Early-Phase Alcoholic Liver Disease: An Update on Animal Models, Pathology, and Pathogenesis

Alcoholic liver disease (ALD) remains to be one of the most common etiology of liver disease and is a major cause of morbidity and mortality worldwide. The pathologic stages of ALD comprises of steatosis, steatohepatitis, and fibrosis/cirrhosis. Steatosis and steatohepatitis represents the early phase of ALD and are precursor stages for fibrosis/cirrhosis. Numerous research efforts have been directed at recognizing cofactors interacting with alcohol in the pathogenesis of steatosis and steatohepatitis. This review will elucidate the constellation of complex pathogenesis, available animal models, and microscopic pathologic findings mostly in the early-phase of ALD. The role of endotoxin, reactive oxygen species, alcohol metabolism, and cytokines are discussed. Understanding the mechanisms of early-phase ALD should provide insight into the development of therapeutic strategies and thereby decrease the morbidity and mortality associated with ALD.

Recommendations to qualify biomarker candidates of drug-induced liver injury

Certain compounds that induce liver injury clinically are not readily identified from earlier preclinical studies. Novel biomarkers are being sought to be applied across the pharmaceutical pipeline to fill this knowledge gap and to add increased specificity for detecting drug-induced liver injury in combination with aminotransferases (alanine and aspartate aminotransferase) – the current reference-standard biomarkers used in the clinic. The gaps in the qualification process for novel biomarkers of regulatory decision-making are assessed and compared with aminotransferase activities to guide the determination of safe compound margins for drug delivery to humans where monitoring for potential liver injury is a cause for concern. Histopathologic observations from preclinical studies are considered the principal reference standard to benchmark and assess subtle aminotransferase elevations. This approach correlates quite well for many developmental compounds, yet cases of discordance create dilemmas regarding which standard(s) indicates true injury. Concordance amongst a broader set of biomarker injury signals in a qualification paradigm will increase confidence, leading to accepted and integrated translational biomarker signals during safety assessment processes across the pharmaceutical industry, with academia, in government and in contractor laboratories.

Prevalence of chronic viral hepatitis in people of south Asian ethnicity living in England: the prevalence cannot necessarily be predicted from the prevalence in the country of origin

The prevalence of hepatitis B and hepatitis C in immigrant communities is unknown. Immigrants from south Asia are common in England and elsewhere, and the burden of viral hepatitis in these communities is unknown. We aimed to determine the prevalence of viral hepatitis in immigrants from south Asia living in England, and we therefore undertook a community-based testing project in such people at five sites in England. A total of 4998 people attending community centres were screened for viral hepatitis using oral fluid testing. The overall prevalence of anti-hepatitis C virus (HCV) in people of south Asian origin was 1.6% but varied by country of birth being 0.4%, 0.2%, 0.6% and 2.7% in people of this ethnic group born in the UK, India, Bangladesh and Pakistan, respectively. The prevalence of hepatitis B surface antigen was 1.2%-0.2%, 0.1%, 1.5% and 1.8% in people of this ethnic group born in the UK, India, Bangladesh and Pakistan, respectively. Analysis of risk factors for HCV infection shows that people from the Pakistani Punjab and those who have immigrated recently are at increased risk of infection. Our study suggests that migrants from Pakistan are at highest risk of viral hepatitis, with those from India at low risk. As prevalence varies both by country and region of origin and over time, the prevalence in migrant communities living in western countries cannot be easily predicted from studies in the country of origin.

Accuracy of frozen section in the diagnosis of liver mass lesions

OBJECTIVE

To evaluate the diagnostic accuracy of intraoperative frozen sections diagnosis of liver lesions thought to be malignant tumours.

METHODS

285 frozen sections of liver from 173 patients were reviewed. The examinations were done between 1998 and 2004.

RESULTS

Final histological diagnosis was divided into positive (32%) and negative (68%) for malignancy. In four cases (2%), diagnosis was deferred to paraffin section. There was one false positive and two false negative diagnoses. Sensitivity was 96.9% and specificity was 99.1%, and the overall accuracy to determine the lesions was 95%. The cases were further analysed to ascertain the nature of diagnostic difficulties, which comprised pathological misinterpretation, sampling error, and technical imperfections. Biliary hamartoma was the most common entity that was confused with malignant tumours in frozen sections.

CONCLUSIONS

The data are in accordance with those of similar studies in other sites, and confirm that the frozen section is an accurate and reliable method for intraoperative diagnosis of suspected liver lesions.

Patients' perspective of pathology specimens. A prospective study

AIM

To determine the degree of patients' interest in surgical pathology specimens. To assess the impact of patients' involvement in surgical pathology on their understanding of (and confidence in) the storage and use of pathology specimens.

METHODS

Forty seven patients were invited to visit the pathology department and view their specimens postoperatively. Those who visited were asked to complete a questionnaire to assess the effect of the visit.

RESULTS

Thirty three of the 47 patients wished to view their specimens, but only 14 actually made the visit. All those who visited indicated that it made them better able to understand the reason for surgery and tissue retention issues, and more likely to consent to the use of excess tissue for research.

CONCLUSION

In general, patients are keen to know what happens to and what is wrong with the organs removed at surgery, and their involvement in surgical pathology can have positive and beneficial effects both for themselves and the profession.

Activation of Nur77 by selected 1,1-Bis(3'-indolyl)-1-(p-substituted phenyl)methanes induces apoptosis through nuclear pathways

Nur77 is an orphan receptor and a member of the nerve growth factor-I-B subfamily of the nuclear receptor family of transcription factors. Based on the results of transactivation assays in pancreatic and other cancer cell lines, we have now identified for the first time Nur77 agonists typified by 1,1-bis(3-indolyl)-1-(p-anisyl)methane that activate GAL4-Nur77 chimeras expressing wild-type and the ligand binding domain (E/F) of Nur77. In Panc-28 pancreatic cancer cells, Nur77 agonists activate the nuclear receptor, and downstream responses include decreased cell survival and induction of cell death pathways, including tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and poly(ADP-ribose) polymerase (PARP) cleavage. Moreover, the transactivation and apoptotic responses are also induced in other pancreatic, prostate, and breast cancer cells that express Nur77. In Panc-28 cells, small inhibitory RNA for Nur77 reverses ligand-dependent transactivation and induction of TRAIL and PARP cleavage. Nur77 agonists also inhibit tumor growth in vivo in athymic mice bearing Panc-28 cell xenografts. These results identify compounds that activate Nur77 through the ligand binding domain and show that ligand-dependent activation of Nur77 through nuclear pathways in cancer cells induces cell death and these compounds are a novel class of anticancer agents.

Outcome of women with inadequate cervical smears followed up for five years

BACKGROUND

The clinical and prognostic significance of "inadequate" cervical smear is unknown, even though women with repeated inadequate smears are referred for colposcopy in the National Health Service (NHS) Cervical Screening Programme.

AIM

To follow up a cohort of women with inadequate cervical smears over the following five years to examine outcomes, including detection of high grade cervical intraepithelial neoplasia (CIN).

METHODS

The study comprised 1972 women with an inadequate cervical smear reported at Walsall Hospitals NHS Trust between 1 April 1995 and 31 March 1996. Results of cervical smears and biopsies taken over the following five years were reviewed to confirm the outcome.

FINDINGS

Within five years, 2.2% of women with an inadequate cervical smear developed histologically confirmed high grade CIN, which was higher than the 1.3% seen among all women with cervical smear tests reported at the same laboratory over the same period, although the difference was not significant at the 95% level of confidence. Where inadequacy resulted from or was contributed to by "polymorphs obscuring", the risk of subsequent development/detection of high grade CIN was 2.6%.

CONCLUSIONS

Women with inadequate cervical smears had an increased risk of detection of high grade CIN in the following five years compared with "all women". This increased risk was not significant, although if a larger number of women had been studied significance may have been reached, so that further studies are needed. The increased risk appeared to be at least partially dependent on the reason for inadequacy.

Survey of NHS staff attitudes to influenza immunisation

There was a low uptake of influenza vaccination among health care workers in year 1999-2000. The study aimed to identify reasons for low uptake and to use the results to improve uptake during current and future campaigns.

A cluster of tuberculosis cases in a family

A 40 year old Indian woman who had recently returned from a visit to India with her eldest son was diagnosed with miliary tuberculosis in January 1994. Contact tracing revealed that her three sons, aged 19, 21, and 22, all had BCG scars from vaccinations administered at birth in India and Heaf tests of grades 2-3. None of them was given chemoprophylaxis, although this was considered, as suggested by the guidelines then available (1990). About 18 months later, the eldest son was notified as a case of tuberculosis. The youngest son, who shared a room with the eldest, developed a right tuberculous pleural effusion over three years after his mother became ill. The 41 year old husband of the index case and their 21 year old son remain well at the time of this report and are being followed up. These cases highlight the importance of stringent follow up, contact tracing, good liaison between general practitioners and chest clinic staff, and chemoprophylaxis for the contacts of tuberculosis cases. Guidelines about the management of contacts of sputum positive cases over 16 years old need to be clarified. A history of a recent overseas trip should raise suspicions of infection with tuberculosis.

GPs and contracting for secondary health care

Publication of the NHS White Paper Working for Patients and subsequent legislation has introduced the requirement for district health authorities to assess the health and health care needs of their resident populations. Sam Ramaiah and colleagues describe their experience in South Tees of working with GPs to fulfil this objective.