I know why the caged bird sings: Distress tolerant individuals show greater resting state connectivity between ventromedial prefrontal cortex and right amygdala as a function of higher vagal tone

BACKGROUND

Intolerance to psychological distress is associated with various forms of psychopathology, ranging from addiction to mood disturbance. The capacity to withstand aversive affective states is often explained by individual differences in cardiovagal tone as well as resting state connectivity of the ventromedial prefrontal cortex (vmPFC), a region involved in the regulation of emotions and cardio-autonomic tone. However, it is unclear which brain regions involved in distress tolerance show greater resting state functional connectivity (rsFC) as a function of resting heart rate variability (HRV).

METHODS

One-hundred and twenty-six adults, aged 20 to 83.5 years, were selected from a lifespan cohort at the Nathan Kline Institute-Rockland Sample. Participants' distress tolerance levels were assessed based upon performance on the Behavioral Indicator of Resiliency to Distress (BIRD) task. Artifact-free resting-state functional brain scans collected during separate sessions were used. While inside the scanner, a pulse oximeter was used to record beat-to-beat intervals to derive high-frequency heart rate variability (HF-HRV). The relationship between HF-HRV and vmPFC to whole brain functional connectivity was compared between distress tolerant (BIRD completers) and distress intolerant (BIRD non-completers).

RESULTS

Groups did not differ in their history of psychiatric diagnosis. Higher resting HF-HRV was associated with longer total time spent on the BIRD task for the entire sample (r = 0.255, p = 0.004). After controlling for age, gender, body mass index, head motion, and gray matter volume. Distress tolerant individuals showed greater rsFC (p < 0.005 (uncorrected), k = 20) between the vmPFC and default-mode network (DMN) hubs including posterior cingulate cortex/precuneus, medial temporal lobes, and the parahippocampal cortex. As a function of higher resting HF-HRV greater vmPFC connectivity was observed with sub-threshold regions in the right amygdala and left anterior prefrontal cortex, with the former passing small volume correction, in distress tolerant versus distress intolerant individuals.

CONCLUSION

In a lifespan sample of community-dwelling adults, distress tolerant individuals showed greater vmPFC connectivity with anterior and posterior hubs of the DMN compared to distress intolerant individuals. As a function of greater HF-HRV, distress tolerant individuals evidenced greater vmPFC with salience and executive control network hubs. These findings are consistent with deficits in neural resource allocation within a triple network resting amongst persons exhibiting behavioral intolerance to psychological distress.

A217 NONINVASIVE ASSESSMENTS TO IDENTIFY PATIENTS WITH ADVANCED FIBROSIS DUE TO NASH: SCREENED POPULATION FROM THE REGENERATE TRIAL

Aims

We explored the ability of noninvasive tests (NITs) to identify patients (pts) with advanced fibrosis due to NASH.

Methods

All screened pts from the ongoing phase 3 REGENERATE with available histology data were included. Five NITs were evaluated using established literature cutoffs to identify or exclude advanced fibrosis (values between upper and lower thresholds were considered indeterminate): Aspartate Transaminase-to-Platelet Ratio Index (APRI; ≥0.57, ≤0.84), Enhanced Liver Fibrosis (ELF; ≥7.7, &lt;9.8), Fibrosis-4 (FIB-4; ≥1.30, &lt;2.67), NAFLD fibrosis score (NFS; ≥−1.455, &lt;0.676), and Transient Elastography (TE; ≥7.9 kPa, &lt;9.6 kPa). Three testing methods applied were single NIT, 2 simultaneous NITs weighted equally (NFS+ELF, FIB-4+ELF, NFS+TE, FIB-4+TE), and 2 sequential NITs with the second test performed only if the first test was indeterminate (NFS→ELF, FIB-4→ELF, NFS→TE, FIB-4→TE).

Results

4133 pts in the REGENERATE screened population had an available biopsy (baseline liver biopsy: F0, 15.5%; F1, 27.2%; F2, 21.2%; F3, 29.6%; F4, 6.5%). Of these, 96% had FIB-4, NFS, and APRI, 41% had TE, and 28% had ELF. Single NITs with upper thresholds demonstrating strong specificity for identification of advanced fibrosis were FIB-4 (97%), NFS (94%), and APRI (86%); NITs with lower thresholds demonstrating good sensitivity for identification of early fibrosis were ELF (100%) and TE (88%). Evaluation of 2 simultaneous NITs resulted in a greater percentage of pts in the indeterminate zone. Application of 2 sequential tests improved the accuracy of identification and reduced misclassification vs 2 simultaneous tests.

