Glutathione-S-Transferase M1 null genotype in autoimmune hepatitis

Autoimmune hepatitis is associated with genes located in the major histocompatibility complex. The search for genes at other loci that may play a role in disease susceptibility and/or severity is an area of active investigation in autoimmune liver diseases. Genes for glutathione-S-transferases, enzymes that are widely distributed and collectively metabolize carcinogens, pollutants, drugs, and a broad spectrum of harmful, foreign compounds have been associated with liver disease. The objective of this study was to search for a relationship between the glutathione-S-transferase Ml null genotype and autoimmune hepatitis using polymerase chain reaction analysis. The findings indicate that the frequency of the null genotype is not increased in patients with autoimmune hepatitis when compared to control subjects. These results coupled with similar ones in primary biliary cirrhosis do not support a role for this mutation in autoimmune liver disease.

Dilatation of biliary strictures through the afferent limb of a Roux-en-Y choledochojejunostomy in patients with sclerosing cholangitis

Repeated dilatation of biliary strictures in patients with sclerosing cholangitis through a subcutaneously placed afferent limb of a choledochojejunostomy is technically feasible and safe. This study is a prospective 15-year evaluation of 36 patients treated by repeat dilatation through this jejunal limb. There was one operative death and one major complication of dilatation. The 5-year survival of all patients was 74%. If patients with cirrhosis or unproven cholangiocarcinoma at the time of operation are not included, the 5-year survival is 86%. The 15-year survival of all patients was 30%; it was 64% if those with cirrhosis and unproven cholangiocarcinoma at the time of operation are not included. Six patients are presently alive with an average survival of 159 months. The study suggests that a combination of repeated dilatations combined with transplantation is the approach of choice in selected patients.

Airborne radon and its progeny levels in the coal mines of Godavarikhani, Andhra Pradesh, India

In India, out of about 0.7 million miners, nearly 0.5 million persons are directly engaged in coal operations. Radon and its progeny levels have been quantified in the coal-mining environment of Godavarikhani, Andhra Pradesh, India using solid-state nuclear track detectors. Seasonal and mine depth variations in radon levels have been recorded resulting in the identification of locations with a high radon level as areas with no mining activity, active mining operational zones and return air ventilation paths. All these radon levels were below the permissible levels. The average concentrations of radon and its progeny levels were found to be 144 +/- 61 Bq m(-3) and 20 +/- 11 mWL (working level) respectively in the two-incline mine, and these values for the five-incline mine are recorded as 315 +/- 71 Bq m(-3) and 30 +/- 9 mWL respectively.

Temperature effects in treatment wetlands

Several biogeochemical processes that regulate the removal of nutrients in wetlands are affected by temperature, thus influencing the overall treatment efficiency. In this paper, the effects of temperature on carbon, nitrogen, and phosphorus cycling processes in treatment wetlands and their implications to water quality are discussed. Many environmental factors display annual cycles that mediate whole system performance. Water temperature is one of the important cyclic stimuli, but inlet flow rates and concentrations, and several features of the annual biogeochemical cycle, also can contribute to the observed patterns of nutrient and pollutant removal. Atmospheric influences, including rain, evapotranspiration, and water reaeration, also follow seasonal patterns. Processes regulating storages in wetlands are active throughout the year and can act as seasonal reservoirs of nutrients, carbon, and pollutants. Many individual wetland processes, such as microbially mediated reactions, are affected by temperature. Response was much greater to changes at the lower end of the temperature scale (< 15 degrees C) than at the optimal range (20 to 35 degrees C). Processes regulating organic matter decomposition are affected by temperature. Similarly, all nitrogen cycling reactions (mineralization, nitrification, and denitrification) are affected by temperature. The temperature coefficient (theta) varied from 1.05 to 1.37 for carbon and nitrogen cycling processes during isolated conditions. Phosphorus sorption reactions are least affected by temperature, with theta values of 1.03 to 1.12. Physical processes involved in the removal of particulate carbon, nitrogen, and phosphorus are not affected much by temperature. In contrast, observed wetland removals may have different temperature dependence. Design models are oversimplified because of limitations of data for calibration. The result of complex system behavior and the simple model is the need to interpret whole ecosystem data to determine temperature coefficients. Temperature seems to have minimal effect on biochemical oxygen demand (0.900 < theta < 1.015) and phosphorus (0.995 < theta < 1.020) removal, and more significant effect on nitrogen removal (0.988 < theta < 1.16). In colder climates, there may be seasonal slowdown of treatment, which can decrease the overall treatment efficiency of constructed wetlands.

