Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Budesonide 9 mg is at least as effective as mesalamine 4.5 g in patients with mildly to moderately active Crohn's disease

BACKGROUND & AIMS

Comparative data on budesonide vs mesalamine for the treatment of mild-to-moderately active Crohn's disease (CD) are sparse. We assessed the efficacy and safety of each therapy in patients with mildly to moderately active CD.

METHODS

We performed a randomized, double-blind, double-dummy, 8-week, multicenter study in which 309 patients with mildly to moderately active CD received pH-modified-release oral budesonide (9 mg/day once daily or 3 mg/day 3 times daily) or Eudragit-L-coated oral mesalamine (4.5 g/day).

RESULTS

The primary efficacy variable, clinical remission (defined as Crohn's Disease Activity Index ≤150), at the final visit occurred in 69.5% (107 of 154) of patients given budesonide vs 62.1% (95 of 153) of patients given mesalamine (difference, 7.4%; 95% repeated confidence interval, -4.6% to 18.0%; P = .001 for noninferiority). Clinical remission rates did not differ significantly between the 2 budesonide groups. Treatment response, defined as Crohn's Disease Activity Index of 150 or less and/or a decrease of 70 or more (Δ70) or 100 or more (Δ100) points from baseline to final visit, did not differ significantly between patients given budesonide vs mesalamine (Δ70, P = .11; Δ100, P = .15), or between the 2 budesonide groups (Δ70, P = .38; Δ100, P = .78). No other efficacy end points differed significantly between groups. Discontinuation because of adverse events occurred in 3% and 5% of budesonide- and mesalamine-treated patients, respectively. There were no clinically relevant differences in adverse events between the 2 budesonide groups.

CONCLUSIONS

Budesonide (9 mg/day) was numerically, but not statistically, more effective than Eudragit-L-coated mesalamine (4.5 g/day) in patients with mildly to moderately active CD. Budesonide (9 mg/day), administered once daily, was as effective as the standard (3 times daily) regimen.

Long-term management and prognosis of autoimmune hepatitis (AIH): a single center experience

BACKGROUND

Controlled trials have firmly established the need for immunosuppressive therapy in autoimmune hepatitis. However, reports about long-term management and prognosis of the disease are scarce.

PATIENTS AND METHODS

We reviewed the charts of 103 consecutive patients with a well-documented long-term course of autoimmune hepatitis who had been carefully managed over a mean observation period of 95 months (12-405 months).

RESULTS

Under immunosuppressive therapy 94 patients (91.2%) reached complete remission after a mean treatment duration of 3 +/- 3 months. 28 of the 103 patients (27.2%) were eligible for a trial of treatment withdrawal after a mean treatment duration of 32.2 months (range: 12-81 months). 21 of these patients (75%) had a relapse following treatment withdrawal. 13.6% of patients had intolerance of or severe side effects to azathioprine. There was no increase in tumor risk during a cumulative observation period of 423 patient-years of azathioprine therapy. Corticosteroid side effects occurred mostly during induction therapy, but were usually minor and resolved upon dose reduction. During a cumulative observation period of 842 patient-years no liver related deaths occurred and no patient had to be referred to liver transplantation, even though 30 patients (29.1%) had histological evidence of cirrhosis at presentation. The overall 5- and 10-year survival of patients with autoimmune hepatitis was identical to an age- and sex-matched control population.

CONCLUSION

Our study shows that the majority of patients with AIH do achieve a complete remission within 3 months, but require long-term or permanent immunosuppressive therapy that is usually well tolerated. Long-term survival in well-managed patients is excellent.

[Synthesis of tumor affinity label Yb-169- and Y-90- porphyrin complexes and animal experimental investigations with various Yb-169-porphyrins]

AIM

It should be shown, that it is possible to insert radioactive isotopes of Yb and Y into some selected porphyrins. Besides, first informations about the biodistribution of Yb-169-por-phyrin-complexes should be obtained.

METHODS

Carrier added radioactive isotopes were used for the synthesis of the metal porphyrin complexes. The animal experiments were done with mamma carcinoma bearing mice. The activity of the organs was determined 5 and 24 h after i.v. injection in a well counter.

RESULTS

Four Yb-169-porphyrin complexes and Y-90-porphyrin complexes could be synthesized in non-carrier-free form. This was verified by absorption spectra, TLC and HPLC. Depending on the complex, the average tumour/background ratios were between 2 and 20.

CONCLUSION

The synthesized radioactive metal-porphyrin complexes showed a clear tumour-affinity which could be used for tumour scintigraphy or perhaps therapy if the synthesis is improved (goal: reduction of carrier, other radionuclides).

Evidence for an overlap syndrome of autoimmune hepatitis and primary sclerosing cholangitis

BACKGROUND/AIMS

Autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis are chronic liver diseases with probable autoimmune background. Overlapping features have been described for primary biliary cirrhosis and autoimmune hepatitis. In contrast, there have been only a few case reports on an overlap of autoimmune hepatitis and primary sclerosing cholangitis.

