Association 1901  |  Plan du site  |  Partenariat  |  Contacts  |+++++++++++
|  Accueil-News  |  Revue de presse  |  Pda du médecin  |  Hepatobase  |  Anatomobase  |  Diététique  |  Forums  |  DES  |  Laboratoires  |

Téléchargement sur votre Agenda de Poche avec Hepatoweb Edition Mobile

Revue de Presse du Mois Mois de Novembre 2001

Archives depuis le 01/09/00

HEPATOLOGY

Table of Contents for November 2001 · Volume 34 · Number 5

Bile acid feeding increased proliferative activity and apical bile acid transporter expression in both small and large rat cholangiocytes
Gianfranco Alpini, Yoshiyuki Ueno, Shannon S. Glaser, Marco Marzioni, Jo Lynne Phinizy, Heather Francis, Gene LeSage
Bile acids (BA) enter cholangiocytes by the Na+-dependent apical BA transporter (ABAT). By this mechanism, taurocholate (TC) and taurolithocholate (TLC) increase cholangiocyte proliferation. No in vivo studies exist regarding the anatomical sites involved in BA-regulation of cholangiocyte growth. Specific cholangiocyte subpopulations participate in BA-regulated proliferation. Proliferation was assessed in liver sections by determining the number of proliferating cellular nuclear antigen (PCNA)-positive cholangiocytes and cytokeratin-19 (CK-19)-positive ducts. We isolated small and large cholangiocytes from rats fed for 1 week TC, TLC, or BA control diet and determined PCNA and ABAT expression and BA transport activity. We evaluated if TC and TLC induction of ABAT expression was dependent on activation of PKC alpha. DNA replication was active only in large normal cholangiocytes. TC and TLC feeding increased proliferation of large cholangiocytes, induced the de novo activation of proliferation of small cholangiocytes, overexpression of ABAT and BA transport activity in large cholangiocytes, and de novo expression of ABAT and BA transport activity in small cholangiocytes. BA-stimulated ABAT expression was dependent on PKC activation in cholangiocytes. TC and TLC stimulate proliferation of small and large cholangiocytes associated with PKC-dependent up-regulation of ABAT. (HEPATOLOGY 2001;34:868-876.)

Relationship of serum leptin concentration and other measures of adiposity with gallbladder disease (*Human Study*)
Constance E. Ruhl, James E. Everhart
Obesity increases the risk of gallstones, especially in women. Most gallbladder disease studies have used body mass index (BMI) as a measure of overall adiposity, although BMI does not distinguish between fat and lean body mass. Central adiposity may also increase gallstone risk, although this is less well studied. Leptin is a peptide whose serum concentration is highly correlated with total body fat mass. We examined the relationship of gallbladder disease with anthropometric measures and serum leptin concentration in a large, national, population-based study. A total of 13,962 adult participants in the Third National Health and Nutrition Examination Survey underwent gallbladder ultrasonography and anthropometric measurements of BMI, body circumferences, and skinfold thicknesses, and a random subgroup of 5,568 had measures of fasting serum leptin concentrations. Gallstone-associated gallbladder disease was defined as ultrasound-documented gallstones or evidence of cholecystectomy. When controlling for BMI and other gallbladder disease risk factors in multivariate analysis, a test for trend for increasing waist-to-hip circumference ratio and risk of gallbladder disease was statistically significant among women (P = .043) and men (P = .007). BMI remained strongly associated with gallbladder disease among women (P < .001), but was unrelated among men (P = .46). Leptin concentration was associated with gallbladder disease in both sexes (P < .001), but not after controlling for BMI and waist-to-hip circumference in either women (P = .29) or men (P = .65). In conclusion, waist-to-hip circumference ratio was related to gallbladder disease among women and men. Serum leptin concentration was not a better predictor of gallbladder disease than anthropometry. (HEPATOLOGY 2001;34:877-883.)

