Risk of hepatitis B virus reactivation in hepatitis B virus + hepatitis C virus-co-infected patients with compensated liver cirrhosis treated with ombitasvir, paritaprevir/r + dasabuvir + ribavirin

Hepatitis B virus may reactivate in patients with chronic hepatitis C treated with direct-acting antivirals. The aim of this study was to investigate the risk of hepatitis B virus (HBV) reactivation in HBV + hepatitis C virus (HCV)-co-infected patients with compensated liver cirrhosis treated with paritaprevir/ombitasvir/ritonavir, dasabuvir with ribavirin. We reviewed prospectively gathered data from a national cohort of 2070 hepatitis C virus patients with compensated liver cirrhosis who received reimbursed paritaprevir/ombitasvir/r, dasabuvir with ribavirin for 12 weeks from the Romanian National Health Agency during 2015-2016. Twenty-five patients in this cohort were HBs antigen positive (1.2%); 15 untreated with nucleotide analogues agreed to enter the study. These patients were followed up: ALT monthly, serology for HBV and DNA viral load at baseline, EOT and SVR at 12 weeks. Hepatitis B virus (HBV)-co-infected patients were all genotype 1b and 52% females, with a median age of 60 years (51 ÷ 74); 76% were pretreated with peginterferon + ribavirin; 72% were with severe necroinflammatory activity on FibroMax assessment; 40% presented comorbidities; and all were HBe antigen negative. Hepatitis C virus (HCV) SVR response rate was 100%. Hepatitis B virus (HBV)-DNA viral load was undetectable in 7/15 (47%) before therapy, and for the other 8 patients, it varied between below 20 and 867 IU/mL. Five patients (33%) presented virological reactivation (>2 log increase in HBV-DNA levels) during therapy. One patient presented with hepatitis associated with HBV reactivation, and two started anti-HBV therapy with entecavir. Hepatitis B virus (HBV) virological reactivation was present in 33% in our patients. Generally, HBV-DNA elevations were mild (<20 000 IU/mL); however, we report one case of hepatitis associated with HBV reactivation.

EMERGENCY SURGICAL TRACHEAL DECOMPRESSION IN A HUGE RETROSTERNAL GOITER

Introduction

Over the past decades, several definitions and classifications of cervico-mediastinal goiters have been proposed. We analyzed and discussed the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and long-term results in a case of a sixty-six years old obese, hypertensive female admitted in the Thoracic Surgery Department with respiratory distress (inspiratory dyspnea, stridor) progressively aggravating during the latest month.

Methods

Cervico-thoracic CT scan revealed the existence of a cervico-mediastinal huge goiter which developed mostly intrathoracic (2/ 3 of the goiter). It determined a tracheal compression, reducing its caliber by two thirds, and its displacement to the right side. The proposed surgical procedure was total thyroidectomy and it involved a bipolar approach (transcervical and transsternal) through a partial upper cervico-sternotomy.

Results

The complete removal of the goiter and the decompression of the trachea have been achieved. Postoperative results were very satisfactory, with the absence of the respiratory distress. The histological examination revealed a multinodular goiter with epithelium hyperplasia.

Conclusion

The presence of a complicated cervico-mediastinal goiter with severe respiratory distress required a surgical excision as the main and immediate treatment option. The surgical procedure represented a milestone for both the anesthesiologist (difficult intubation, with a thin tracheal tube in the absence of the jet ventilation technology) and for the surgeon. The goiter's excision from the visceral mediastinum was very difficult because of its huge dimensions and close relations with trachea and great vessels (anterior) and esophagus, erector spinal muscles and the spine (posterior).

Cytokine gene polymorphisms support diagnostic monitoring of Romanian multiple myeloma patients

INTRODUCTION

Cytokines and their receptor genes are very polymorphic. SNPs in the promotor region of the gene may influence the rate of cytokine secretion and may affect the biological activity of the encoded cytokine. A number of cytokines and cytokine receptors have been directly linked to the development of human cancers. The aim of our study was to determine the cytokine gene polymorphism in Romanian multiple myeloma patients.

MATERIAL AND METHODS

Cytokine genotyping was performed in 80 patients and 100 healthy blood donors using molecular biology methods (SSP-Invitrogen, USA).