Noncirrhotic portal hypertension

Noncirrhotic portal hypertension represents a heterogeneous group of conditions that have distinct clinical and hemodynamic features that often help distinguish them from cirrhosis. [figure: see text] The sites of portal flow resistance may not be precisely localized to one area of the hepatic lobule and may extend beyond the site where the pathogenetic process began. Even in patients with portal hypertension caused by an increased flow, there may be subsequent development of increased resistance. The prognosis is variable; outcomes are better in patients with presinusoidal portal hypertension. A good understanding of the presentation of the various noncirrhotic conditions that cause portal hypertension will help determine the cause, the site of resistance, and the therapeutic plan. Ascites is not a feature of presinusoidal portal hypertension, whereas it may be the predominant feature in postsinusoidal portal hypertension.

Hepatitis C, cryoglobulinemia, and cutaneous vasculitis associated with unusual and serious manifestations

Hepatitis C viral infection is currently the leading cause of chronic hepatitis and cirrhosis. It also is a major predisposing factor for the development of hepatocellular carcinoma. It is estimated that approximately 1-2% of patients with hepatitis C infection have nonhepatic manifestations that are protean in nature. In this report, we describe six unusual cases of nonhepatic manifestations: abdominal vasculitis in two, peripheral neuropathy in two, and one patient each with central nervous system vasculitis and necrotizing cutaneous vasculitis. All patients had cutaneous vasculitis and cryoglobulinemia. None of our patients had cirrhosis, yet three of the six patients died. Because of the severe manifestations, aggressive therapy was instituted with interferon, immunosuppressive medications, i.v. immunoglobulin, and plasmapheresis. Our report underscores the importance of recognizing nonhepatic manifestations in patients with hepatitis C infection that may be associated with high morbidity and mortality.

Spatio-temporal patterns of soil phosphorus enrichment in Everglades water conservation area 2A

The Florida Everglades have undergone significant ecological change resulting from anthropogenic manipulation of historical regimes of hydrology, nutrient loading, and fire. Water Conservation Area 2A (WCA-2A) in the northern Everglades has been a focal point for the study of ecological effects of nutrient loading, especially phosphorus (P), from the nearby Everglades Agricultural Area (EAA). The overall objective of our study was to evaluate recent (1990 to 1998) changes in the spatial extent and patterns of soil P enrichment in Everglades WCA-2A. Surface soil was sampled to a depth of 10 cm at 62 sites within WCA-2A during 1998 for analysis of total phosphorus (TP) content. Geostatistical methods were used to create an interpolated grid of soil TP values across WCA-2A. Comparison of the results of this study with a similar study performed in 1990 showed that the extent of soil P enrichment in surface soil and sediments increased between 1990 and 1998, as evidenced by increased coverage of highly P-enriched soil near the primary surface inflows and a general increase in the concentration of soil TP in the interior regions of WCA-2A. Approximately 73% (31 777 ha) of the total land area of WCA-2A was considered P-enriched (soil total P > 500 mg kg(-1)) in 1998, compared with 48% of the land area (20,829 ha) in 1990, an average increase of 1,327 ha yr(-1). Study results indicate that the soil P enrichment "front" has advanced further into the relatively unimpacted interior of WCA-2A during the past several years.

Large cystic lesions of the liver in adults: a 15-year experience in a tertiary center

BACKGROUND

Cystic lesions of the liver consist of a heterogeneous group of disorders and may present a diagnostic and therapeutic challenge. Large hepatic cysts tend to be symptomatic and can cause complications more often than smaller ones.

STUDY DESIGN

We performed a retrospective review of adults diagnosed with large (> or = 4 cm) hepatic cystic lesions at our center, over a period of 15 years. Polycystic disease and abscesses were not included.

