Norfloxacin with itopride versus norfloxacin alone in secondary prophylaxis of spontaneous bacterial peritonitis: a randomized trial

Background

Bacterial translocation is considered the pathophysiological hallmark in the development of spontaneous bacterial peritonitis (SBP). Prokinetics can increase gastrointestinal (GIT) motility, reduce small bowel transit time, decrease bacterial translocation, and the possibility of SBP. The aim of this work was to compare the effectiveness and safety of itopride and norfloxacin versus norfloxacin only in secondary prophylaxis for cirrhotic ascitic patients with spontaneous bacterial peritonitis.

Results

Regarding the baseline clinical manifestations and laboratory investigations, there was no significant difference between both groups. The incidence of a recurrent SBP in group I, who had received itopride plus norfloxacin, reduced with a significant difference than other group II (P=0.018). The median time for recurrence of SBP was highly longer in group I than group II with a significant difference (P=0.042).

Conclusions

The combined usage of itopride with norfloxacin in patients with cirrhosis and ascites can decrease the occurrence of a recurrent SBP and significantly improve the survival of patients.

Trial registration

ClinicalTrials.gov Identifier: NCT04161768.

Hypervascular Nodules and Stiffer Liver are Associated with Recurrence after Microwave Ablation in Patients with Hepatocellular Carcinoma: A Double-Center Analysis

Background and Aims  The aim of this study was to detect the most important risk factors for recurrence after microwave ablation (MWA) of hepatocellular carcinoma (HCC). Methods  A total of 92 patients with 110 HCC focal lesions (FLs) underwent MWA therapy. All the patients underwent triphasic CT before and after 1 and 3 months of MWA therapy. Complete ablation and recurrence rates were recorded, and the risk factors associated with recurrence were analyzed. Results  Regarding the 110 HCC FLs that were detected pre-MWA, adequate ablation was recorded post-MWA procedure in 88 FLs (80%) and incomplete ablation in 22 FLs (showed residual contrast enhancement). However, there were newly detected lesions (17 FLs). The rate of recurrence was significantly higher in patients with multiple larger (> 4 cm) sized and hypervascular nodules. Diabetics were significantly associated with a higher recurrence rate of HCC. The rate of recurrence was significantly higher in patients with baseline level of serum alfa-fetoprotein (AFP) ≥200 ng/mL. Stiffer liver> 25 kPa had higher incidence for recurrence after ablation. Conclusion  Meticulous follow-up is mandatory in diabetic patients, patients with AFP > 200 ng/dL starting value, hypervascular large hepatic FL, and in stiffer liver> 25 kPa, as these patients have higher incidence for recurrence after ablation.

Cyclin dependent kinase inhibitor p27(kip1) expression and subcellular localization in relation to cell proliferation in hepatocellualr carcinoma