Conclusions

Sequential NIT strategies may decrease liver biopsy rates while maintaining the accuracy of noninvasive diagnosis in pts with advanced fibrosis due to NASH.

Funding Agencies

Intercept Pharmaceuticals

Differential expression of miRNAs in the visceral adipose tissue of patients with non-alcoholic fatty liver disease

BACKGROUND

Progression of non-alcoholic fatty liver disease (NAFLD) can be facilitated by soluble molecules secreted by visceral adipose tissue (VAT). MicroRNAs (miRNAs) are likely to regulate some of these molecular pathways involved in pathogenesis of NAFLD.

AIM

To profile miRNA expression in the visceral adipose tissue of patients with NAFLD.

METHODS

Visceral adipose tissue samples were collected from NAFLD patients and frozen. Patients with biopsy-proven NAFLD were divided into non-alcoholic steatohepatitis (NASH) (n = 12) and non-NASH (n = 12) cohorts controlled for clinical and demographic characteristics. Extracted total RNA was profiled using TaqMan Human MicroRNA arrays. Univariate Mann-Whitney comparisons and multivariate regression analysis were performed to compare miRNA profiles.

RESULTS

A total of 113 miRNA differentially expressed between NASH patients and non-NASH patients (P < 0.05). Of these, seven remained significant after multiple test correction (hsa-miR-132, hsa-miR-150, hsa-miR-433, hsa-miR-28-3p, hsa-miR-511, hsa-miR-517a, hsa-miR-671). Predicted target genes for these miRNAs include insulin receptor pathway components (IGF1, IGFR13), cytokines (CCL3, IL6), ghrelin/obestatin gene, and inflammation-related genes (NFKB1, RELB, FAS). In addition, two miRNA species, hsa-miR-197 and hsa-miR-99, were significantly associated with pericellular fibrosis in NASH patients (P < 0.05). Levels of IL-6 in the serum negatively correlated with the expression levels of all seven miRNAs capable of down regulating IL-6 encoding gene.

CONCLUSIONS

miRNA expression from VAT may contribute to the pathogenesis of NAFLD - a finding which may distinguish relatively simple steatosis from NASH. This could help identify potential targets for pharmacological treatment regimens and candidate biomarkers for NASH.

Ciprofloxacin-induced acute cholestatic liver injury and associated renal failure. Case report and review

Ciprofloxacin, a commonly prescribed fluoroquinolone antibiotic, has generally been well-tolerated; however, there are rare reports of associated hepatic failure or renal failure. We describe a case of a 65 year-old man with a history of ischemic cardiomyopathy who was treated with ciprofloxacin 500 mg twice daily for cellulitis. Six days into his treatment course, he developed acute cholestatic jaundice and acute anuric renal failure. Clinical, laboratory, and pathologic data suggest that the patient had developed reversible, severe ciprofloxacin-induced cholestatic liver injury and acute tubular necrosis requiring hemodialysis. Within two months of stopping the ciprofloxacin, the patient was off dialysis and back to his baseline creatinine in three months. Liver tests normalized by five months. This report illustrates a case of cholestatic liver injury and renal failure involving ciprofloxacin use. We review the literature regarding hepatic and renal injury as it relates to ciprofloxacin. To our knowledge, this represents the first case report of simultaneous acute cholestatic liver injury and renal failure secondary to ciprofloxacin.

Adipokines and cytokines in non-alcoholic fatty liver disease

BACKGROUND

Several adipocytokines have been implicated in the pathogenesis non-alcoholic fatty liver disease (NAFLD).

AIM

To assess adipocytokines in NAFLD patients and controls.

METHODS

A total of 95 patients (26 non-alcoholic steatohepatitis (NASH), 19 simple steatosis (SS), 38 obese controls and 12 non-obese controls) were included. Fasting serum insulin, glucose, visfatin, resistin, adiponectin, tumour necrosis factor-alpha (TNF-alpha), interleukin-8 (IL-8) and IL-6 were determined. Univariate and multivariate analyses were used to compare groups and determine associations.