Contractile hyporesponsiveness of hepatic arteries in humans with cirrhosis: Evidence for a receptor-specific mechanism (*Human Study*)
Michael Schepke, Jörg Heller, Sebastian Paschke, Julia Thomas, Martin Wolff, Markus Neef, Max Malago, Gerhard J. Molderings, Ulrich Spengler, Tilman Sauerbruch
Splanchnic vasodilatation and vascular hyporesponsiveness to vasopressors are characteristic features of patients with cirrhosis. Although the vascular response to different vasopressors has been shown to be attenuated in cirrhosis, alterations on the receptor level are discussed controversially. Thus, impaired postreceptor signaling has been postulated. However, so far this has not been studied in human splanchnic vessels. Therefore, we assessed the vascular response of human hepatic arteries after activating the G-protein­dependent signal transduction pathway by stimulation with angiotensin II, the thromboxane A2 analog U46619, or by G-protein activation with NaF/AlCl3. After endothelium denudation, cumulative isometric concentration contraction curves were obtained for hepatic arteries from 32 cirrhotic patients undergoing liver transplantation and from 40 organ donors after stimulation with either angiotensin II (10­11-10­5 mol/L), U46619 (10­10-10­6 mol/L) or AlCl3 (30 µmol/L)/NaF (10­4-3 ¥ 10­2 mol/L). Hepatic arteries from cirrhotic patients were markedly less responsive to angiotensin II (P < .0001) than those from organ donors. Both stimulation of the G-protein phospholipase C pathway via the thromboxane A2 receptor and receptor-independent G-protein stimulation with AlCl3/NaF, induced an intact contractile response. In conclusion, the G-protein­dependent signal transduction system itself is unaltered in cirrhosis. Hence, the cause of the hyporesponsiveness to some vasoconstrictors in cirrhosis appears to be a receptor-specific phenomenon localized upstream from the G-protein level. (HEPATOLOGY 2001;34:884-888.)

Outcome of liver transplantation in patients with diabetes mellitus: A case-control study (*Human Study*)
Preeti R. John, Paul J. Thuluvath
The influence of preexisting diabetes mellitus (DM) on outcome after orthotopic liver transplantation (OLT) has not been well defined. The objective of our study was to compare the morbidity and mortality after OLT in 57 patients with preexisting DM (3 type I, 54 type II) with 114 age-, sex-, and race-matched patients without DM (case controls). The demographics were similar in both groups. Pretransplantation serum creatinine was significantly higher in the diabetic group compared with case controls. The incidence of the following complications was significantly higher in the diabetic group after OLT: cardiovascular (61.4% vs. 21.9%, P < .001), major (54.4% vs. 29.8%, P = .002) and minor infections (29.8% vs. 7.9%, P < .0001), renal (59.7% vs. 20.2%, P < .001), ophthalmologic (10.5% vs. 0.9%, P = .01), respiratory (24.6% vs. 7.0%, P = .001), neurologic (31.6% vs. 7.0%, P < .001), hematologic (19.3% vss 2.6%, P = .001), musculoskeletal (24.6% vs. 5.3%, P = .001), and malignancy (22.8% vs. 10.5%, P = .03). The duration of hospital stay, cost of hospitalization, retransplantation, and overall graft survival were similar. Acute rejection was seen in 50.9% of diabetics compared with 25.4% in controls (P = .0009). One-year (87% vs. 77%) and 2-year (81.6% vs. 70.1%) patient survival was similar, but 5-year survival was lower in the DM group (34.4% vs. 67.7%, P = .002). In conclusion, preexisting diabetes is associated with a significant post-OLT morbidity and mortality, and our observations suggest that patients with DM warrant more rigorous pre- and post-OLT evaluation. (HEPATOLOGY 2001;34:889-895.)

Effective treatment of small murine hepatocellular carcinoma by dendritic cells
Wei-Chen Lee, Hui-Chuan Wang, Long-Bin Jeng, Yang-Jen Chiang, Chen-Rong Lia, Pei-Fang Huang, Miin-Fu Chen, Shiguang Qian, Lina Lu
Hepatocellular carcinoma (HCC) is a common malignancy with a poor prognosis. This investigation examined whether dendritic cell­based immunotherapy can treat murine HCC effectively. Bone marrow­derived dendritic cells were propagated from C57BL/10J mice in GM-CSF (4 ng/mL) and interleukin (IL)-4 (1,000 µ/mL). The dendritic cells were pulsed with a Hepa1-6 lysate overnight and employed to treat murine HCC. For in vivo study, HCC was created by inoculation of hepa1-6, 5 ¥ 105 cells, in the flank of C57BL/10J mice. HCC were categorized into small (3 ¥ 3-mm) and large (5 ¥ 5-mm) tumors. These HCC were treated by dendritic cells intravenously, twice at weekly intervals. The results revealed that lymphocytes could be gathered around small HCC after administration of Hepa1-6 lysate­pulsed dendritic cells. Seven of 12 (58.3%) small HCC could be eradicated completely by dendritic cell­based immunotherapy, and 33.3% of the small tumors responded to immunotherapy partially which were held in a stable condition for 34.0 ± 7.4 days before the tumors regrew. For large HCC, lymphocytes did not gather around the tumors, and the tumors cannot be eradicated effectively by dendritic cells. However, dendritic cell­based immunotherapy could slow down the growth rate of large tumors (116.2 ± 91.4 mm3 vs. 234.0 ± 149.1 mm3 of the control on day 7, P = .043; and 280.3 ± 224.7 mm3 vs. 870.0 ± 418.9 mm3 of the control on day 17, P < .001). Conclusively, dendritic cells pulsed with a Hepa1-6 lysate can be employed to treat small HCC in vivo effectively. However, the efficacy of dendritic cell­based immunotherapy decreases while tumors grow. (HEPATOLOGY 2001;34:896-905.)