RESULTS

Seventy-eight patients were identified. In 57 the lesions were simple cysts, in 8 echinococcal cysts, in 8 hepatobiliary cystadenomas, and in 1 hepatobiliary cystadenocarcinoma. In four patients, the precise diagnosis could not be ascertained. Mean size was 12.1 cm (range, 4 to 30 cm). Most simple cysts were found in women (F:M, 49:8). Bleeding into a cyst (two patients) and infection (one patient) were rare manifestations. Percutaneous aspiration of 28 simple cysts resulted in recurrence in 100% of the cases within 3 weeks to 9 months (mean 4(1/2) months). Forty-eight patients were treated surgically by wide unroofing or resection (laparoscopically in 18), which resulted in low recurrence rates (11% for laparoscopy and 13% for open unroofing). Four of the eight patients with echinococcal cysts were symptomatic. All were treated by open resection after irrigation of the cavity with hypertonic saline. There was no recurrence during a followup period of 2 to 14 years. Hepatobiliary cystadenomas occurred more commonly in women (F:M, 7:1) and in the left hepatic lobe (left:right, 8:0). Seven were multiloculated. All were treated by open resection, with no recurrence, and none had malignant changes. Cystadenocarcinoma was diagnosed in a 77-year-old man, and was treated by left hepatic lobectomy.

CONCLUSIONS

Large symptomatic simple cysts invariably recur after percutaneous aspiration. Laparoscopic unroofing can be successfully undertaken, with a low recurrence rate. Open resection after irrigation with hypertonic saline is a safe and effective treatment for echinococcal cysts. Hepatobiliary cystadenomas have predilection for women and for the left hepatic lobe. Malignant transformation is an uncommon but real risk. Open resection is a safe and effective treatment for hepatobiliary cystadenoma, and is associated with a low recurrence rate.

Phosphorus sorption characteristics of estuarine sediments under different redox conditions

Phosphorus (P) plays a major role in eutrophication of aquatic systems. Estuarine sediments could function as sources or sinks for P to the overlying water column depending upon their physico-chemical characteristics. Understanding of P sorption phenomena in estuarine sediments is important in regulating the P availability in estuaries. Phosphorus sorption characteristics of sediments from the Indian River Lagoon, Florida, USA, were determined to examine the role of selected physico-chemical properties of the sediments on soluble reactive P status in estuary water. Mean equilibrium P concentrations (EPCo) of 0.75 mg L(-1) and mean P sorption maxima (Smax) of 32.2 mg kg(-1) were obtained under anaerobic conditions, compared with EPCo of 0.05 mg L(-1) and Smax of 132.7 mg kg(-1) under aerobic conditions. The higher EPCo values under anaerobic conditions and the greater Smax values under aerobic conditions were associated with amorphous and poorly crystalline iron. These results suggest that sediments enriched with amorphous and poorly crystalline forms of iron act as an excellent reservoir for P by adsorbing excessive P in aerobic sediment zones and releasing it upon burial under anaerobic conditions. This study also indicates that P compounds in sediments independently maintain equilibrium with P in solutions. Thus, heterogeneous systems like soil and sediment simply behave as a mixture of homogeneous surfaces as far as their P sorption characteristics are concerned, and hence can be successfully described by the Langmuir and Freundlich models.

Assessment of electrokinetic removal of heavy metals from soils by sequential extraction analysis