RESULTS

Serum TNF-alpha and IL-8 were higher in NAFLD patients when compared with both obese and non-obese controls. Analysis involving all patients revealed a significant correlation between serum TNF-alpha and IL-8 (P < 6.319e-08), and between IL-6 and IL-8 (P < 5.271e-15). Homeostatic model assessment scores negatively correlated with adiponectin in NAFLD (P < 0.0032). Serum visfatin was higher in all three obese groups than in non-obese controls (P < 0.02, P < 0.002 and P < 0.008). Visfatin in NASH patients was lower than SS and obese controls. Although TNF-alpha was associated with NAFLD (P < 0.02), it was interdependent on visfatin. In comparison to SS, four factors were independently associated with NASH: age, alanine aminotransferase, IL-8 and adiponectin (P < 0.05). Multivariate analysis indicated that TNF-alpha was the only independent predictor of fibrosis in NASH (P < 0.0004).

CONCLUSION

These findings support a complex interaction between adipocytokines and the pathogenesis of NAFLD.

Interferon alpha 2B and ribavirin in severe recurrent cholestatic hepatitis C

Severe recurrent cholestatic hepatitis C after liver transplantation has a poor prognosis and no standard therapy is currently available. Four cases of severe recurrent cholestatic hepatitis C treated with a combination of interferon alpha 2b and ribavirin are described. All four patients were transplanted for hepatitis C-related cirrhosis. The mean age at transplantation was 45 years (range 41-51 years). Three of the patients were male and one was female. All four patients had hepatitis C virus viremia before and after liver transplantation. At 2 to 23 months after liver transplantation, all four patients developed jaundice, cholestatic elevation of liver enzymes, and histopathology consistent with severe recurrent cholestatic hepatitis C. Combination of interferon and ribavirin was given with prompt virological suppression. Despite this rapid viral suppression, all four patients developed progressive graft failure with three deaths.

Rates and risk factors of liver fibrosis progression in patients with chronic hepatitis c

BACKGROUND AIMS

In hepatitis C there is controversy over the linearity of the rate of progression and the significance of gender, mode of infection and viral factors.

METHODS

2313 untreated patients with a reliable estimated duration of infection and liver fibrosis were included. Fibrosis progression was calculated using the Kaplan-Meier method and the rate of fibrosis progression using the hazard function. Seven risk factors were assessed: age at biopsy, gender, alcohol consumption, mode of infection, activity grade, hepatitis C virus genotype and RNA level.

RESULTS

The percentage of patients without cirrhosis was 91% after 20 years of infection (95% CI:90-92%) and 56% after 40 years (95% CI:48-64%). Three independent factors were associated (P < 0.001) with a faster progression rate: age at infection, alcohol consumption of 50 g or more per day, and male gender. The mode of infection, histologic activity, genotype and viral load were not independently associated with fibrosis. Fibrosis progression was mainly dependent on age and the duration of infection and can be divided into four successive periods with very slow, slow, intermediate and rapid progression rates.

CONCLUSION

In patients infected with hepatitis C, the majority of fibrosis progression occurred in those aged fifty years or older.

Impact of interferon alfa-2b and ribavirin on progression of liver fibrosis in patients with chronic hepatitis C

The extent of liver fibrosis is an important prognostic factor in patients infected with hepatitis C virus. Administration of a combination of interferon and ribavirin produces a superior viral clearance response rate than interferon alone. The effect of this combination regimen on hepatic fibrosis has not been established. To determine the impact of combination regimen or interferon alone on the progression of liver fibrosis we pooled individual data of 1,509 patients with pretreatment and post-treatment biopsies from 3 randomized trials. Fibrosis progression and regression rates between biopsies were calculated by the Kaplan-Meier method and by the fibrosis progression rate per year. The percentage of patients without significant fibrosis (stage 0 or 1) at 96 weeks was 68 +/- 4% (mean +/- SE) when treated by combination regimen for 48 weeks, 64 +/- 4% by interferon alone for 48 weeks, 42 +/- 7% by combination regimen for 24 weeks (lower than both 48-week regimens P <.001), and 24 +/- 9% interferon alone for 24 weeks (lower than the combination regimen for 24 weeks; P =.02). Three factors were independently associated with fibrosis reduction: sustained viral response, duration of treatment, and baseline fibrosis stage (all P <.001 in proportional hazards regression model). These results show that interferon and ribavirin combination therapy significantly reduces the rate of fibrosis progression in patients with hepatitis C. This effect was most prominent in patients who achieved a virologic response, those receiving 48 weeks of therapy, and in patients with significant fibrosis at baseline.