METHODS

We describe three male patients with clinical and histological overlapping features of primary sclerosing cholangitis and autoimmune hepatitis.

RESULTS

All initially asymptomatic patients had elevated levels of aminotransferases, alkaline phosphatase, gamma-glutamyltranspeptidase and IgG. Anti-nuclear antibodies and/or smooth muscle antibodies were positive and anti-neutrophil cytoplasmic antibodies were detected in all patients. Retrograde endoscopic cholangiography showed bile-duct strictures characteristic for primary sclerosing cholangitis. Histopathology showed necro-inflammatory activity of portal tracts with bridging necrosis in all patients at the time of first diagnosis. Aminotransferase levels and the necro-inflammatory activity responded well to immunosuppressive treatment. Predominant periductular fibrosis as a typical histopathological feature of primary sclerosing cirrhosis was seen to develop in all patients. Cholestatic serum parameters remained elevated and periductular fibrosis as endoscopic bile duct changes progressed despite immunosuppression.

CONCLUSIONS

We suggest that these patients present an overlap syndrome of autoimmune hepatitis and primary sclerosing cholangitis as they fulfill the diagnostic criteria for both conditions.

Parenchymal and nonparenchymal liver cells and their interaction in the local immune response

Nonparenchymal liver cells (Kupffer cells, sinusoidal endothelial cells, Ito-cells and liver-associated lymphocytes) interact with hepatocytes and with each other by soluble mediators and direct cell-cell contact. The acute phase response is a nonspecific reaction of the organism to trauma, injury or infection and its main constituents the acute phase proteins are produced by hepatocytes. The profile of acute phase protein production is influenced by the local presence of cytokines with IL-6 as the principal regulator. Nonparenchymal cells (Kupffer cells, sinusoidal endothelial cells and Ito-cells) are a source of IL-6 and therefore participate in the generation of acute phase response. The release of IL-10 by Kupffer cells with consecutive down-regulation of IL-6 production may be a mechanism by which resolution of acute phase response is achieved. Still, the mechanisms underlying chronic inflammation remain unclear. Concerning the antigen-specific immune response nonparenchymal liver cells have a number of important functions. They can act as antigen-presenting cells (Kupffer cells) or mediate effector functions (liver associated lymphocytes). Local interaction of nonparenchymal cells with hepatocytes can be mediated by cytokines and/or adhesion molecule expression which again may lead to mutual influence of immunological functions, e.g. TNF-alpha release by Kupffer cells may enhance MHC-II expression on hepatocytes and consequently augment antigen-presenting capacity leading to an improved antigen-specific immune response. Leukocytes are attracted and home to the liver by mechanisms poorly defined because the initial contact between leukocytes and macrovascular endothelium.(ABSTRACT TRUNCATED AT 250 WORDS)

Posttransfusional, LKM-1-autoantibody-positive hepatitis C virus infection, cryoglobulinemia, and aplastic anemia

Aplastic anemia is occasionally caused by viral hepatitis, hepatitis C virus being the most important factor. Pathogenetically, decreased bone marrow function, abnormalities of the bone marrow microenvironment, and immune-mediated suppression of hematopoiesis are important. Hepatitis C virus infection is associated with a variety of extrahepatic manifestations including autoimmune features like cryoglobulinemia, Sjögren's syndrome, and autoimmune hepatitis. Here we report the case of a 42-year-old man with aplastic anemia due to posttransfusional hepatitis C virus infection associated with cryoglobulinemia and LKM-1 autoantibodies. Following a triple immunosuppressive therapy, there was a complete reconstitution of the bone marrow. Serum HCV-RNA as well as plus- and minus-stranded HCV-RNA in peripheral blood mononuclear cells (PBMC) were detected before immunosuppressive therapy. After therapy, serum HCV-RNA persisted. Furthermore, PBMC now were positive for plus-stranded RNA only. However, in bone marrow-derived precursor cells we failed to demonstrate HCV molecules after therapy. This would argue for reconstituted PBMC from newly generated uninfected precursor cells. It remains unclear as to whether the autoimmune character of the disease or the hepatitis C virus infection itself have contributed to the pathogenesis of the aplastic anemia.

Significance of IgG and IgM HCV antibody secretion in vitro in patients with chronic hepatitis C: correlation with disease activity and response to interferon-alpha

