Efficacy of high-dose interferon in combination with ribavirin in patients with chronic hepatitis C resistant to interferon alone

OBJECTIVE

Interferon combined with ribavirin has efficacy in the treatment of patients with chronic hepatitis C virus (HCV) infection. However, its utility in patients who have not responded to prior interferon therapy is not clear. Furthermore, the effect of using an increased dose of interferon in combination with ribavirin in patients with chronic hepatitis C resistant to conventional doses of interferon is not known. The aim of our study was to evaluate the effect of high-dose interferon in combination with ribavirin on the efficacy of treating patients with chronic hepatitis C resistant to interferon monotherapy in a large multicenter trial.

METHODS

We randomized 154 patients with chronic hepatitis C who failed to achieve a sustained response with prior interferon therapy to receive either 3 or 5 MU of interferon alpha-2b and ribavirin (1000-1200 mg/day) for 12 months. There were 119 patients who had not responded and 35 who initially responded but relapsed after prior interferon monotherapy. Serum HCV RNA levels were measured at entry, 6, and 12 months of treatment and at the end of a 6-month follow-up period.

RESULTS

The mean age of the subjects was 47 yr (range 28-68 yr), and 110 (71.4%) were men. One hundred thirty-two patients (86%) had HCV genotype 1, whereas 21 (14%) had cirrhosis. Eighty-one subjects (53%) were randomized to receive 3 MU of interferon alpha-2b. Fifteen of 35 relapse subjects (43%) and 12 of 119 prior nonresponder entrants (10%) achieved a sustained virological response to the 12-month course of treatment. Overall, 11 of 81 patients (14%) receiving 3 MU, and 16 of 73 patients (22%) receiving 5 MU of interferon maintained an undetectable HCV RNA level after cessation of therapy. The difference in sustained response rates between the two interferon dosage groups did not reach statistical significance (p = 0.09). However, among the nonresponder patients alone, there was an increased sustained response in the high-dose interferon group compared with the standard interferon dose group (15.5% vs 4.9%, p = 0.055). Twenty-six patients discontinued therapy before 6 months, including 10 patients (12.3%) in the 3-MU and 16 patients (21.9%) in the 5-MU groups (p = 0.17).

CONCLUSIONS

Sustained virological response to combined interferon alpha-2b and ribavirin was significantly higher in relapse patients than those who did not respond to prior interferon monotherapy. Although, when all treated patients were analyzed, there was no significant difference in sustained response between subjects receiving 3 and 5 MU of interferon, among the prior nonresponder patients, treatment with 5 MU of interferon with ribavirin resulted in a slightly increased response compared with treatment with the standard interferon dosage. The tolerability of the treatment regimens was comparable.

Assessment of hepatitis C virus RNA and genotype from 6807 patients with chronic hepatitis C in the United States

Hepatitis C virus (HCV) RNA status and HCV genotype have become important tools in the diagnosis and monitoring of therapy in chronic HCV infection. To establish a database with respect to HCV genotype and serum HCV RNA concentrations in chronic hepatitis C patients in the United States, we analysed 6807 chronic hepatitis C patients who had HCV RNA and HCV genotype tests conducted at a central laboratory. The HCV RNA concentration cut-off for the lower 25th percentile of this population (low titre) was 0.9 x 106 copies ml-1. The median HCV RNA concentration was 3.5 x 106 copies ml-1 and the cut-off for the upper 25th percentile (high titre) was 5 x 106 copies ml-1. Male patients had a median HCV RNA concentration of 3.9 x 106 copies ml-1, which was significantly higher than the median HCV RNA level for females (2.75 x 106 copies ml-1; P < 0.001). HCV genotype 1 was detected in 73% of patients; genotype 2 in 14%; genotype 3 in 8%; mixed genotype in 4%; and genotypes 4, 5 and 6 with a frequency of < 1%. Patients from the Northeast, Southeast and Midwest had significantly (P < 0.001) more infections with genotype 1 than patients from the Western and Southern regions. African-American patients were more likely to be infected with genotype 1 when compared with Caucasian, Hispanic or Asian Pacific Islanders (P < 0.001). Patients infected with HCV genotype 1 and mixed HCV genotypes had significantly higher serum HCV RNA concentrations when compared with HCV genotypes 2 and 3 (P < 0.001 for all comparisons).