TT virus infection in patients with chronic hepatitis C virus infection--effect of primers, prevalence, and clinical significance. Hepatitis Interventional Therapy Group

BACKGROUND/AIM

A novel DNA virus, TT virus (TTV), was recently identified in patients with post-transfusion non-A-G hepatitis. The aim of this study was to determine the prevalence and clinical significance of TTV infection in patients with chronic hepatitis C virus (HCV) infection.

METHODS

We analyzed pretreatment serum samples from 171 United States and European patients who relapsed after interferon-alpha treatment and were recruited into an interferon-alpha-2b/ribavirin combination treatment trial. TTV DNA was detected by PCR using two different set of primers (TTV-A and TTV-B) derived from open reading frames 1 and 2, respectively.

RESULTS

TTV was detected in 29.2% of the patients with the TTV-A primer set, 70.8% with the TTV-B primer-set, and 72.5% if positive by either/both sets of the primers. The amplicons generated by primer set A were sequenced and a phylogenetic tree was constructed. The 50 isolates belonged to group la (n=8), 1b (n=17), 2a (n=21), 2b (n=3), and 4 (n=1). There was no difference in demographic (age, sex distribution, estimated duration of HCV infection), biochemical (serum ALT levels), virologic (serum HCV RNA levels, HCV genotype distribution), or histologic scores, and their subsequent response to either interferon-alpha-2b or interferon-alpha-2b/ribavirin combination treatment.

CONCLUSIONS

The prevalence of TTV infection reported previously may have been significantly underestimated, based on the primers originally described and used by most studies. Although TTV infection is very common in patients with chronic HCV infection, it has no identifiable clinical significance.

Is an "a la carte" combination interferon alfa-2b plus ribavirin regimen possible for the first line treatment in patients with chronic hepatitis C? The ALGOVIRC Project Group

Randomized trials have shown the enhancement of efficacy with interferon alfa-2b and ribavirin (IFN-R) in comparison with interferon monotherapy (IFN) as first line treatment of chronic hepatitis C. Further definition of response based on disease, patient, and treatment characteristics is needed to determine the degree of benefit for the various patient subgroups. The aim of this study was to answer this question by analyzing the data from 1,744 naive patients included in trials that compared 24- or 48-week IFN-R treatment. Response factors were identified by logistic regression and receiver operating characteristics curves. Five independent characteristics were associated with a sustained loss of hepatitis C virus (HCV) RNA (<100 copies/mL) 24 weeks after the end of treatment: genotype 2 or 3, baseline viral load less than 3.5 million copies/mL, no or portal fibrosis, female gender, and age younger than 40 years. There was a significant advantage for IFN-R in comparison with IFN alone whatever the combination of factors. The most efficient strategy is to treat all patients for 24 weeks. If the 24-week polymerase chain reaction (PCR) is positive, treatment can be stopped. If the 24-week PCR is negative, patients with fewer than 4 favorable factors should be treated for an additional 24 weeks.

CONCLUSION

The combination of IFN-R is better as first line treatment than IFN monotherapy. For patients who are PCR negative after 24 weeks of treatment, genotyping and baseline viral load, fibrosis stage, gender, and age are useful predictive factors in determining whether to continue an additional 24 weeks of treatment.

Clinical, virological and histological implications of GB virus-C/hepatitis G virus infection in patients with chronic hepatitis C virus infection: a multicentre study based on 671 patients

To determine the prevalence, as well as the clinical, virological and histological implications of GB virus C/hepatitis G virus (GBC-C/HGV) infection in patients with chronic hepatitis C virus (HCV) infection, sera from 671 well-characterized patients with chronic HCV infection were tested for GBV-C/HGV RNA using a sensitive and specific reverse transcription 'nested' polymerase chain reaction (RT-nPCR). GBV-C/HGV RNA was detected in 65 of 671 (9. 7%) patients with chronic HCV infection. Importantly, GBV-C/HGV co-infection was not associated with any changes in indices of liver diseases, including serum alanine transaminase levels, Knodell score or histology activity index (HAI). In this cohort, GBV-C/HGV co-infection was weakly associated with a shorter mean estimated duration of HCV infection and a higher median HCV viraemia level. We conclude that GBV-C/HGV has minimal or no impact on liver disease activity in patients with chronic HCV infection. This data supports the notion that GBV-C/HGV may not be a hepatitis virus.

Lamivudine as initial treatment for chronic hepatitis B in the United States

BACKGROUND AND METHODS

Although the nucleoside analogue lamivudine has shown promise in patients with chronic hepatitis B, long-term data on patients from the United States are lacking. We randomly assigned previously untreated patients with chronic hepatitis B to receive either 100 mg of oral lamivudine or placebo daily for 52 weeks. We then followed them for an additional 16 weeks to evaluate post-treatment safety and the durability of responses. The primary end point with respect to efficacy was a reduction of at least 2 points in the score on the Histologic Activity Index. On this scale, scores can range from 0 (normal) to 22 (most severe abnormalities).

RESULTS

Of the 143 randomized patients, 137 were included in the efficacy analysis: 66 in the lamivudine group and 71 in the placebo group. The other six patients were excluded at the base-line visit because of the absence of a documented history of hepatitis B surface antigen for at least six months. After 52 weeks of treatment, lamivudine recipients were more likely than placebo recipients to have a histologic response (52 percent vs. 23 percent, P<0.001), loss of hepatitis B e antigen (HBeAg) in serum (32 percent vs. 11 percent, P=0.003), sustained suppression of serum hepatitis B virus (HBV) DNA to undetectable levels (44 percent vs. 16 percent, P<0.001), and sustained normalization of serum alanine aminotransferase levels (41 percent vs. 7 percent, P<0.001), and they were less likely to have increased hepatic fibrosis (5 percent vs. 20 percent, P=0.01). Lamivudine recipients were also more likely to undergo HBeAg seroconversion, defined as the loss of HBeAg, undetectable levels of serum HBV DNA, and the appearance of antibodies against HBeAg (17 percent vs. 6 percent, P=0.04). HBeAg responses persisted in most patients for 16 weeks after the discontinuation of treatment. Lamivudine was well tolerated. Self-limited post-treatment elevations in serum alanine aminotransferase were more common in lamivudine recipients: 25 percent had serum alanine aminotransferase levels that were at least three times base-line levels, as compared with 8 percent of placebo recipients (P=0.01). The clinical condition of all patients remained stable during the study.

CONCLUSIONS

In U.S. patients with previously untreated chronic hepatitis B, one year of lamivudine therapy had favorable effects on histologic, virologic, and biochemical features of the disease and was well tolerated. HBeAg responses were generally sustained after treatment.

Pruritus as a presenting symptom of chronic hepatitis C

Pruritus is a common symptom in cholestatic liver disease but is rare in chronic hepatitis C. Eight patients with chronic hepatitis C and severe pruritus were compared with regard to biochemical, serological, and histological features to eight disease controls with primary biliary cirrhosis and seven with cirrhosis due to hepatitis C. Among those with severe pruritus associated with chronic hepatitis C, serum aminotransferases were raised in all, alkaline phosphatase in four, and gamma-glutamyl-transpeptidase levels in all except one. Serum cholylglycine levels were elevated in seven of eight patients. Liver biopsies showed moderate to severe fibrosis in all patients and cirrhosis in five. Compared to control subjects with cirrhosis due to hepatitis C but no pruritus, ductopenia, and cholestatic changes were prominent, although less so than in controls with primary biliary cirrhosis. Chronic hepatitis C with moderate to severe fibrosis may result in low-grade cholestasis with pruritus, possibly in association with bile duct disappearance.

