The albumin-bilirubin grade uncovers the prognostic relationship between hepatic reserve and immune dysfunction in HIV-associated hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of liver-related mortality in people living with HIV, where co-infection with hepatotropic viruses accelerates the course of chronic liver disease.

AIM

To evaluate whether the albumin-bilirubin (ALBI) grade, a more accurate marker of liver dysfunction in HCC, might identify patients with progressive liver dysfunction in the context of HIV/hepatitis co-infection.

METHODS

Using uni- and multi-variable analyses, we studied the albumin-bilirubin grade as a predictor of overall survival (OS) in a large, multi-center cohort of patients with HIV-associated HCC recruited from 44 centres in 9 countries within the Liver Cancer in HIV study group. Patients who underwent liver transplantation were excluded.

RESULTS

A total of 387 patients, predominantly HCV co-infected (78%) with balanced representation of all Barcelona Clinic Liver Cancer (BCLC) stages (A = 33%, B = 18%, C = 37%, D = 12%) were recruited. At HCC diagnosis, 84% had been on anti-retrovirals for a median duration of 8.8 years. The albumin-bilirubin grade identified significant differences in median survival of 97 months for grade 1 (95% CI 13-180 months), 17 months for grade 2 (95% CI 11-22 months) and 6 months for grade 3 (95% CI 4-9 months, P < .001). A more advanced albumin-bilirubin grade correlated with lower CD4 counts (464/373/288 cells/mm³ for grades 1/2/3) and higher HIV viraemia (3.337/8.701/61.845 copies/mL for grades 1/2/3, P < .001).

CONCLUSIONS

In this large, multi-center retrospective study, the albumin-bilirubin grade highlights the interplay between liver reserve and immune dysfunction as prognostic determinants in HIV-associated HCC.

A TOMM40 poly-T variant modulates gene expression and is associated with vocabulary ability and decline in nonpathologic aging

The Translocase of Outer Mitochondrial Membrane 40 Homolog and Apolipoprotein E (TOMM40-APOE) locus has been associated with a number of age-related phenotypes in humans including nonpathologic cognitive aging, late-onset Alzheimer's disease, and longevity. Here, we investigate the influence of the TOMM40 intron 6 poly-T variant (rs10524523) on TOMM40 gene expression and cognitive abilities and decline in a cohort of 1613 community-dwelling elderly volunteers who had been followed for changes in cognitive functioning over a period of 14 years (range = 12-18 years). We showed that the shorter length poly-T variants were found to act as a repressor of luciferase gene expression in reporter gene constructs. Expression was reduced to approximately half of that observed for the very long variant. We further observed that the shorter poly-T variant was significantly associated with reduced vocabulary ability and a slower rate of vocabulary decline with age compared to the very long poly-T variants. No significant associations were observed for memory, fluid intelligence or processing speed, although the direction of effect, where the short variant was correlated with reduced ability and slower rate of decline was observed for all tests. Our results indicate that the poly-T variant has the ability to interact with transcription machinery and differentially modulate reporter gene expression and influence vocabulary ability and decline with age.

The protein tyrosine phosphatase N22 gene is associated with juvenile and adult idiopathic inflammatory myopathy independent of the HLA 8.1 haplotype in British Caucasian patients

OBJECTIVE

To examine single-nucleotide polymorphisms (SNPs) of the protein tyrosine phosphatase N22 gene (PTPN22) and to study the relationship between PTPN22 and the HLA region in patients with idiopathic inflammatory myopathies (IIMs).

METHODS

PTPN22 SNPs were assessed in a large, cross-sectional, case-control study from the UK involving patients with adult or juvenile IIM, comprising patients with polymyositis (PM) (n=114), dermatomyositis (DM) (n=102), myositis associated with another connective tissue disease (myositis-CTD overlap syndrome) (n=64), or juvenile DM (n=101), in comparison with 748 control subjects. Seventeen PTPN22 SNPs were genotyped using the Sequenom MassArray iPLEX platform. Serotyping for myositis-specific/myositis-associated autoantibodies (MSAs/MAAs) was performed by radioimmunoprecipitation.

RESULTS

A significant association was noted between the R620W variant (rs2476601) and IIM (corrected P [Pcorr]=0.0009 versus controls), and specifically with the clinical subgroup of PM (Pcorr=0.003 versus controls). A weaker association was noted with juvenile DM (Pcorr=0.009 versus controls). No significant associations were noted after stratification by serologic subgroups. The association with the R620W variant was independent of alleles forming the HLA 8.1 haplotype. No other PTPN22 SNPs were associated with IIM. The PTPN22 haplotype containing the R620W T allele was the only haplotype significantly associated with IIM.