Hepatitis C virus antibodies are found in the serum of most patients with chronic hepatitis C. However, the significance of the humoral response is still uncertain. In this study, in vitro IgG and IgM anti-hepatitis C virus secretion by peripheral blood mononuclear cells of patients with chronic hepatitis C was analyzed. Peripheral-blood mononuclear cells from 21 of 36 patients (58.3%) secreted IgG anti-hepatitis C virus in vitro, as demonstrated with anti-hepatitis C virus-specific enzyme immunoassays and recombinant immunoblot assays. Ten of the 36 patients (27.8%) showed both IgG and IgM anti-hepatitis C virus core in vitro. In 9 of these 10 patients, IgM anti-hepatitis C virus was also detected in serum. Patients with in vitro IgM or IgG anti-hepatitis C virus secretion had higher ALT levels in serum than did patients without such secretion in vitro (99.5 +/- 22.1 and 85.6 +/- 34.4 vs. 38.1 +/- 37.4 U/L; p < 0.0001, p < 0.001). Furthermore, with a histology activity score it was demonstrated that patients with in vitro IgM or IgG HCV antibodies (or both) had more severe chronic active hepatitis than did patients without in vitro hepatitis C virus antibody secretion (p < 0.01). To analyze the therapy outcome, we included in this study 18 patients who had received interferon-alpha previously. Seven of eight in vitro hepatitis C virus antibody-positive patients were nonresponders, whereas the in vitro hepatitis C virus antibody-negative patients were mostly complete therapy responders (8 of 10).(ABSTRACT TRUNCATED AT 250 WORDS)

Mixed cryoglobulinemia type II in chronic hepatitis B associated with HBe-minus HBV mutant: cellular immune reactions and response to interferon treatment

The case of a young female patient with chronic active hepatitis B, vasculitic purpura, edema, and circulating immune complexes due to mixed cryoglobulinemia is described. Serum transaminases were elevated. Serological assays showed hepatitis B surface antigen (HBsAg), antibody to hepatitis B e antigen (anti-HBe), and antibody to hepatitis B core antigen (anti-HBc) antibodies but no antibody to hepatitis C virus (anti-HCV) or antibody to hepatitis delta virus (anti-HDV) antibodies. Using hepatitis B virus-polymerase chain reaction (HBV-PCR) and direct sequencing a precore/core (preC/C) mutant unable to synthesize HBeAg was detected in serum. HBV antigens were demonstrated in the circulating immune complexes. Following 1 month of treatment with interferon-alpha 2b3 miu three times weekly, alanine aminotransferases returned to normal levels while cryoglobulins and immune complexes disappeared from serum. In addition, 2 months after the onset of treatment serum HBV-DNA was no longer detectable by PCR. Prior to treatment the analysis of cellular immune reactions of peripheral blood mononuclear cells showed a major proliferative response to HBcAg, preS1Ag and HBxAg and a minor response to HBeAg and HBsAg. One month after conclusion of treatment a decline in T-cell reactivity against all HBV antigens was observed. During clinical response to the therapy, however, a strong proliferative response of T cells to HBcAg and HBeAg was demonstrated. In conclusion, immune complex disease may complicate chronic hepatitis B in patients expressing HBe-minus HBV mutants. Treatment with interferon-alpha was found to be effective in mixed cryoglobulinemia even in the presence of HBe-minus HBV mutants.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of the in vitro cytokine production by liver-infiltrating T cells of patients with autoimmune hepatitis

The pathogenic mechanisms underlying the development of autoimmune hepatitis (AIH) are still unclear. Since AIH is associated with the presence of various autoantibodies and certain HLA subtypes, it is likely that T and B cells play a major role in this disease. In this study we have determined the functional capacities of in vivo preactivated liver-infiltrating T cells (LTC) from patients with AIH. As controls we used LTC from patients with non-autoimmune hepatitis (non-AIH). Our results show that preactivated LTC from patients with AIH predominantly (190/255 clones) reside in the CD4+ population, whereas LTC in non-AIH are dominated by the CD8+ phenotype (148/254 clones). In view of this finding we have investigated the cytokine secretion patterns of 102 randomly chosen CD4+ T cell clones from six patients with AIH. As controls we have used 58 CD4+ LTC from 11 patients with non-AIH. All clones were stimulated by lectin and irradiated accessory cells and subsequent cytokine production was evaluated. LTC from patients with AIH have a lower interferon-gamma (IFN-gamma)/IL-4 ratio compared with LTC from non-AIH. Although clones from some patients with AIH produced very high amounts of IL-4 in vitro, this was not a constant finding. These results show that in vivo preactivated LTC from patients with AIH are mostly CD4+ T cells that produce more IL-4 than IFN-gamma. In contrast, LTC from patients with non-AIH are dominated by CD8+ and CD4+ T cells that produce significantly less IL-4 than IFN-gamma. Thus, liver-infiltrating T cells from patients with AIH and non-AIH belong to different functional T cell subsets. This may have implications for the regulation of humoral and cellular immune responses in inflammatory liver disease.