Immunohistochemical detection of hepatitis C antigen by monoclonal antibody TORDJI-22 compared with PCR viral detection

We sought to determine the sensitivity and specificity of immunohistochemistry using the TORDJI-22 MoAb (BioGenex, San Ramon, Calif), which is specific for the C-100 protein of the hepatitis C virus, compared with reverse transcriptase-polymerase chain reaction (RT-PCR) of tissue for viral RNA. RT-PCR had been performed on 52 fixed tissue specimens. Immunohistochemistry was performed using prediluted antibody with the alkaline phosphatase/fast red (BioGenex) technique. Predigestion with Protease XXIV (BioGenex) and other procedures followed the manufacturer's protocols. Positive immunohistochemistry was narrowly defined as tightly clumped, perinuclear red granules in hepatocytes. Of the specimens, 28 were positive by RT-PCR. With RT-PCR as the standard of comparison, immunohistochemistry yielded a sensitivity of 70% and specificity of 84%. Positive cells, when present, were usually very rare. With stringent criteria, immunohistochemistry with the TORDJI-22 monoclonal antibody is a very specific, fairly sensitive diagnostic test for hepatitis C virus in fixed liver tissues.

Molecular marker analysis of Salmonella typhimurium from surface waters, humans, and animals

Salmonella contamination of North Sea water was detected for the first time in 1988 in Germany during routine examinations of bathing areas. Since then, subsequent isolations along the coast have been reported regularly. To define the source of contamination, strains isolated from seawater and rivers were studied by molecular marker methods. Their properties were compared with those of strains originating from possible sources of contamination such as humans, cattle, and sewage treatment plant water. Plasmid profile analysis of whole bacterial populations and the determination of antibiotic resistance patterns demonstrated, that contamination through the surrounding cattle industry could be excluded. Cattle isolates belonged to a widespread clone of phage type 204c which was multiresistant and exhibited an unique plasmid pattern which was never found in sea water isolates. Outer membrane protein and lipopolysaccharide analysis failed to demonstrate differences among the Salmonella populations and proved in this case insufficient for molecular marker discrimination.

[Occurrence of Salmonella in coastal North Sea water and their hygienic relation to indicator bacteria and sources of contamination]

The quantity of salmonella, fecal coliform bacteria and fecal streptococci was measured in 2003 water samples from North Sea coastal water, drainage canals, the lower River Ems and sewage works. The presence of salmonella did not correlate to an increasing presence of fecal indicator bacteria. In several cases more than 10(3) salmonella per litre were found in samples whose fecal coliform levels met the strictest quality requirements (in accordance with the levels stipulated by EEC bathing water regulations). Additionally 226 marine sediment samples were measured for their content of salmonella only. While salmonella were present in 12.3% of at least 1 litre of the North Sea water samples (bathing places excepted) and in about 7% of sediment samples (10 g), no salmonella were traced in 400 samples from marine water bathing places. The general contamination with salmonella of sea water bathing places can therefore be regarded as low. More frequent occurrences on the beaches must be seen as the result of a concrete case of contamination or other disturbance. The serovarieties of the salmonella isolated from North Sea and Ems waters indicate in comparison with isolations from sewage works, infected humans and calves from the region that the contamination of the local coastal water mainly stems from sewage works and could also on a small scale be caused by sea birds. Salmonella from agricultural sources proved to be irrelevant in this study. Molecular biological examinations of the plasmid profiles for example could give more precise informations. The establishment of serovarieties which are relatively unimportant for human medicine (eg. S. mbandaka) in sewage works, drainage canals and the North Sea reveal the problem involved in evaluating such finds in bathing water samples, because in EEC regulations no differentiation or quantification is made.