Hepatitis B virus X protein increases expression of p21Cip-1/WAF1/MDA6 and p27Kip-1 in primary mouse hepatocytes, leading to reduced cell cycle progression
Liang Qiao, Kevin Leach, Robert McKinstry, Donna Gilfor, Adly Yacoub, Jong Sung Park, Steven Grant, Philip B. Hylemon, Paul B. Fisher, Paul Dent
Previously, we have linked prolonged intense mitogen-activated protein kinase (MAP kinase; MAPK) signaling in hepatocytes to increased expression of p21Cip-1/WAF1/MDA6 (p21) and p16INK4a (p16), that leads to a p21-dependent growth arrest. In this study, we investigated the impact of hepatitis B virus X protein (pX) expression on MAPK-modulated cell cycle progression in primary mouse hepatocytes. In hepatocytes, expression of pX enhanced protein levels of p21 and p27, but not of p16. The elevated levels of p21 and p27 correlated with reduced DNA synthesis in wild-type (+/+) hepatocytes and with a weak stimulation of DNA synthesis in p21 null (­/­) cells. Antisense p27 messenger RNA (mRNA) (p27as) increased DNA synthesis in +/+ and p21 ­/­ cells, and pX blunted this effect in +/+ cells. In p21 ­/­ cells, however, p27as permitted pX to further stimulate DNA synthesis. These data argue that a reduced ability to enhance expression of both p21 and p27 is required to fully reveal the growth-potentiating properties of pX. This finding also implies that depending on the functional status of the p21 and p27 genes, expression of pX can have 2 very different effects on hepatocyte proliferation. Prolonged intense MAPK signaling reduced DNA synthesis in +/+ cells and enhanced DNA synthesis in p21 ­/­ cells. The enhancement of DNA synthesis in p21 ­/­ cells was blocked by pX, and the effect of pX was abrogated by p27as. Furthermore in p21 ­/­ cells, overexpression of p16 blocked MAPK-stimulated DNA synthesis, and this effect was partially reversed by p27as. These data argue that p27 can also cooperatively interact with p16 to inhibit DNA synthesis in hepatocytes. Collectively, our findings show that reduced expression of p16, p21, and p27, which can occur during hepatocellular carcinoma, enhances the ability of MAPK signaling and pX to cause proliferation in hepatocytes. Thus loss of cyclin kinase inhibitor function may play an important role in the process of tumor progression after chronic hepatitis B virus infection. (HEPATOLOGY 2001;34:906-917.)