Hepatocellular carcinoma (HCC) is one of the most prevalent malignancies worldwide, with a recently increased incidence in Egypt. Its prognosis is still poor although many advances in its clinical study. In this work the cell cycle regulation in relation to cell proliferation, as an important determinant of tumor behavior, was evaluated in HCC, as a new aspect of interest in cancer research. The present work involved 27 patients with hepatic focal lesions either being; HCC (group I; n=20 cases) or cirrhotic nodules (group II; n =7 cases). In addition, five controls (group III) with normal liver were studied. p27 production pattern, as an important and recently studied cell cycle regulator, both at mRNA and protein levels was studied by RT-PCR and immunohistochemistry (IHC) assay respectively. This in relation with IHC detection of proliferating cell nuclear antigen (PCNA) as a cell proliferation marker. The present work reported that hepatic tissue expression of p27 both at mRNA and protein levels was significantly decreased in HCC group compared to other groups. However there is no significant difference could be detected in between group II and III. Furthermore reduced p27 expression (mRNA and protein) was significantly related to tumor invasiveness, advanced clinical stage and poor cellular differentiation. While no relation could be detected between p27 expression and either of patient's age, gender, viral hepatitis status, alpha-fetoprotein, Child's grade or vascular invasion. In addition cytoplasmic expression of p27 was positively associated with increased tumor foci number and poor cellular differentiation with a stronger and higher incidence in HCC patients. The present work also reported increased positive rate of PCNA expression in HCC in comparison to other groups. PCNA in HCC, as a cell proliferation marker was found to be positively associated with increased number of tumor foci, advanced tumor invasiveness, stage and grade. PCNA expression was also increased with HBV and HCV/HBV coinfection with no other significant data in HCC. Interestingly and in contrary to our expectation, no significant relationship could be detected between the expression of p27 mRNA and p27 protein, as well as between the expression of p27 (both at mRNA and protein levels) and PCNA in HCC group, while these relations could be detected significantly in the other studied groups. In conclusion, reduced p27 and increased PCNA expressions may play a great role in hepatocarcinogenesis and suggested to be significant predictors of aggressive tumor behavior. p27 and PCNA may act independently with disturbed in between relationship in HCC that may be responsible for carcinogenesis. Whether the expression of p27 protein is regulated at the transcriptional level or by other mechanisms needs to be verified. Finally altered subcellular localization and cytoplasmic sequestration of p27 may be an alternative way to inactivate p27 with a possible evident role in HCC. These finding may help in planning new treatment strategies for HCC, however, large scale in vitro and in vivo studies are needed.

Significance of toll-like receptors 2 and 4 mRNA expression in chronic hepatitis C virus infection

Hepatitis C virus (HCV) induces inflammatory signals leading to progressive liver damage. The mechanism of HCV involvement in the host's innate immune responses has not been well characterized and little is known about the molecular mechanisms by which immune cells recognize HCV. In this work we studied Toll-like receptor (TLR) 2 and TLR4, in chronic HCV infection, as recently detected important components of the innate immunity in humans, as microbial recognition receptors. The study involved 30 HCV patients; 15 with chronic hepatitis (group I) and 15 with liver cirrhosis (group II), in addition to 10 healthy controls (group III). mRNA expression of TLR2 and TLR4 in peripheral blood mononuclear cells (PBMCs) was examined using reverse transcriptase PCR. This was carried out in relation to quantitative analysis of HCV-RNA by Real time-PCR and serum tumor necrosis factor-alpha (TNF-alpha) estimation by ELISA. Significant correlation was found, in HCV patients, between the viral load and TLR2 (r = 0.704; p < 0.01 in group I & r = 0.629; p <0.05 in group II) and TLR4 (r = 0.549; p < 0.05 in group I & r = 0.596; p < 0.05 in group II) and between TLR2 and TLR4 (r = 0.814; p < 0.001 in group I & r = 699 p < 0.01 in group II). Over expression of TLR2 and TLR4 was detected in chronic hepatitis patients as compared to controls (p < 0.001). In cirrhotic patients down regulation of TLR4 mRNA expression was found when compared to group I chronic hepatitis (p < 0.001), while TLR2 showed steady over expression. A positive correlation was also detected between TLR2 expression and TNF-alpha in HCV patients (r = 0.571; p < 0.05 in group I & r = 0.723; p < 0.01 in group II), while a weak relationship was found between TLR4 and TNF-alpha in cirrhotic patients. (r = 0.359; p > 0.05). TLR2 correlated significantly with the hepatic necroinflammatory activity grade (r = 0.629; p < 0.05 in group I & r 0.502; p < 0.05 in group II), while TLR4 correlated with the fibrosis stage (r = 0.682; p < 0.01). On the other hand no correlation could be detected between TLR2 and TLR4 and the child's grade in cirrhotic patients. It is concluded that TLR2 and TLR4 may play a vital role in HCV recognition, initiation and progression of HCV induced liver diseases. Lager scale studies as well as advanced molecular researches on immune-modulation of TLRs are recommended. This may have the way to a new therapeutic tool for HCV.