RESULTS

Analyzing each polymorphic site, there was an increased frequency of the following genotypes in patients compared to control group: Interleukin-1beta (IL-1β) pos.+3962 TT, IL-12 pos.-1188 CC, gamma-Interferon (γ-IFN) pos.+874 AA, Transforming Growth Factor- beta1 (TGF- β1) codon10 TT, IL-2 pos.-330 TG and pos.+166 TT, Interleukin-4Receptor alpha (IL-4Rα) pos.-33 TC, IL-10 pos.-1082 GG and pos.-592 CC, IL-6 pos.-174 GG. It should be noted that almost one third of multiple myeloma patients had IL-6 pos.-174 GG genotype and 62% IL-10 GCC haplotype. These identified haplotypes are high interleukins producer, and this fact was confirmed by serum IL-6 and IL-10 levels performed by ELISA and enhanced chemiluminiscence methods.

CONCLUSION

These markers could be successfully used, together with other specific clinical and biological parameters, as reliable individualized prognostic factors in multiple myeloma patients.

Hand transplant--a challenge in immunological management of patients

The concept of composite tissue allotransplantation (CTA) for restoration of congenital or acquired deformities is not new and the recent success of clinical composite tissue allotransplantation (CTA) attests to the fact that composite tissue allografts have tremendous potential in these life-enhancing reconstructions. A hand transplant, unlike a solid organ transplant, involves multiple tissues (skin, muscle, tendon, bone, cartilage, fat, nerves and blood vessels) and can be considered the 'gold standard' in CTA. In this regard, no other organ or tissue transplant matches the hand transplant in its immunogenicity as well as complexity. Development of assays that allow us to monitor the current state of an immune response (rejection/tolerance) is of great interest and requires an in-depth understanding of the complex and rare phenomenon of tolerance.

'Immunogenetics of Aging': report on the activities of the 15th International HLA and Immunogenetics Working Group and 15th International HLA and Immunogenetics Workshop

'Immunogenetics of Aging' is a component that was first included in the 14th International HLA and Immunogenetics Workshop (IHIWS) and developed further within the 15th Workshop. The aim of this component was to assess the impact of human leukocyte antigen (HLA) genes, cytokine genes, and some innate immunity genes such as killer-cell immunoglobulin-like receptors (KIRs) and mannose-binding lectin 2 (MBL2) in successful aging and their contribution to the better understanding of immune dysfunction in old age. Within the 15th IHIWS new populations were included in the analysis. Additional cytokine gene polymorphisms were assessed and innate immunity genes were analyzed for possible relevance in longevity. The results showed that longevity might be associated with anti-inflammatory cytokine gene profiles, decreased frequency of interleukin-10 (IL-10) and transforming growth factor-B1 haplotypes associated with a low level of gene expression, and increased frequency of haplotypes determining a high level of expression. Extended tumor necrosis factor-A and IL-12B genotypes were also likely relevant to longevity. Data also showed that innate immunity genes are associated with susceptibility to infections in the elderly and showed that these genes might be an important genetic marker in aging. Decreased frequencies of KIR2DS5 and A1B10 haplotypes, and an increased proportion of MBL2-deficient haplotypes were found in the group with higher cytomegalovirus-specific IgG antibody levels. Together, these studies emphasize the relevance of genes regulating immune functions in maintaining human longevity and stress the importance of further clarifying their impact on successful aging.

Cytotoxic antibodies--valuable prognostic factor for long term kidney allograft survival

BACKGROUND

Since the first attempts of kidney transplant, the inflammation mediated by T lymphocytes was considered one of the most important processes implicated in graft rejection but, multiple acute and chronic graft rejects revealed that the inflammation process is not singular and humoral mechanisms may play a role in the development of chronic vascular rejection.

MATERIAL AND METHODS

We evaluated 500 Romanian patients registered on the kidney transplant waiting list. We performed anti-HLA class I and class II antibodies screening and identification. Laboratory tests were performed at Centre for Immunogenetics and Virology, Fundeni Clinical Institute, Bucharest, Romania. The methods used are represented by ELISA (GTI Diagnosis, USA) and Luminex (Tepnel, USA) RESULTS: pretransplant evaluation of the subjects illustrates that 145 patients (29%) have been sensitized and 355 patients (71%) have not been sensitized. The most frequent types of anti-HLA antibodies were A2 (13%), B42 (10%), DR7 and DR11 (13%). Post transplant, the most cases with de novo antibodies were observed in the first 6 months post transplantation. High serum levels of Il-2 Receptor, TNF-alpha and neopterin in post transplant sensitized patients were observed following de novo cytotoxic antibodies occurrence.

CONCLUSION

post renal transplantation, patients present high risk in developing de novo cytotoxic antibodies, especially those who had HLA mismatch with the donor. These antibodies are predictors for acute graft rejection and for graft failure.