Transforming growth factor and activin tonically inhibit DNA synthesis in the rat liver
Takeshi Ichikawa, You-Qing Zhang, Kimitaka Kogure, Yoshihisa Hasegawa, Hitoshi Takagi, Masatomo Mori, Itaru Kojima
The present study was conducted to assess the role of transforming growth factor (TGF-) and activin(s) in the regulation of the mass of the liver. To this end, we eliminated TGF- or activin signaling in intact rat liver by adenovirus-mediated transfer of the gene encoding truncated type II TGF- receptor (AdextTR) or truncated type II activin receptor (AdextAR). In intact rat liver that received a single application of either AdextTR or AdextAR via the portal vein, DNA synthesis as assessed by bromodeoxy uridine (BrdU) labeling was induced. In AdextTR- or AdextAR-treated rats, nuclear labeling was significantly higher than that in AdexLacZ, adenovirus vector encoding Escherichia coli -galactosidase gene, or saline-treated rats at 3, 5, 7, and 9 days of infusion. The peak of the BrdU labeling was observed after 7 days of infusion and the labeling decreased thereafter. Apoptosis of hepatocytes, assessed by the terminal deoxynucleotidyl transferase (TdT)-mediated, dUTP-biotin nick-end labeling method was detected after 9 days of infusion. Immunoreactivity of TGF- and activin A increased in the liver after the blockade of the activin or TGF- signaling. TGF- and activin A may have been up-regulated when the action of these ligands was blocked. These results indicate that blockade of the action of either TGF- or activin leads to the initiation of DNA synthesis in intact liver. TGF- and activin tonically inhibit hepatocyte growth even in intact liver and may play a critical role in the maintenance of constant liver mass. (HEPATOLOGY 2001;34:918-925.)

1,25-Dihydroxycholecalciferol reduces rejection and improves survival in rat liver allografts
Claudio A. Redaelli, Markus Wagner, Ying-Hua Tien, Luca Mazzucchelli, Philip F. Stahel, Martin K. Schilling, Jean-François Dufour
Vitamin D3 affects the immuno response and improves experimental autoimmune diseases. We investigated the effect of 1,25-dihydroxycholecalciferol (1,25[OH]2D3) Rocaltrol as a single immunosuppresive agent and in combination with low-dose cyclosporin A (CsA) in vascularized liver allografts in rats in a high-responder strain combination (ACIÞLewis). Recipients were placed on a low-calcium diet 7 days before transplantation and were treated with 0.1 or 1 µg/kg/d 1,25(OH)2D3 intraperitoneally beginning 3 days before transplantation. Treatment combining 1,25(OH)2D3 with CsA (2 mg/kg/d) was also tested. Graft function and survival, histologic rejection, and concentrations of interleukin (IL)-2, -4, -10, and -12 in serum and in grafts were measured. 1,25(OH)2D3 increased allograft survival in a dose-dependent manner when compared with controls (P < .05 for both groups). Serum bilirubin, aspartate transaminase (AST), and lactate dehydrogenase (LDH) activities were significantly lower in 1,25(OH)2D3-treated animals. Vitamin D reduced the concentration of IL-2 and IL-12 in serum and in grafts, and increased IL-4 and IL-10 in the grafts. The rejection activity index 10 days after transplantation was significantly lower in low- and high-dose 1,25(OH)2D3-treated rats compared with vehicle-treated controls (P < .0001 for both groups). The combination of either low-dose or high-dose vitamin D3 and CsA prolonged graft survival when compared with low-dose CsA only (P < .05 for both groups). After 3 weeks, hypercalcemia developed in high-dose 1,25(OH)2D3-treated rats. It is concluded that 1,25(OH)2D3 prolongs survival of liver allografts in rats by decreasing the severity of acute rejection. Analogues of vitamin D with fewer hypercalcemic effects may have potential as immunosuppressive drugs in liver transplantation. (HEPATOLOGY 2001;34:926-934.)

Alcohol-induced free radicals in mice: Direct toxicants or signaling molecules?
Ming Yin, Erwin Gäbele, Michael D. Wheeler, Henry Connor, Blair U. Bradford, Anna Dikalova, Ivan Rusyn, Ronald Mason, Ronald G. Thurman
Tumor necrosis factor (TNF-) and free radicals are produced in early alcohol-induced liver injury. Recently, pathology caused by alcohol was blocked nearly completely in tumor necrosis factor receptor 1 (TNF-R1) knockout mice. With this model, it is now possible to evaluate whether free radicals are directly toxic or act as redox regulators of TNF- production. Specifically, if free radicals were directly toxic, a parallel decrease in free radicals and pathology in TNF-R1 knockout mice would be predicted. If they only affect TNF- production, radicals would be expected to remain high while pathology is diminished. Accordingly, free radical production in TNF-R1 knockout mice was studied here. The enteral alcohol delivery model used mice lacking TNF-R1 (p55) and wild-type control C57Bl/6J mice. Animals received a liquid diet continuously with either ethanol or isocaloric maltose-dextrin as control for 4 weeks. Urine ethanol levels fluctuated from 10 to 500 mg/dL in a cyclic pattern in mice receiving ethanol. Ethanol elevated liver:body weight ratios, serum alanine transaminase (ALT) levels, and pathology scores in wild-type mice. These parameters were blunted nearly completely in TNF-R1 knockout mice. Ethanol treatment increased free radical production in wild-type mice compared with animals fed a high-fat control diet. There were no differences in intensity of free radical signals regardless of the presence or absence of TNF-R1; however, pathology differed markedly between these groups. These findings are consistent with the hypothesis that free radicals act as redox signals for TNF- production and do not directly damage cells in early alcohol-induced hepatic injury. (HEPATOLOGY 2001;34:935-942.)

Up-regulated expression of the receptor for advanced glycation end products in cultured rat hepatic stellate cells during transdifferentiation to myofibroblasts
Heinz Fehrenbach, Ralf Weiskirchen, Michael Kasper, Axel M. Gressner
Receptor for advanced glycation end products (RAGE) is a member of the immunoglobulin superfamily of cell-surface molecules. Blockade of RAGE has been reported to considerably improve liver function and accelerate regeneration after hepatectomy. The aim of this study was to investigate the cell type­specific expression of RAGE, and to examine whether transdifferentiation of hepatic stellate cells (HSC) into myofibroblasts (MFB) is associated with changes in RAGE expression. Northern blot analysis revealed that RAGE mRNA was exclusively expressed by HSC isolated from rat liver, while no transcripts were seen in hepatocytes, Kupffer cells, or sinusoidal endothelial cells. Expression of RAGE mRNA was up-regulated during transdifferentiation of HSC into MFB. Concomitantly, expression of RAGE protein was increased as confirmed by Western blotting and immunohistochemistry. As assessed by radioactive labeling, transforming growth factor 1 (TGF-1) induced a time-dependent 2- to 15-fold increase in the de novo synthesis of RAGE protein, which was completely abolished using PD098059, a specific inhibitor of the mitogen-activated protein kinase (MAPK) kinase. As shown by double-immunofluorescence staining, RAGE colocalized with -smooth muscle actin, and immunoelectron microscopy demonstrated the most prominent labeling for RAGE at filopodial membranes of MFB. In conclusion, this study demonstrates that expression of RAGE is restricted to rat HSC, and that expression is up-regulated during activation of HSC and transition to MFB. The preferential immunogold labeling of RAGE to focal membrane areas of filopodia of MFB is suggestive of a role of RAGE in the spreading and migration of activated HSC/MFB, major players in liver fibrogenesis. (HEPATOLOGY 2001;34:943-952.)

TAK1/JNK and p38 have opposite effects on rat hepatic stellate cells
Bernd Schnabl, Cynthia A. Bradham, Brydon L. Bennett, Anthony M. Manning, Branko Stefanovic, David A. Brenner
After liver injury, hepatic stellate cells (HSCs) undergo a process of activation with expression of smooth muscle -actin (-SMA), an increased proliferation rate, and a dramatic increase in synthesis of type I collagen. The intracellular signaling mechanisms of activation and perpetuation of the activated phenotype in HSCs are largely unknown. In this study the role of the stress-activated protein kinases, c-Jun N-terminal kinase (JNK) and p38, were evaluated in primary cultures of rat HSCs. The effect of JNK was assessed by using an adenovirus expressing a dominant negative form of transforming growth factor (TGF-)-activated kinase 1 (TAK1) (Ad5dnTAK1) and a new selective pharmacologic inhibitor SP600125. The effect of p38 was assessed with the selective pharmacologic inhibitor SB203580. These kinases were inhibited starting either in quiescent HSCs (culture day 1) or in activated HSCs (culture day 5). Although blocking TAK1/JNK and p38 decreased the expression of -SMA protein in early stages of HSC activation, no effect was observed when TAK1/JNK or p38 were inhibited in activated HSCs. JNK inhibition increased and p38 inhibition decreased collagen 1(I) mRNA level as measured by RNase protection assays, with maximal effects observed in early stages of HSC activation. Furthermore, TAK1/JNK inhibition decreased HSC proliferation, whereas p38 inhibition led to an increased proliferation rate of HSCs, independently of its activation status. These results show novel roles for the TAK1/JNK pathway and p38 during HSC activation in culture. Despite similar activators of TAK1/JNK and p38, their functions in HSCs are distinct and opposed. (HEPATOLOGY 2001;34:953-963.)

Tauroursodeoxycholic acid protects hepatocytes from ethanol-fed rats against tumor necrosis factor­induced cell death by replenishing mitochondrial glutathione
Anna Colell, Olga Coll, Carmen García-Ruiz, Raquel París, Claudio Tiribelli, Neil Kaplowitz, José C. Fernández-Checa
Mitochondrial glutathione (GSH) plays a key role against tumor necrosis factor (TNF)-induced apoptosis because its depletion is known to sensitize hepatocytes to TNF. The present study examined the role of tauroursodeoxycholic acid (TUDCA) administration to chronic ethanol-fed rats on mitochondrial GSH levels and kinetics, mitochondrial membrane physical properties, TNF-induced peroxide formation, and subsequent hepatocyte survival. TUDCA selectively increased the levels of GSH in mitochondria without an effect on cytosolic GSH. This outcome was accompanied by improved initial rate of GSH transport examined at low (1 mmol/L) and high (10 mmol/L) GSH concentrations both in intact mitochondria and mitoplasts prepared from ethanol-fed livers. Assessment of membrane fluidity revealed an increased order parameter in mitochondria and mitoplasts from ethanol-fed rats compared with pair-fed controls, which was prevented by TUDCA administration. Compared with hepatocytes from pair-fed rats, TNF stimulated peroxide generation in hepatocytes from ethanol-fed rats, preceding TNF-induced cell death. Administration of TUDCA to ethanol-fed rats prevented TNF-induced peroxide formation and cell death, an effect that was reversed on depletion of the recovered mitochondrial GSH levels by (R,S)-3-hydroxy-4-pentenoate before TNF treatment. The protective effect of TUDCA against TNF was not because of activation of phosphatidylinositol 3-kinase, discarding a role for a survival-dependent pathway. Thus, these findings reveal a novel role of TUDCA in protecting hepatocytes in long-term ethanol-fed rats through modulation of mitochondrial membrane fluidity and subsequent normalization of mitochondrial GSH levels. (HEPATOLOGY 2001;34:964-971.)

Intermittent ischemia reduces warm hypoxia-reoxygenation­induced JNK1/SAPK1 activation and apoptosis in rat hepatocytes
Dominique Crenesse, Marina Laurens, Jean Gugenheim, Catherine Heurteaux, Raffaele Cursio, Bernard Rossi, Annie Schmid-Alliana
Prolonged liver ischemia followed by reperfusion (I/R) causes functional and structural damage to liver cells, resulting in necrosis and apoptosis. c-jun N-terminal kinase 1/stress-activated protein kinase 1 (JNK1/SAPK1) is activated during I/R and participates in the onset of the apoptosis program. Excessive blood loss during surgery can hinder postoperative recovery. Intermittent portal triad clamping (PTC) is better tolerated than prolonged continuous ischemia. This study was designed to demonstrate that intermittent ischemia could improve postischemic survival rates by a decrease of JNK1/SAPK1 and caspase 3 activation, which were involved in the apoptosis process. Rats were subjected to intermittent 1-hour ischemia (15-minute ischemia/5-minute reperfusion, 4 times), followed by 220-minute reperfusion, or to continuous ischemia (1 hour), followed by 240-minute reperfusion. Mortality rates were assessed on day 7. Serum aspartate transaminase (AST), alanine transaminase (ALT), and lactate deshydrogenase levels (LDH) were measured 6 hours after ischemia. This study was completed in primary cultured isolated rat hepatocytes, subjected to the same continuous or intermittent hypoxic conditions. The activation status of JNK1/SAPK1 was evaluated by immunoprecipitation or Western blotting experiments. Apoptosis was assessed by measuring caspase activation and by terminal deoxynucleotidyl transferase­mediated dUTP biotin nick end labeling (TUNEL) reaction. Eighty percent of the intermittent-ischemia group was alive 7 days after surgery and serum enzyme levels were significantly decreased. Intermittent hypoxia or ischemia did not lead to JNK1/SAPK1 activation, but at least 3 hypoxia-reoxygenation (H/R) sets were necessary to inhibit kinase activation. Consequently, caspase 3 activation and apoptosis were dramatically reduced. Intermittent ischemia is a powerful, protective way to reduce I/R damage of the liver, by reduction of JNK1/SAPK1 activation associated with a down-regulation of caspase 3 activity, which leads to inhibition of hepatocyte apoptosis. (HEPATOLOGY 2001;34:972-978.)