Response to higher doses of interferon alfa-2b in patients with chronic hepatitis C: a randomized multicenter trial. Hepatitis Interventional Therapy Group

To evaluate response rates to 3, 5, or 10 million units (MU) of interferon alfa-2b, given thrice weekly, and to determine whether higher doses of interferon increase the likelihood or durability of the response, a multicenter, randomized trial was performed at nine academic medical centers in the United States. Two hundred forty eight patients with chronic hepatitis C were randomized to receive 3, 5, or 10 MU of interferon alfa-2b thrice weekly for 12 weeks. Based on the alanine aminotransferase (ALT) response at treatment-week 12, the patients were rerandomized to additional therapy at the same or at increased doses for an additional 12 to 36 weeks; in the case of no response to the highest dose, the patients were discontinued from the study. Serum ALT concentrations and liver histology were measured. The overall complete response rates to 3, 5, or 10 MU were not different at treatment-week 12 (31% vs. 42% vs. 40%, not significant). The majority of week-12 responders continued to respond during additional treatment. When the treatment was discontinued, 15.4% to 19.0% of patients maintained their response. Of the nonresponders to 3 MU at week 12, who were continued on 3 MU for an additional 12 weeks, none responded. However, response to additional therapy occurred in 12% of week-12 nonresponders, whose dose was escalated from 3 or 5 MU to 10 MU. The only baseline features associated with the treatment response were the absence of fibrosis or cirrhosis on the pretreatment liver biopsy and viral genotype. We conclude that the initial response to interferon in patients with chronic hepatitis C is not increased by treatment with higher doses of the drug. Patients who do not respond to 3 MU by treatment-week 12 will not respond with continued therapy at that dose; however, a proportion of patients who do not respond to 12 weeks of treatment with 3 or 5 MU may respond to higher doses. Although the long-term sustained response rates are marginally increased with interferon doses above 3 MU three times per week, the side effects are difficult to tolerate. The analysis of baseline factors in relation to response identified no single baseline factor associated with a low-enough response rate to warrant withholding interferon therapy from patients with chronic hepatitis C.

Indian childhood cirrhosis in an American child

Indian childhood cirrhosis is a fatal liver disease characterized by a striking accumulation of copper-containing granules within hepatocytes. A two-year-old American boy, the product of a third-cousin marriage, with clinical, biochemical, and histological signs of Indian childhood cirrhosis was studied. Liver biopsies at 22 and 30 months of age revealed a rapid progression from fibrosis to micronodular cirrhosis, with many of the remaining hepatocytes staining strongly for copper and copper-binding proteins. Electron microscopy showed characteristic dense granules containing copper and sulfur by electron probe analysis. Hepatic copper content was 1500 micrograms/g dry weight (normal, 20-50). Urinary copper was 3.6 mumol/d (229 micrograms/24 hours; normal, 15-20), and serum ceruloplasmin was 352 mg/L (normal, 150-320). The case suggests that both genetic and environmental components contribute to the manifestations of Indian childhood cirrhosis, and that the diagnosis of Indian childhood cirrhosis should be considered even in non-Indian infants with progressive liver disease.

Encapsulated hepatocellular carcinoma: radiologic findings and pathologic correlation

The encapsulated form of hepatocellular carcinoma (HCC) is a pathologic subtype that has been found to occur with variable frequency in typical HCC in Japanese radiological, surgical, and autopsy series. It is well-differentiated tumor that tends to grow slowly and noninvasively, and has a better prognosis than other gross forms of HCC. Among the 73 cases of typical HCC in patients of non-Asian extraction in our files, 11 could be positively identified as encapsulated based on strict pathological criteria. The purpose of this study was to review the radiographic appearance of these encapsulated tumors. Radiographically, the tumors demonstrated a hyperdense rim in 5 of 9 cases with postinfusion computed tomography scans, an anechoic halo in 4 of 6 cases with ultrasonograms, and an avascular rim on the capillary phase in 5 of the 8 cases with angiograms. Encapsulated HCC can be found in non-Asian patients, and the radiographic and pathologic findings are similar to the descriptions in the Japanese series.

Small bile duct abnormalities in sarcoidosis

We report four patients with hepatic involvement of sarcoidosis manifested primarily by bile duct depletion. The patients developed fever, weight loss, anorexia, a markedly elevated alkaline phosphatase, and mildly abnormal serum levels of aspartate aminotransferase. Endoscopic retrograde cholangiopancreatography showed slight intrahepatic irregularities but were not diagnostic of sclerosing cholangitis. Liver biopsy showed predominantly bile duct depletion, ranging from an estimated 10-100% absence of bile ducts in portal areas, which correlated with the degree of fibrosis. The degree of bile duct depletion is useful as a histological marker in patients with sarcoid liver disease. Steroids improve symptoms, but do not inhibit the development of "ductopenia."