The role of liver biopsies in psoriatic patients receiving long-term methotrexate treatment. Improvement in liver abnormalities after cessation of treatment

Liver biopsy specimens from 168 patients who underwent a total of 364 biopsies were examined. Of 83 patients receiving biopsies before methotrexate treatment, 14 had one or more risk factors predictive of liver abnormality but they had normal pretreatment biopsy specimens. Among 17 patients with abnormal biopsy specimens before methotrexate treatment, only 1 had an identifiable risk factor and 5 had abnormal results of liver function tests. The probability of a normal biopsy specimen after methotrexate treatment dropped below 50% at a cumulative methotrexate dose of 3115 mg for the 31 patients with biopsy specimens from before and after methotrexate treatment and 5776 mg for those who had biopsies only after methotrexate treatment; this difference was statistically significant and is thought to be related to the fact that the patients who had biopsies before and after methotrexate treatment had received most of their medication by the parenteral rather than the oral route. A significant association existed between biopsy grade after methotrexate treatment and obesity. Other risk factors were not correlated with biopsy grade. Blood chemistry tests were not predictive of histopathologic findings. Eight of 11 patients with fibrosis or cirrhosis showed meaningful improvement in liver histologic findings after methotrexate treatment had been withdrawn for 6 months or more; none had progression of abnormalities.

Neocortical morphometry and cholinergic neurochemistry in Pick's disease

With a computerized image-analysis apparatus for neocortical morphometry and chemical methods for evaluation of the cholinergic system, five brain specimens of Pick's disease (PD) were studied and the results compared to those from specimens of age-matched normal subjects and Alzheimer's disease (AD). The PD specimens showed major reductions in brain weight, frontal and temporal cortical thickness, and large neuron populations, compared with controls. Lesser reductions were seen in small neurons and thickness of the inferior parietal cortex. The authors found no relationship between age of onset or disease duration and either the degree of cortical thinning or neuron loss or the number of Pick bodies in the neocortex and hippocampus. PD specimens were more atrophic than AD brains, having lower brain weights and more fronto-temporal thinning. Large neurons were comparably reduced in the two conditions in the frontal and temporal lobes, but small neuron losses were greater in the PD midfrontal area. Only the AD cases showed loss of large neurons in the inferior parietal region. Levels of choline acetyltransferase were normal in PD and reduced in AD, whereas muscarinic receptor binding was decreased in both.

Peptide radioimmunoassays: a BASIC program for data reduction

A BASIC computer program is listed and described which may be used for calculating large amounts of data generated by radioimmunoassays. The user is given the opportunity to construct standard curves and to calculate mass quantities from raw counts or to incorporate previously determined protein values with mass quantities for final data expression. Calculated data may be viewed onscreen or obtained as printed copy.

Senile dementia of the Alzheimer type without neocortical neurofibrillary tangles

Senile dementia of the Alzheimer type (SDAT) is typified pathologically by neuritic plaques (NP) and neurofibrillary tangles (NFT) in the neocortex and hippocampus. However, in a large series of cases (60) over age 74 a significant minority (30%) lacked neocortical tangles. In order to determine if these latter cases (Group B) otherwise differ from the majority which have both neocortical plaques and tangles (Group A), various clinical and neuropathological parameters were measured for both groups and the results compared. The following indices were examined: degree of dementia, rate of progression of dementia, age at death, brain weight, cerebral hemispheric weight, cortical cell counts from the frontal, temporal, and parietal lobes, the number of neocortical NP, the number of hippocampal NP and NFT, and the levels of neocortical choline acetyltransferase and somatostatin. The two groups showed no statistically significant differences in any of these categories except for increased numbers of neocortical NP in Group A in midfrontal and superior temporal regions. However, cases in Group A showed greater pathologic abnormality in nearly every parameter, albeit without attaining statistical significance. We conclude that SDAT with neocortical NFT is the same disease as SDAT without them, although the presence of such tangles is associated with a tendency towards greater severity.

Long-term effects of etretinate on the liver in psoriasis

Etretinate is an aromatic retinoid and derivative of vitamin A soon to be approved for general use in the U.S. as therapy for severe psoriasis. We report on liver morphology and function in 18 subjects who received the drug for at least 5 years as part of a clinical trial. The majority (14) suffered no or mild and reversible structural liver changes; mild transient elevations in serum triglyceride and liver enzymes were noted occasionally. Of the remaining four patients, mild periportal fibrosis was documented in two, another had changes similar to chronic active hepatitis, and a fourth had cirrhosis that was unrelated to alcohol use. Liver function data, cumulative drug dose, and treatment duration were generally not reflective of these changes. The results of this study suggest a need for periodic liver biopsy to monitor patients on long-term etretinate therapy.

