Increased liver mast cell recruitment in patients with chronic C virus-related hepatitis and histologically documented steatosis

Hepatitis C virus (HCV) is still one of the major causes of chronic viral infection worldwide, and hepatic steatosis is a frequent pathological finding in patients with chronic HCV-related diseases. It is unclear whether the steatosis is associated with host factors or the virus itself, although a consistent relationship has been found between steatosis and a necro-inflammatory reaction with the increased secretion of immuno-regulators. A primary sources of inflammatory mediators are mast cells (MCs) bone marrow-derived cells that are detected in both normal and diseased livers. We determined MC density and correlated it with the fibrosis, inflammatory reaction and steatosis observed in the liver biopsies of patients affected by HCV with or without steatosis. All the histological features were assessed using a computer-aided image analysis system. There was a statistically significant difference in MC density between the HCV-infected patients with and without steatosis, with the lower mean value being detected in those without (P < 0.02). Furthermore, a nonstatistically significant difference in fibrosis and inflammation between the two patient groups was found. In conclusion, this is the first study showing a significant increase in MC density in the tissues of patients with chronic HCV infection and histologically documented steatosis.

Computer-aided morphometry of liver inflammation in needle biopsies

AIM

To introduce a computer-aided morphometric method for quantifying the necro-inflammatory phase in liver biopsy specimens using fractal geometry and Delaunay's triangulation.

METHODS

Two-micrometer thick biopsy sections taken from 78 chronic hepatitis C virus-infected patients were immunohistochemically treated to identify the inflammatory cells. An automatic computer-aided image analysis system was used to define the inflammatory cell network defined on the basis of Delaunay's triangulation, and the inflammatory cells were geometrically classified as forming a cluster (an aggregation of a minimum of three cells) or as being irregularly distributed within the tissue. The phase of inflammatory activity was estimated using Hurst's exponent.

RESULTS

The proposed automatic method was rapid and objective. It could not only provide rigorous results expressed by scalar numbers, but also allow the state of the whole organ to be represented by Hurst's exponent with an error of no more than 12%.

CONCLUSION

The availability of rigorous metrical measures and the reasonable representativeness of the status of the organ as a whole raise the question as to whether the indication for hepatic biopsy should be revised by establishing clear rules concerning the contraindications suggested by its invasiveness and subjective interpretation.

[Fractal analysis of liver fibrosis]

This study realized by two different study groups use of Fractal geometry to quantify the complex collagen deposition during chronic liver disease. Thirty standard needle liver biopsy specimens were obtained from patients with chronic HCV-related disease. Three mu-thick sections were cut and stained by means of Picrosirius stain, in order to visualise collagen matrix. The degree of fibrosis was measured using a quantitative scoring system based on the computer-assisted evaluation of the fractal dimension of the deposited collagen surface. The obtained results by both study groups, show that the proposed method is reproducible, rapid and inexpensive. The complex distribution of its collagenous components can be quantified using a single numerical score. This study demonstrated that it is possible to quantify the collagen's irregularity in an objective manner, and that the study of the fractal properties of the collagen shapes is likely to reveal more about its structure and the complex behaviour of its development.

Mast cell density, hepatic stellate cell activation and TGF-beta1 transcripts in the aging Sprague-Dawley rat during early acute liver injury

Mast cells (MCs) have been indicated as a source of various inflammatory cytokines, chemokines and growth factors. This study evaluates liver tissue MC density as a quantitative marker of acute liver inflammation in 2- and 19-month old rats treated with carbon tetrachloride (CCl4) toassess the relationships between MC density, hepatocellular damage, mRNA encoding TGF-beta1, hepatic stellate cell (HSC) activation and collagen levels. Consecutive histological sections from each age group were stained with toluidine blue to identify granulated MCs, Direct Red 80 to recognize collagen matrix, and by immunohistochemistry to identify activated hepatic stellate cells (HSCs), which were subsequently counted by means of a computer-aided image analysis. Histology showed hepatocellular necrosis with inflammatory cell infiltration and collagen matrix deposition. Two and 24 hours after intoxication, MC density had considerably increased in the younger rats, but less in those aged 19 months. Although the untreated older rats had a larger area occupied by activated HSCs than the untreated younger rats, the increase in the number of HSCs was greater in the younger rats both two and 24 hours after intoxication. The greater MC density in younger rats suggests that older rats have a reduced immune response or recruit fewer MCs. The activated HSCs and TGF-beta1 transcripts did not increase significantly during the study period, thus indicating that these are later events in chemically induced hepatic toxicity. In conclusion. MC density may be an index of acute liver inflammation after CCl4 intoxication.

