Safety and Efficacy of Dolutegravir Plus Rilpivirine in Treatment-Experienced HIV-Infected Patients: The DORIVIR Study

Objectives:

To analyze the efficacy and safety of dolutegravir/rilpivirine (DTG/RPV) in HIV-infected patients who switched from any other antiretroviral therapy (ART).

Methods:

Open-label, multicenter study including patients who switched to DTG/RPV between February 2015 and February 2016. Efficacy (HIV RNA <50 copies/mL), adverse events, and metabolic changes at 24 weeks were analyzed.

Results:

A total of 104 participants were included, who switched for the following reasons: toxicity/intolerance (42.3%), convenience (27.8%), and drug interactions (17.3%). Prior regimens are protease inhibitor (56.7%), integrase strand transfer inhibitor (26.9%), and non-nucleoside reverse transcriptase inhibitor (16.3%). Efficacy at 24 weeks was 88.4% (intention to treat) and 96.8% (per protocol). Triglyceride levels were reduced, on average, by 12.7% and a mean decrease of 9.0% in the glomerular filtration rate was observed as well (P values of .003 and .002, respectively), whereas total cholesterol, HDL cholesterol, LDL cholesterol, creatinine, and glutamic-pyruvic transaminase remained unchanged. No patient discontinued due to adverse events.

Conclusions:

Dolutegravir/RPV is effective and safe in long-term HIV-infected patients under any prior ART. Toxicity, convenience, and interactions were the main reasons for changing. At 24 weeks, the lipid profile improved with a decrease in triglycerides.

Non-cellulosic polysaccharide content in feed ingredients and ileal and total tract non-cellulosic polysaccharide digestibility in 21- and 42-day-old broilers fed diets with and without added composite enzymes

An initial study profiled non-cellulosic polysaccharide (NCP) levels in feed ingredient samples-corn, soybean meal (SBM), whole soybean, and distillers dried grains with solubles (DDGS). A separate NCP digestibility assay was performed in broilers at day 21 (grower phase) and day 42 (finisher phase) fed corn-soy based diets with and without composite enzymes (phytases, multi-carbohydrases, and proteases). Negative control (NC), NC + composite enzymes (NC+E), and positive control (PC) diets were tested. Negative control and NC + E diets were isocaloric, 3,020 kcal/kg ME at grower phase and 3,026 kcal/kg ME at finisher phase. Positive control diet was formulated to meet the Cobb standard nutrient specifications. Diets, pooled digesta, and excreta samples from all treatment diets were collected from 21- and 42-day-old birds and NCP content analyzed as soluble NCP (S-NCP) and insoluble NCP (I-NCP) fractions. Digestibility coefficient (DC) values were determined for all dietary treatments for both the feeding periods. Results from the ingredient analysis showed NCP levels of ∼7 to 10% in corn samples, ∼8 to 11% in SBM samples, ∼11 to 14% (including pectin level) in whole soybean, and ∼12 to 17% in DDGS samples, suggesting variation (P < 0.05) in NCP levels existed within ingredient samples. Digestibility assays showed that enzyme treated (NC + E) diet improved DC values at day 21 from 6 to 10 units and 6 to 9 units for ileal and total tract collection, respectively, for I-NCP fraction (P < 0.05) compared to DC values for NC or PC diets. The ileal DC values at day 42 were not different between treatment diets (∼0.6) but total tract DC values improved 9 to 11 units for broilers fed NC + E diet compared to NC or PC diets. Higher DC values for S-NCP were observed for all treatments for both feeding periods (∼0.7-ileal and ∼0.8-total tract) compared to DC values for I-NCP. Overall, the use of supplemental enzymes in corn-soy-based diets showed improvement in total NCP digestion.

Role of the water-drinking test in medically treated primary open angle glaucoma patients

PURPOSE

The water-drinking test (WDT) has recently re-emerged as a possible way to determine the competency of the trabecular meshwork. We performed a prospective interventional study to test the hypothesis that the WDT could be useful in assessing fluctuations in patients undergoing treatment for primary open angle glaucoma (POAG).

METHODS

We included 122 patients; 62 on medical treatment for POAG (n=123 eyes) and 60 controls (n=120 eyes). The study group had been on intraocular pressures (IOP) lowering treatment continuously for at least 3months with stable IOP. The WDT was performed during fasting and was considered positive if it fluctuated ≥6mmHg.

RESULTS

The patients on medical treatment had a mean age of 50.56±18.45 years vs. 51.35±11.22 for the controls (P=0.34); with 71% being female in the study group and 77% in the control group. In the study group; 52% were on beta blockers (n=64), 27% combination of two or more medications (n=33), 19% prostaglandin analogues (n=24) and 2% alpha agonists (n=2). The WDT was positive in 17.07% (n=21) in the study group and 2.5% (n=3) in the control group (P=0.0001). The mean fluctuation was 7.14±2.15mmHg in the study group and 6.00±0mmHg in the controls (P=0.33). A positive WDT was found in 33.33% (n=11) of those on combination therapy; 12.5% (n=3) prostaglandin analogues and 10.94% (n=7) beta blockers (P=0.03). Combination therapy had the highest positive WDT fluctuation (7.54±2.87) followed by prostaglandin analogues (7.00±1.00) and beta blockers (6.57±0.78) with a P value of 0.44.

CONCLUSIONS

The WDT can identify significant fluctuations in eyes with POAG that are medically treated.

Versatile genetic assembly system (VEGAS) to assemble pathways for expression in S. cerevisiae

We have developed a method for assembling genetic pathways for expression in Saccharomyces cerevisiae. Our pathway assembly method, called VEGAS (Versatile genetic assembly system), exploits the native capacity of S. cerevisiae to perform homologous recombination and efficiently join sequences with terminal homology. In the VEGAS workflow, terminal homology between adjacent pathway genes and the assembly vector is encoded by 'VEGAS adapter' (VA) sequences, which are orthogonal in sequence with respect to the yeast genome. Prior to pathway assembly by VEGAS in S. cerevisiae, each gene is assigned an appropriate pair of VAs and assembled using a previously described technique called yeast Golden Gate (yGG). Here we describe the application of yGG specifically to building transcription units for VEGAS assembly as well as the VEGAS methodology. We demonstrate the assembly of four-, five- and six-gene pathways by VEGAS to generate S. cerevisiae cells synthesizing β-carotene and violacein. Moreover, we demonstrate the capacity of yGG coupled to VEGAS for combinatorial assembly.

Prognostic value of flow cytometry in surgically treated primary gastric lymphoma

AIM

To investigate whether flow cytometry could help to define the optimal therapeutic strategy of primary gastric lymphomas.

MATERIAL AND METHOD

Retrospective study of 46 patients having primary gastric lymphoma--according to Dawson criteria--in Ann Arbor stage IE and IIE, who were surgically treated. From selected paraffin-embedded tissue blocks of the tumor, DNA content was studied by flow cytometry (FC). Other pathological tumor features were analysed by hematoxiline-eosine and Giemsa stains as well as immunohistochemical study; any possible influence on postoperative survival was investigated through statistical analysis.

RESULTS

The DNA ploidy pattern was diploid in 40 cases (87%) and aneuploid (hyperdiploid) in 6 (13%). Postoperative survival probability (PSP) was 62.7% at 5 years. Statistical analysis showed significant prognostic value for Ann Arbor classification--with higher PSP for stage IE (p = 0.009)--and FC parameters: diploid tumors had higher PSP than aneuploid tumors. Also tumors having S-phase (p = 0.044) or G2-M phase values (p = 0.023) under the respective mean values had higher PSP. No influence on PSP was found for wall invasion, Helicobacter pylori infection, Isaacson's histologic type or resection margin involvement. No significant relationship was appreciated between Isaacson's histologic type and DNA ploidy patterns.

CONCLUSION

FC could be useful in assessing gastric lymphoma prognosis.

HER2/neu overexpression/amplification in advanced gastric cancer (AGC) patients (pts): Correlation with clinicopathological parameters

15046

Background: HER2/neu protein is overexpressed in several types of human cancers. Its amplification is associated with poor prognosis and constitutes a predictive factor of response to therapy. In this phase II study, we investigate the correlation between the HER2/neu overexpression/amplification and clinicopathological characteristics of AGC pts. Objective: To prospectively determine the frequency of HER2/neu expression and to evaluate the relationship with clinicopathological characteristics in AGC pts. Methods: HER2/neu expression/amplification has been examined by immunohistochemistry (IHC) and/or fluorescence in situ hybridization (FISH). HER2/neu has been considered overexpressed if: IHC=3; IHC=2 and FISH+ or FISH+. Clinical stage, prior therapies, tumor localization and histological characteristics have been also recorded. Results: Between Feb/2004 and Dec/2006, 181 pts have been tested for HER2/neu status. 132 (73%) males, median age 66 yrs (r-29–83). 24 (13.5%) pts were HER2/neu +. At screening, metastatic disease was the most frequent clinical stage (163, 91.1% vs 16, 8.9% locoregional advanced), being mainly localized in liver (45.3%), lymph nodes (41.4%), peritoneum (28.2%). 88 pts underwent prior surgery, 19 pts received adjuvant irradiation and 24 prior chemotherapy (21 pts adjuvant, 4 neoadjuvant). Primary tumor localization was 140 (79.5%) gastric and 33 (18.8%) gastroesophageal junction (GEJ). HER2/neu overexpression was found in 10.9% of tumors with gastric localization and in 24.2% of GEJ tumors (p=0.084). Adenocarcinoma was the histological type in 98% cases (34.9% diffuse, 43.2% intestinal, 0.6% mucoid, 21.3% unknown subtype). No statistically significant relationship was found between HER2/neu expression and histological subtype (7% type diffuse, 18.1% type intestinal, 13.9% unknown; p=0.186). Conclusions: HER2/neu overexpression/amplification was found in 13.5%. There were no significant correlation of HER2/neu overexpression/amplification with both tumor localization and histological subtype. The study is ongoing.

No significant financial relationships to disclose.

A novel mutation in the E-cadherin gene in the first family with hereditary diffuse gastric cancer reported in Spain

AIMS

Mutations of the E-cadherin gene (CDH1) result in dominantly inherited hereditary diffuse gastric cancer (HDGC). We report a study in the first family diagnosed with HDGC in Spain, examining the presence of mutations in the CDH1 gene.

METHODS

The presence of mutations was studied by direct sequencing of all CDH1 exons. Immunohistochemical analysis with specific antibodies was used to detect the expression of E-cadherin in normal and tumour tissue.

RESULTS

A novel 1610delC mutation in exon 11 has been found in a Spanish family diagnosed with HDGC. This mutation generates a premature stop codon at position 1667 giving rise to a truncated protein that lacks the transmembrane and beta-catenin-binding domains. The presence of a 1610delC germline mutation was confirmed in three family members diagnosed with diffuse gastric cancer, and also in six asymptomatic members. Of note, the diffuse gastric cancer coexisted with a gastric lymphoma in the proband. Furthermore, immunohistochemical analyses of tumour tissue showed the complete absence of E-cadherin in the proband, revealing a second genetic hit at the CDH1 locus.

CONCLUSIONS

We have identified a HDGC family in Spain that carries a novel germline truncating mutation in the CDH1 gene.

Increased expression of Ob-Rb and its relationship with the overexpression of TGF-beta1 and the stage of fibrosis in patients with nonalcoholic steatohepatitis

AIMS

The main aim of this study was to examine the relationship of the leptin system in steatosis and nonalcoholic steatohepatitis (NASH). The study also analysed the pathogenic role of the leptin system in the development of hepatic fibrosis and its relation with the TGF-beta1 system.

MATERIALS AND METHODS

The study included 90 subjects, 55 with NASH and 35 with simple steatosis. Gene expression of leptin, leptin receptor and TGF-beta mRNA was analysed by real-time PCR on liver tissue. Leptin serum levels were determined by RIA. Leptin receptor expression was also assessed by immunohistochemistry.

RESULTS

Increased expression was found for leptin receptor mRNA (P=0.0016) and its protein (P<0.05) in patients with NASH, especially those with fibrosis. There was a marked increase in gene expression of TGF-beta1 in patients with NASH (P=0.0002). A strong correlation was demonstrated between leptin receptor gene expression and TGF-beta1 gene expression (P=0.023). No leptin expression was found in the liver tissue. All patients showed a marked hyperleptinemia, which was closely related to the anthropometric characteristics analysed and independent of development or not of NASH.

CONCLUSIONS

The results of the study demonstrate for the first time increased leptin receptor expression in liver tissue and its relationship with overexpression of TGF-beta1 and the degree of hepatic fibrosis.

Inhibition of in vitro gamete adhesion and in vivo fertility in mice by immunization with a synthetic peptide

PROBLEM

To evaluate the contraceptive ability of a synthetic peptide in in vitro and in vivo fertility in the mouse.

METHOD OF STUDY

A synthetic peptide segment: GELRERAPGQGTNG (SP) was used to immunize female B6CF1 (C57BL/6 x BALB/c) mice. A peptide with an amino acid sequence QQPLSIQQHERG (p2control) was used as control. Anti-SP and anti-p2control antisera were used to evaluate sperm function inhibition in vitro. Fertility of immunized mice was determined by microscopic evaluation of the number and state of preimplantation embryos (8-16 cell stage).

RESULTS

In the mouse, anti-SP antisera recognized surface antigens in the acrosome region of mature and capacitated sperm. Anti-SP antisera inhibited in vitro sperm binding to zona pellucida. In vivo, immune response against SP in Freund's adjuvant resulted in a significant increase (P < 0.01) in the number of dead embryos and eggs (a mean of 66%, in contrast with < 25% in control mice). Fertility inhibition in vivo and in vitro was not observed when the p2control peptide was used in the immunizations.

CONCLUSIONS

These results would suggest that the SP sequence is involved in gamete adhesion, and an antifertility vaccine against the SP peptide segment could be feasible.

Pancreatitis autoinmune. ¿Una entidad poco frecuente o infradiagnosticada? Características anatomopatológicas, clínicas e inmunológicas

In the last few years, reports of pancreatic inflammatory diseases caused by immunological mechanisms and with good response to steroid treatment have increased. Although this entity has been known by a number of names, at present the most widely accepted is that of autoimmune chronic pancreatitis (ACP). The present report describes the clinical, immunological, morphological, functional and pathological characteristics of two patients recently studied at our unit and discusses currently used diagnostic tests. The two patients had a complete response to steroid therapy. In our opinion, ACP is probably underdiagnosed in Spain. The availability of morphological, pathological and serological diagnostic tools developed in recent years will help to precisely determine the epidemiology of this process. Thus, quantification of serum levels of anti-carbonic anhydrase II and IgG4 has greatly contributed to the diagnosis of ACP. These tests should be performed in patients with a possible diagnosis of ACP, those suffering from diabetes mellitus type I with impairment of exocrine function, and those with alcoholic pancreatitis and a poor response to alcohol elimination. Once we are able to diagnose and determine the real prevalence of ACP in our setting, the most appropriate therapy and prognosis of this disease can be established.

The macrophage infiltration index and matrix metalloproteinase-II expression as a predictor of chronic allograft rejection

The presence of macrophages on renal biopsy specimens is considered an important cofactor in the development of chronic allograft nephropathy (CAN). Macrophages can activate the expression of matrix metalloproteinases (MMP), which induce glomerulosclerosis, arteriosclerosis, and interstitial fibrosis. The aim of our study was to demonstrate if they were related to the development of CAN. We analyzed matrix metalloproteinase (MMP) expression with specific monoclonal antibodies on 53 kidney biopsies performed due to the suspicion of a first acute rejection (AR) episode: 24 of the grafts have been lost due to CAN and the rest are still functioning. The group with CAN showed worse graft function and greater proteinuria from the beginning. The macrophage infiltration index (MI) expression was significantly higher in that group also (18.8 +/- 12 vs 12.5 +/- 9.15; P < .05), with a more important presence of macrophages in the interstitium and tubules. We observed a positive correlation between MI and tubular infiltration (r(2) = 0.52; P < .001) and between MMP-II and MI in the interstitium (r(2) = 0.3; P < .05) and with the global MI (r(2) = 0.3; P < 0.05). The last correlation was more powerful in the group with CAN (r(2) = 0.4; P < .05). According to our experience, global MI and tubular infiltration during an AR episode are good markers of long-term graft survival. The correlation between MI and MMP-II supports the role of macrophages in the development of CAN, although further studies are needed to clarify the nature of this relationship.

Markers of Fibrosis in Early Biopsies of Renal Transplants

Many factors are involved in the development of chronic allograft nephropathy (CAN). Extracellular matrix turnover depends on the balance between fibrogenic and antifibrogenic cytokines. The aim of our study was to analyze the presence of transforming growth factor beta-1 (TGF-beta1), matrix metalloproteinase-2 (MMP-2), and mast cells in 53 early transplant biopsies using immunochemistry with specific monoclonal antibodies. We divided the patients into two groups depending on graft evolution (lost due to CAN versus functioning), renal function, presence of proteinuria, and graft survival. There were no differences in the demographic or immunological data. Renal function was worse and proteinuria greater among the group with CAN. The presence of mast cells was similar in both groups, but TGF-beta1 was expressed more and MMP-2 less in the CAN group. We observed a negative correlation between donor age and mast cells, and a positive correlation between TGF-beta1 and MMP-2. Grafts from younger donors showed better renal function, less proteinuria, greater graft survival, and less frequent development of CAN. According to our experience, cytokines involved in matrix turnover are expressed in early stages, correlating with donor age. The expressions of TGF-beta1 and MMP-2 seem to be important for the development of fibrosis in CAN.

Protective Effect of Vitamin E in an Animal Model of LPS-Induced Inflammation

PROBLEM

Many sterility outcomes may be associated to the presence of an inflammatory response that would lead to an inability of the endometrium to support implantation and maintain viable embryos. We have established an animal model of inflammation in which the systemic administration of lipopolysaccharyde (LPS) results in a low embryo implantation rate. The purpose of this work was to investigate the effect of the inflammatory agent LPS on embryo viability and to verify the ability of vitamin E to modulate the inflammatory effect of LPS on embryo viability.

METHOD OF STUDY

For pre-implantation studies B6CBAF1 mice, which were intraperitoneally inoculated with LPS (4-10 mg/kg), were used. Mice were also treated with vitamin E (4-10 mg/kg) before or after LPS injection. Embryos were obtained from the oviduct after each treatment.

RESULTS

The LPS produces a decrease in the number of pre-implantational embryos in a concentration dependent manner. The LPS effect can be partially reversed or prevented by vitamin E. Preliminary results show that inflammatory cytokines are secreted by intraperitoneal macrophages in LPS treated mice.

CONCLUSION

Our results demonstrate the ability of vitamin E to avoid an inflammatory environment and to allow viability of embryos.

Lack of Apaf-1 expression confers resistance to cytochrome c-driven apoptosis in cardiomyocytes

Apoptosis plays a role in cardiomyocyte death in several cardiovascular disorders. Here, we show that primary postnatal cardiomyocytes did not die upon activation of the intrinsic (cytochrome c-dependent) apoptotic pathway. Release of cytochrome c from mitochondria to the cytosol occurred, but did not activate the effector phase of apoptosis. Myocardial cells did not express apoptotic protease-activating factor-1 (Apaf-1), the allosteric activator of caspase-9 acting downstream of cytochrome c release. Forced expression of Apaf-1 restored the competence to complete the cytochrome c-induced apoptotic program and this effect was prevented by overexpression of Bcl-X(L). However, cardiomyocytes were able to enter the apoptotic program when it was initiated by activation of death receptors, as observed during serum deprivation and metabolic inhibition. Our results indicate that regulation of Apaf-1 expression may be a new regulatory mechanism developed in postmitotic cells in order to prevent irreversible commitment to die after release of cytochrome c.

Expression of complement regulatory proteins [membrane cofactor protein (CD46), decay accelerating factor (CD55), and protectin (CD59)] in endometrial stressed cells

In the female reproductive tract, the complement system represents a defense mechanism that can act directly against pathogens and cells, and mediates inflammatory response. Endometrial cells are protected from autologous complement attack by membrane-bound complement regulatory proteins (CRPs) that prevent complement activation: membrane cofactor protein (CD46), decay accelerating factor (CD55), and protectin (CD59). In this work we show that all CRPs were overexpressed after LPS exposure. Maximal stimulatory effect was detected after 6h, and was declining after 12h, reaching control levels in 24h. CD59 was the protein showing the more prominent effect. There seems to be a slight increase of CRP expression in the endometrium of sterile patients that have anti-endometrial antibodies (AEA) in their serum. Our results suggest that under stress, the high expression of CRPs (CD46, CD55, and CD59) could protect endometrial injured cells against complement mediated lysis. The survival of these cells with some biochemical modifications would enable autoimmune response.

Involvement of the Fas system in liver allograft rejection

OBJECTIVE

Recent studies suggest that apoptosis is an important mechanism of cell death in the rejection of liver allografts and that this process is mediated via Fas. The aim of this study was to analyze the expression of the Fas system during the liver allograft rejection and its evolution after treatment.

METHODS

We evaluated 14 patients with liver allograft rejection before and after treatment. Fas immunostaining was performed by the labeled streptavidin-biotin peroxidase method using a 200-fold dilution of a monoclonal antibody. Assessment of apoptosis was determined by the terminal deoxynucleotidyltransferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL) technique on deparaffined liver samples. Serum levels of soluble Fas antigen (sFas) were detected by an enzyme immunoassay procedure. Twelve liver transplant patients without allograft rejection were analyzed as a control group.

RESULTS

The number of hepatocytes expressing Fas antigen, the percentage of apoptotic hepatocytes, and the sFas levels were higher in patients with liver allograft rejection than in controls (27.9+/-23.1% vs 1.4+/-1.2%, p < 0.001; 2.2+/-0.9% vs 1.0+/-0.1%, p = 0.02; 24.2+/-39.6 vs 2.8+/-4.0 IU/ml, p = 0.03, respectively). There was a correlation between the levels of sFas, AST (r = 0.86, p < 0.001), ALT (r = 0.78, p = 0.02), and gamma-globulin levels (r = 0.86, p < 0.001). After the rejection treatment we found a significant decrease in the Fas antigen expression (18.6+/-13.3%, p < 0.05), TUNEL index (0.2+/-0.4, p < 0.05), and levels of sFas (9.9+/-30.25 IU/ml, p = 0.005).

CONCLUSIONS

1) The demonstration of hepatocytes with Fas antigen expression and the labeling of the nuclei by the TUNEL assay suggest that apoptosis mediated by the Fas system plays a role in the pathogenesis of liver allograft rejection. 2) The Fas expression and the sFas levels decreased in patients with treatment response.

Apoptosis mediated by the Fas system in the fulminant hepatitis by hepatitis B virus

The pathogenesis of the fulminant hepatitis B is poorly understood and both viral factors and the hosts immune response play a role. Previous studies in liver tissues of patients with chronic hepatitis B showed overexpression of Fas antigen and this was correlated with the activity of the hepatitis. The present study was done to determine the role of Fas in fulminant hepatitis B and the virological characteristics of hepatitis B infection. We studied three patients with fulminant hepatitis B. HBV-DNA was detected by dot-blot hybridization and polymerase chain reaction. The S and C gene were sequenced. Levels of serum soluble Fas antigen were detected by enzymoimmunoassays procedure. Apoptosis was determined by the TUNEL technique. Fas antigen expression was evaluated by a immunoperoxidase method. Ten healthy subjects acted as controls. The three patients showed a high expression of Fas antigen particularly among infiltrating lymphocytes; in these areas we also found many cells with in situ DNA nick labelling signals in the nuclei of most viable hepatocytes. Serum levels of soluble Fas antigen were higher in patients with fulminant hepatitis B than in controls. No specific genome mutations of hepatitis B virus were found. These data suggest that the Fas system involved in the liver injury of patients with fulminant hepatitis B.

Concurrent tubulovillous adenoma and transitional cell carcinoma associated with diffuse gastric and intestinal metaplasia of the defunctioned ureter

Villous adenoma is a common lesion of the gastrointestinal tract, but it is rare in the ureter. Thus, as far as we know, only one case limited to this location has been described. Intestinal metaplasia of the urothelium is not rare. However, only one case of gastric metaplasia with pseudopyloric glands has been described in the literature. We here report in detail on a tubulovillous adenoma of the ureter associated with diffuse gastric and intestinal metaplasia and a concurrent primary, solid, high grade transitional cell carcinoma, with extensive clear cell change, in a 56-year-old male patient. He had undergone a left nephrectomy for renal tuberculosis twenty years earlier, and the lesions developed in the ureteric stump. To the best of our knowledge, such a combination of lesions has not been reported previously either in the ureter or in the rest of the urinary tract. The coexistence of diverse lesions in our case might represent the pluripotentiality of the urothelium in association with chronic inflammation and neoplastic induction. The present report also emphasizes the metaplastic and malignant potential of a defunctioned urothelial structure. This case is of particular interest, because these coexistent lesions arose simultaneously with an anatomically separate adenocarcinoma of the rectum (Dukes' B). The patient died 76 days after admission. The dismal prognosis of our case was determined by the advanced anatomical stage and the histological high grade of the transitional cell carcinoma of the ureter.

Gene expression of tumor necrosis factor alpha and TNF-receptors, p55 and p75, in nonalcoholic steatohepatitis patients

The main objective of this study was to analyze the pathogenic role of the tumor necrosis factor alpha (TNF-alpha) system in the development of nonalcoholic steatohepatitis (NASH). Fifty-two obese patients were studied. We investigated: (1) the expression of mRNA of TNF-alpha and their p55 and p75-receptors by quantitative reverse-transcriptase polymerase chain reaction (RT-PCR) in hepatic and adipose tissues; and (2) the relationship between TNF-alpha, p55, and p75 and the severity of NASH. Obese patients without NASH were the control group. A remarkable increase in the expression of mRNA of TNF-alpha was found in patients with NASH in hepatic tissue (0.65 +/- 0.54) and in peripheral fat (0.43 +/- 0.45); in the control samples, the mRNA expression was 0.28 +/- 0.32, P <.007, and 0.26 +/- 0.22, P <.018, respectively. Furthermore, we found a significant increase in the mRNA levels of p55 receptor (2.42 +/- 1.81 vs. 1.56 +/- 1.17; P <.05); however, the mRNA expression of the p75 receptor was similar in both patients. Those patients with NASH with significant fibrosis presented an increase in the expression of mRNA TNF-alpha in comparison with those with a slight or nonexistent fibrosis. An overexpression of TNF-alpha mRNA is found in the liver and in the adipose tissue of NASH patients. The levels of mRNA-p55 are increased in the liver tissue of NASH patients. This overexpression is more elevated in patients with more advanced NASH. These findings suggest that the TNF-alpha system may be involved in the pathogenesis of NASH.

Are there predictive factors of severe liver fibrosis in morbidly obese patients with non-alcoholic steatohepatitis?

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is a clinicopathological entity characterized by the presence of steatosis and lobular and/or portal inflammation with or without fibrosis. Patients with non-alcoholic fatty liver and fibrosis on liver biopsy have increased liver-related deaths.

METHODS

181 wedge liver biopsies, taken at the time of bariatric surgery from patients with a mean body mass index (BMI) of 47, were studied. In all cases, the liver biopsy was performed without knowledge of the patient's clinical and biochemical data, which were then examined with univariate and multivariate analysis.

RESULTS

Diagnosis of NASH was established in 105 patients (91%); 74 patients (70%) showed mild steatosis, 20 (19%) had moderate inflammation and fibrosis, and 11 (10%) had steatosis with severe fibrosis. None of the liver biopsies showed cirrhosis. Age was the only independent predictor of moderate and severe fibrosis (p = 0.001).

CONCLUSIONS

Since only age was a predictor of moderate or severe fibrosis, and no clinical or biochemical abnormalities detected slowly progressive hepatic fibrosis, liver biopsy is the only means of detecting progression to more advanced liver disease in a NASH patient.

Papillary adenoma of the kidney with mucinous secretion

Although infrequently, mucin secretion has previously been reported in papillary renal cell carcinoma. We here investigate the presence of mucin in a series of 93 renal papillary adenomas in 58 patients. Acid mucin was present in four cases (4.3% of the tumors; 6.9% of the patients), in which basophilic mucin secretion was evident with hematoxylin-eosin. To the best of our knowledge mucin secretion has not been reported in renal papillary adenoma. We describe two different types of mucin secretion: intracytoplasmic and luminal. The secretion was intracellular in numerous scattered tumor cells in two cases, focal luminal in one case, and mixed intracellular and luminal in another case. Mucin production, despite its low frequency, can be considered as an additional feature of renal papillary adenoma. Mucin production suggests that renal papillary adenoma and papillary renal cell carcinoma are actually not two independent biological processes, but a continuum of one biological process.

[Selective intestinal bacterial decontamination in experimental acute pancreatitis]

BACKGROUND

Bacterial translocation implies the transit of viable gastric microflora from the intestinal lumen through the intestinal wall to the mesenteric ganglia and seems to be the mechanism by which microflora reach necrotic tissue in acute pancreatitis (AP). This occurs in 40-70% of necrotizing hemorrhagic AP and plays a major role in up to 80% of deaths from this cause.

AIMS

To analyze the possible influence of bacterial decontamination in the gut on bacterial translocation in severe experimental AP.

METHODS

Severe AP was induced in 43 male Sprague-Dawley rats by administration of 0.2 ml of 2.5% taurodeoxycholate sodium in NaOH glycyl-glycine buffer after cannulizing the bilio-pancreatic duct through the duodenum and clamping the common bile duct in the hepatic junction. The rats were divided into two groups: a) control group: 24 rats in which only AP was induced; b) problem group: 19 rats that underwent bacterial decontamination through the administration of 4 mg/ml gentamicin, bacitracin and neomycin in the drinking water during the 5 days prior to AP induction. Twenty-four hours after AP induction, laparotomy was performed and a sample for the culture of mesenteric lymphatic ganglia, pancreas, liver, spleen, peritoneum and cecum was obtained.

RESULTS

Seven rats in the control group died. Of the 17 rats that survived 24 hours, positive cultures in the pancreas were obtained in nine. In the problem group, two rats died within 24 hours. Of the remaining 17 rats, positive pancreatic cultures were obtained in 2 while in 15 pancreatic cultures were negative. No microflora were cultured in the peritoneum. The microflora most frequently cultivated were Escherichia coli, enterococcus and proteus. No differences were found in the percentage of Gram-positive and Gram-negative bacteria between the two groups.

CONCLUSIONS

a) The majority of the bacteria in AP tissue originate in the intestinal microflora, E. coli being the most prevalent. b) One of the main mechanisms in this process is bacterial translocation via the lymphatic pathway; transit directly through the transperitoneal pathway is not essential. c) Bacterial translocation already occurs in the earlier phases of AP. d) Bacterial decontamination prior to AP decreases the frequency of bacterial translocation and does not interfere in the Gram-positive/Gram negative balance, nor does it increase fungal infections.

Involvement of the fas system in hepatitis C virus recurrence after liver transplantation

To date, there have been no reports of the involvement of the Fas system in recurrent hepatitis C virus (HCV) infection after orthotopic liver transplantation (OLT). In 25 patients who underwent OLT for HCV-related liver cirrhosis, we evaluated the expression of the Fas antigen (FasAg) on hepatocytes, apoptic hepatocytes, and serum levels of soluble Fas (sFas). The level of HCV viremia and HCV genotype were determined by polymerase chain reaction. Serum sFas levels were determined by an enzyme immunoassay procedure. DNA fragmentation was determined by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) technique on deparaffinized liver samples. FasAg expression was evaluated by an immunoperoxidase method. Sixteen patients had evidence of recurrent HCV disease. The number of hepatocytes expressing FasAg and the percentage of apoptotic hepatocytes was greater among patients who developed recurrent hepatitis than among those who did not (P <.01 and P <.0001, respectively). There was a correlation between hepatic expression of FasAg, intensity of lobular inflammation (P =.007), and TUNEL index (P <.001). The levels of sFas were greater among the patients with recurrent HCV hepatitis than those without recurrent hepatitis (P <.04). We conclude that (1) Fas expression is up-regulated in recurrent HCV after OLT and is related to the grading of liver disease; likewise, levels of sFas were greater in the patients with recurrent HCV hepatitis; and (2) the demonstration of hepatocytes with FasAg expression and the labeling of the nuclei by TUNEL assay suggest that hepatic apoptosis mediated by the Fas system may have a role in the pathogenesis of recurrent HCV hepatitis after OLT.

[Soluble Fas in acute rejection in patients with liver transplantation. Response to treatment]

It has been suggested that in the cellular rejection of hepatic graft, the lesion provoked by cytotoxic T-lymphocytes might be mediated by the Fas antigen/Fas ligand system, producing cell death by apoptosis.

AIM

To determine whether soluble Fas (sFas) is increased during treatment and to evaluate response to treatment.

MATERIAL AND METHODS

Fourteen patients with orthotopic liver transplantation who presented an episode of acute cellular rejection were studied. Serum levels of sFas were detected by enzyme-immunoanalysis at diagnosis and again 5 days after treatment was completed. As control groups, sFas was analyzed in 12 patients with liver transplantation without rejection and in 10 healthy subjects.

RESULTS

sFas levels were found to be significantly higher in patients with rejection than in those without rejection and in healthy subjects (24.2 +/- 39.1 vs. 2.8 +/- 4.0 vs. 0.6 +/- 1.5 UI/ml; p = 0.03). In patients with acute cellular rejection, immunosuppressive treatment significantly decreased sFas levels compared with basal values (24.2 +/- 39.1 vs. 9.9 +/- 30.2 UI/ml; p = 0.005). A clear correlation between the serum levels of sFas, glutamate oxaloacetate transaminase (GOT), glutamate-pyruvate transaminase/glutamic-pyruvic transaminase (GPT) and gamma-glutamyl transferase (GGT).

CONCLUSIONS

a) The increase of sFas during rejection and the decrease in patients with a good evolution suggests that the Fas system may play an important role in the hepatocyte lesion produced by an apoptosis mechanism in these patients. b) Monitoring sFas could be useful in diagnosing rejection and in evaluating response to treatment.

Synchronous ipsilateral sebaceous lymphadenoma and acinic cell adenocarcinoma of the parotid gland

The synchronous or metachronous occurrence of 2 tumors of the salivary glands in a patient is rare. These tumors are usually benign and of the same histologic type. Here we report a 78-year-old woman who developed a sebaceous lymphadenoma and an acinic cell adenocarcinoma simultaneously in the left parotid gland. To our knowledge, this combination of neoplasms has not been reported before.

Papillary (chromophil) renal cell carcinoma with mucinous secretion

We investigated the presence of mucin in a series of 20 papillary renal cell carcinomas. Acid mucin was present in three cases (15%), in which basophilic mucin secretion was evident with hematoxylin-eosin. This secretion reacted positively with Mayer's mucicarmine, Alcian blue and high-iron diamine, but was negative for PAS in all the cases, indicating the presence of sulphomucins. We describe two different types of mucin secretion: luminal and intracytoplasmic. The secretion was abundant, diffuse or extensive, luminal in two cases and intracellular in numerous scattered tumor cells in one case. All tumors were < 3 cm in diameter (low grade, stage I). In the three mucin-secreting papillary tumors mentioned above, the immunohistochemical and lectin studies indicate both a proximal and a distal tubular staining pattern. Mucinous secretion in these tumors can be ascribed either to modulation or direct metaplasia of the tumor epithelium. Mucin production, despite its low frequency, can be considered an additional feature of papillary renal cell carcinoma. Thus, the presence of luminal or intracytoplasmic mucin deposition does not exclude papillary renal cell carcinoma from the differential diagnosis in cases of intra- or extrarenal carcinomas.

Primary pure intratesticular fibrosarcoma

Testicular sarcoma appears to be a rare stromal tumor usually of indolent course with potential for distant metastases. A pure primary intratesticular fibrosarcoma in a 71-year-old male is presented. By the time the tumor became evident metastases had already occurred widely. The course was rapidly fatal. A review of the literature yielded only one case reported previously. The present case illustrates that pure fibrosarcoma occurs occasionally as a stromal tumor and may be associated with a dismal prognosis. The diagnosis of pure fibrosarcoma should be made only after extensive sampling of the testicular tumor to rule out an associated germ cell component. The differential diagnosis also includes the fibroma of gonadal stroma origin and the unclassified sex cord-stromal tumor with a predominance of spindle cells.

