in the literature. Despite the age quite advanced of the population and multidigital amputations (more than two fingers were amputated in 16 cases), 21 patients had a good or fair result on a global score including mobility, sensibility, daily use, cortical integration, cold intolerance or pain and appearance. In congenital malformations, hypoplasia or aplasia of the thumb in presence of long fingers remains one of the best indication of pollicization. Out of 35 operated children, 27 were reviewed with a sufficient follow up (mean 6 years) to assess the result. Sensibility and growth were excellent (3 cases need some secondary shortening) mobility was close to normal in 61% of cases but the main concern was the strength which reached only 42% of the standard.

[Percutaneous needle aponeurotomy. Complications and results]

Recently French rheumatologists have repopularized fasciotomy using a percutaneous needle technique. This blind approach has been claimed to be plagued by numerous complications. We reviewed the charts of 211 patients treated consecutively on 261 hands and 311 fingers to assess the rate of postoperative complications. The first 100 patients were evaluated with a mean follow up of 3.2 years to assess the rate of recurrences and extension of the disease. In the whole group the mean age was 65 years and delay between onset and treatment was six years. Rupture of the cords were performed only in the palm in 165 cases, in the palm and finger in 111 and purely at digital level in 35. Complications were scarce without infection or tendon injury but one digital nerve was found injured during the second procedure. Postoperative gain was prominent at metacarpophalangeal joint level (79% versus 65% at interphalangeal level). Reoperation rate was 24%. In the group controlled at 3.2 years follow up, recurrence rate was 58% and disease "activity" 69%. Fifty nine hands need further surgery. The ideal indication for this simple and reliable technique is an elderly patient with a bowing cord and a predominant MP contracture.

Correction of first web space deficiency in congenital deformities of the hand with the pseudokite flap

The authors describe a new flap to enlarge or create a first web in patients with congenital deficiencies of the hand. This lozenge-shaped flap is harvested from the dorsoradial aspect of the index finger based on a narrow proximal skin bridge protecting its axial vascularization. A dorsal skin graft of the donor site is avoided by closure using a rhomboid flap. Procedures in 16 patients were performed and reviewed; the only complication was insertion of a small split-thickness graft in five patients to avoid tension at the metacarpophalangeal joint level. The flap lengthened the web fold an average of 3.2 cm without "pseudolengthening" the thumb.