Electrokinetic remediation of metal-contaminated soils is strongly affected by soil-type and chemical species of contaminants. This paper investigates the speciation and extent of migration of heavy metals in soils during electrokinetic remediation. Laboratory electrokinetic experiments were conducted using two diverse soils, kaolin and glacial till, contaminated with chromium as either Cr(III) or Cr(VI). Initial total chromium concentrations were maintained at 1000mg/kg. In addition, Ni(II) and Cd(II) were used in concentrations of 500 and 250mg/kg, respectively. The contaminated soils were subjected to a voltage gradient of 1 VDC/cm for over 200h. The extent of migration of contaminants after the electric potential application was determined. Sequential extractions were performed on the contaminated soils before and after electrokinetic treatment to provide an understanding of the distribution of the contaminants in the soils. The initial speciation of contaminants was found to depend on the soil composition as well as the type and amounts of different contaminants present. When the initial form of chromium was Cr(III), exchangeable and soluble fractions of Cr, Ni, and Cd ranged from 10 to 65% in kaolin; however, these fractions ranged from 0 to 4% in glacial till. When the initial form of chromium was Cr(VI), the exchangeable and soluble fractions of Cr, Ni and Cd ranged from 66 to 80% in kaolin. In glacial till, however, the exchangeable and soluble fraction for Cr was 38% and Ni and Cd fractions were 2 and 10%, respectively. The remainder of the contaminants existed as the complex and precipitate fractions. During electrokinetic remediation, Cr(VI) migrated towards the anode, whereas Cr(III), Ni(II) and Cd(II) migrated towards the cathode. The speciation of contaminants after electrokinetic treatment showed that significant change in exchangeable and soluble fractions occurred. In kaolin, exchangeable and soluble Cr(III), Ni(II), and Cd(II) decreased near the anode and increased near the cathode, whereas exchangeable and soluble Cr(VI) decreased near the cathode and increased near the anode. In glacial till, exchangeable and soluble Cr(III), Ni(II), and Cd(II) were low even before electrokinetic treatment and no significant changes were observed after the electrokinetic treatment. However, significant exchangeable and soluble Cr(VI) that was present in glacial till prior to electrokinetic treatment decreased to non-detectable levels near the cathode and increased significantly near the anode. In both kaolin and glacial till, low migration rates occurred as a result of contaminants existing as immobile complexes and precipitates. The overall contaminant removal efficiency was very low (less than 20%) in all tests.

Hydrologic influence on stability of organic phosphorus in wetland detritus

Accretion of organic matter in wetlands provides long-term storage for nutrients and other contaminants. Water-table fluctuations and resulting alternate flooded and drained conditions may substantially alter the stability of stored materials including phosphorus (P). To study the effects of hydrologic fluctuation on P mobilization in wetlands, recently accreted detrial material (derived primarily from Typha spp.) was collected from the Everglades Nutrient Removal Project (ENRP), a constructed wetland used to treat agricultural drainage water in the northern Everglades. The detrital material was subjected to different periods of drawdown and consecutive reflooding under laboratory conditions. The 31P nuclear magnetic resonance (31P NMR) spectroscopy analysis revealed that sugar phosphate, glycerophosphate, polynucleotides, and phospholipids (glycerophosphoethanolamine and glycerophosphocholine) were the major forms of P in the detrital material. After 30 d of drawdown, polynucleotides were reduced to trace levels, whereas sugar phosphate, glycerophosphate, and phospholipids remained the major fractions of organic P. Microorganisms seemed to preferentially utilize nucleic acid P, perhaps to obtain associated nutrients including carbon and nitrogen. At the end of the 30-d reflooding period, cumulative P flux from detritus to water column accounted for 3% of the total P (< or = 15 d of drawdown) and further decreased to 2% at 30 d of drawdown, but increased to 8% at 60 d of drawdown. The drawdown (< or = 30 d) not only reduced P flux to the water column, but also increased the humification and microbial immobilization of P. Excessive drawdown (60 d), however, triggered the release of P into the water column as the water content of detritus decreased from 95 to 11%.

Impact of histological grade of hepatocellular carcinoma on the outcome of liver transplantation

HYPOTHESIS

Histological grade of hepatocellular carcinoma (HCC) is an important prognostic factor affecting patient survival after orthotopic liver transplantation (OLT).

DESIGN

Retrospective analysis.

SETTING

University-based teaching hospital.

PATIENTS

Of 952 OLTs performed between June 1991 and January 1999, 56 OLT recipients had histologically proven HCC in the explant liver. Of those, 53 patients with complete clinicopathologic data were analyzed. A single pathologist blinded to the outcome of each patient reviewed all histological specimens.

RESULTS

Median follow-up was 709 days. Overall survival for patients with tumors sized 5 cm or less at 1, 3, and 5 years was 87%, 78%, and 71%, respectively (Kaplan-Meier). Univariate analysis revealed the size, number, and distribution of tumors; the presence of microscopic vascular invasion and lymph node metastasis; histological differentiation; and pTNM stage to be statistically significant factors affecting survival. Multivariate analysis revealed histological differentiation and pTNM stage to be the independent and statistically significant factors affecting survival (P =.002 and.03, respectively). When pTNM stage was excluded from multivariate analysis, histological differentiation and size remained the significant independent factors (P =.02 and.03, respectively). Three-year survival for patients with small (</=5 cm) tumor with well- to moderately differentiated and poorly differentiated HCC was 82% and 67%, respectively. Three-year survival for patients with large (>5 cm) tumor with well- to moderately differentiated and poorly differentiated HCC was 62.5% and 0%, respectively.