Primary immunodeficiencies of the B lymphocyte

The immune response consists of two main components: humoral immunity represented by B lymphocytes and cellular immunity maintained by the T lymphocytes. Immunoglobulins, produced by B-lymphocytes, are the main mediators of humoral immunity, and deficiencies at this level affect the body's response to infection. Plasmocytes produce nine antibody izotypes: immunoglobulins G (IgG1, IgG2, IgG3, IgG4), immunoglobulins M (IgM), immunoglobulins A (IgA1, IgA2), immunoglobulins D (IGD) and immunoglobulins E (IgE). Primary hypogammaglobulinemias are characterized by the occurrence of recurrent infections and, paradoxically, by the occurrence of autoimmune diseases. Characteristic for these diseases is that symptoms occur at 7-9 months after birth, when transplacental antibody titers transmitted from the mother decrease, and the infant's body is unable to synthesize them to normal levels. Primary hypogammaglobulinemias are transmitted genetically, but mutations at the molecular level are still not fully understood. The most common are: Bruton agammaglobulinemia, transient newborn hypogammaglobulinemia, selective immunoglobulin deficiency and variable common immunodeficiency. Treatment consists of monthly antibiotics and immunoglobulins, depending on antibody titers (except for IgA deficiency).

Clinical and therapeutical importance of HBV genotyping in Romania

In a country with a high prevalence (16%) of chronic serum HBsAg carriers like Romania there is a special interest in the diagnosis, epidemiology, clinics, pathology and treatment of HBV infection The idea of HBV genotyping arose from the need of understanding the complex interactions between virus and host. The purpose of this article is to present a study which aimed to identify the circulating HBV genotypes in Romania. correlate them with the clinical outcome and by HBV genotyping, to make a selection of patients for the most appropriate antiviral therapy. 130 patients were selected from different areas of the spectrum of HBV infection in which a quantitative determination of HBV-DNA was performed. HBV A genotype is associated with the inactive carrier status: a symptomatic HBV-HDV was identified in the double infection. The HBV D genotype has the most common HBV genotype (66%) and is associated with active viral infection and hepatocellular carcinoma. Long term HBV chronic infection revealed a mixture of A and D genotypes in most cases. For a proper selection of patient for the antiviral therapy, we should mandatorily genotype the HBV virus before the onset of treatment and all genotyping data must be correlated with liver biopsy assessments.

14th International HLA and Immunogenetics Workshop: report on the immunogenetics of aging

The 'Immunogenetics of Aging' is a newly included component within the 14th International HLA and Immunogenetics Workshop. The aim of this component was to determine the contribution of human leukocyte antigen (HLA), cytokine genes and other major histocompatibility complex-encoded loci to successful aging and to determine an increased capacity to reach the extreme limits of life span. Two main data sets from four European populations were included in this study: unrelated healthy elderly individuals and ethnically matched young controls, and families with longevity members. Analysis was focused on HLA class I and II and cytokine gene polymorphisms. Preliminary results showed increased frequencies of DRB1*11- and DRB*16-associated haplotypes that were found to be protective for autoimmune diseases in some populations. Additionally, in families with longevity members, alleles and haplotypes positively associated with autoimmunity were not observed. Analysis of cytokine gene polymorphisms showed prevalence of anti-inflammatory profiles in healthy elderly individuals. Inheritance of extended haplotypes in families with longevity members allowed the identification of immunogenetic profiles that could be predictive for longevity. These preliminary studies indicate the relevance of genes regulating immune functions in human longevity and the importance of clarifying further their impact in successful aging.

Pycnogenol efficacy in the treatment of systemic lupus erythematosus patients

A pilot study was performed to evaluate the efficacy of Pycnogenol treatment in systemic lupus erythematosus (SLE) patients. Eleven SLE patients were treated with first line medication according to disease activity and in addition, six of them received Pycnogenol and five a placebo. The SLE disease activity index (SLEDAI), serum anti-dsDNA antibodies, fibrinogen, C-reactive protein levels, erythrocyte sedimentation rate, production of reactive oxygen species (ROS) by neutrophils, spontaneous apoptosis and p56(lck) specific activity in peripheral blood lymphocytes were evaluated. Pycnogenol treatment determined a significant reduction of ROS production, apoptosis, p56(lck) specific activity and erythrocyte sedimentation rate. In addition, the decrease of SLEDAI was significant in the Pycnogenol treated group compared with the placebo group (p = 0.018). The results obtained suggest that Pycnogenol could be useful for second line therapy to reduce the inflammatory feature of SLE.