Catecholamine mechanisms in the feedback effects of estradiol benzoate on the release of LH and prolactin

The role of hypothalamic catecholamines and luteinizing hormone releasing hormone (LHRH) in the negative feedback effect of estradiol benzoate (EB) on luteinizing hormone (LH) release was studied in chronic ovariectomized rats. Administration of 10 micrograms EB decreased plasma LH levels and increased LHRH content in the medial basal hypothalamus (MBH) 1 day after injection. Inhibition of dopamine and norepinephrine synthesis with alpha-methyl-p-tyrosine (alpha-MT) reduced the LHRH content in the MBH in both oil- and EB-treated animals and partially reversed the decrease in plasma LH levels. Inhibition of norepinephrine synthesis with fusaric acid decreased LHRH content in both oil- and EB-treated rats but had no effect on plasma LH levels. The results suggest that at least a portion of the inhibitory effect of EB on LH release is due to the stimulation of an inhibitory dopaminergic mechanism which reduces LHRH release from the MBH. This feedback mechanism is apparently not susceptible to dopaminergic receptor blockade since administration of pimozide had no effect on LH levels. The stimulatory feedback effect of EB on prolactin release was studied in the same animals. alpha-MT and EB produced additive effects on plasma prolactin levels whereas fusaric acid blocked the EB-induced increase in plasma prolactin levels. Pimozide appeared to potentiate the effect of EB on prolactin release. The results reconfirm the possible role of noradrenergic neurons in the release of prolactin induced by EB and also suggest that EB stimulates a dopaminergic mechanism which is inhibitory to prolactin release but is normally masked by increased noradrenergic activity.

Liver biopsies upsilon liver scans in methotrexate-treated patients with psoriasis

The possibility of hepatotoxic reactions in 24 patients receiving long-term methotrexate therapy for psoriasis was evaluated by both liver biopsies and technetium TC 99 m sulfur-colloid liver scans. The two diagnostic methods were compared in a retrospective analysis. Six of 17 patients with clinically normal liver biopsy interpretations were found to have abnormal liver scans, while three of five patients with histologically proved fibrosis had completely normal liver scans. We conclude that hepatotoxic reactions from long-term methotrexate use in psoriasis cannot be reliably evaluated by the technetium Tc 99m sulfur colloid liver scan.

The endoscopy corner. Primary sclerosing cholangitis

Retrograde endoscopic cholangiography is an effective means of evaluating the biliary ductal system. It can provide a nonoperative modality for diagnosing PSC and for assessing the effects of therapeutic interventions on the diameter of the bile ducts.

Liver involvement in the syndrome of mixed cryoglobulinemia

A study of liver abnormalities in 36 patients with mixed cryoglobulinemia in the absence of underlying infectious, connective tissue, or lymphoproliferative disorders revealed clinical or biochemical evidence of liver dysfunction in 84%. Hepatomegaly was detected in 77%, splenomegaly in 54%, and abnormalities in bilirubin, alkaline phosphatase, or serum glutamic oxalacetic transaminase in 77%. Only four of the patients had overt liver disease. Of 15 biopsies from 12 patients, there was normal tissue structure in two, minimal nonspecific changes in one, portal fibrosis in three, chronic persistent hepatitis in one, chronic active hepatitis in two, chronic active hepatitis with cirrhosis in four, and postnecrotic cirrhosis in two. These findings, together with the previously reported high incidence of serologic evidence of hepatitis B virus (HBV) infection, support the view that the syndrome of purpura, arthritis, and nephritis is often a consequence of immune-complex vasculitis secondary to HBV infection.

Carcinoma of the gallbladder: a diagnosis aided by endoscopic retrograde and percutaneous hepatic cholangiography

In a patient with obstructive jaundice, extrinsic compression of the common bile duct (Mirizzi syndrome) due to squamous cell carcinoma of the gallbladder was documented with the combination of endoscopic retrograde cholangiography and pancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC).