[The contribution of teleconsultation and isolation of symptomatic cases in control of the COVID-19 outbreak a military base]

Position du problème

La première vague de la COVID-19 a déferlé sur la France au cours du premier trimestre 2020 entraînant une saturation du réseau de soins. Nous avons voulu étudier, au sein d’une antenne médicale militaire française soutenant un des plus grands effectifs des armées, l’impact de la téléconsultation ainsi que de l’isolement systématique de tous les cas possibles, probables et confirmés de COVID-19.

Méthodes

Il s’agit d’une étude rétrospective réalisée du 9 mars au 31 mai 2020 à partir de notre registre d’activité. Les variables recueillies étaient notamment le type d’épisode, le statut professionnel, la classification du cas et la date de début des symptômes. Nous avons mis en parallèle notre activité à celle de SOS Médecins et des services d’urgence d’Île-de-France.

Résultats et discussion

Au cours de cette période, 1719 épisodes de soins (téléconsultations ou consultations physiques) ont été enregistrés dont 91 % (n = 1561) en lien avec la COVID-19. Nous avons identifié 598 cas “suspects” (possibles et probables) et confirmés. Les téléconsultations “isolées” (non suivies d’une consultation médicale en présentiel, d’un prélèvement ou ayant nécessité l’envoi de prompt-secours) ont représenté 86 % des épisodes de soins (n = 1482). La comparaison de notre activité et du nombre de nouveaux cas aux bases de données de SOS Médecins et des services d’urgences d’Île-de-France laisse supposer que notre stratégie d’isolement a été rapidement efficace.

Conclusion

L’apport de la téléconsultation a été majeur et sécurisant. La téléconsultation permet d’absorber un volume de patients important, est facile à mettre en œuvre et se caractérise par l’absence de risque nosocomial. L’isolement des patients contaminés doit constituer une priorité en période épidémique. Cette attitude doit s’étendre, lorsque l’on veut maitriser rapidement une épidémie, à l’ensemble des patients symptomatiques.

Polychlorinated biphenyl congeners in the aquatic environment of the Mekong River, South of Vietnam

Polychlorinated biphenyl compounds (PCBs) were analyzed in sediments and clams' soft tissues from sampling sites in the Mekong River delta from the border with Cambodia to the coast of South China Sea. Concentrations of 13 individual PCB congeners are reported. Median concentration of SigmaPCB congeners was 0.279 ng g(-1) dry weight (range 0.106-2.016 ng g(-1) dry weight) in sediments, and 5.20 ng g(-1) dry weight (range 1.89-19.37 ng g(-1)) in clams. Distribution and bioaccumulation of PCBs in the delta are discussed. It is concluded that in the Mekong River delta PCB concentrations were generally lower than in other regions of Vietnam and their likely sources have been waste discharges from repair workshops and other facilities in the delta cities.

Agrochemical and polychlorobyphenyl (PCB) residues in the Mekong River delta, Vietnam

An environmental survey on pesticide residues and polychlorobyphenyl compounds (PCBs), encompassing more than 70 polar and non-polar compounds quantifiable by the techniques used, was performed in the Mekong River delta based on analyses of water, sediment and bivalve mollusc samples. Few polar compounds, such as diazinon and fenotrothion, were detected in water but a high number of non-polar chlorinated compounds, such as DDT, HCH, endosulfan and PCBs, were detected in sediments and biota. The highest concentrations measured were of DDT with an average 6.3 ng g(-1) dry weight (range 0.32-67 ng g(-1)) in sediments and 38.6 ng g(-1) (range 5.5-123 ng g(-1)) in molluscs' soft tissues. Amongst chlorinated compounds, DDT concentrations were followed in decreasing order by those of PCB, endosulfan, hexachlorocyclohexane and chlordane. Residues of organochlorine compounds originate from local usage of agrochemicals although with a likely contribution also of atmospheric deposition of residues (not measured) originated elsewhere. Concentrations of PCB and pesticide residues in the aquatic environment of the Mekong River delta are lower than values reported for other regions of Vietnam and Asia. Nevertheless, current concerns about the effects of chlorinated compounds on public health advise improved control of chemical residue discharges in order to abate environmental contamination.

Cytochrome P450 and liver diseases

Cytochrome P-450 (CYPs) are involved in the metabolism of drugs, chemicals and endogenous substrates. The hepatic CYPs are also involved in the pathogenesis of several liver diseases. CYP-mediated activation of drugs to toxic metabolites induces hepatotoxicity. Well-known examples include acetaminophen and halothane. In some instances, covalent binding of the toxic metabolite to CYP leads to the formation of anti-CYP antibodies and immune-mediated hepatotoxicity (hydralazine, tienilic acid). Anti-CYP2D6 antibodies are also present in the serum of patients with type II autoimmune hepatitis, but the mechanism leading to their presence and their pathogenic significance remains unclear. Several studies support a role for CYP2E1 in the pathogenesis of alcoholic liver disease and non-alcoholic steatohepatitis. In these conditions, enhanced CYP2E1 activity is associated with lipid peroxidation and the production of reactive oxygen species with secondary damage to cellular membranes and mitochondria. Because of its ability to activate carcinogens, a role for CYP2E1 as a cofactor for hepatocellular carcinoma has also been postulated. On the other hand, drug metabolism is impaired in patients with liver disease, particularly that mediated by CYPs. The content and activity of CYP1A, 2C19 and 3A appear to be particularly vulnerable to the effect of liver disease while CYP2D6, 2C9 and 2E1 are less affected. The pattern of CYPs isoenzymes alterations also differs according to the etiology of liver disease. A strong relationship between the activity of CYPs and the severity of cirrhosis has been demonstrated, but the usefulness of measuring CYP activity to assess hepatic functional reserve remains uncertain.

Toxaphene residues from cotton fields in soils and in the coastal environment of Nicaragua

Toxaphene (camphechlor) was intensively used in the cotton growing fields of Nicaragua for decades with application rates as high as 31 kg ha(-1) in 1985. Although the use of this compound has recently been discontinued in the country, its intensive use in the past and its long persistence in soil allowed for the build up of large reservoirs of toxaphene in agriculture soils and a wide dispersal of residues in the environment. Measurements of toxaphene in coastal areas on the coast of the Pacific Ocean show that environmental concentrations are particularly high in the district of Chinandega, the traditional cotton growing region. Toxaphene residues measured in soils attained 44 microg g(-1) (dry weight) while concentrations in lagoon sediments attained 6.9 microg g(-1) (dry weight) near the mouth of the rivers flowing across the agricultural region. Measurements in aquatic biota showed concentrations as high as 1.6 microg g(-1) (dry weight) in the soft tissues of clams. The toxaphene reservoir in soils combined with the obvious persistence of this compound in soils and lagoon sediments allows predicting that toxaphene will remain in the coastal ecosystem at relatively high concentrations for many years. Toxic effects in lagoon fauna are likely to be observed especially in benthic species that may recycle this compound from sediments. Consumption of seafood, in particular of clams (Anadara spp.) from the more contaminated areas, may expose the population to unacceptably high intake of toxaphene, 30 microg d(-1) per person, with the diet.