"Trial moves rapidly on, when the judge has determined the sentence beforehand" (W. Scott: Ivanhoe, 36) or pitfalls in serosurvey of anti-hepatitis C antibody in children

Hepatitis C is and will be a major public health concern. Confirmed infections were reported from all Romanian counties but important differences between regions raise several explanations. Differences may reflect the different levels of testing, the performances of laboratories in confirming initially reactive samples or the risk factors higher prevalence. We have suggested that the prevalence of anti HCV infections can be a surrogate marker for the quality of parenteral medical or paramedical interventions. Present report identified additional problems in the surveillance of HCV infection in children. We screened 1787 samples from children hosted in orphanages (children under three years old) or in preschool children institutions (between 3-7 years old). We detected 31 repeatedly reactive samples with two EIA screening kits but confirmed only 8 in WB anti HCV. Four confirmed samples come from children under four months old suggesting maternally transmitted antibodies. In highly endemic area, many infants have maternally derived antibodies and the wane of reactivity comes with age above 12 months. Therefore, the prevalence of anti HCV antibody in infants reflects the prevalence in adult population. Confirmatory tests are mandatory for the serosurvey in children. More frequent than adults samples, children EIA reactive samples give indeterminate or negative Western Blot profiles. Only the viral load evaluation can confirm those samples as false positive or, on the contrary, samples at the beginning of seroconversion.

[Goodpasture's syndrome--a case report]

A female subject case aged 64 years is presented. The history shows several hospital admissions for lung diffuse infiltrative processes, accompanied with hemoptoic sputa. These infiltrations had a regressive evolution either spontaneously or under treatment. The diagnosis of Goodpasture syndrome was fixed post-mortem by alterations evidenced in the kidneys.

[Experimentation of apiarian preparations for the direct and the indirect capping of the dental pulp]

With a view to extend the range of biologically active preparations for the direct and the indirect capping of the dental pulp the authors have used a paste made from an alcoholic solution of propolis and zincoxyde. The study was carried on in 150 teeth with indirect capping of deep cavities, and 50 teeth with direct capping. The evolution of the cappings was followed clinically, radiologically and morphologically. The results obtained showed that the paste with propolis exerts effects similar to those of zinc eugenate. The morphologic study of the indirect capping showed that secondary dentin developed shortly after the application of the paste, and that it was followed by the development of pulpolites and the sclerous transformation of the pulp. In teeth with direct capping a protective film developed at the opening of the dental chamber. With time the pulpal wound undergoes cicatrization by a process of fibrosis and there is a trend to remineralization. No areas of pulpal degenerescence were found the rest of the pulpal tissue, and this suggests that the paste is more histophilic than the pastes based on calcium hydroxide, with which an area of necrosis occurred at the opening of the chamber, and calcium and fibrous degenerescence occurred in the coronal pulp.

Comparative experimental research into the nootropic action of procaine and pyracetam

Procaine exerts a positive influence in different tests that prove its nootropic effects: it improves the learning process in small animals, increases the resistance to hypoxemia induced by curarization and hypobarism, augments the effort endurance. The effect is clearly shown at the dose of 5 mg/kg b.w. in subchronic treatment (five to eight days). A higher dose of procaine--25 mg/kg b.w.--does not influence significantly these tests, but ensures a partial protection against gastric ulcers induced by contention. The efficiency is inferior to pyracetam. Neither procaine nor pyracetam succeeds in protecting against supramaximal electroshock or in influencing EEG changes due to hexobarbital. As shown by EEG, the two substances have different mechanisms of action: procaine triggers cortical inhibitory effects while pyracetam manifests itself by activating phenomena.

[Adverse reactions to antitubercular treatment with rifampin (Considerations on 14 cases]

An analysis of a group of 120 patients with pulmonary tuberculosis undergoing rifampicin treatment attempted to perform a study of adverse reactions induced by this drug used in modern therapeutic regimens of short duration (6 to 9 months). This was prompted by the increasing number of papers in the specialized literature concerned with such adverse reactions that occur in 10--50 percent of all cases treated with rifampicin. Adverse reactions to rifampicin (influenza-like syndrome, digestive syndrome, hepatic syndrome) were relatively rare in the group presented here (11,8 percent), when compared with the data in the literature. Although no severe adverse reactions occured, suppression of rifampicin therapy was necessary in most of the cases, and this modified the efficiency of the treatment. This low incidence has however a statistical significance indicating that larger groups should be investigated.