CONCLUSIONS

In our retrospective experience, histological differentiation had a statistically significant effect on the prognosis of HCC after OLT. However, before altering the current OLT selection criteria for patients with HCC, prospective studies are required to confirm the impact of histological grade on clinical outcome.

Efficacy and safety of pegylated (40-kd) interferon alpha-2a compared with interferon alpha-2a in noncirrhotic patients with chronic hepatitis C

Administration of interferon (IFN) 3 times weekly in patients with chronic hepatitis C (CHC) is associated with low sustained responses, which may be, in part, related to this regimen's inability to maintain IFN concentrations sufficient to suppress viral replication. An enhanced IFN molecule produced by the covalent attachment of a branched 40-kd polyethylene glycol moiety to IFN alpha-2a (PEG[40kd] IFN alpha-2a) exhibits sustained absorption, a restricted volume of distribution, and reduced clearance compared with unmodified IFN alpha-2a. One hundred fifty-nine patients with CHC participated in a randomized, ascending-dose (45 or 90, 180, 270 microg) study comparing PEG(40kd) IFN alpha-2a administered once weekly with 3 MIU IFN alpha-2a administered 3 times weekly for 48 weeks to determine the most appropriate PEG(40kd) IFN alpha-2a dose for subsequent clinical trials. Efficacy was assessed by measuring hepatitis C virus (HCV) RNA following a 24-week treatment-free period. Sustained virological responses for PEG(40kd) IFN alpha-2a once weekly were 10% (45 microg; not significant), 30% (90 microg; P = .009), 36% (180 microg; P = .0006), and 29% (270 microg; P = .004), compared with 3% for the 3-times-weekly 3-MIU IFN alpha-2a regimen. The types and frequencies of adverse events and laboratory abnormalities were similar among all groups. In conclusion, once-weekly PEG(40kd) IFN alpha-2a was associated with a higher number of sustained virological responses compared with IFN alpha-2a 3 times weekly in patients with CHC, but had a similar safety profile. The 180-microg PEG(40kd) IFN alpha-2a dose appeared to be the optimal dose based on sustained virological response and its associated side-effect profile.

Benign and solid tumors of the liver: relationship to sex, age, size of tumors, and outcome

From 1983 through 1997, our center diagnosed 130 cases of benign neoplasms: 27 with focal nodular hyperplasia (FNH), 25 with hepatic adenoma, 71 with cavernous hemangioma, and seven with mixed tumors of different diagnoses. Most often these lesions were seen in females [female-to-male ratio (f/m): 5.5/1]. Hepatic adenomas and mixed tumors were seen exclusively in females and FNH predominantly in females (f/m: 26/1). Hemangiomas, however, were not uncommon in men (f/m: 52/19) relative to the other tumors (P < 0.001). Furthermore patients with hemangioma were older (mean age: 49 years) whereas patients with hepatic adenoma, FNH, and mixed tumors were often younger (mean age: 33, 35, and 44 years respectively; P < 0.004). Oral contraceptive steroid use was related by 21 of 25 patients (84%) with hepatic adenoma, 22 of 26 (85%) females with FNH, five of seven (71%) females with mixed tumors, and 10 of 52 (19%) patients with hemangioma. Ninety-five of the 130 patients (73%) had one or more symptoms. There was no statistically significant correlation between symptoms and the size of the lesion, the final diagnosis, and whether there were solitary or multiple masses. Three of 25 (12%) with hepatic adenoma presented with rupture, and one of 27 (4%) with FNH had such a consequence. None of the hemangiomas presented with rupture or progressed to such a state. One patient with hepatic adenoma (4%) had a focus of malignancy. Surgical removal of benign tumors was performed in 82 of 130 patients (63%), and there was one operative mortality (1.2%) in a patient who had a caudate lobe FNH. The types of surgical procedures included segmentectomy (62%), lobectomy (34%), and trisegmentectomy (4%). In two of 84 patients who had undergone laparotomy resection was not technically possible. Resection is recommended in all cases of hepatic adenoma because of fear of rupture or associated focus of malignancy. FNH was not observed to undergo a malignant transformation and will rarely rupture. Surgery is only recommended for symptomatic hemangioma, and size of the lesion is not a criterion for excision.