Primary amyloid tumor (amyloidoma) of the jejunum with spheroid type of amyloid

The present report documents an incidentally discovered, solitary amyloidoma of the jejunum in a 70 year old man with no predisposing disorder or other sites of deposition of amyloid, as was demonstrated at autopsy. Amyloid tumors of the intestine have been reported only rarely. In those reports the deposits were conventional in type, forming large masses of acellular, eosinophilic, homogeneous material. In the case described here the deposits were in the form of corpora amylacea-like structures, or spheroids. To the best of our knowledge, the corpora amylacea-like structures, or spheroid amyloid, have not been previously described in bowel amyloidoma. This rare form of amyloid deposition should be recognized so as to prevent misdiagnosis.

Laryngeal melanosis: report of four cases and literature review

OBJECTIVE

Laryngeal melanosis is a rare condition defined by the presence of melanocytes within the laryngeal epithelial lining. Our aims were (1) to review our cases together with those in the literature, and (2) to determine whether melanocyte incidence is increased with exposure to irritant stimuli such as tobacco.

METHODS

A retrospective study of all cases diagnosed with laryngeal melanosis in our hospital from January 1, 1990, to December 31, 1996, was accomplished. To determine the melanocyte incidence in the normal larynx as well as the influence of tobacco in development of laryngeal melanosis, 16 age-matched controls, 8 of whom were smokers and 8 of whom were not, were chosen, and a histochemical and immunohistochemical study was performed. The following antibodies were used: S-100 protein, CD1a, and HMB-45. A comparative study of the melanocyte incidence between patients with laryngeal melanosis and the controls was carried out. Also, a comparative study between smoking and nonsmoking patients was performed.

RESULTS

Laryngeal melanosis was diagnosed in 4 patients at our hospital during this period of time. In the comparative study, the number of melanocytes in the 4 patients with laryngeal melanosis was higher than in the 8 smoking (p < 0.01, Mann-Whitney U test) and 8 nonsmoking (p < 0.01) controls, and there was a trend toward a higher number of melanocytes in the 8 smoking patients than in the 8 nonsmoking (p = 0.064) controls.

CONCLUSIONS

Laryngeal melanosis was more frequent in smoking men older than 50 years. Our observations underline the association of LM with larynx carcinoma and its relation to a stimulus such as tobacco. In fact, we have found activated melanocytes in our cases of laryngeal melanosis. They were identified by immunoreactivity for HMB-45.

Diffuse expansive cavernous hemangioma of the gallbladder

Although hemangiomas are common hepatic tumors, their occurrence in the gallbladder is extremely rare. In the present report, we describe a diffuse expansive cavernous hemangioma of the gallbladder. The patient was a 50-year-old woman presenting with a 24-hour history of persistent right upper abdominal quadrant pain. The lesion caused a voluminous enlargement of the gallbladder creating a clinical impression of a cystic mesenteric tumor. The vascular origin of the tumor was confirmed by immunohistochemistry. Only 4 cases, including the present one of cavernous hemangioma involving the gallbladder have been reported in the English literature. The average age of presentation is 52.5 years (range 43-60 years), and the female to male ratio is 3:1. The lesions can be symptomatic and may have confusing radiographic appearances. Lithiasis has not been associated with the cavernous hemangioma of the gallbladder.

A model of blast overpressure injury to the lung

Despite decades of animal experiments, data on blast injury to the lung cover only a limited number of circumstances and are in a fragmented form. This paper develops a mathematical model of the chest wall dynamics and the subsequent generation of strong pressure waves within the lung, which have been hypothesized as the mediator of injury. The model has been compared to an extensive database of observed pathologies from animal tests. The incidence of injury and lethality is found to follow a log-normal correlation with the computed total energy in these waves and, when the energy is normalized by the lung volume, the lethality correlation applies to all large animal species. Small animals also correlate with the normalized energy, but at a different value, and it is speculated that structural differences, other than lung volume, may be involved. This relatively simple model allows the potential for blast injury to the lung to be determined from measured or computed pressure traces without additional animal testing. Improved occupational exposure criteria should follow from this methodology.

Glandular inclusions in inguinal hernia sacs: a clinicopathological study of six cases

Glandular inclusions in inguinal hernia sacs are not frequent. We present six cases of inguinal hernia with this finding, which represents an incidence of 2.6% in males and shows a predominance in the prepubertal stage. Five patients showed cryptorchidism and two cases were related to congenital malformations of the single umbilical artery type and 47,XY chromosome disorder with chromosomal marker. The most important differential diagnosis must be made with normal histological structures such as the vas deferens or epididymis. The mean diameter of the inclusions was 0.1988 mm and there was a significant difference in size between the inclusions and the vas deferens, but not the epididymis. Differentiation from the latter is based on the absence of a well-developed muscular coat in the wall of the inclusions. It is important to recognize that these inclusions can occur in hernia sacs because of the clinical and medicolegal implications that arise if they are confused with true epididymis or vas deferens. They may arise from paratesticular embryonal remnants.

Radiohistology and histochemistry of barium granuloma of the colon and rectum

Barium granuloma of the colon and rectum is a rare complication of X-ray examination of the digestive tract using barium. The authors report 5 new cases occurring in the last 3 years. Histological examination revealed a granulomatous reaction with greyish finely granular refractile PAS-negative material located in the cytoplasm of histiocytes and in the interstitial space. The radiographic study of the paraffin blocks confirmed the nature of this material, which was X-ray opaque, and this was corroborated histochemically with the rhodizonate technique.