A randomized, double-blind, placebo-controlled trial of recombinant human alpha-interferon therapy for chronic non-A, non-B (type C) hepatitis

The effects of alpha-interferon therapy were evaluated in a prospective, randomized, double-blind, controlled trial of recombinant human interferon alfa-2b versus placebo in patients with well-documented chronic non-A, non-B hepatitis (type C). Forty-one patients, of whom 37 (90%) had hepatitis C virus antibodies in their serum, were enrolled in the trial. Twenty-one patients received interferon (2 million units) and 20 received placebo as subcutaneous injections three times weekly for 6 months. Mean serum aminotransferase activities and liver histology improved significantly in interferon-treated patients but not in placebo recipients. Ten interferon-treated patients (48%) had a complete response to therapy as shown by a reduction of mean serum aminotransferase activities into the normal range during therapy; three more patients had a partial response with aminotransferase activities decreasing by more than 50% on average. In follow up, however, serum aminotransferase levels usually returned to pre-treatment levels; at 6 to 12 months after stopping interferon, only two (10%) patients still had normal aminotransferase activity. These results indicate that alpha-interferon therapy is beneficial in reducing the disease activity in chronic hepatitis C. Only a minority of patients, however, appear to have a long-term response. In this study, interferon was generally well tolerated, with only one patient discontinuing therapy because of adverse effects.

Recombinant interferon alfa therapy for chronic hepatitis C. A randomized, double-blind, placebo-controlled trial

Infection with the hepatitis C virus may result in chronic liver disease for which no effective therapy is now available. We studied the effects of recombinant human interferon alfa in a prospective, randomized, double-blind, placebo-controlled trial in patients with well-documented chronic hepatitis C. Forty-one patients were enrolled in the trial, 37 of whom were later found to have antibody to hepatitis C virus. Twenty-one patients received interferon alfa (2 million units) subcutaneously three times weekly for six months, and 20 received placebo. The mean serum aminotransferase levels and the histologic features of the liver improved significantly in the patients treated with interferon but not in the patients given placebo. Ten patients treated with interferon (48 percent) had a complete response, defined as a decline in mean serum aminotransferase levels to the normal range during therapy; three others had a decrease in mean aminotransferase levels of more than 50 percent. After treatment ended, however, serum aminotransferases usually returned to pretreatment levels; 6 to 12 months after the discontinuation of interferon therapy, only two patients (10 percent) still had normal values. We conclude that interferon alfa therapy is beneficial in reducing disease activity in chronic hepatitis C; however, the beneficial responses are often transient.

Alcohollike liver disease in nonalcoholics. A clinical and histologic comparison with alcohol-induced liver injury

Individuals who deny alcohol consumption may develop liver injury that histologically resembles the liver injury found in alcoholic patients. To determine whether any clinical or histologic features distinguish alcoholic and nonalcoholic subjects with "alcohollike" liver injury, the clinical records and liver biopsy specimens of 68 alcoholic and 39 nonalcoholic patients with alcohollike injury on liver biopsy were compared. The clinical and biochemical features of the two groups differed significantly. Alcoholism was associated with more severe clinical and biochemical manifestations of liver disease. However, there was considerable overlap among histologic features of the two clinically defined groups. Based on histology alone, alcoholic and nonalcoholic patients were often indistinguishable. The observations suggest that the clinical differences between the alcoholic and non-alcoholic patients cannot be attributed to qualitative or quantitative differences in liver histology. On the other hand, histologic similarities between the two groups raise the possibility that a shared condition, perhaps nutritional or hormonal, is responsible for the histologic expression of alcohollike injury in both groups.

The effect of lumbar puncture procedure on blood glucose level and leukocyte count in infants

Blood glucose level, urea concentration, and total white blood cell count were determined both before and 10-15 minutes after lumbar puncture (LP) procedure in 26 infants suspected of having meningitis. There was a significant (p less than 0.001) increase in the peripheral white blood cell (WBC) count (mean +/- standard deviation) from 10,960 +/- 3,500 cells/microliter before to 13,300 +/- 3,970 cells/microliter following the LP procedure, due to relative rise in the neutrophils and lymphocytes. Blood glucose levels did not change significantly following this procedure (85.3 +/- 13.4 mg/dl and 84.1 +/- 12.6 mg/dl respectively). An LP procedure does not impair correct cerebrospinal fluid glucose/blood glucose determination but may cause elevation of peripheral WBC count.