Global intercomparison for the determination of chlorinated pesticides, PCBs and petroleum hydrocarbons in sediment sample IAEA-417

A world-wide interlaboratory comparison exercise was organised using a lagoon sediment as sample material (IAEA-417) for the analyses of chlorinated pesticides, PCB congeners and petroleum hydrocarbons. The sample material was analysed by 97 laboratories from 46 countries, representing a rather wide distribution for such an interlaboratory comparison exercise. Whereas quite variable results were reported for most chlorinated pesticides, more consistent interlaboratory results were obtained for PCB congeners and polycyclic aromatic hydrocarbons (PAHs). Nevertheless, many laboratories reported results in sufficiently dose agreement that after statistical screening of the data, consensus values were obtained for the concentration of several analytes in this sediment sample. The results allow reference concentration values to be assigned for several analytes. Thus, the sediment sample IAEA-417 can be used as a reference material for quality control of data in the determination of chlorinated compounds and petroleum hydrocarbons in moderately polluted sediments.

Distribution, fate and effects of pesticide residues in tropical coastal lagoons of northwestern Mexico

Analyses of pesticide residues in sediments, water and biota of the Altata-Ensenada del Pabellon coastal lagoon system in Sinaloa, Mexico, showed the presence of organochlorine and organophosphorus compounds. For all the compounds analysed, concentrations in sediments were higher near the points of water discharge from ponds and drainage from the agricultural area. Among the organochlorines, total DDTs displayed the largest sedimentary reservoir, followed by total endosulfans and chlorpyrifos. In sediments, as well as in biota, pp'-DDT concentrations were lower than those of DDT metabolites, which confirms the reduction in the previous massive use of this compound in agriculture. Endosulfan is currently used in the region and endosulfan residues in lagoon sediments attained levels considered to be toxic to meiofauna, therefore constituting an ecological risk to lagoon ecosystems. There was a large sedimentary reservoir of chlorpyrifos but its ecotoxicological risk is difficult to assess due to lack of adequate comparative data. Nevertheless, concentrations of chlorpyrifos which approach acute toxic levels for shrimp were recorded in lagoon water. This suggests that drainage from agricultural fields during high runoff may, on occasion, cause mass mortality of shrimp and fish Organophosphorus pesticides are widely regarded to degrade very rapidly in aquatic systems. Experimental research performed with 14C-labelled chlorpyrifos and parathion has shown that they may be stabilised for relatively long periods of time through sediment-water partitioning. This extension of their environmental half-lives increases their potential for impacting on coastal ecosystems. Since organophosphorus pesticides are highly toxic for aquatic organisms at concentrations generally lower than organochlorines, their presence in the lagoon water and sediment is a matter for much concern. The increased use of tropical coastal lagoons for shrimp and fish farming requires the implementation of environmental management practices to protect these ecosystems from the impact of agricultural activities. Environmental management aims to preserve the ecosystem integrity of these coastal lagoons and, through improving the water quality, to allow the development of aquaculture and reduce human exposure to pesticide residues in food.

Persistent organochlorine residues in sediments from the Black Sea

The extent of contamination of the Black Sea by selected organochlorine compounds has been assessed through the analysis of surficial sediments taken from throughout the region. Concentrations of HCHs at sites influenced by the Danube delta are among the highest recorded on a global basis (up to 40 ng g(-1) dry wt). The ratio between the alpha- and gamma-isomers was relatively low indicating contamination through the use of lindane. Concentrations of DDTs (0.06-72 ng g(-1) dry wt) and PCBs (0.06-72 ng g(-1) dry wt) were not especially high in comparison to levels reported from throughout the world. The DDE/DDT ratio was, however, low indicating fresh inputs and hence current usage of DDT within the Black Sea region.

Petroleum and PAH contamination of the Black Sea

Concern has been expressed regarding the extent of contamination of the Black Sea. Analyses of coastal sediments taken from throughout the region indicate, however, that levels of petroleum hydrocarbons (2-300 microg g(-1) dry wt total hydrocarbons) are generally comparable to those encountered in the Mediterranean and are lower than concentrations reported for highly contaminated areas such as the Gulf, Hong Kong, Taiwan and New York Bight. Highest concentrations of total hydrocarbons (>100 microg g(-1) dry wt) were associated with discharges from Odessa, Sochi and the River Danube. Chronic/degraded petroleum was the major contributor at these sites. Samples from the Ukrainian coastline were comparatively clean (<10 microg g(-1) dry wt total hydrocarbons). Major contributions of fresh oil (as indicated by sigma n-C14-34) occur through the River Danube. Concerning total PAH, concentrations (7-638 ng g(-1) dry wt) compare to relatively unpolluted locations in the Mediterranean and are much lower than levels reported for polluted UK estuaries (e.g. Mersey, Tyne, Thames). Both pyrolytic and petrogenic PAH are present in most samples, although petroleum derived PAH are dominant at Sochi and pyrolytic sources are prevalent in the Bosphorus region. The absence of a correlation between total hydrocarbons and PAH (R2 = 0.04) indicates different primary sources for the two.

Development of a risk-based TMDL assessment approach using the integrated modeling system GIBSI

Using the integrated modeling system GIB SI and a case study, this paper presents the development of a risk-based TMDL assessment approach that links wet (nonpoint/diffuse) and dry weather (point) sources to a probability of exceeding water quality standards (WQS) governing wateruses. The case study focused on determining whether WQS defining recreational uses of water requiring direct and prolonged contact were attainable if the waste water effluent of a small town was treated using aerated lagoons and if the agricultural nonpoint source (NPS) loads were reduced using different fertilization rates. Dry weather sources were assumed to solely contribute to bacteriological impairment of the studied river reach. Meanwhile, both wet and dry weather sources were assumed to contribute to aesthetic impairment. Simulation results showed that treating the waste water effluent while reducing the agricultural NPS loads by 27% allowed on average over a four-year study period for attainment of the bacteriological WQS 100% of the summer time while lowering the probability of exceeding the aesthetic WQS from 0.32 to 0.19 (30 to 18 days). The results of this study showed this risk-based assessment approach was well suited to establish TMDL. These probabilities should be evaluated using long meteorological series.

An unusual case of hepatic abscess

A case of recurring primary hepatic actinomycosis is reported. A 50-year-old man presented with fever, weight loss and multiple hepatic masses. A diagnosis was obtained by cytological examination of a biopsy sample taken from the largest hepatic mass, which revealed the presence of Actinomyces species. The patient was treated with penicillin for 12 months and did well. Seven years later, he presented with similar symptoms but with a single large liver mass and a pulmonary infiltrate in the right lower lobe. Liver biopsy showed an inflammatory pseudotumour, and lung biopsy showed the presence of Actinomyces species. Again, the patient was treated with penicillin. Five months later, the patient was doing well, and a follow-up computed tomography scan showed partial regression of the hepatic pseudotumour. This case indicates that hepatic actinomycosis can recur several years after an appropriate treatment and stresses the need for careful follow-up in such patients.

Differential alteration of cytochrome P450 isoenzymes in two experimental models of cirrhosis

Liver diseases are associated with a decrease in hepatic drug elimination, but there is evidence that cirrhosis does not result in uniform changes of cytochrome P450 (CYP) isoenzymes. The objective of this study was to determine the content and activity of four CYP isoenzymes in the bile duct ligation and carbon tetrachloride (CCl4)-induced models of cirrhosis. The hepatic content of CYP1A, CYP2C, CYP2E1, and CYP3A was measured by Western blot analysis. CYP activity in vivo was evaluated with breath tests using substrates specific for different isoenzymes: caffeine (CYP1A2), aminopyrine (CYP2C11), nitrosodimethylamine (CYP2E1), and erythromycin (CYP3A). Bile duct ligation resulted in biliary cirrhosis; CYP1A, CYP2C and CYP3A content was decreased and the caffeine, aminopyrine, and erythromycin breath tests were reduced whereas CYP2E1 content and the nitrosodimethylamine breath test were unchanged compared with controls. CCl4 treatment resulted in cirrhosis of varying severity as assessed from the decrease in liver weight and serum albumin. In rats with mild cirrhosis, CYP content was comparable with controls except for a decrease in CYP2C. The activity of CYPs was also unchanged except for an increase in CYP2E1 activity. In rats with more severe cirrhosis, the content of all four CYP isoenzymes and the caffeine, aminopyrine, and erythromycin breath tests were reduced whereas the nitrosodimethylamine breath test was unchanged. In both models of cirrhosis, there was a significant correlation between the breath tests results and the severity of cirrhosis as assessed from serum albumin levels. These results indicate that content and the catalytic activity of individual CYP enzymes are differentially altered by cirrhosis in the rat and also suggest that drug probes could be useful to assess hepatic functional reserve.

Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial

BACKGROUND AND AIMS

The transjugular intrahepatic portosystemic shunt (TIPS) is a new therapeutic modality for variceal bleeding. In this study we compared the two year survival and rebleeding rates in cirrhotic patients treated by either variceal band ligation or TIPS for variceal bleeding.

METHODS

Eighty cirrhotic patients (Pugh score 7-12) with variceal bleeding were randomly allocated to TIPS (n=41) or ligation (n=39), 24 hours after control of bleeding.

RESULTS

Mean follow up was 581 days in the ligation group and 678 days in the TIPS group. The two year survival rate was 57% in the TIPS group and 56% in the ligation group (NS); the incidence of variceal rebleeding after two years was 18% in the TIPS group and 66% in the ligation group (p<0.001). Uncontrolled rebleeding occurred in 11 patients in the ligation group (eight were rescued by emergency TIPS) but in none of the TIPS group. The incidence of encephalopathy at two years was 47% in the TIPS group and 44% in the ligation group (NS).

CONCLUSIONS

TIPS did not increase the two year survival rate compared with variceal band ligation after variceal bleeding in cirrhotic patients with moderate or severe liver failure. It significantly reduced the incidence of variceal rebleeding without increasing the rate of encephalopathy.

Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites

The diagnosis of refractory ascites in cirrhotic patients carries a poor prognosis and liver transplantation should always be considered in this situation. Identification of patients who will not respond to diuretic therapy usually requires several weeks of observation during which a trial of diuretics is instituted using stepwise increases in dosage in order to classify ascites as refractory. In the present study we evaluated the effect of a single dose of 80 mg intravenous furosemide on urinary sodium excretion over 8 hours in cirrhotic patients with ascites responsive to diuretic treatment (group 1; n = 14) and patients with refractory ascites (group 2; n = 15). The test was performed after 3 days without diuretics and patients were on a 80 mEq sodium/day diet. Refractory ascites was defined by the absence of response after 3 months of high doses of diuretics (spironolactone 200 mg/d + furosemide 80 mg/d + metolazone 2.5 mg/d) and the need for repeated paracentesis. The two groups had similar degrees of liver and renal dysfunction as assessed by the Pugh score and creatinine clearance. The effects of furosemide on 8-hour natriuresis was much higher in patients with responsive ascites as compared with patients with refractory ascites (125 +/- 46 vs. 30 +/- 16 mEq; mean +/- SD; P <.0001). A natriuresis lower than 50 mEq/8 hours was observed in all group-2 patients as compared with none from group 1. The present study shows that patients with refractory ascites can be identified quickly and accurately by using this simple furosemide-induced natriuresis test, which could be very useful to select patients for liver transplantation.

Chlorinated pesticides and PCBs in sediments and molluscs from freshwater canals in the Hanoi region

The concentrations of organochlorine pesticides and PCBs were determined in surface sediments and freshwater molluscs (Angulyagra sp.) from water canals in the region of Hanoi city. Results obtained show that the concentration of sigma DDT compounds in sediments range from 7 to 80 ng/g (dry weight) and from 6 to 864 ng/g (dry weight) in the soft tissues of molluscs. The concentrations of sigma DDTs were higher in populated sites and much lower in rural sites, indicating that the DDT has been used for mosquito control and not as a crop protection chemical. Hexachlocyclohexanes (HCHs) have also been widely used in the region but the current environmental concentrations are much lower than those of DDT's, which is due to the less persistence of those compounds. Polychlorinated biphenyls (PCBs) were measured, for example as aroclor 1254, in concentrations up to 40 ng/g (dry weight) and up to 76 ng/g (dry weight) in sediments and molluscs, respectively. Molluscs from water canals are a very popular food in the region. Taking into consideration the high DDT levels measured in these molluscs their consumption is worrisome and may expose the population to high levels of endocrine disrupting substances. Current PCB levels in sediments are lower than usually measured in industrialized countries. Therefore, PCB concentrations in aquatic molluscs are still also relatively low. These snails do not have enzyme ability to metabolize most of the CB congeners and, thus, are passive accumulators and a significant transfer pathway of CBs to consumers. Therefore, measures to phase out the use of these persistent and bioaccumulable chemicals should be adopted in order to prevent further environmental contamination.

Decreased in vivo metabolism of drugs in chronic renal failure

Chronic renal failure (CRF) is associated with a decrease in renal excretion of drugs, but its effects on the liver metabolism of xenobiotics are poorly defined. The objectives of this study were to determine the effects of CRF on hepatic cytochrome P450 (CYP450) and its repercussions on in vivo hepatic metabolism of drugs. Two groups of rats were studied: control paired-fed and CRF. CRF was induced by subtotal nephrectomy. Total CYP450 activity and protein expression of several CYP450 isoforms (CYP1A2, CYP2C11, CYP3A1, CYP3A2) were assessed in liver microsomes. In vivo cytochrome P450 activity was evaluated with breath tests using substrates for different isoenzymes: caffeine (CYP1A2), aminopyrine (CYP2C11), and erythromycin (CYP3A2). Creatinine clearance was reduced by 60% (P <. 01) in rats with CRF. Compared with control paired-fed rats, total CYP450 activity was reduced by 40% in rats with CRF. Protein expression of CYP2C11, CYP3A1, and CYP3A2 was considerably reduced (more than 45%, P <.001) in rats with CRF, whereas the levels of CYP1A2 were unchanged. In rats with CRF, there was a 35% reduction in the aminopyrine (CYP2C11) and the erythromycin (CYP3A2) breath tests compared with control animals (P <.001). The caffeine (CYP1A2) breath tests remained comparable to controls. Creatinine clearance correlated with the aminopyrine and erythromycin breath tests (r(2) = 0.73 and r(2) = 0.81, respectively, P <.001). In conclusion, CRF is associated with a decrease in total liver CYP450 activity in rats (mainly in CYP2C11, CYP3A1, and CYP3A2), which leads to a significant decrease in the metabolism of drugs.

Determination of organochlorinated compounds and petroleum hydrocarbons in sediment sample IAEA-408. Results from a world-wide intercalibration exercise

A sediment sample from the intertidal mudflats of the Tagus estuary was prepared, homogenised and distributed globally to laboratories as the IAEA-408 intercomparison material for the analyses of organochlorinated pesticides, PCBs and petroleum hydrocarbons (PHs). A total of 48 laboratories from 36 countries reported their results. The data from participants show that there still remain some difficulties with the accurate determination of organic contaminants such as pesticides and polycyclic aromatic hydrocarbons (PAHs). More consistent interlaboratory results were obtained for PCBs congeners. The final results of this intercomparison exercise enable individual participants to assess their performance and, where necessary, to introduce appropriate modifications in their analytical procedures. Furthermore, as a series of statistical criteria was fulfilled for a number of compounds, the sample IAEA-408 can now be used as a reference material for quality control in the determination of some persistant organic pollutants (POPs) in marine sediment samples.

Genotypic succession of mutations of the hepatitis B virus polymerase associated with lamivudine resistance

BACKGROUND/AIMS

Hepatitis B mutant strains of virus emerging during treatment with the nucleoside analog lamivudine are being increasingly recognized. In the majority of lamivudine-resistant isolates the mutations have been reported to occur within the YMDD motif of the viral polymerase, either as a single mutation M552I or as M552V concomitant with L528M. We analyzed the time course and genetic succession pattern during the emergence of lamivudine resistance.

METHODS

Seven patients with breakthrough viremia in the setting of chronic hepatitis (n=5) or recurrent HBV after liver transplantation (n=2) were investigated. Pre- and post-breakthrough serum samples were evaluated by single- or second-round PCR amplification and sequencing analysis.

RESULTS

Genotypic succession of the virus populations was observed to occur from M552I to M552I/L528M (n=2) and from L528M to M552V/L528M (n=1). The double mutations M552I/L528M (n=4) or M552V/L528M (n=2) were found in six out of seven patients, and represented the stable virus populations throughout the follow-up period. Breakthrough viremia was not associated with the single L528M mutation. The mean duration of uninterrupted treatment with lamivudine until breakthrough was 422 days (range 182-642) and was longer in the setting of chronic hepatitis B than in recurrent hepatitis B after liver transplantation. HBV DNA levels after breakthrough were lower than pretreatment levels in the majority of patients with chronic hepatitis but higher after liver transplantation.

CONCLUSION

Our observations show that the virus populations conferring resistance to lamivudine can evolve from single to double mutations at amino acid 552 and 528 of the HBV polymerase, and that M552I/ L528M or M552V/L528M seem to be the predominant mutations arising during long-term antiviral therapy with lamivudine.

A case of giant cell hepatitis recurring after liver transplantation and treated with ribavirin

A patient who underwent orthotopic liver transplantation for giant cell hepatitis with cirrhosis and in whom giant cell hepatitis recurred twice after orthotopic liver transplantation is reported. He was treated with ribavirin with an excellent result. The literature on this subject is reviewed. This observation clearly confirms the efficacy of ribavirin for the treatment of giant cell hepatitis, thus providing evidence for its viral origin.

Fulminant hepatitis A in patients with chronic liver disease

Fulminant hepatitis is a rare complication of acute hepatitis A virus (HAV) infection. We report three cases of fulminant hepatic failure with death due to HAV infection in patients with pre-existing chronic liver disease. Data from the literature also indicate a high case fatality rate during HAV superinfection in patients with chronic hepatitis B, particularly those with cirrhosis, and in patients with alcoholic cirrhosis. In patients with chronic hepatitis C, results are conflicting with some reports indicating a high fatality rate of HAV superinfection and others not, irrespective of the presence or absence of cirrhosis. Based on our observations and this review of the literature, we suggest that patients with chronic liver disease should be vaccinated against hepatitis A.

Ineffectiveness of hepatitis B vaccination in cirrhotic patients waiting for liver transplantation

Cirrhotic patients who undergo liver transplantation are at risk of acquiring de novo hepatitis B virus (HBV) infection at the time of transplantation. It is common practice to immunize these patients against HBV, but the efficacy of vaccination is uncertain. The response to vaccination with a recombinant HBV vaccine was examined in 49 patients with cirrhosis before liver transplantation. Patients received three doses (20 mg) of Engerix-B (SmithKline Beecham) at zero, one and two months before transplantation, and their response was measured on the day of liver transplantation (9.3+/-1.2 months after the initial dose of vaccine). Results were compared with those reported in healthy adults vaccinated according to the same schedule. Fourteen of 49 cirrhotic patients (28%) developed antibodies to hepatitis B surface antigen (anti-HBs) levels of more than 10 U/L after vaccination compared with 97% of healthy controls. Four patients (8%) had anti-HBs levels of more than 100 U/L compared with 83% in healthy individuals. Mean anti-HBs titre in the 14 responders was 62 U/L compared with 348 U/L in controls. No factor was identified that predicted response to vaccination. One of 49 patients acquired de novo HBV infection at the time of liver transplantation. Current HBV vaccination of cirrhotic patients waiting for liver transplantation is ineffective, and new strategies need to be developed to increase the response rate.

Fulminant hepatitis A in patients with chronic liver disease

Fulminant hepatitis is a rare complication of acute hepatitis A virus (HAV) infection. We report three cases of fulminant hepatic failure with death due to HAV infection in patients with pre-existing chronic liver disease. Data from the literature also indicate a high case fatality rate during HAV superinfection in patients with chronic hepatitis B, particularly those with cirrhosis, and in patients with alcoholic cirrhosis. In patients with chronic hepatitis C, results are conflicting with some reports indicating a high fatality rate of HAV superinfection and others not, irrespective of the presence or absence of cirrhosis. Based on our observations and this review of the literature, we suggest that patients with chronic liver disease should be vaccinated against hepatitis A.

Prediction of cyclosporine clearance in liver transplant recipients by the use of midazolam as a cytochrome P450 3A probe

BACKGROUND

Interindividual differences in the kinetics of cyclosporine (INN, ciclosporin) result in part from variations in the activity of cytochrome P450 3A (CYP3A). The biotransformation of midazolam to 1'-hydroxymidazolam is also catalyzed by CYP3A. The objective of this study was to examine the usefulness of midazolam as a CYP3A probe to predict cyclosporine clearance.

METHODS

Twenty-six stable liver transplant recipients receiving immunosuppressive therapy with oral cyclosporine (Neoral) were studied. Midazolam (0.015 mg/kg) was administered intravenously and a blood sample was obtained 1 hour later. The plasma concentration of midazolam and 1'-hydroxymidazolam was measured by gas chromatography-mass spectrometry. Blood concentration of cyclosporine was measured by a fluorescence polarization assay. Cyclosporine clearance was calculated as daily dose divided by trough level.

RESULTS

There were large interindividual variations in cyclosporine clearance and in midazolam metabolism. Cyclosporine blood levels correlated poorly with dose (r = -0.016). However, there was a significant correlation between cyclosporine clearance and the plasma concentration of 1'-hydroxymidazolam (r = 0.559; P < .001) or the midazolam/1'-hydroxymidazolam plasma concentration ratio (r = 0.668; P < .001).

CONCLUSION

Heterogeneity in CYP3A activity contributes to interpatient differences in cyclosporine dosage requirements after liver transplantation. Midazolam metabolism correlated with cyclosporine clearance, but it accounted for only about 40% of the variability in the apparent oral clearance of cyclosporine and this relationship is not tight enough to be useful in the prediction of cyclosporine dosage requirements in the clinical setting.

Lamivudine treatment for decompensated cirrhosis resulting from chronic hepatitis B

The prognosis of decompensated cirrhosis resulting from chronic hepatitis B is poor, and the benefits of treatment with interferon are outweighed by serious side effects and by the risk of fatal exacerbation of disease activity. Lamivudine rapidly reduces hepatitis B virus (HBV)-DNA in serum to undetectable levels. We have treated 35 patients with chronic hepatitis B and decompensated cirrhosis with lamivudine 100 mg or 150 mg orally once daily. Pretreatment, all were positive for HBV-DNA in serum. Ten had Child-Pugh class B and 25 had Child-Pugh class C liver disease. Seven patients underwent liver transplantation within 6 months of treatment initiation, 5 patients died within 6 months, and 23 patients were treated for at least 6 months (mean = 19 months). In a majority of these 23 cases, there was a slow but marked improvement in liver function, which was most apparent after 9 months of treatment, with a decrease in serum bilirubin from 67 +/- 13 to 30 +/- 4 micromol/L (P <.05, baseline vs. 9 months), an increase in serum albumin from 27 +/- 1 to 34 +/- 1g/L (P <.05), and a decrease in Child-Pugh score from 10.3 +/- 0.4 to 7.5 +/- 0.5 (P <.05). Three patients developed resistance to lamivudine because of a mutation in the YMDD motif, but liver function did not deteriorate. We conclude that inhibition of viral replication with lamivudine results in a significant improvement of liver function in patients with decompensated HBV cirrhosis, but the long-term benefits remain uncertain.

Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study

OBJECTIVE

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. Treatment of GAVE with surgical or nonsurgical portal decompression, beta-blockers, or endoscopic therapy provides disappointing results. In the present study, we evaluated the efficacy of estrogen-progesterone therapy, which has been reported to control chronic bleeding in gastrointestinal vascular malformations, such as Osler-Weber Rendu disease or angiodysplasia, in GAVE-related chronic bleeding.

METHODS

Six cirrhotic patients who bled chronically from GAVE were included. Three had alcoholic cirrhosis, two cryptogenic cirrhosis, and one primary biliary cirrhosis. Grade 1 esophageal varices were noted in four patients. Bleeding could not be controlled by beta-blockers, and endoscopic therapy was not considered given the extension of the antral vascular lesions.

RESULTS

Before the start of therapy, transfusion requirements averaged 3.5 units/month over a 1.5-11 month period of observation. Patients were then treated with a combination of ethynil estradiol 30 microg and noretisterone 1.5 mg daily. During follow-up (range 3-12 months), bleeding did not recur in four patients; in one patient, treatment with estrogen progesterone decreased the need for transfusions from 4 units/month to 1.4 unit/month; this patient stopped the treatment inadvertently after 6 months and severe anemia recurred with a need for 4 units of blood in the following month; reintroduction of the treatment resulted in an increase of hemoglobin levels without the need for blood transfusions during the following 4 months. In the last patient, a 5-month treatment did not improve chronic bleeding.

CONCLUSIONS

The present study suggests that estrogen-progesterone therapy is useful in the treatment of chronic bleeding related to GAVE; however, these findings require confirmation by a controlled trial.

Organochlorine pesticides and PCBs along the coast of north Vietnam

Organochlorine pesticides and polychlorinated biphenyls (PCBs) were determined in sediments and clams collected from the coast of the north of Vietnam during the rainy season (August-September 1997). Results show that the organochlorine pesticides of major concern are HCHs (1.2-33.7 ng g-1 dry wt.), DDTs (6.2-10.4 ng g-1 dry wt.) and HCB (0.1-6.5 ng g-1 dry wt.). PCBs, in aroclor 1254 equivalents, were also generally present in concentrations ranging from 0.47 to 28.1 ng g-1 sediment dry wt. Concentrations measured in the soft tissues of clams (Meretrix meretrix) generally reflect the level of contamination at the sampling sites. In the clams, the concentrations of DDTs (12.0-23.3 ng g-1 dry wt.) and PCBs (5.1-25.3 ng g-1 dry wt.) were generally higher than those of other chlorinated hydrocarbons. These results underscore the need to improved environmental protection measures in order to reduce the exposure of the population to these persistent and bioaccumulative compounds through food ingestion.

Levels and trends of PCBs, chlorinated pesticides and petroleum hydrocarbons in mussels from the NW Mediterranean coast: comparison of concentrations in 1973/1974 and 1988/1989

A mussel watch survey was conducted in 1988-1989 along the Mediterranean coast of France and Italy, between Sete and Genoa, in order to assess contamination by organochlorine pesticides, PCBs and petroleum hydrocarbons. Results show concentrations of DDTs (average 130 ng g-1 dry wt.) and PCBs (average 527 ng g-1 dry wt.) higher in coastal areas receiving river discharges and close to large cities. Concentrations of total aliphatics (average 470 micrograms g-1 dry wt.) and PAHs (average 233 micrograms g-1 dry wt.) were generally higher also near large harbours, namely Marseille, Toulon and Genoa. PAHs in mussel samples from Genoa and Monaco were mostly of pyrolytic sources, likely forest fires and exhaust gases from cars, whereas PAHs in other stations were mainly of petrogenic sources. Comparison of chlorinated hydrocarbon concentrations measured in 1988-1989 with those measured in a similar survey carried out at the same sites in 1973-1974, shows that DDTs and PCBs decreased by a factor of approximately 5 in 15 years. This decrease is in agreement with the ban on DDT implemented in 1975 in western Europe and gradual cessation of PCBs production in the 1970s and 1980s. Nevertheless, the residues of these compounds measured in mussels confirm the well-known long persistence of DDTs and PCBs, which are still present in relatively high concentrations in a few areas.

Risk factors for the development of bacterial infections in hospitalized patients with cirrhosis

OBJECTIVE

Bacterial infection is a frequent and severe complication of cirrhosis. Cirrhotic patients admitted for gastrointestinal bleeding are at high risk of such a complication and have been targeted in trials of antibiotic prophylaxis. However, it has not been shown that these patients are at a higher risk than cirrhotic patients hospitalized for other reasons. This prospective study was performed to assess the risk of bacterial infection in unselected hospitalized cirrhotic patients and to evaluate possible risk factors for this complication.

METHODS

One hundred-forty hospitalized cirrhotic patients without clinical evidence of infection at the time of initial presentation were followed-up prospectively for manifestations of infection.

RESULTS

Twenty-eight (20%) patients developed an infection during their hospitalization. Infections without a specific site (39%) and spontaneous bacterial peritonitis (32%) were the most common diagnoses. Univariate analysis showed that patients who developed an infection were more likely to have a low serum albumin level, to be admitted for gastrointestinal bleeding, to stay in the intensive care unit, and to undergo therapeutic endoscopy. Logistic regression identified admission for gastrointestinal bleeding (odds ratio (OR) = 4.3, 95% confidence interval (CI) = 1.7-10.9) and a low serum albumin (OR = 1.3, 95% CI = 1.03-1.22) as the only two variables independently associated with the development of an infection.

CONCLUSION

The present study indicates that patients with severe cirrhosis who are admitted for gastrointestinal bleeding have a higher risk of developing a bacterial infection during their hospitalization than other cirrhotic patients.

Multicenter study of lamivudine therapy for hepatitis B after liver transplantation. Lamivudine Transplant Group

Hepatitis B after liver transplantation is often fatal, and no proven medical therapy exists for this condition. We chose to study the potential efficacy of lamivudine therapy for patients with chronic hepatitis B after liver transplantation. Fifty-two patients with chronic hepatitis B after liver transplantation were treated in an open label, multicenter study. Each had detectable hepatitis B virus (HBV) DNA in serum and 45 (87%) had detectable serum hepatitis B e antigen before treatment. Patients were treated for 52 weeks with lamivudine (100 mg daily). The primary endpoint was undetectability of HBV DNA; secondary endpoints included normalization of serum alanine transaminase (ALT) levels, disappearance of hepatitis B e antigen, and improvement in liver histology. After treatment, 60% of patients had undetectable HBV DNA by solution hybridization assay, 14 (31%) of the initially positive patients lost hepatitis B e antigen; hepatitis B surface antigen was undetectable in 3 (6%); and serum ALT levels normalized in 71%. Blinded histological assessments showed improvement in the histological activity index (P =.007 for periportal necrosis,.001 for lobular necrosis, and.013 for portal inflammation). YMDD variants of HBV, potentially associated with drug resistance, were detected in 14 (27%) of the patients. Repeat liver biopsies in 7 patients with the mutated virus were unchanged in 2, improved in 2, and worse in 3. We conclude that lamivudine is a potentially effective therapy for hepatitis B after liver transplantation.

Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension

BACKGROUND

Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) are increasingly recognised as separate entities. The pathogenic role of portal hypertension for the development of GAVE is still controversial.

AIMS

To evaluate the effects of portal decompression on chronic bleeding related to GAVE in cirrhotic patients.

METHODS

Eight patients with cirrhosis and chronic blood loss related to GAVE were included. GAVE was defined endoscopically and histologically.

RESULTS

All patients had severe portal hypertension (mean portocaval gradient (PCG) 26 mm Hg) and chronic low grade bleeding. Seven patients underwent transjugular intrahepatic portosystemic shunt (TIPS) and one had an end to side portacaval shunt. Rebleeding occurred in seven patients. In these, TIPS was found to be occluded after 15 days in one patient; in the other six, the shunt was patent and the PCG was below 12 mm Hg in five. In the responder, PCG was 16 mm Hg. Antrectomy was performed in four non-responders; surgery was uneventful, and they did not rebleed after surgery, but two died 11 and 30 days postoperatively from multiorgan failure. In one patient, TIPS did not control GAVE related bleeding despite a notable decrease in PCG. This patient underwent liver transplantation 14 months after TIPS; two months after transplantation, bleeding had stopped and the endoscopic appearance of the antrum had normalised.

CONCLUSIONS

Results suggest that GAVE is not directly related to portal hypertension, but is influenced by the presence of liver dysfunction. Antrectomy is a therapeutic option when chronic bleeding becomes a significant problem but carries a risk of postoperative mortality.

Effect of cyclosporine A on cytochrome P-450-mediated drug metabolism in the partially hepatectomized rat

Despite its hepatotoxic potential, cyclosporine A (CsA) has been reported to positively influence compensatory liver growth. To probe the physiological consequences of CsA on the recovery of liver function, studies were initiated in the 2/3 partially hepatectomized (PHx) rat, taking the recovery of cytochromes P-450-dependent drug metabolism as primary outcome. CsA was administered at a dose of 3. 33 mg/kg/day for 10 days. Drug metabolism was evaluated by the recovery of 14CO2 after administration of isotopically labeled model drugs and by studying the expression of the P-450 transcripts involved in their biotransformation before and 24 to 96 h after PHx. Before PHx, neither the steady-state mRNA nor the in vivo disposition of caffeine (CYP1A2), erythromycin (CYP3A2 and 3A1), or aminopyrine (CYP2B1 and 2C11) were influenced by CsA. Studies 24 h after PHx revealed a 29 to 39% reduction in the elimination of [14C]aminopyrine and [14C]erythromycin, which was unaffected by CsA. Their metabolism at 48 to 96 h after PHx also remained unaffected by CsA. By contrast, postPHx, [14C]caffeine elimination decreased to a level closely proportional to the loss in liver mass. In addition, CsA accelerated the recovery and/or prevented the decrease of caffeine elimination 24 h after PHx but not at later time points, indicating an early, but unsustained, beneficial effect of CsA on the recovery of CYP1A2-mediated activities. These data show that at the critical time of greatest loss in liver mass, CsA has only a selective influence on the biotransformation of cytochrome P-450 protein-dependent activities and that its effect on the regeneration process does not translate into an overall accelerated recovery of the hepatic drug-metabolizing function.

Identification of quinine metabolites in urine after oral dosing in humans

A gas chromatographic-mass spectrometric method was used to separate quinine and its metabolites present in urine after oral dosing of 300 mg quinine in humans. The technique allowed the separation of quinine and ten metabolites. Four of these metabolites were definitely identified as 3-hydroxyquinine, 2'-quinone, O-desmethylquinine and 10,11-dihydroxydihydroquinine, by comparing their methane chemical ionization mass spectra with those of authentic standards prepared by organic synthesis. Six other metabolites are described for the first time in human urine. From their electron impact and chemical ionization mass spectra, we propose these compounds to be 3-hydroxy-2'-quinone, O-desmethyl-2'-quinone, O-desmethyl-3-hydroxyquinine, O-desmethyl-3-hydroxy-2'-quinone, 10,11-dihydroxydihydro-2'-quinone and 10,11-dihydroxydihydro-O-desmethylquinine. These secondary metabolites probably arose from further biotransformation of the four primary metabolites.

Characterization of cytochrome P450 2E1 activity by the [14C]nitrosodimethylamine breath test

The objective of this study was to measure the rate of demethylation of nitrosodimethylamine in vivo in the rat and determine its value to assess CYP2E1 activity in intact animals. Nitrosodimethylamine labeled with 14C on both methyl groups was administered to rats and exhaled 14CO2 was collected during 2-3 h. The nitrosodimethylamine breath test was increased by inducers of CYP2E1, such as ethanol (+139%) and 4-methylpyrazole (+115%), and decreased by the inhibitor diallyl sulfide (-53%). In addition, the nitrosodimethylamine breath test was not changed significantly by inducers specific for other cytochrome P450 such as beta-naphthoflavone, dexamethasone, and phenobarbital. The specificity of the induction by 4-methylpyrazole and of the inhibition by diallyl sulfide for CYP2E1 was determined using the [14C]caffeine (CYP1A2), [14C]aminopyrine (CYP2C11), and [14C]erythromycin (CYP3A2) breath tests. 4-Methylpyrazole treatment caused a small increase of the caffeine (+33%) and aminopyrine (+9%) breath tests and no change of the erythromycin breath test. Diallyl sulfide treatment led to a small decrease of the caffeine breath test (-33%) and of the aminopyrine breath test (-13%) but a 23% increase of the erythromycin breath test. It is concluded that the [14C]nitrosodimethylamine breath test is useful to assess CYP2E1 activity in vivo in the rat.

Lack of relationship between preoperative measures of the severity of cirrhosis and short-term survival after liver transplantation

The purpose of this study was to evaluate the prognostic value of clinical measures of the severity of disease in cirrhotic patients who were candidates for liver transplantation at our institution. The records of the 132 cirrhotic patients who were candidates for a first transplantation between January 1, 1987, and December 31, 1994, were reviewed. One hundred nine patients (82.6%) received grafts, and 23 (17.4%) died while on the waiting list. The variables examined included level of medical urgency at the time of enlistment, date of transplantation, serum creatinine level, variables that constitute the Child-Pugh score and Shaw's risk score (serum bilirubin and albumin, prothrombin time, ascites, encephalopathy, nutritional status, age, and operative blood loss), and 6-month survival status after transplantation. The proportion of patients who died awaiting a graft increased as a function of the Child-Pugh score at enlistment (score 5-6, 0%, n = 6; score 7-9, 7%, n = 54; score 10-11, 18%, n = 33; score 12-15, 33%, n = 39; P = .01). Six-month survival rates after transplantation were similar irrespective of the Child-Pugh score or Shaw's risk score. Stepwise multiple logistic regression models identified the degree of ascites, serum bilirubin, and operative blood loss as significant variables for the prediction of overall mortality 6 months posttransplantation (model chi 2 = 12.8; P = .025; r = 0.32), but the model explained only 10% of the outcomes observed. We concluded that the Child-Pugh score is a valid prognostic index for survival up to the time of transplantation for cirrhotic patients on the waiting list; however, clinical measures of the severity of cirrhosis are poor predictors of 6-month survival after transplantation.

Quantitative assessment of serum hepatitis B e antigen, IgM hepatitis B core antibody and HBV DNA in monitoring the response to treatment in patients with chronic hepatitis B

Virological response to treatment of chronic hepatitis B is defined as the loss of serum hepatitis B virus DNA (HBV DNA) and hepatitis B e antigen (HBeAg). The quantitative measurement of HBV DNA is useful for monitoring and predicting the response to therapy with interferon-alpha (IFN-alpha). In this study, we evaluated whether quantitative measurement of serum HBeAg and IgM antibody to hepatitis B core antigen (HBcAb) could also be used in this manner. Using a microparticle-capture enzyme immunoassay (IMx), a standard curve of fluorescence rate vs HBeAg concentration was constructed to provide quantitative results. The IgM HBcAb index was also measured using a microparticle enzyme immunoassay and serum HBV DNA was measured by a solution hybridization assay. We studied 48 patients who were initially positive for HBeAg and HBV DNA and who were treated with IFN-alpha2b. Their sera were serially evaluated for HBeAg concentration, and results were compared with HBV DNA levels. In the 14 patients who responded to IFN, similar disappearance curves were observed with good intraindividual correlation between the levels of the two markers. In the 34 non-responders, HBeAg levels decreased during treatment but never became negative; HBV DNA levels also decreased during treatment and became transiently undetectable in six patients, falsely suggesting treatment success. The IgM HBcAb index paralleled changes in alanine aminotransferase (ALT) concentration and did not provide additional information. Multiple logistic regression indicated that baseline ALT and HBeAg concentrations were independent predictors of the response to treatment and the addition of neither HBV DNA nor IgM HBcAb improved the model. We conclude that quantitative measurement of HBeAg provides information similar to that of HBV DNA in monitoring and predicting the response to treatment; this technique could be readily adaptable to clinical laboratories.

Clearance by the liver in cirrhosis. III. Propranolol uptake by the isolated perfused human liver

In cirrhosis, intrahepatic shunts and capillarization of sinusoids can result in impaired extraction of substrates by the liver irrespective of the metabolic capacity of the liver (intact hepatocyte theory). To evaluate the role of anomalies of uptake in impaired drug disposition, we studied the steady-state hepatic clearance and single-pass hepatic uptake of propranolol in isolated perfused livers obtained from patients with cirrhosis at the time of transplantation and from organ donors with normal liver architecture. The kinetics of propranolol transport in the liver were characterized by means of the multiple-indicator dilution technique, and the outflow pattern of propranolol in the hepatic veins was resolved into throughput material, which had swept past the hepatocytes along with albumin, and returning material, which had entered the cells but returned in the outflow after escaping cellular sequestration and metabolism. The steady-state clearance of propranolol was decreased in cirrhotics compared with organ donors, and the outflow profile differed between the two groups. In cirrhotic livers, half of the propranolol in the outflow consisted of throughput material and the other half of returning material; in organ donors, all of the propranolol in the outflow was returning material. In the presence of albumin and alpha 1-acid glycoprotein in the perfusate, about 80-85% of propranolol was protein bound; removal of albumin and alpha 1-acid glycoprotein from the perfusate it cirrhotic livers resulted in an increase in the free fraction of propranolol, an increase in steady-state extraction, and a decrease in the throughput component of propranolol in the outflow. We conclude that impaired uptake of protein-bound propranolol, as a result of capillarization and intrahepatic shunts, contributes to its impaired elimination in cirrhosis.

Adding sodium dodecyl sulfate and Pseudomonas aeruginosa UG2 biosurfactants inhibits polycyclic aromatic hydrocarbon biodegradation in a weathered creosote-contaminated soil

The effect of two anionic surfactants was assessed during biodegradation of 13 of the 16 USEPA priority polycyclic aromatic hydrocarbons (PAH) in a wood-preserving soil contaminated with creosote and pentacholorophenol for a period of at least 20 years. Sodium dodecyl sulfate (SDS) and biosurfactants from Pseudomonas aeruginosa UG2 were utilized at concentrations of 10, 100 and 500 micrograms/g soil. Because both surfactants are readily biodegradable, the microcosms received a fresh spike of surfactant every 2 weeks. Biodegradation of aged PAH residues was monitored by GC/MS for a period of 45 weeks. Results indicated that the biodegradation of the three-ring PAH was rapid and almost complete but was slowed by the addition of 100 micrograms/g and 500 micrograms/g chemical surfactant. Similarly, at the same concentrations, the two surfactants significantly decreased the biodegradation rate of the four-ring PAH. In this case, the inhibition was more pronounced with SDS. High-molecular-mass PAH (more than four rings) were not biodegraded under the test conditions. It was suggested that the preferential utilization of surfactants by PAH degraders was responsible for the inhibition observed in the biodegradation of the hydrocarbons. The high biodegradability and the inhibitory effect of these two surfactants would have a significant impact on the development of both above-ground and in situ site reclamation processes.

Variability in hepatic iron concentration measurement from needle-biopsy specimens

BACKGROUND/AIM

Quantitative measurement of hepatic iron by biochemical analysis of liver biopsy samples is required to assess hepatic iron stores accurately. Cirrhotic livers, however, contain variable amounts of fibrous tissue and the distribution of iron within the hepatic parenchyma is not always uniform. The aim of this study was to assess the variability in hepatic iron concentration measurement from needle-biopsy specimens.

METHODS

The livers from eight patients with cirrhosis selected because of elevated serum ferritin were obtained at the time of liver transplantation (n = 6) or at autopsy (n = 2). Multiple needle biopsies were done, and hepatic iron concentration was measured by atomic absorption spectroscopy. The hepatic iron index was calculated as iron concentration divided by age.

RESULTS

Four cases had a mean hepatic iron index above 2.0, in the range of that reported in patients with homozygous genetic hemochromatosis, whereas the other four had an hepatic iron index of less than 2.0. The intra-individual coefficient of variation for hepatic iron concentration ranged from 11.3 to 43.7%, averaging 24.9%. The coefficient of variation was smaller in biopsy samples > 4 mg dry weight than in samples < 4 mg (19.8% vs 28.6%, p < 0.05). Histological examination of surgical biopsies from these livers showed large amounts of fibrous tissue, and inhomogeneous distribution or iron in the hepatic parenchyma.

CONCLUSIONS

This study demonstrates an important variability in the measurement of hepatic iron content from needle biopsy specimens in patients with severe cirrhosis.

Hepatitis after the use of germander, a herbal remedy

The authors report two cases of hepatic injury associated with the ingestion of germander, a herbal medicine used to facilitate weight loss. In both patients, hepatitis characterized by asthenia, jaundice and a marked increase in serum amino-transferase levels occurred after 5 to 6 months of germander use. The jaundice disappeared within 8 weeks after germander use was stopped, and the overall outcome was favourable. The subsequent resumption of germander therapy by one patient was soon followed by the recurrence of hepatitis. Similar reports from France have led to the banning of germander in that country. Like several other herbal remedies, germander may be hepatotoxic, and many herbal medicines may not be as safe as the public generally assumes.