Extrahepatic manifestations of chronic viral hepatitis

Hepatitis B (HBV) and C (HCV) viruses are well-recognized causes for chronic hepatitis, cirrhosis, and even for hepatocellular carcinoma. Apart from liver disease, these viral infections are known to be associated with a spectrum of extrahepatic manifestations. The prevalence of clinically significant extrahepatic manifestations is relatively low, but it can be associated with significant morbidity and even mortality. An awareness and recognition of these manifestations is of paramount importance in facilitating early diagnosis and in offering treatment. However, treatments are not necessarily effective, and patients may continue with disabling extrahepatic manifestations. Hepatitis B virus has been well recognized as causing a variety of manifestations that include skin rash, arthritis, arthralgia, glomerulonephritis, polyarteritis nodosa, and papular acrodermatitis. More recently, infection with hepatitis C virus has elicited considerable interest for its role in a spectrum of extrahepatic manifestations. Among the best-reported are cryoglobulinemia, glomerulonephritis, high titer of autoantibodies, idiopathic thrombocytopenic purpura, lichen planus, Mooren's corneal ulcer, Sjögren's syndrome, porphyria cutanea tarda, and necrotizing cutaneous vasculitis. The precise pathogenesis of these extrahepatic complications has not been determined, although the majority represent the clinical expression of autoimmune phenomena.

Phosphorus flux from wetland soils affected by long-term nutrient loading

Wetland soils play a key role in the cycling of nutrients within an ecosystem. Since soils are potentially a source or a sink for inorganic nutrients, it is important to quantify their influence on overlying water quality in order to understand their importance in overall ecosystem nutrient budgets. Laboratory and field studies were performed in the northern Everglades (WCA-2A) to determine the magnitude of phosphorus (P) flux between the soil and the overlying water column, under various redox conditions. The P flux was estimated using three techniques: intact soil cores, in situ benthic chambers, and porewater equilibrators. There was reasonable agreement between the P flux estimated using intact soil cores and benthic chambers; however, P flux estimates using the porewater equilibrators were considerably lower than the other two techniques. Models of solute flux, based solely on soil physico-chemical characteristics, may substantially underestimate soil-water nutrient exchange processes. Phosphorus flux measured with the intact soil cores varied from 6.5 mg m(-2) d(-1) near nutrient inflow areas to undetectable flux 4 km away from the inflow. Oxygen consumption varied from 4 mg m(-2) d(-1) near the inflow to a constant 1 to 2 mg m(-2) d(-1) at a distance of 4 km from the inflow. Rate of consumption of NO3- -N and SO4(2-) showed no significant trend with respect to distance from inflow. Nitrate N and SO4 consumption rates averaged 120 and 130 mg m(-1) d(-1), respectively. Consumption of O2 was correlated with P flux, whereas NO3- -N and SO4(2-) consumption were not.

The use of macrophyte-based systems for phosphorus removal: an overview of 25 years of research and operational results in Florida

Phosphorus (P) removal from wastewaters and surface runoff using macrophyte-based systems (MBS) has been a topic of great interest in Florida for over 25 years. During this period, P removal by both treatment wetlands and floating aquatic macrophyte systems has been evaluated from both a research and operational standpoint. Several factors have contributed to the increased focus on the use of MBS for P removal. First, there exist no conventional technologies that can cost-effectively achieve the low outflow P concentrations required to protect the integrity of Florida's relatively pristine surface waters. Second, because MBSs typically provide some water storage, they can accommodate the wide ranges of flows typical for runoff sources such as agricultural drainage waters. Finally, many regions in Florida have sufficient area for deployment of the relatively land-intensive MBS technologies. The first P removal work in Florida was initiated in the mid-1970s, and involved pilot-scale research on domestic wastewater treatment by natural wetlands. Parallel studies were performed with managed (periodically harvested) floating plant systems (i.e., Eichhornia crassipes) for tertiary treatment. Since that time, the range of operational systems that have been deployed include emergent macrophyte-based and forested wetlands, managed floating plant systems, and submerged macrophyte-based systems. Waters treated by MBS include domestic effluents, agricultural runoff and eutrophic lake waters. Phosphorus removal targets for MBS in Florida have been as low as 10 microg/L. In this paper, we summarize research and operational results for MBS in Florida over the past 25 years.