CONCLUSION

The R620W variant is a significant risk factor for IIM, independent of the HLA 8.1 haplotype. Unlike that in the HLA region, risk is not increased in individuals possessing MSAs/MAAs. These results are further evidence that the PTPN22 gene confers autoimmune susceptibility.

Polymorphisms in the tumour necrosis factor gene are not associated with severity of inflammatory polyarthritis

BACKGROUND

Tumour necrosis factor alpha (TNFalpha) is a powerful inflammatory mediator in rheumatoid and other types of inflammatory arthritis. Polymorphisms within the TNFalpha gene have previously been investigated to determine their role in the aetiopathogenesis of rheumatoid arthritis (RA), but it is unclear whether reported associations are with susceptibility to, or severity of, disease.

OBJECTIVE

To examine the association between both individual TNFalpha single nucleotide polymorphisms (SNPs) and haplotypes with the development and severity of erosions by 5 years in patients with inflammatory polyarthritis (IP).

METHODS

438 patients from the Norfolk Arthritis Register observational inception cohort of patients with IP were x rayed 5 years after disease onset. They were genotyped for nine SNPs mapping to the TNFalpha gene, using a SNaPshot primer extension assay. Haplotypes were constructed in patients with IP, who were compared for the presence and extent of erosions at 5 years.

RESULTS

No association between individual TNFalpha SNPs or haplotypes in the patients who developed erosions at 5 years compared with those who remained non-erosive was found. Restricting analysis to patients who satisfied ACR criteria for RA by 5 years did not affect the conclusions.

CONCLUSION

The TNFalpha gene does not seem to be associated with severity as assessed by erosive outcome at 5 years in patients with IP.

Impulsiveness, serotonin genes and repetition of deliberate self-harm (DSH)

BACKGROUND

Few studies have investigated independent associations of psychological, biological and social variables with repeated deliberate self-harm (DSH). Serotonin function has been linked to impulsive and suicidal behaviour and genetic polymorphisms have been identified within the serotonin system that could account for this link. This study tested hypotheses linking impulsiveness, genetic polymorphisms of tryptophan hydroxylase (TPH) and the 5-HT2c receptor and repeated DSH.

METHODS

Individuals presenting after DSH were interviewed, completed personality questionnaires and gave venous blood samples. Genotypes were determined for TPH intron7 and 5-HT2c (cys-ser) polymorphisms. Follow-up to identify repetition of DSH was for 1 year.

RESULTS

Males with the 5-HT2c serine variant were more impulsive than those with the cysteine variant (039 standardized units, P = 0.041, 95% CI 0.017 to 0.076). There was no association between impulsiveness and the TPH intron7 polymorphism overall but a weak association with the L allele in men (0.41 standardized units, P = 0.05, 95 % CI 0.001 to 0.82). Impulsiveness, although high in the group as a whole, did not distinguish those who repeated DSH.

CONCLUSIONS

The personality trait of impulsiveness may in part be related to genotypes of the 5-HT2c receptor and TPH gene in men. Impulsiveness does not differ between those who do and do not repeat DSH.

Comparison of three solid phase supports for promoting three-dimensional growth and function of human liver cell lines

An extracorporeal liver support system will require that liver cells maintain their normal differentiated function. This is more likely to be achieved utilizing a three-dimensional culture configuration rather than a simple monolayer culture. We present data on a human liver cell line attached and maintained on different three-dimensional supports, porous glass (Siran), silicon (Immobasil), and calcium-alginate beads. Albumin, fibrinogen, prothrombin, alpha1-acid glycoprotein and alpha1-antitrypsin secretions were measured. Proliferation was slower on each of the three-dimensional supports than on the monolayer culture. The protein secretion of all 5 proteins was highest in cells encapsulated in alginate; silicon beads supported greater protein secretion than glass. Cells on silicon or within alginate were rounded; those on glass grew in 2 configurations as flattened monolayers and as rounded colonies. Cells in alginate secreted as much protein as the whole liver (e.g., albumin, 14.88 g/10(12) cells/day compared to the whole liver, approximately 12 g/day). Three-dimensional culture of a human liver cell line leads to both proliferation and a high synthetic capacity, an important feature of cells suitable for an extracorporeal liver support system.

Outcome study using an administrative database: terminal salpingostomy, physician case load and live birth rates

Information on the outcome following salpingostomy performed for infertility in everyday practice is needed to counsel patients, determine the best approach to this condition and clarify whether the outcome is superior when surgery is performed by a physician who maintains a high volume of ongoing experience. A total of 547 consecutive subjects were identified over a 5 year period using the Alberta Health Care Claims Database. Their claims history was analysed over a follow-up of 2-7 years, to identify pregnancy-related events, loss to follow-up and events which would result in sterility. Pregnancies were cross-checked with the only in-vitro fertilization programme serving the region. The overall cumulative live birth and tubal pregnancy rates were 11.7 and 7.2% respectively. Live birth rates were significantly higher when practitioners had performed >10 procedures within the study period. Live birth rates would appear to be substantially lower in everyday practice than following surgery performed by acknowledged experts. A high volume of ongoing experience appears to be associated with superior live birth rates. It is unclear whether this association relates to case selection, surgical expertise or both variables.

Observations on the pathology of non-alimentary lymphomas in the horse

A retrospective study was carried out on post-mortem and biopsy tissue samples from 26 horses with non-alimentary lymphoma. On the basis of their histopathology and cytology, the cases were grouped into several categories: (1) Lymphoblastic lymphomas (6 cases) and primary lymphoblastic leukaemia (2 cases). (2) Histiolymphocytic lymphomas involving the skin (6 cases) or lymph nodes (3 cases). (3) Lymphomas showing follicular development (4 cases). (4) Plasmacytic lymphomas (4 cases). (5) Lymphocytic lymphoma (1 case). Most affected horses were middle-aged or old but lymphoblastic neoplasms tended to affect younger horses than other forms. The course of the disease was highly variable. The most rapidly progressive forms were of lymphoblastic cytology, whereas some cases with histiolymphocytic skin nodules appeared to be only slowly progressive. Further information is needed on the pathology and clinical behaviour of some types of lymphoma, particularly those manifesting in the skin. Elucidation of the histogenetic relationships of the different cytological types of lymphoma will involve the development of immunohistochemical and other techniques which are specifically applicable to the horse.

Vascular malformations and angiomatous lesions in horses: a review of 10 cases

Vascular malformations and angiomas are rather uncommon in horses and the literature concerning these lesions is reviewed. The pathology is described in 10 additional cases. These lesions were classified as arteriovenous malformation (one case), haemangiomas (six cases), 'proliferative angiomas' (two cases) and lymphangioma (one case). The haemangiomas and lymphangioma were probably hamartomatous in origin. Both cases of 'proliferative angioma' developed in aged animals and their pathogenesis was uncertain. More information is needed on the natural history and behaviour of lesions of this type.

Alimentary lymphomas in the horse

A series of 9 cases of primary diffuse alimentary lymphoma of the equine small intestine is described. Clinically, the principal effects were attributable to malabsorption and disordered alimentary function and several cases had severe anaemia; in four this was of the haemolytic type. Hypoalbuminaemia and elevated gamma globulin levels were often present. The neoplasms were confined mainly to the small intestine and mesenteric lymph nodes, sometimes with some involvement of other lymph nodes as well. The large bowel was affected in one horse, but none of the cases showed detectable invasion of parenchymatous organs. Evidence is presented that some of these lymphomas were of follicle centre cell origin and it is suggested that they had probably arisen from B lymphocytes in gut-associated lymphoid tissue.

Chronic inflammatory and lymphoproliferative lesions of the equine small intestine

A retrospective study was made of 20 horses with severe and extensive chronic disease of the small intestine. Many of the animals had clinical evidence of malabsorption, with progressive loss of weight, hypoalbuminaemia and sometimes anaemia. All but two of the horses were Thoroughbreds. The pathology was diverse. Nine of the cases were alimentary lymphomas (Platt, 1986) and five had lymphocytic and eosinophilic infiltrations in the bowel wall which were considered to be probable reactions to parasitic invasion. One had acute thrombosis associated with partial occlusion of the anterior mesenteric artery by a verminous thrombus, superimposed on granulomatous lesions resulting from earlier ischaemic episodes. Two animals, from one stud, had dense mononuclear infiltration of the intestinal mucosa with villous atropy accompanying an unidentified acid-fast bacillary infection in the mesenteric lymph nodes and other sites. Three horses had granulomatous or lymphogranulomatous infiltration of the small intestine accompanied by marked mucosal and villous atrophy. One of these had multiple abscessation in part of the affected bowel. Only the three latter cases had lesions resembling those of equine granulomatous enteritis and the results of this study indicate the rarity of this condition in Thoroughbreds in Britain. The different types of lesion were only distinguishable by histological examination, since their clinical effects and gross pathology were not characteristic.

Pathological observations on an outbreak of paralysis in broodmares

A description is given of the pathological changes present in 8 mares which died or were euthanased in the course of an outbreak of paralysis on a Thoroughbred studfarm. In all cases the principal changes were in the central nervous system (CNS) and consisted of a severe and widespread vaculitis in the brain, cord, sheaths of nerves, capsules of ganglia and occasionally elsewhere in the body. Associated with the damage to vessel walls there was haemorrhage and exudation of plasma into the perivascular tissues. Involvement of neurones was minimal and no neuronophagia was present. Six cases had malacic foci in the brain, related to thrombosis of local arteries. Acinar necrosis in the mammary gland was present in one case. Examinations of the CNS and cerebrospinal fluid (CSF) for the presence of equid herpesvirus 1 (EHV1) or other microbial agents proved negative but EHV1 was isolated from the spleen of one mare and from the pharyngeal mucos membrane in another. The pathogenesis of this type of paralysis is discussed.

Observations on vaccine and post-infection immunity in contagious equine metritis

The vaccination of four ponies on two occasions with a formolised culture of Haemophilus equigenitalis produced a high circulating antibody titre to the organism in each pony. Three out of four vaccinated and all of three unvaccinated ponies developed typical symptoms of contagious equine metritis (CEM) when subsequently challenged with a vaginal exudate containing H equigenitalis. Similarly, three ponies which had previously been infected with H equigenitalis and which had recovered spontaneously also developed contagious equine metritis when rechallenged with the organism. The clinical and bacteriological symptoms in the vaccinated ponies and in the rechallenged ponies were less severe than those observed in the unvaccinated ponies but H equigenitalis was still recovered 17 days after challenge from the three vaccinated ponies which had developed CEM. The vaccinated pony which remained free from infection did not exhibit the highest circulating antibody titre of the vaccinates before challenge.

Yersiniosis in a free-living fallow deer

A case of yersiniosis in a free-living fallow deer is described. Pathological examination revealed an emaciated carcase with numerous abscesses of various sizes throughout the abdominal and thoracic cavities. Staining of material from the abscesses showed a small Gram-negative coccobacillus which was identified as Yersinia pseudotuberculosis type 1A.

The experimental infection of ponies with contagious equine metritis

Four pony mares were readily infected with the organism of contagious equine metritis by intracervical inoculation and one by coitus with an infected stallion. Infected mares developed an acute endometritis with local destruction of the endometrial epithelium. In 2 experimentally infected mares, infection appeared to have been spontaneously eliminated from the genital tract within 3 to 4 weeks. A third mare however remained persistently infected in the clitoral fossa over a long period and was a symptomless carrier. Four pony stallions were readily infected in the urethral fossa and the organism survived for varying periods without giving rise to any signs of infection. From 2 of these animals it appeared eventually to have been eliminated spontaneously. An experimentally infected stallion transmitted infection to a healthy mare by coitus. Bacteriological examination of infected pony stallions may occassionally give false negative results and fail to reveal the organism in the external genitalia. Repeated bacteriological examinations need to be undertaken before it can be concluded that a stallion is free of infection.

Joint-ill and other bacterial infections on thoroughbred studs

From a perinatal survey carried out on Thoroughbred studs, information was obtained on the incidence, mortality and long-term effects of joint-ill and other bacterial infections. Many of these infections occurred in foals with a history of other perinatal abnormalities, and in foals in which receipt of colostrum was delayed. There was no direct relationship between the incidence of infection and maternal age, but prenatal lactation and loss of colostrum were more frequent in older mares. There was a significant reduction in the incidence of infections in foals given neomycin and framomycin during the first 30 days of life.

Klebsiella and Enterobacter organisms isolated from horses

An account is given of K. pneumoniae capsule types occurring in horses, with particular reference to strains originating from the genital tract in the mare and the external genitalia of the stallion. A survey of the prevalence of K. pneumoniae and E. aerogenes strains in the preputial flora of healthy stallions is described. The majority of horses were found to be carriers of these organisms. The cultural characteristics of these preputial strains are described and compared with those of K. pneumoniae strains associated with epidemic metritis in mares. The epidemiological significance of certain K. pneumoniae capsule types is discussed.

Infection of the horse fetus

Many infections of the equine placenta and fetus result from ascending spread along the cervical canal. Most abortions due to infection occur during the later stages of pregnancy and the possible effects of intrauterine infection on the developing fetus and young foal are discussed.