Simultaneous staining of cytoplasmic iron and collagen matrix in human liver biopsy specimens

One of the major liver fibrogenic activators is the cellular iron overload that can severely damage parenchymal and non-parenchymal cells. The aim of this study was to investigate a histochemical staining technique that allows the simultaneous detection of the irregular deposition of matrix collagen and both the amount and distribution of iron in liver cells on the same histological section. The method was evaluated using 3-microm histological sections obtained from ten standard liver biopsy specimens taken from patients with hepatitis C virus-related diseases and simultaneous liver cell iron overload. The results indicate that the double-staining technique is simple, sensitive and rapid, and can be routinely applied to liver biopsy specimens for diagnostic purposes. Furthermore, it may also facilitate the study of the complex relationship between hepatic fibrosis and iron overload during common genetic or secondary liver metabolic disorders.

[Geometrical analysis of benign and malignant breast lesions]

PURPOSE

The aim of this study was to describe a computer-assisted method based on fractal dimension and the coefficient of roundness, two mathematical descriptors of irregularly shaped objects, in order to discriminate benign and malignant mammographic lesions.

MATERIAL AND METHODS

Twenty-three digitized mammograms were classified as containing benign lesions (n=12) or as containing malignant lesions (n=11) on the basis of readings by two independent radiologists. Morphometrical and fractal analysis of the breast lesions were automatically performed by a computer-assisted image analysis system.

RESULTS

The method shows, for the first time, two parameters that allow the classification of irregularly shaped objects, such as benign and malignant breast lesions. A significant increase was obtained when comparing the fractal dimension and the coefficient of roundness of benign versus malignant mammographic lesions.

DISCUSSION AND CONCLUSIONS

Benign and malignant breast lesions are characterized by complex morphologies. Complexity is the main property of all biological systems, including natural and pathological structures. In this study, we showed that fractal geometry allows quantitative measurement of the complex morphology of benign and malignant mammographic lesions. Furthermore, this mathematical approach may be helpful for the study of the non-linear dynamic processes involved in breast carcinogenesis.

Fractal geometry: a useful tool for quantifying irregular lesions in human liver biopsy specimens

Irregularity and complexity are the main features of every biological system, including human tissues, cells and sub-cellular components. These two properties of the organized biological matter cannot be quantified by means of the classical Euclidean geometry, which is able to measure regular object, practically unknown in Nature. The aims of our paper were a) to underline the importance of the shape of a biological structure, b) to investigate the fractal geometry for quantifying the liver histo-pathological structures, and c) to explain the significance of several terms used in the fractal analysis of complex biological systems.

Fractal and spectral dimension analysis of liver fibrosis in needle biopsy specimens

OBJECTIVE

To evaluate the usefulness of a reliable and reproducible mathematical scoring system based on fractal geometry for quantifying the irregular pattern in fibrosis commonly seen in liver biopsy specimens from chronic liver diseases.

STUDY DESIGN

The study used 26 standard liver biopsy specimens obtained from patients with chronic hepatitis C virus-related liver disease. The degree of fibrosis in each specimen was estimated using a quantitative scoring system based on the computer-assisted evaluation of both the fractal and spectral dimensions of deposited collagen. The fractal dimension was then compared with the percent area of collagen measured using an image analysis system.

RESULTS

The fractional dimension of its irregular shape defines fibrosis as a natural fractal structure. The complex distribution of its collagenous components (unmeasurable by means of the usual morphometric parameters) can be optimally quantified using a single numerical score that seems to be a better alternative to the semiquantitative methods adopted so far. The proposed method is reproducible, rapid and inexpensive; furthermore, supported by specific software, its mathematical approach excludes subjectivity and eliminates the external factors capable of influencing staging and classification.

CONCLUSION

This study demonstrated that it is possible to quantify the irregularity of the structures of the liver in an objective manner and that the box-counting fractal dimension does not depend on the amount of collagen deposited on the slide. Furthermore, as has been found in other fields of investigation, study of the fractal properties of the liver is likely to reveal more about its structure and the pathogenesis of liver diseases.

Geometry of liver system functioning: from a helix to a trajectory on curved space

Autoisodiasostasis of the liver, i.e., its self-maintenance without change over the course of time, is characterized by a bistable equilibrium between two extreme states called homopoiesis (during which the liver system repairs its worn structures and replicates its cells) and homoerhesis (during which it satisfies the needs of the body). Retinol binding protein traffic within the hepatocyte, made visible by means of immunohistology, has been used as a prototype for studying the competition processes and dynamics of autoisodiasostasis. An account is given of the oscillation of autoisodiasostasis between homopoiesis and homeorhesis through intermediate phases. The phase cycle of autoisodiasostasis is illustrated in the form of bi-dimensional and tri-dimensional diagrams. The temporal behaviour of the systems is represented as a helix trajectory obtained by projecting homopoiesis-homeorhesis phase cycles onto a time series. A unified topological representation of the uncoupled but combined processes of competition and autoisodiasostasis is proposed.

Hepatocellular carcinoma in Italian patients with cirrhosis

BACKGROUND AND METHODS

Patients with cirrhosis of the liver are recognized as being at risk for hepatocellular carcinoma. The magnitude of the risk, the natural history of this disease, and the possibilities for detecting potentially curable tumors in patients in the Western world are unknown. To address these questions, we examined 447 Italian patients with well-compensated cirrhosis (which was of viral origin in 62 percent of them) from 1985 through 1990, performing serum alpha-fetoprotein assays and real-time ultrasonography every 3 to 12 months.

RESULTS

Hepatocellular carcinoma was found in 30 patients (7 percent) at base line and in another 29 patients (7 percent of 417 patients free of tumor at base line) during follow-up periods averaging 33 months (range, 1 to 48). The cumulative hazard of the development of hepatocellular carcinoma during follow-up was higher among patients with persistently elevated serum alpha-fetoprotein levels (12 with tumors among 42 with such levels) than among those with fluctuating levels (11 among 82) or those with consistently normal levels (6 among 255). Only 17 patients had potentially operable tumors. The proportion of potentially operable tumors among those detected during follow-up was significantly lower than the proportion at enrollment (4 of 29 vs. 13 of 30, P = 0.027). The survival at one year of the 12 patients who underwent surgery was 67 percent, and the tumor-recurrence rate was 60 percent. Outcome was not appreciably different for the five patients who refused surgery.

CONCLUSIONS

In the West, as in Asia, patients with cirrhosis of the liver are at substantial risk for hepatocellular carcinoma, with a yearly incidence rate of 3 percent. Our screening program did not appreciably increase the rate of detection of potentially curable tumors.

[Neurotic and depressive status related to organic pathology in patients in thermal therapy]

Females and males with no psychiatric history, 25-75 years old, attending thermal facilities in Boario Terme (N = 449) and in Sangemini Terme (N = 40) were administered, on the 2nd-3rd day of their admission, a questionnaire expressly conceive in order to declare conscious motivations for thermal treatments and, in addiction, the Middlesex Hospital Questionnaire (MHQ), the Zung Self Rating Scale for Depression (ZUNG-D) and the State and Trait Anxiety Inventory (STAI), in order to detect neurotic symptoms and/or anxious or depressive complaints in this kind of population. A re-test was performed after 10 days by 73 subjects, in order to verify the impact of thermal treatments on psychoneurotic profiles. Baseline data were compared with those from normal controls and psychiatric outpatients. All statistical comparisons (probands versus matched controls; test versus re-test) were analysed by means of two-tailed Student "t" test (lever of significance: p less than 0.05). In the light of the data so obtained, subjects attending thermal facilities show a typical MHQ psychoneurotic profile, more marked in females and in subjects with gastrointestinal referred somatic disease and partially responding to thermal treatments, which supports the hypothesis that a particular form of neurosis may play a significant role in motivating request of thermal therapies. The results are largely discussed.

Liver system. V. Activation-extinction line of cyclic hepatocyte activities

The excitation-extintion line of hepatocytes from an inert state towards the stabilization of a given activity is described. Within the cell, the switching on of any given activity is a competitive process among different activities. The process is driven by the influence field created in the environment of the Rappaport acinus by sinusoidal blood which changes its characteristics during its passage from the portal zone to the central vein. Every step of the excitation-extintion pathway follows the so-called law of autoisodiasostasis (AIS), i.e. it is characterized by an oscillatory motion between restoring (homopoiesis or HP) and working (homeorhesis or HR) states. Since the cyclical bistable equilibrium of AIS characterizes all conditions of hepatocyte activities, the AIS cycle can be defined a limit cycle.

Modeling of biological and medical systems: a systemic strategy

A strategy in the frame of General System Theory is proposed for the study of biological systems for medical purposes. Its definition and use requires in each experiment the collaboration between physician and system scientists and hence the definition of a common language, by which the real system under study is described. The strategy is based on three intermingled steps: first an ingenuous model is proposed, gathering all the medical knowledge about the studied system, organized within an informal frame derived from the state space approach. Next, a functional model is derived, enlightening the organization of the relations in the medical model. Finally, this organization is formalized by the most suitable algebraic tools, which are thereafter translated into APL programs. This last version is used for simulation, which is exploited not only as a tool to describe and make provisions on the dynamics of the models, but also to deepen and improve the knowledge about the observed system.

Liver system. IV. More on the liver micro-unit: physics and geometry of its action

The geometry of liver functional micro-units is described in the light of the immunohistologic features of human hepatocytes stained with a retinol-binding protein antibody. The stained cells were distributed into two ordered sets which provided a provisional representation of the law regulating both the motion and the alternation of the rest-work phases (homopoiesis and homorhesis configurations, respectively) which reflect bistable liver micro-unit equilibrium (auto-isodiasostasis). Oscillations between the HP and HR states generate a relaxation cycle that can be assumed to be shared by all micro-units and to be regulated by feedback mechanisms. A model illustrating the compactness of the liver's global action as a result of the activity of each micro-unit is also proposed.

A computer-assisted study of macrophage behavior in HBV and nAnB related infectious chronic active hepatitis

Activated intralobular macrophages were quantified as their lysozyme contents in liver biopsies from patients with chronic HBV and nAnB active hepatitis, and subjects with no evident liver histological damage. There were more macrophages (0.62 +/- 0.06/2,500 mu 2) with a larger area (20.36 +/- 0.87 mu 2) in HBV-related chronic active hepatitis than in controls (0.21 +/- 0.04/2,500 mu 2 and 16.01 +/- 1.48 mu 2), whereas in nAnB chronic active hepatitis their numbers were similar to that in the controls (0.22 +/- 0.03/2,500 mu 2) and their area was smaller (11.68 +/- 0.79 mu 2).

Atrial natriuretic factor in cirrhotic patients with tense ascites. Effect of large-volume paracentesis

The plasma levels of atrial natriuretic factor in liver cirrhosis can be affected by various factors, such as ascites, renal function, use of diuretics drugs and dietary sodium intake. Moreover, the influence of high intra-abdominal pressure on cardiac atrial natriuretic factor release in patients with tense ascites has not been investigated. The aim of the present study was to evaluate the circulating levels of atrial natriuretic factor and their relationships to plasma renin activity, aldosterone concentration, and urinary sodium excretion in 45 cirrhotic patients divided into 4 groups: (a) cirrhotics without ascites; (b) nonazotemic cirrhotics with ascites; (c) cirrhotics with ascites and functional renal failure; and (d) cirrhotics with ascites taking diuretics. In some patients with tense ascites, atrial natriuretic factor was also measured after rapid abdominal relaxation by large volume paracentesis. Plasma levels of atrial natriuretic factor obtained in 13 healthy control subjects after 5 days on a 40-50 mEq sodium daily intake were 22.8 +/- 3.3 pg/ml. Mean plasma atrial natriuretic factor levels were normal in patients without ascites (35.1 +/- 11.4 pg/ml) and in those with ascites taking diuretics (27 +/- 9.2 pg/ml), but elevated in patients with ascites not taking diuretics (59.6 +/- 12 pg/ml) and in those with ascites and functional renal failure (58.5 +/- 16.6 pg/ml). These data show that plasma atrial natriuretic factor levels are elevated only in cirrhotic patients who are ascitic and not taking diuretics. In these patients atrial natriuretic factor levels were directly correlated with urinary sodium excretion, even though sodium balance was positive. This could be the consequence of the contrasting effects of antinatriuretic factors, as suggested by the inverse relationships between atrial natriuretic factor and urinary sodium on the one hand and plasma renin activity and plasma aldosterone concentration on the other. Twenty-six patients with tense ascites (12 taking diuretics and 14 not) were treated with rapid large-volume paracentesis (6500 +/- 330 ml of ascitic fluid removed in 168 +/- 16 min). At the end of the procedure, plasma atrial natriuretic factor levels had increased in all patients (from 45.5 +/- 10.1 to 100 +/- 17 pg/ml), whereas plasma renin activity and plasma aldosterone concentration had decreased (from 10.3 +/- 1.6 to 7 +/- 1.3 ng/ml/h, and 1160 +/- 197 to 781 +/- 155 pg/ml, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)

Prevalence of antibodies to hepatitis C virus in Italian patients with hepatocellular carcinoma

A sensitive radioimmunoassay was used to detect antibodies to hepatitis C virus (HCV) in patients with hepatocellular carcinoma and chronic hepatitis. HCV antibodies (anti-HCV) were detected in 86 of 132 patients with hepatocellular carcinoma with no relation to the presence or absence of hepatitis B surface antigen (HBsAg). The prevalence of anti-HCV was also high in patients with diseases thought to predispose to hepatocellular carcinoma, such as non-A, non-B chronic hepatitis and cirrhosis (74%). In HBsAg-negative patients with hepatocellular carcinoma the prevalence of anti-HCV was lower than that in patients with non-A, non-B chronic hepatitis (16% vs 55%); the prevalence of serum antibodies to hepatitis B core antigen (anti-HBc), a marker of hepatitis B virus infection, was 70% and 28%, respectively. In HBsAg-negative patients with hepatocellular carcinoma, anti-HCV and anti-HBc occurred together nearly three times as often as in patients with chronic hepatitis (54% vs 19%). These data indicate that, in Italy, HCV is an important factor associated with hepatocellular carcinoma and non-A, non-B chronic hepatitis.

Prevalence of antibodies to hepatitis C virus in Italian patients with hepatocellular carcinoma

A sensitive radioimmunoassay was used to detect antibodies to hepatitis C virus (HCV) in patients with hepatocellular carcinoma and chronic hepatitis. HCV antibodies (anti-HCV) were detected in 86 of 132 patients with hepatocellular carcinoma with no relation to the presence or absence of hepatitis B surface antigen (HBsAg). The prevalence of anti-HCV was also high in patients with diseases thought to predispose to hepatocellular carcinoma, such as non-A, non-B chronic hepatitis and cirrhosis (74%). In HBsAg-negative patients with hepatocellular carcinoma the prevalence of anti-HCV was lower than that in patients with non-A, non-B chronic hepatitis (16% vs 55%); the prevalence of serum antibodies to hepatitis B core antigen (anti-HBc), a marker of hepatitis B virus infection, was 70% and 28%, respectively. In HBsAg-negative patients with hepatocellular carcinoma, anti-HCV and anti-HBc occurred together nearly three times as often as in patients with chronic hepatitis (54% vs 19%). These data indicate that, in Italy, HCV is an important factor associated with hepatocellular carcinoma and non-A, non-B chronic hepatitis.

Liver system. II. A categorical coarse model for its autoisodiasostasis

In the context of the system theoretic theory of the liver, a new categorical approach is introduced, by which autoisodiasostasis is characterized in terms of the splitting of certain idempotents. Equifinal behaviors are then described in this setting.

The liver as a self-organizing system. I. Theoretics of its representation

The liver is described as a composite system consisting of a set of operative creodic microunits open to a continuous flow of matter, energy and informations. Its dynamics depend on two interactive and interrelated subsystems with actions described as homopoiesis and homeorhesis, making it an autoisodiasostic system. The system's emergent (equifinal) or emergence states, operative potential, diffusion and reaction phenomena and compensation states are also formally described. For readers not familiar with the language of general system theory, of system dynamics and of categorical analysis, a glossary of some terms is provided.

Liver system. III. Prototype to study its unstable equilibrium on human biopsy samples

Autoisodiasostasis of the liver, i.e., its self-maintenance without change over the course of time, is characterized by a bistable equilibrium between two extreme phases called homopoiesis, during which the liver system repairs its worn structures and replicates its cells, and homeorhesis, during which it satisfies the body's needs. Albumin traffic through the hepatocyte, rendered visible by means of an immunohistological method, has been used as a prototype model to study the dynamics of autoisodiasostasis. An account is given of the oscillation of autoisodiasostasis between homopoiesis and homeorhesis through two intermediate phases. The phase cycle of autoisodiasostasis is illustrated in the form of atemporal bidimensional and tridimensional diagrams. The temporal behavior of the system is represented as a helix trajectory obtained by the projections of homopoiesis-homeorhesis phase cycle on time series.

Beta-blockade prevents recurrent gastrointestinal bleeding in well-compensated patients with alcoholic cirrhosis: a multicenter randomized controlled trial

To assess the efficacy of beta-blockers in preventing rebleeding in selected cirrhotic patients and to compare the tolerance, safety and patient compliance of a selective and a nonselective beta-blocker, 94 patients were randomly assigned to propranolol (32 patients), atenolol (32 patients) or placebo (30 patients). Randomization was made at least 15 days after the bleeding episode. Propranolol was given orally at increasing doses until the resting pulse rate was reduced by approximately 25%. Atenolol was given at a fixed dose of 100 mg per day. Patients were followed up for a mean of 357 days. Rebleeding occurred in 14 patients in the placebo group, 10 in the atenolol group and eight in the propranolol group. The incidence of rebleeding was significantly lower in patients receiving propranolol than in those on placebo (propranolol vs. placebo: p = 0.01, logrank test). Atenolol was less effective than propranolol (atenolol vs. placebo: p = 0.065, logrank test). Bleeding-free survival was better for patients on active drugs than for those on placebo (propranolol vs. placebo = p = 0.01, atenolol vs. placebo: p = 0.05, logrank test). Retrospective analysis revealed that, whatever the type of treatment, abstinence from alcohol was crucial in preventing rebleeding. We conclude that beta-blocker treatment is effective in preventing rebleeding from esophageal varices in carefully selected alcoholic cirrhotic patients who survive at least 2 weeks after acute variceal hemorrhage and stop drinking.

[Study of the motivations for balneotherapy. Considerations on the needs of thermal baths users]

After a brief reminder of the dual therapeutic aspect (biological and psychological) of spa treatment, the results are presented of a series of psychological reaction tests (McFarland's Psychosomatic Inventory, the Middlesex Hospital Questionnaire, the Rorschach test) given to a randomized sample of 106 patients together with semistructured interviews conducted by two different psychiatrists. The results show substantial agreement between the motivations volunteered verbally and those revealed by the tests and may be summed up as affective rigidity, impoverished emotional life and difficulty in handling body-related anxieties. It is therefore suggested that it would be useful to create a psychosocial spa centre able to provide global treatment adapted to the specific needs of individual users.

[Psychological profile of the spa user. Preliminary study of motivations for spa treatment]

The main psychological and possible psychopathological traits of the spa user are identified and classified in order to clarify motivational aspects. Two different self-assessment tests, the Middlesex Hospital Questionnaire (MHQ) and the Minnesota Multiphasic Personality Inventory (MMPI) were given, the first to 500 subjects who had undergone spa treatment cycles lasting at least 10 days and the second to a control group of 50. MHQ data showed a significant incidence of certain neurotic traits, especially phobia, obsession and somatisation in the first group. Despite their different areas of competence and survey methods, both questionnaires produced results to support the hypothesis that a particular form of neurosis may play a significant part in motivating recourse to spa treatment.

[Familial hypoalphalipoproteinemia. Vergani's disease]

Deficiencies of lipoproteins occur as genetic disorders or may be presenting features of underlying disease. Familial high density lipoprotein (HDL), or alpha-lipoprotein, deficiency so far described includes Tangier disease, Lecithin: cholesterol acyltransferase (LCAT) deficiency, A-I Variants syndrome and Fish-eye disease. In 1981 Vergani described a familial aggregation of low HDL-cholesterol (less than 33 mg/dl) and Apo A (about 50% of normal levels) in the presence of normal VLDL and LDL-cholesterol. LCAT and lipoprotein lipase activities, both extrahepatic and hepatic, were normal. By zonal ultracentrifugation HDL2 subclass was found to be reduced. HDL apoproteins, examined by isoelectric focusing in polyacrylamide gel, were qualitatively normal. No disorders to which low levels of HDL might be secondary (e.g., overweight, cigarette smoking, nephropathy, liver disease) are present in the affected members. The underlying biochemical defect is unknown but probably involves altered synthesis or catabolism of HDL. Familial hypo-alpha-lipoproteinemia is accompanied by a high prevalence of premature myocardial infarction and sudden death. The genetic analysis of the disorder is consistent with autosomal inheritance. The criteria for the definition of familial hypo-alpha-lipoproteinemia are, therefore, as follows: 1) low HDL-cholesterol level in the presence of normal VLDL and LDL-cholesterol levels; 2) absence of diseases or factors to which hypo-alpha-lipoproteinemia might be secondary; 3) presence of a similar lipoprotein pattern in a first degree relative.

Serum marker of type III procollagen in patients with idiopathic hemochromatosis and its relationship to hepatic fibrosis

A radioimmunoassay for serum procollagen III aminopeptide (sPIIIP) was proposed recently for monitoring hepatic fibroplasia in patients with various inflammatory hepatic lesions. To determine whether sPIIIP also can detect fibroplasia in noninflammatory liver disorders, we measured this index in 16 patients with idiopathic hemochromatosis (IHC) at various stages of the disease and iron overload. Interestingly, we found normal levels of sPIIIP in 12 out of 16 patients examined (75%), despite clear histologic features of fibrosis or cirrhosis. The levels of sPIIIP exhibited no relationship to any of the clinical, laboratory, or histologic parameters of the disease. Thus, unlike other types of cirrhosis, in which sPIIIP is increased, the liver disease in IHC may be a fibrotic process unrelated to type III collagen stimulation. Accordingly, the determination of sPIIIP in these patients is of no value for monitoring the fibrosis associated with the liver disease.

[Familial alpha lipoprotein deficiency. Tangier disease, familial hypoalphalipoproteinemia and familial deficiency of lecithin cholesterol acyltransferase deficiency]

The plasma lipoproteins are a group of macromolecules all of which transport lipids, including cholesterol, triglyceride and phospholipid, and all of which have one or more protein constituents, called apoproteins. It is becoming apparent that the apoproteins play an important role in lipoprotein metabolism. Recently the so called "alpha hypothesis" has been proposed, according to which a protective role for HDL in atherosclerosis has been postulated. Three "experiments of nature", characterized by deficiencies of HDL as genetic disorders, namely Tangier disease, familial hypoalphalipoproteinemia, familial lecithin: cholesterol acetyltransferase deficiency, support the "alpha hypothesis". The first italian cases with the genetic disorders are presented.

Persistence of circulating HBsAg/IgM complexes in acute viral hepatitis, type B: an early marker of chronic evolution

Serial serum samples from 110 patients with acute viral hepatitis type B were tested for HBsAg/IgM complexes by a newly developed solid-phase radioimmunoassay. In 102 patients the infection resolved and they recovered from the disease. In these patients, HBsAg/IgM complexes were either absent from the outset of disappeared from serum within four weeks of admission, long before HBsAg had cleared or serum alanine aminotransferase had returned to normal, 8 patients progressed to chronic HBsAg carrier state and chronic liver disease. In these patients, HBsAg/IgM complexes were detectable in the serum on admission, and never disappeared. These results indicate that persistence of circulating complexes containing HBsAg and IgM after the early phase of acute viral hepatitis type B is a predictor of disease chronicity. As early as the fifth week of illness those in whom chronic liver disease developed could be distinguished from those who recovered.

A combination of chenodeoxycholic acid and ursodeoxycholic acid is more effective than either alone in reducing biliary cholesterol saturation

The effects on biliary lipids of 10 mg per kg per day of chenodeoxycholic acid (CDCA), 10 mg per kg per day of ursodeoxycholic acid (UDCA), and their equimolar combination (5 mg per kg per day of each), all administered for 45 to 60 days, were investigated in 18 patients with gallstones in a double-blind study with a balanced latin square design. The molar percentage of cholesterol in bile (initial value 9.7 +/- 2.2) was significantly lower after UDCA (5.4 +/- 1.3) and the combination (5.2 +/- 1.2) than after CDCA (7.2 +/- 1.7). Nevertheless, when the ability to solubilize cholesterol was calculated, taking into account the percentage of biliary UDCA, then the differences in cholesterol saturation induced by UDCA alone and the combination also became considerable (saturation index: 0.94 +/- 0.12 as compared to 0.81 +/- 0.12). The total bile acid pool increased significantly after treatment with CDCA and the combination, but not after UDCA. Lithocholic acid was increased significantly only by treatment with CDCA. Diarrhea was observed in five patients with hypertransaminasemia and in four patients after CDCA, whereas both UDCA and the combination were well-tolerated. We conclude that the administration of a combination of equimolar doses of CDCA and UDCA can be recommended for medical treatment of gallstones since it has greater effects on bile cholesterol saturation than either alone, is better tolerated than CDCA, and is less expensive than UDCA.

Acute ethanol administration increases biliary concentrations of total and unconjugated bilirubin in rabbits

Epidemiological investigations have revealed that alcoholic cirrhosis is associated with a high frequency of pigment gallstones, but only scanty information is available on the effects of ethanol on biliary secretion of bilirubin. We have injected intravenously 1.0 and 1.5 g/kg body wt of ethanol into six cholecystectomized rabbits and a common bile duct fistula. Experiments were performed ten days after surgery and a stream-splitting apparatus was interposed in the circuit in order to withdraw continuously biliary samples without interruption of enterohepatic bile circulation. Analysis of hourly data showed that both ethanol doses significantly increase the biliary concentration of total bilirubin, without affecting bile flow and lipid composition. Alcohol also promoted the efflux of unconjugated bilirubin into bile. The maximum effect occurred within the first 5 hr following alcohol administration. Thereafter the bile returned to normal. Since excessive concentrations of biliary unconjugated bilirubin favor pigment gallstone development, it can be speculated that alcohol acts as a risk factor for pigment lithiasis by enhancing the biliary levels of this form of pigment.

Serum total lipids, lipoprotein cholesterol, and apolipoprotein A in acute viral hepatitis and chronic liver disease

Serum total lipids, lipoprotein cholesterol, apolipoprotein A (Apo A), and liver function tests have been investigated in patients with acute viral hepatitis and chronic liver disease. Hypertriglyceridaemia, absence of alpha and pre beta bands on the lipoprotein electrophoresis pattern, low level of Apo A, and presence of abnormal lipoproteins (beta-VLDL and beta2-LP) were observed in the early phase of acute hepatitis. A positive correlation was found between Apo A and high-density lipoprotein cholesterol, and a negative one between Apo A and triglyceride, bile acids, total bilirubin, and serum alanine aminotransferase. Lipoprotein abnormalities found in the early phase of acute hepatitis are probably due to low lecithin-cholesterol acyltransferase activity. The reappearance of alpha lipoprotein and the increase of Apo A are sensitive indices of improvement of liver function. In chronic liver disease low levels of cholesterol and Apo A indicate the severity of liver cell injury.

Serum total lipids, lipoproteins cholesterol, apoproteins A and B in cardiovascular disease

Serum total lipids and lipoproteins cholesterol were determined in 33 survivors of myocardial infarction (MI) and in 75 subjects with peripheral vascular disease (PVD). Measurements were also made by a quantitative immunological assay of Apoprotein A (Apo A) and B (Apo B). Apo A levels were significantly lower in cases than in controls. In those cases with low levels of Apo A, high density lipoprotein has a higher cholesterol content as compared with controls. A negative correlation between high density lipoprotein cholesterol and low density lipoprotein cholesterol was found in controls and PVD subjects. The findings suggest that Apo A is associated to MI and PVD and its quantitative determination is predictive of cardiovascular disease.

[Behavior of total lipids, cholesterol, lipoproteins and apolipoprotein A in the blood of subjects with acute hepatitis and chronic hepatopathy]

Serum total lipids, lipoprotein cholesterol, apolipoprotein A (Apo A) and liver function parameters have been investigated in patients with acute viral hepatitis and chronic liver disease. Hypertriglyceridaemia, absence of alpha and pre beta bands on the lipoprotein electrophoresis pattern, low level of Apo A, presence of abnormal lipoproteins (beta-VLDL and beta2-LP) were observed in the early phase of acute hepatitis. A positive correlation was found between Apo A and triglyceride bile acids, log total bilirubin, log SGPT. Lipoprotein abnormalities are probably due to low lecitin-cholesterol aciltransferasi activity. The reappearance of alpha lipoprotein and the increase of Apo A are sensitive indices of improvement of liver function. In chronic liver disease the levels of cholesterol and Apo A correlate with changes in the hepatocellular function.

Correction of abnormal coagulation in chronic liver disease by combined use of fresh-frozen plasma and prothrombin complex concentrates

The effect on abnormal coagulation tests of infusions of fresh-frozen plasma (F.F.P), prothrombin complex concentrates, and a combination of these treatments was compared in 30 patients with chronic liver disease undergoing needle biopsy. A single dose of F.F.P. (12 ml/kg body-weight) was found to be the least effective therapeutic regimen. The concentrate containing factors II, IX, and X was also not adequate, but the additional administration of factor-VII concentrate corrected the prothrombin-time (P.T.) and "Normotest" (N.T.) in most patients. However, this regimen did not correct the prolonged kaolin activated partial thromboplastin-time (K.P.T.T.). The results of tests for exploring both the extrinsic (P.T. and N.T.) and intrinsic (K.P.T.T.) coagulation systems only became normal after the combined administration of a lower dose of F.F.P. (8 ml/kg body-weight) and of both concentrates (12 units/ml). There was no clinical or laboratory evidence of thrombotic complications. No patient developed acute hepatitis or hepatitis-B surface antigen in the twelve months after biopsy. These results indicate that prothrombin-complex concentrates in combination with F.F.P. may therefore be used to allow liver biopsy to be performed safely in patients presenting with severe coagulation defects.

Rosette inhibition test in chronic liver disease

A role has recently been assigned to cell-mediated immunity in chronic liver diseases in addition to the well-known alterations of humoral immunity. We now report the results of the rosette inhibition test for the evaluation of T-lymphocyte "sensitization" in patients with different chronic liver disorders. A cell-mediated immune reaction was found in 81% of patients with chronic active hepatitis and in 71% with primary biliary cirrhosis, whereas patients with chronic persistent hepatitis showed no reaction. The correlation with the incidence of hepatitis B antigen showed that T-lymphocyte sensitization was more frequent in the group of HB-positive patients. Finally, improvement of the test was observed in four out of nine patients given immunosuppressive treatment.

[Controlled clinical trial of 2-mercapto-propionyl-glycine in chronic hepatopathies]

A controlled clinical trial comparing 2-Mercapto-Priopionyl-Glycine (2-MPG) plus B12 vitamin with B12 vitamin alone in chronic liver disease has been conducted in seven hospitals in Italy. Patients were divided into two groups on the basis of liver histology; group I included 26 patients showing histological evidence for chronic persistent hepatitis (C.P.H.) (according to De Groote et al.) whereas group II consisted of 54 patients with chronic aggressive hepatitis (C.A.H.) or compensated liver cirrhosis. Patients of each group were randomly allocated to 2-MPG plus B12 vitamin, or to placebo plus B12 vitamin, in a double-blind way. The drug (or placebo) was diluted in 500 ml of 10% Levulose, and administered intravenously; 1000 gamma of B12 vitamin were added to each bottle. Patients in the 2-MPG group received 2.5 gms of the drug daily; the treatment lasted for 30 days. The following parameters were checked in all patients on admission, and repeated at the end of treatment: Serum bilirubin, serum Cholesterol, A.P., BSP retention, Prothrombin time, S-GOT, S-GPT, Gamma-GT, Total serum Protein, serum electrophoresis, Immunoglobulins. Patients given 2-MPG showed significant decreases of serum transaminases, and improvement of BSP retention.

[Incidence of HBsAg in persons living with HBsAg carriers]

The prevalence of HBsAg was studied, by Counterelectrophoresis and Radioimmunoassay, in 232 household contacts of 65 HBsAg carriers. The overall incidence of HBsAg in household contacts was 14,65%, as compared with the generally accepted figure of about 1% in the general population in Italy. As far as the prevalence of HBsAg and abnormal liver function tests is concerned, no differences were found between contacts of carriers with Chronic Active Liver Disease and contacts of asymptomatic carriers. The prevalence of HBsAg was similar in spouses (13,5%) and in blood relatives (15,3%) of carriers. It is concluded that: 1) Household contacts of HBsAg carriers are at higher risk of acquiring HBsAg infection than the general population. 2) Such risk is not increased by the presence of Chronic Active Liver Disease in the index cases. 3) Further studies are required in order to clarify the relative roles of environmental and genetic factors as determinants of HBsAg transmission.