The hepatic microcirculation in the isolated perfused human liver

In cirrhosis, capillarization of sinusoids could result in impaired exchanges between the hepatocytes and the blood perfusing the liver and contribute to liver failure irrespective of the metabolic capacity of the liver. To characterize anomalies of the hepatic microcirculation, we used the multiple-indicator dilution approach in isolated perfused livers obtained from patients with cirrhosis at the time of transplantation, and from organ donors with normal or near-normal livers or hepatic steatosis. In organ donors, the sinusoidal volume and the permeability of sinusoids to albumin, sucrose, and water were found to be comparable to that of normal dog and rat livers. The sinusoidal volume and the extravascular volume (EVV) accessible to diffusible tracers were larger after hepatic artery than after portal vein injection, probably because of an unshared arterial sinusoidal bed. In cirrhotic livers, two kinds of alterations were found: the appearance of a barrier between the sinusoids and the hepatocytes (capillarization) and intrahepatic shunts. The extravascular space accessible to albumin decreased with increasing severity of cirrhosis, and the diffusion of sucrose in the space of Disse showed a barrier-limited pattern, instead of the normal flow-limited behavior. In cirrhotic livers, a correlation was found between the hepatic extraction of indocyanine green (ICG) and the extravascular space accessible to albumin (r = .84, P < .05), suggesting that the impaired access of this protein-bound dye to the hepatocyte surface contributed to its impaired elimination. Intrahepatic shunts were found between portal and hepatic vein (21% +/- 16% of portal flow), but not between hepatic artery and hepatic veins. We conclude that (1) the behavior of diffusible tracers in human livers with normal liver architecture is comparable to that reported in normal animals; (2) the permeability of sinusoids in cirrhotic livers is abnormal, (3) permeability changes are related to changes in liver function in cirrhosis.

Liver blood flow in chronic hemodialysis patients

The purpose of this study was to assess liver blood flow and cardiac output in chronic hemodialysis patients (n = 7) before and after a hemodialysis session, and to compare it to normal volunteers (n = 11). We used the hepatic clearance of sorbitol to calculate liver blood flow and echocardiograms to evaluate cardiac output. The latter was higher in hemodialysis patients (predialysis 4.7 +/- 1.8 liters/min, postdialysis 4.5 +/- 0.9 liters/min) compared to normal subjects (3.8 +/- 0.9 liters/min, p = 0.09 and p = 0.05). Hepatic blood clearance of sorbitol was similar in hemodialysis patients before and after dialysis (1,610 +/- 266 and 1,541 +/- 415 ml/min) as well as in normal volunteers (1,565 +/- 313 ml/min). The hepatic extraction ratio of sorbitol is slightly decreased in hemodialysis patients (n = 3) (0.87 +/- 0.03) compared to values reported in the literature for healthy subjects. We conclude that liver blood flow is not significantly altered in hemodialysis patients.

Suspected ciprofloxacin-induced hepatotoxicity

OBJECTIVE

To report a case of probable ciprofloxacin-induced hepatotoxicity.

CASE SUMMARY

A 44-year-old woman developed severe hepatitis 3 weeks after initiation of a 7-day course of oral ciprofloxacin therapy. Liver biopsy showed severe hepatic necrosis, and other causes of liver injury were excluded. Liver function test results returned to normal 4 months after the appearance of jaundice.

DISCUSSION

The time course of events suggested that ciprofloxacin was the cause of severe hepatitis in this patient, and other causes of hepatitis were ruled out. Hepatotoxicity has been reported with other fluoroquinolone antibiotics, and there have been previous unpublished reports to the manufacturer of possible hepatotoxicity caused by ciprofloxacin.

CONCLUSIONS

It is suggested that ciprofloxacin can cause severe hepatic injury and that healthcare providers should be aware of this possible adverse drug reaction.

Comparison of Microbial Sulfuric Acid Production in Sewage Sludge from Added Sulfur and Thiosulfate

Microbial leaching is one of the most attractive methods of removing toxic metals from sewage sludge. Sulfuric acid produced by indigenous microflora by the oxidation of elemental sulfur and sulfur compounds solubilizes toxic metals. The oxidation of sulfur compounds can be achieved by the direct oxidation to sulfates or by indirect oxidation, through the production and accumulation of soluble intermediate (S₂ O^2- ₃ , S₃ O^2- ₆ , S₄ O^2- ₆ ) compounds. The production of these intermediates may create a potential danger of acidification of the receiving waters or the agricultural soil where the leached sludge is ultimately destined, via slow oxidation of the intermediates with subsequent sulfuric acid production. The objective of this research was to investigate the formation of S₂ O^2- ₃ , S₃ O^2- ₆ , and S₄ 2^- ₆ during metal bioleaching using elemental sulfur and thiosulfate as energy substrates for growth of indigenous thiobacilli (sulfur-oxidizing microorganisms) in sludge. The results obtained showed that intermediates were not formed when elemental sulfur was used as a substrate, whereas trithionate and tetrathionate accumulated in the sludges when thiosulfate was used as substrate. Moreover, the metabolism of thiosulfate was much slower than that of elemental sulfur in sludge medium. Therefore, the utilization of thiosulfate for the growth of indigenous thiobacilli in sewage sludge is a less attractive alternative for the metal bioleaching.

A long-term follow-up study of asymptomatic hepatitis B surface antigen-positive carriers in Montreal

BACKGROUND/AIMS

Prospective studies from the Far East and Alaska have shown an increased mortality from cirrhosis and/or hepatocellular carcinoma in asymptomatic hepatitis B virus (HBV) carriers. The magnitude of this risk in apparently healthy North American carriers remains undefined.

METHODS

The outcomes of 317 asymptomatic hepatitis B surface antigen-positive carriers from the Montreal area were examined after 16 years of follow-up. A majority of carriers were of French Canadian origin, were positive for antibody to hepatitis B e antigen, and had normal serum transaminase levels; institutionalization in orphanages as infants or children was the most important epidemiological risk factor, suggesting horizontal transmission of HBV during childhood.

RESULTS

At follow-up, mean age was 46 +/- 8 years; 3 carriers had died of HBV-related cirrhosis, 1 of alcoholic cirrhosis, and 9 of causes unrelated to liver disease. No carrier died of hepatocellular carcinoma; had the risk of hepatocellular carcinoma been similar to that reported from the Far East and Alaska, 17 cases of hepatocellular carcinoma-related deaths would have been expected. During follow-up, the annual negativation rate for hepatitis B surface antigen was 0.7%.

CONCLUSIONS

In asymptomatic HBV carriers from Montreal, a majority are "healthy" carriers and remain asymptomatic after 16 years of follow-up and the risk of death from HBV-related cirrhosis and/or hepatocellular carcinoma is low.

Clearance by the liver in cirrhosis. II. Characterization of propranolol uptake with the multiple-indicator dilution technique

We studied the steady-state hepatic extraction and single-pass hepatic uptake of propranolol in isolated perfused livers from normal rats and compared these values with those of rats with carbon tetrachloride-induced cirrhosis, rats treated with chlorpromazine (an inhibitor of propranolol metabolism) and rats with acute liver injury. The kinetics of propranolol transport in the liver were characterized by means of the multiple-indicator dilution technique, and estimates of cellular influx, efflux and sequestration rate constants were obtained with a computer fit to the model of Goresky. The outflow pattern of propranolol in the hepatic veins was then resolved into throughput material, which had swept past the hepatocytes along with albumin, and returning material, which had entered the cells but returned in the outflow after escaping metabolic sequestration. The steady-state extraction of propranolol was significantly decreased in the three experimental groups compared with that in controls, but the outflow profile differed within each group. In cirrhotic animals, influx was markedly decreased and the sequestration rate constant remained unchanged; most of the propranolol in the outflow consisted of throughput material. In rats treated with chlorpromazine, the sequestration rate constant was decreased, and propranolol in the outflow was mainly returning material. In rats with acute liver injury, both influx and sequestration rate constants were decreased. Indicator dilution curves for nonsequestered tracers showed a decreased transit time for red blood cells and abnormal diffusion of albumin and sucrose into the space of Disse in cirrhotic rats compared with the other groups.(ABSTRACT TRUNCATED AT 250 WORDS)