Autoreactive liver-infiltrating T cells in primary biliary cirrhosis recognize inner mitochondrial epitopes and the pyruvate dehydrogenase complex

Primary biliary cirrhosis (PBC) is characterized by lymphoid infiltrates in the portal tracts of the liver and the occurrence of antimitochondrial autoantibodies in serum directed against components of the pyruvate dehydrogenase complex and the other alpha-keto acid dehydrogenase complexes. These enzymes are located on the inner mitochondrial membrane. The destruction of the biliary tract in PBC is thought to be mediated by autoreactive liver-infiltrating T cells exerting cytotoxic activity or releasing certain lymphokines. In this study the reactivity of liver infiltrating T cells was shown to a bovine pyruvate dehydrogenase complex (PDH), a purified E2 subunit (PDH-E2) and a crude preparation of human liver mitoplasts (HLM), i.e. mitochondria depleted of their outer membranes. Peripheral blood lymphocytes (PBL) from 11 of 15 patients (73.3%) with PBC showed a HLA class II-restricted proliferative response to the PDH complex whereas PBL from patients with chronic viral hepatitis, autoimmune hepatitis or extrahepatic cholestatic icterus (n = 20) and healthy controls (n = 5) did not. In addition 13 of 15 PBL from patients with PBC (86.6%) and three of nine PBL from patients with autoimmune hepatitis (33.3%) reacted with the crude HLM preparation whereas no reactivity was found with PBL from eight patients with chronic viral hepatitis, three patients with extrahepatic cholestasis or five healthy controls. Clonal analysis of 115 liver-infiltrating T cells derived from two diagnostic liver biopsies of patients with PBC revealed a predominance of activated CD4+CD8- T helper cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Pneumatoceles and pneumothoraces complicating staphylococcal pneumonia: treatment by synchronous independent lung ventilation

A 54 year old man with a staphylococcal sepsis developed staphylococcal pneumonia complicated by multiple pneumatoceles and bilateral tension pneumothoraces caused by bronchopleural fistulae. Excessive enlargement of the right sided pneumatoceles and a tension pneumothorax not improved by drainage led to mediastinal shift and compression of the right lung. Reversal of the mediastinal shift and closure of the bronchopleural fistulae was achieved by assisted independent lung ventilation.

Lack of surface expression for the B-cell autoepitope of cytochrome P450 IID6 evidenced by flow cytometry

The major target antigen of LKM-1 autoantibodies in chronic active hepatitis is cytochrome P450 IID6. The role of LKM-1 autoantibodies in the pathogenesis of the disease is not clear. A crucial point is the expression of the target epitope on the hepatocyte membrane. Cultured rat hepatocytes were used in this study. Time dependent analysis of cytochrome P450 IID6 specific RNA-level revealed a constant decrease in culture. A high amount of the specific RNA-level was present after culturing the hepatocytes for 24 hours at the time of the membrane studies. To investigate membrane surface expression, we used recombinant human cytochrome P450 IID6 to affinity purify the specific autoantibody from patients sera. Indirect immunofluorescence studies and flow cytometry analysis were performed with viable, unfixed rat hepatocytes. As positive control, a monoclonal antibody against rat MHC class I antigens was used. More than 85% of viable hepatocytes showed a positive membrane staining after the incubation with the monoclonal antibody to MHC class I antigens. Affinity purified monospecific LKM-1 autoantibody, sera from control subjects and from patients with liver diseases showed a membrane staining of less than 10%. Thus, no significant expression of the B cell autoepitope of LKM-1 antigen was found on the plasma membrane of viable hepatocytes with the methods applied.

[Infiltrating T-cells in primary biliary cirrhosis recognize mitochondrial epitopes]

The primary biliary cirrhosis (PBC) is characterized by lymphoid infiltrates in the portal tracts of the liver and occurrence of antimitochondrial autoantibodies (AMA) in serum directed against the pyruvate dehydrogenase complex or other enzyme complexes that are located on the inner mitochondrial membranes. The destruction of the biliary tracts is thought to be mediated by autoreactive liver infiltrating T-cells. In this study we demonstrate the reactivity of peripheral and liver-infiltrating T-cells against a crude preparation of human liver subcellular fractions measured by the tritium-thymidine uptake. Peripheral blood mononuclear cells (PBMC) from 13 of 15 patients with PBC and from 3 of 9 patients with chronic autoimmune hepatitis recognized human liver mitoplasts, i.e. mitochondria depleted of their outer membranes. PBMC from patients with chronic viral hepatitis B and C or with extrahepatic cholestatic icterus and PBMC from healthy controls did not recognize this antigen. Monoclonal antibodies against HLA-class II molecules blocked this proliferative response. Clonal analysis of 115 liver-infiltrating T-cells derived from two diagnostic liver biopsies of patients with PBC revealed a predominance of activated CD4+CD8- T helper cells. Six CD4- positive T-cell clones were reactive to the HLM preparation when the antigen was presented by autologous B cell lines. MAb against HLA-class II or HLA-DR inhibited the response whereas mAb against HLA-DP did not. These clones did not respond to other subcellular fractions of human liver tissue. We conclude that among liver-infiltrating T-cells in PBC autoreactive T-cells exist that recognize some epitopes on the inner mitochondrial membranes.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver-infiltrating T helper cells in autoimmune chronic active hepatitis stimulate the production of autoantibodies against the human asialoglycoprotein receptor in vitro

Autoantibodies against the human asialoglycoprotein receptor (ASGPR) occur in the sera of patients with autoimmune liver disorders. Liver-infiltrating T cell clones that specifically recognize the ASGPR have been described in patients with autoimmune chronic active hepatitis (AI-CAH) and primary biliary cirrhosis (PBC). Recently, we have shown that peripheral blood mononuclear cells (PBMC) from patients with AI-CAH or PBC but not chronic viral hepatitis secreted anti-ASGPR antibodies in vitro. In this study we characterized the influence of liver-infiltrating T cells on the secretion of ASGPR-specific autoantibodies by autologous B cells in cell culture supernatants. T cell clones from liver biopsies of three patients with chronic autoimmune liver disorders (one with AI-CAH, two with PBC) were isolated and investigated for their proliferative response to soluble ASGPR and their helper function provided to autoantibody-secreting B lymphocytes. PBMC from these patients secreted autoantibodies spontaneously in their cell culture supernatants and showed a proliferative response to ASGPR. T cell-depleted PBMC, however, lacked spontaneous antibody secretion. Four CD4+CD8- liver-infiltrating T cell clones showed a proliferative response to ASGPR and also induced spontaneous anti-ASGPR antibody production in cell culture supernatants when added to autologous T cell depleted PBMC. Activated supernatants of these T cell clones failed to induce antibody production. None of seven CD4+CD8- and two CD4-CD8+ T cell clones non-responding to ASGPR provided this help for antibody secretion. Anti-ASGPR secretion in vitro could not be inhibited by the addition of MoAbs raised against monomorphic determinants on HLA class II molecules. The addition of purified ASGPR or polyclonal-activating pokeweed mitogen showed no influence on the production of autoantibodies in these cultures. These data show that B lymphocytes require T cell help for the production of ASGPR-specific antibodies. This help can be provided by ASGPR-responsive T helper cells via cellular interactions.

Hepatitis C virus antibody secretion in vitro by peripheral blood lymphocytes

A recombinant polypeptide corresponding to a virus-specific cDNA clone (c100-3) serves as the antigen for a hepatitis C virus (HCV) antibody assay. Previous investigations have shown an 80% prevalence of HCV antibodies in sera of patients suffering from post-transfusional chronic hepatitis non-A, non-B, but positive results were also obtained for 30 to 70% of sera from patients with chronic hepatitis B or autoimmune hepatitis. In this study we show that HCV antibodies are secreted by peripheral blood lymphocytes (PBL) in vitro. PBL from 12/35 patients with chronic non-A, non-B hepatitis and 1/6 patients with chronic active hepatitis B spontaneously secreted HCV antibodies in cell culture supernatants. The results were confirmed by neutralisation assay and ELISAs using recombinant and synthetic polypeptides derived from the c100-3 antigen and from the HCV core antigen. Two patients suffering from non-A, non-B hepatitis were negative for HCV antibodies in serum, but their PBL produced HCV c100-3 antibodies in vitro. PBL from patients suffering from autoimmune chronic hepatitis, primary biliary cirrhosis, toxic-liver injury and healthy blood donors did not produce antibodies to HCV c100 antigen irrespective of HCV antibody test results in their sera. Polyclonal B cell activation or mitogenic stimulation of T helper cells led to increased immunoglobulin synthesis by PBL in vitro, but did not lead to enhancement of specific HCV antibody production. In addition, HCV antibody production was not induced by these stimulation procedures in control lymphocytes. This spontaneous HCV antibody production in vitro suggests persistent antigenic stimulation of the B cells in vivo.

Human asialoglycoprotein receptor as an autoantigen in chronic hepatitis

ASGPR may play a role in the pathogenesis of autoimmune chronic liver diseases. Several lines of evidence support this hypothesis. Antibodies to rabbit ASGPR could be found in various inflammatory liver diseases. In contrast, ASGPR preparations derived from human liver (h-ASGPR) were recognized predominantly by sera from patients with ai-CAH. Moreover, anti-h-ASGPR showed a close correlation to the inflammatory activity of ai-CAH both in terms of prevalence (88% in histologically proven active diseases), immunoglobulin class (IgM antibodies restricted to active inflammation) and behavior during treatment. Anti-h-ASGPR secretion could also be found in vitro, when PBL of patients were stimulated in cell culture. Anti-h-ASGPR antibodies did not correlate with a subgroup of ai-CAH; they also occurred in nearly 15% of patients with PBC. Other inflammatory liver diseases, as well as nonhepatic autoimmune disorders, seldom exhibited anti-h-ASGPR (less than 5%). Additionally, PBL and T-cell clones obtained from liver biopsies in patients with ai-CAH and PBC responded to h-ASGPR. Liver-infiltrating T cells were predominantly of CD4 phenotype and HLA class II restricted. Thus, the human ASGPR has been shown to represent a common target for humoral and cellular autoimmune response in chronic hepatitis probably contributing to disease induction or perpetuation.

Clonal analysis of liver-infiltrating T cells in patients with LKM-1 antibody-positive autoimmune chronic active hepatitis

Autoantibodies against microsomal antigen of liver and kidney (LKM-1) are diagnostic markers for a subgroup of autoimmune chronic active hepatitis (AI-CAH). Cytochrome P450dbl, now classified as cytochrome P450 IID6, is the major antigen of LKM-1 antibodies. Immunohistological studies suggest that hepatic injury in AI-CAH is mediated by liver-infiltrating T cells. In the present study the specificity and function of liver-infiltrating T cells was analysed at the clonal level. Phenotypical characterization of 189 T cell clones isolated from four liver biopsies of LKM-1 antibody-positive patients showed an enrichment of CD4+ CD8- T cell clones proliferated specifically in the presence of recombinant human LKM-1 antigen (rLKM). This reaction was restricted to autologous antigen-presenting cells and to HLA class II molecules. In order to see whether rLKM was also recognized by peripheral blood T lymphocytes (PBL) we tested the proliferative response of PBL from several individuals. PBL from three of the four patients with LKM-1 antibody-positive AI-CAH proliferated to rLKM, whereas no response was seen with PBL from patients with LKM-1 antibody-negative chronic liver diseases and from healthy blood donors. These data demonstrate that the LKM-1 antigen is recognized by liver-infiltrating T cells in LKM-1 antibody-positive AI-CAH. For further functional characterization, liver-derived T cell clones were tested for their cytotoxic activity. In the presence of phytohaemagglutinin 24 out of 26 CD4- CD8+ but also 20 out of 63 CD4+ CD8- T cell clones lysed autologous as well as allogenic EBV-transformed B cell lines or K562 cells. Five CD4- CD8+ T cell clones lysed autologous but not allogenic B cell lines spontaneously in a HLA class I-restricted manner. Although the antigen specificity of these clones is still unknown the data show the presence of autoreactive T cells at the site of inflammation that could contribute in the pathogenesis of AI-CAH.

The human hepatic asialoglycoprotein receptor is a target antigen for liver-infiltrating T cells in autoimmune chronic active hepatitis and primary biliary cirrhosis

Autoantibodies to the human hepatic asialoglycoprotein receptor have been found in nearly 50% of the sera of patients with autoimmune chronic active hepatitis and in 15% of patients with primary biliary cirrhosis. In this study we demonstrate that the human hepatic asialoglycoprotein receptor is also a target antigen for T cell-mediated immune responses. Peripheral blood lymphocytes of 37% (7 of 19) of patients with autoimmune chronic active hepatitis and 33% (2 of 6) of patients with primary biliary cirrhosis showed a proliferative response to highly purified human hepatic asialoglycoprotein receptor, whereas no proliferation was found with peripheral blood lymphocytes of patients with chronic viral hepatitis (0 of 13) and healthy blood donors (0 of 4). Moreover, we isolated T-cell clones from liver biopsy samples of two patients with autoimmune chronic active hepatitis and two patients with peripheral blood lymphocytes. Between 2.8% and 14.3% of these clones showed a specific proliferative response to purified human hepatic asialoglycoprotein receptor. The response was restricted to autologous antigen-presenting cells and could be blocked by monoclonal antibodies against human leukocyte antigen-DR molecules. The response of T cells to the human hepatic asialoglycoprotein receptor did not require the lectinlike activity of the asialoglycoprotein receptor. Thus the human hepatic asialoglycoprotein receptor could be identified as a major target antigen of humoral and cellular immune reactions in autoimmune-mediated liver diseases.

[Spontaneous intramural hematoma of the intestinal wall--an unusual hemorrhagic manifestation of hemophilia A]

Gastrointestinal bleeding is a well known event in patients suffering from blood dyscrasias. In contrast spontaneous nontraumatic hematoma of the bowel is a rare complication, requiring a different therapeutic management, which depends on localization and extent of the hematoma. We report about two hemophiliac patients presenting with acute abdominal pain caused by spontaneous intramural hematomas.

[Retractile mesenteritis. Diagnostic and therapeutic aspects]

An 18-year-old boy, who had severe abdominal pain for 18 months associated with marked weight loss, was found to have a stenosed ileal sling on double-contrast radiology of the small intestine. At operation a plate-like tumour was extending from the pancreas to the aortic bifurcation. Histological examination of removed tissue revealed retractile mesenteritis (mesenteric panniculitis; liposclerotic mesenteritis). The symptoms regressed and the patient again gained weight under immunotherapy with 1 mg/kg of prednisone and 2 mg/kg of cyclophosphamide daily. Subsequently, under prednisone alone, there was a recurrence, which responded within five weeks to daily 60 mg prednisone and 125 mg cyclophosphamide. The patient remains symptom-free on 125 mg cyclophosphamide and 10 mg prednisone daily.

[Herman Hager (1816-1897)--the heights and depths of his life]

The "Hager", undoubtedly a practical, indispensable encyclopedia of more than 10,000 pages is to be found in every German pharmacy. The changeable life of his author, Hans Hermann Julius Hager, who was born in Berlin, is reflected in a contradictory way in pharmaceutical history. Although he never completed a study he reached the highest degree of pharmaceutical science as a genuine autodidact but was neglected and insulted during life time. He died in very poor circumstances at Neuruppin, where he had come to live at his son's place one year before his death.

[Cystic pancreas adenoma. On the clinical relevance of histologic typing]

Although pancreatic cystadenomas are rare neoplasms, they are found today in rising frequencies due to improvement of diagnostic tools. There exist two types of cystadenoma: microcystic serous cystadenoma and mucinous cystadenoma. Usually, histological distinction from cystadenocarcinoma is readily made, but it may be difficult in the case of the mucinous variant. This subtype is supposed to be potentially malignant, whereas microcystic serous cystadenoma is always benign. In order to elucidate the characteristics of both variants, 5 own cases are reported in this article.

A new hereditary bone dysplasia with characteristic bowing and thickening of the distal ulna

An autosomal dominant hereditary bone dysplasia was observed in three members of a Sardinian family living in Germany--the father and two sons. The guiding clinical symptom is thickening of the wrist proximal to the styloid process of the ulna. The radiologically recognizable changes--non-calcified cartilaginous islands protruding like cones into the metaphysis--begin with the onset of puberty and are not always associated with pain. Varying degrees of thickening and bowing of the relatively poorly mineralized metaphyseal region, particularly of the distal ulna, occur at the end of skeletal development. Thickening of the dorsum sellae is also characteristic. Serum calcium levels remain slightly elevated throughout life. The metatarsals, metacarpals and the distal fibula are dysplastic to varying degrees. The two boys display a coxa valga. Skeletal development is retarded. A developmental disorder of the vertebral column may form part of the condition, which defied allocation to any of the acknowledged forms of skeletal disease.

Expression of c-myc in stimulated T lymphocytes of the helper/inducer phenotype producing lymphokine(s) supporting multilineage colony formation

Phytohemagglutinin (PHA) renders human peripheral T lymphocytes competent to replicate their DNA and divide. The stimulation of peripheral T cells of the T4 phenotype by PHA, which appears to be a transcription-dependent event, leads to the production and release of lymphokines supporting proliferation and differentiation of human pluripotent stem cells (CFU-GEMMT). Supernatants of PHA-stimulated lymphocytes of the suppressor/cytotoxic phenotype (T8) failed to demonstrate reasonable activity to support the growth of CFU-GEMMT. Stimulation of T lymphocytes of the T4 but not of the T8 phenotype leads to an increased intracellular level of c-myc mRNA. This would be consistent with the c-myc gene product functioning as an intracellular mediator of the growth and lymphokine production response to PHA. Although the function of the c-myc gene product is not yet clear, it seems likely that it is involved in the control of cell proliferation. Such a contribution to control of cell proliferation by c-myc would probably be mediated by a family of genes inducing lymphokine production to stimulate proliferation of human pluripotent stem cells.

[Radiation exposure and radiation risk in angiocardiography in adults]

In 100 patients, the X-ray exposure during routine angiocardiography was measured from which calculations were performed for the integral dose (the energy transferred to the body by the exposure), the mean body dose and the radiation risk (according to ICRP 26, 1977). Fluoroscopy contributed 21% and angiocardiography 79% of the total exposure. The mean body dose was 0.9 rd. The average of the area-dose product was 10,200 Rcm2 with a skin exposure in the central beam of 36.1 rd. The genetic risk (probability of X-ray-induced mutation in progeny) is 1 : 75,000 after average exposures and 1 : 7,700 at maximal doses. The somatic risk (probability of X-ray-induced lethal disease) in the patients studied is 1 : 11,000 after average exposures and approximately 1 : 4,400 at maximal doses. The genetic and somatic risks, thus, are small as compared with those of cardiac catheterization and contrast angiocardiography.

[Pathobiochemistry of minerals and trace elements. I. Metabolism of zinc in the mother and newborn during the perinatal period (author's transl)]

In 468 mothers and their newborns the zinc levels in blood and serum were measured after the birth. Zinc levels were low in normal and also in complicated pregnancies. The fall in the level was the same in primi and multipara. There was no correlation between the blood group or the Rhesus factor or Apgar score and zinc metabolism. In male newborns the zinc level was significantly lower than in female newborns. The Apgar score was not affected by the course of pregnancy or the sex of the foetus. We suggest that the recommendations of Mischel [19], Apgar [1,2] and Sandstead [20] to substitute zinc as well as calcium and iron to protect the physiological metabolism of mother and child during pregnancy should be investigated by further research.

[Fundamental facts on dosimetry in the assessment of radioexposure and risk of such exposure in children (author's transl)]

Various methods for determining exposure to radiation are critically reviewed on the basis of 358 x-ray examinations of children (218 cardiac catheters with angiocardiography, 39 gastrointestinal examinations, 101 urological examinations). It is shown that the surface dose is an insufficient parameter for the actual exposure of the child to radiation. Estimates of the radiation risk based thereon are misleading. Even the determination of the area dose product and the integral dose alone will not allow any valid comparison of the exposure in different age groups. The important factor for an accurate determination of the somatic radiation risk is the ratio of integral dose to the body mass (mean body dose), since this is the only factor which is independent of body variables, i.e. only this figure will yield the relation of radiation risks in different age groups. Independent of the examination methods, a higher radiation risk must be assumed in infants than in older children or adults. These relationships are demonstrated on the basis of the author's own measurements and calculations.

[Infection due to Yersinia enterocolitica in healthy and chronically ill children (author's transl)]

A septicaemic course of infection due to Yersinia enterocolitica developed in three children, two Italian girls with thalassemia (serotype 03) and a previously healthy boy (serotype 09). There were marked gastrointestinal symptoms. The boy required two transfusions for acute haemolysis. Because it may take a serious course, the possibility of this organism as the causative agent should be considered in the differential diagnosis of severe infections, especially in patients with chronic debilitating disease. The death rate is about 30%.

[Radiation exposure and radiation risks from body scanners (author's transl)]

The exposure received during investigation with the Delta 50 FS body scanner was measured in 150 patients. On the basis of data in IRCP 26, the somatic and genetic risk from the absorbed dose was calculated. The somatic risk per examination varies between 1:40 000 and 1:310 000, depending on the part of the body examined. The genetic risk (probability of radiation induced malformation in off-springs) is of the order of 1:19 000 to 1:1 5 million.

[Radiation-risk in catheterization and angiocardiography of the child (author's transl)]

The skin exposure and the energy transferred to the body (integraldose) increase with the child's growth. Nevertheless the mean body dose (integraldose/body-weight) is the highest in the youngest patient. The probability of roentgenray induced letal malignancy is approximately 1:9000--1:17000. The morbidity risk may be 2--3 times higher at the least.

[Radiation risk for the child in urinary tract roentgendiagnostic (author's transl)]

During one urogramm skin doses were measured between 0,1--0,9 Roentgen (R) in the radiation field. The testes dose was 6--41 mR. In mictioncysto-urethrography the skin dose was between 0,2 and 4,2 R/examination, and the testes dose 50--80 mR. The energy transferred to the body by the X-rays (integral dose) was 5,6--23 mJoule (mJ) per urogramm. The mean-body-dose (integral dose/bodyweight) was 1,3--0,6 mJ/kg per examination. The probability to induce a lethal disease (for example leukemia or malignoma) by this dose is approximately 1:50 000--1:500 000. The probability that exposure of the gonades induces mutations and thereby malformations in the following two generations is equally about 1:50 000--1:500 000.

[Radiation dose and risk in gastrointestinal roentgendiagnostic of the child (author's transl)]

In gastrointestinal roentgendiagnostic of the child the exposure of the skin and the testis depends on body height and body weight. The dose grows with the age. The squaredose product (Rcm2) and the energy absorbed by the body (integraldose, rdkg) increases comparably. On the other hand the quotient integraldosis/body weight is similar for the different age-groups. The radiation risk (the probability to die as consequence of a roentgenray induced disease) is approximately 1:100,000 to 1:10,000,000.

[Visceral kala-azar disease in a child (author's transl)]

Repeated blood cultures were negative in a six-year-old boy with high septic temperature. Rheumatoid arthritis, typhoid and brucellosis were excluded. There was no evidence of leukaemia (bone-marrow tests). There was hepatomegaly with increased transaminase activity. Cortisone treatment was begun for suspected collagen disease. Several liver needle biopsies at first revelaed increasingly severe necrotising changes, predominantly in the centres of the acini. There were no parasites demonstrable histologically. The spleen was increased in the isotope scan but, covered by the liver, not definitely palpable. Diagnosis of mediterranean Kala-Azar disease was then suspected (the parents reporting a camping holiday in Yugoslavia) and finally proven serologically. The previously treatment-resistant disease improved dramatically after administration of trivalent antimony (Fuadin).

[Radiation protection measurements at the intensive care unit and in the operating room]

For chest X-ray in the ward and for intraoperative cholangiography the registered doses were low. A limitation of the exposures or the operations was not necessary. For osteosynthesis operations the doses for the patient and the staff could be kept low by preparing the operation adequately, by using modern image-intensifer units with grid and automatic regulation in fluoroscopy, and with discipline in using fluoroscopy. During one week a surgeon could do eight osteosynthesis operations without reaching legally imposed dose limit. The control area could be restricted to a space around the patient with a radius of two meters.

[Differences of X-ray exposure between roentgen examen with a conventional roentgen-screen-system and with an image intensifer-television-unit (author's transl)]

During roentgen examens of patients in the II. Medizinische Poliklinik the X-ray exposure was determined. It corresponded to the datas described in literature. Two groupes were compared: 518 patients examined with a conventional roentgen-screen-system and 642 patients examined with an image-intensifer-television-system. The results demonstrated that with exception of thoracical X-ray examination the replacing of the old system by the television system brought a remarkable increase of the X-ray exposure. The doses depended of the patients constitution to a high degree.