A multicenter, randomized trial of daily high-dose interferon-alfa 2b for the treatment of chronic hepatitis c: pretreatment stratification by viral burden and genotype

OBJECTIVES

The aim of this study was to determine prospectively whether an intensive regimen of daily, high-dose interferon would improve the response rate for the treatment of chronic hepatitis C in patients with unfavorable virological characteristics.

METHODS

A total of 104 patients with chronic hepatitis C were randomized at eight centers to receive interferon alfa-2b at a dose of 5 million units (MU) daily or 3 MU t.i.w. for a period of 24 wk. Patients were prospectively randomized by low or high viral burden and stratified by genotype. HCV RNA was measured by quantitative polymerase chain reaction, and response rates were compared between the dosage regimens.

RESULTS

HCV RNA levels dropped more rapidly to lower levels in the group treated with 5 MU daily. In this group, the initial virological response (IR) at wk 12 and the end-of-treatment response (ETR) at wk 24 were double that of patients treated with standard interferon (66% vs 33% and 48% vs 24%, p < 0.01). Sustained response rates were low for both dose groups (14% vs 4%, p = 0.08). Genotype-related differences in initial response rates were present in the standard dose group (63% non-1 genotype vs 24% genotype 1; p = 0.005) but not in those treated with 5 MU daily (66% vs 67%, p = NS). Using multivariate analysis, only the interferon dose was associated with IR and ETR (p = 0.002).

CONCLUSIONS

Daily, high dose interferon rapidly dropped HCV RNA and increased initial and end-of-treatment response rates when compared to t.i.w. regimens. This effect, independent of viral burden and genotype, suggests that patients with unfavorable viral characteristics might benefit from an intensive regimen that promotes rapid viral clearance. These data support further study of the use of high-dose induction regimens. However, improvements in sustained response rates will require additional therapeutic maneuvers such as prolonged therapy or the adjunctive use of ribavirin.

Controlled-release, pegylation, liposomal formulations: new mechanisms in the delivery of injectable drugs

OBJECTIVE

To review recent developments in novel injectable drug delivery mechanisms and outline the advantages and disadvantages of each.

DATA SOURCES

A MEDLINE (1995-January 2000) search using the terms polyethylene glycol, liposomes, polymers, polylactic acid, and controlled release was conducted. Additional references were identified by scanning bibliographies.

STUDY SELECTION AND DATA EXTRACTION

All articles were considered for inclusion. Abstracts were included only if they were judged to add critical information not otherwise available in the medical literature.

DATA SYNTHESIS

A number of systems that alter the delivery of injectable drugs have been developed in attempts to improve pharmacodynamic and pharmacokinetic properties of therapeutic agents. New drug delivery systems can be produced either through a change in formulation (e.g., continuous-release products, liposomes) or an addition to the drug molecule (e.g., pegylation). Potential advantages of new delivery mechanisms include an increased or prolonged duration of pharmacologic activity, a decrease in adverse effects, and increased patient compliance and quality of life. Injectable continuous-release systems deliver drugs in a controlled, predetermined fashion and are particularly appropriate when it is important to avoid large fluctuations in plasma drug concentrations. Encapsulating a drug within a liposome can produce a prolonged half-life and a shift of distribution toward tissues with increased capillary permeability (e.g., tumors, infected tissue). Pegylation provides a method for modification of therapeutic proteins to minimize many of the limitations (e.g., poor stability, short half-life, immunogenicity) associated with these agents.

CONCLUSIONS

Pegylation of therapeutic proteins is an established process with new applications. However, not all pegylated proteins are alike, and each requires optimization on a protein-by-protein basis to derive maximum clinical benefit. The language required to describe each pegylated therapeutic protein must be more precise to accurately distinguish each protein's differential pharmacologic properties.