Lipomatous tumors of the liver: evaluation with CT and US

Seven cases of lipomatous masses within the liver parenchyma were demonstrated with computed tomography (CT). Five of these cases were obtained from a retrospective review of 50 cases of renal angiomyolipoma in which the liver was adequately demonstrated. The other two cases were from the files of the Armed Forces Institute of Pathology and had no associated renal lesions. Three of the five cases were associated with tuberous sclerosis. In all seven cases, the fatty tumors appeared on CT scans as a well-defined, 0.8-13-cm mass, with attenuation coefficients of less than -30 HU. On ultrasound studies, the lesions were well circumscribed, highly echogenic, and similar to hemangiomas. While distinctly rare lesions, these lipomatous masses are not as unusual as the literature would indicate. One may anticipate such masses in patients with renal angiomyolipomas and in a relatively high percentage of those with tuberous sclerosis.

Pilot study of recombinant human alpha-interferon for chronic type B hepatitis

Nine patients with chronic type B hepatitis were entered into a preliminary study of recombinant, human alpha-interferon therapy. Patients received one to four courses of interferon, each consisting of a fixed dose of 18, 36, 50, 68, or 100 million units given three times a week for 2 wk. Side effects including fever, chills, fatigue, myalgias, headache, and neutropenia were common and especially severe with higher doses. Serum hepatitis B virus DNA polymerase activity fell during therapy to 15%-30% of the pretreatment levels irrespective of interferon dose, but rose to the initial level by 10 days after the course ended. During follow-up, 2 patients had a sustained clinical remission in which hepatitis B virus DNA, DNA polymerase, and hepatitis B e antigen disappeared from serum and amino-transferase activities fell to normal. One patient became hepatitis B surface antigen negative. We conclude that higher doses (50 and 68 million units) of interferon have greater side effects than lower doses (18 and 36 million units), without having any greater antiviral efficacy. Further studies should be directed at therapy with lower doses given over longer periods.

Fibrolamellar hepatocellular carcinoma

Fibrolamellar hepatocellular carcinoma (HCC) has recently been separated as a distinct clinicopathologic entity with a better prognosis than the usual HCC associated with cirrhosis. The mean age of our 17 patients was 20 years. Alpha fetoprotein levels were normal, and none of the risk factors for HCC was present. Distinctive histologic features included deeply eosinophilic polygonal hepatocytes and abundant fibrous stroma. Calcification was present on plain films of five of 13 cases. Sonography usually showed a homogeneous, echogenic mass. Computed tomography (CT) demonstrated small, central calcification in four of ten cases. A central echodensity, hypodense on CT scans, was seen in two cases and corresponded to a central scar. By combining clinical and laboratory data with radiologic tests, a correct diagnosis can often be suggested before biopsy is performed.

Misdiagnosed Salmonella septicemia and endarteritis due to a lactose-fermenting strain: bacteriologic and epidemiologic considerations

In a case of septicemia and endarteritis the causative agent was initially misidentified. The Salmonella had atypical biochemical properties and was resistant to numerous antibiotics. Therapy with gentamicin and cephalothin failed to eliminate the organism. Identification of the organism as a lactose-fermenting Salmonella serotype typhimurium var. copenhagen was confirmed. The possible dissemination of the isolate from Brazil was analyzed by serologic studies of family members and friends.

Isolation of Corynebacterium xerosis from clinical specimens: infection and colonization

Eleven patients were colonized or infected with diphtheroids identified as Corynebacterium xerosis. All the patients were compromised hosts by nature of their underlying disease and/or therapy. Two patients developed bacteremia following colonization of the respiratory tract with C. xerosis. Other patients were colonized at various sites, which included the respiratory tract, abdominal and thoracic wounds, amputated limb, and arterial-venous shunt. Distinctive features for the identification of C. xerosis include negative reactions for hemolysis, urease, and motility, and positive reactions for catalase, glucose, sucrose and nitrate reduction. Antimicrobial susceptibility tests were performed by the disk diffusion method. In many instances the organisms were resistant to the antimicrobial regimens received by the patients. This was most frequent for nafcillin, gentamicin, kanamycin, clindamycin, and chloramphenicol. On the other hand, the organisms were highly susceptible to penicillin, ampicillin, cephalothin and carbenicillin.