Lipopolysaccharide results in a marked decrease in hepatocyte nuclear factor 4 in rat liver
Bin Wang, Shi-Rong Cai, Cuihua Gao, Frances M. Sladek, Katherine Parker Ponder
The acute-phase response can result in decreased liver-specific functions and death as a result of liver failure. We show here that lipopolysaccharide (LPS), an endotoxin that induces the acute-phase response, results in a marked decrease in the major isoforms of the transcription factor, hepatocyte nuclear factor 4 (HNF-4), in livers of rats. HNF-4 is a nuclear receptor that is critical for the expression of several liver-specific genes. This decrease in HNF-4 is primarily the result of a posttranscriptional mechanism, because mRNA levels are normal, and there are no major changes in the splicing patterns. This decrease was of functional significance, because expression of a gene that is highly dependent on HNF-4, HNF-1, was reduced. Interleukin-1 (IL-1) is a cytokine whose levels are increased in vivo in response to LPS. IL-1 resulted in a decrease in HNF-4 levels in HepG2 cells. This IL-1­induced decrease was likely caused by degradation via the proteasome, because it was prevented by the addition of the proteasome inhibitor, MG132. We conclude that the decrease in HNF-4 that occurs in vivo after the administration of LPS may be the result of IL-1­induced degradation, and likely contributes to the liver insufficiency that occurs. IL-1 antagonists or proteasome inhibitors might increase HNF-4 protein levels in the acute-phase response, which could result in increased liver function and survival. (HEPATOLOGY 2001;34:979-989.)

Defective mitogen-activated protein kinase (ERK2) signaling in gastric mucosa of portal hypertensive rats: Potential therapeutic implications
Hirofumi Kawanaka, Morimasa Tomikawa, Michael K. Jones, Imre L. Szabo, Rama Pai, Dolgor Baatar, Kouji Tsugawa, Keizo Sugimachi, I. James Sarfeh, Andrzej S. Tarnawski
Portal hypertensive (PHT) gastropathy is a frequent, serious complication of liver cirrhosis. PHT gastric mucosa has numerous abnormalities such as reduced mucosal potential differences, reduced surface oxygenation, and increased susceptibility to injury caused by alcohol, aspirin, and other noxious factors. Because such mucosal injury is initially mediated by oxygen free radicals, and because mitogen-activated protein (MAP) kinase (ERK2) protects against cellular stress and induces cell proliferation, we postulated that oxidative stress-induced ERK2 activation is defective in PHT gastric mucosa. Here we show that in PHT gastric mucosa, ERK2 activation by oxidative stress is impaired. This impairment is mediated by overexpression of MAP kinase phosphatase-1 (MKP-1), which results from the underlying and continual oxidative state associated with portal hypertension, and is ameliorated by inhibiting MKP-1. Furthermore, we found that supplementing vitamin E, a free radical scavenger, reduces the oxidative state in PHT gastric mucosa, normalizes MKP-1 expression, and thereby reverses impairment of oxidative stress-induced ERK2 activation. Finally, we show that orally administered vitamin E completely reverses the increased susceptibility of PHT gastric mucosa to alcohol injury. Our findings point to a new molecular and mechanistic basis for PHT gastropathy and provide a new therapeutic modality for protection of PHT gastric mucosa. (HEPATOLOGY 2001;34:990-999.)

Prospective study on anti-hepatitis C virus­positive patients with persistently normal serum alanine transaminase with or without detectable serum hepatitis C virus RNA (*Human Study*)
Michelle Martinot-Peignoux, Nathalie Boyer, Dominique Cazals-Hatem, Bach-Nga Pham, Anne Gervais, Véronique Le Breton, Stéphane Levy, Claude Degott, Dominique-Charles Valla, Patrick Marcellin
A significant proportion of patients with detectable antibodies to hepatitis C virus have normal serum alanine transaminase levels. Our aim was to study the outcome of this group. Between 1992 and 1999, 135 consecutive anti-HCV-positive patients with persistently normal ALT were followed for 3.6 ± 2.3 years (0.5 to 8.5 years), 108 had a liver biopsy at inclusion, and 24 had a second liver biopsy 3.5 ± 1.0 years later. Serum HCV RNA was detectable with PCR in 94 patients (69%) and not detectable in 41 patients (31%). Patients with and without detectable serum HCV RNA had similar epidemiological characteristics. Serum ALT levels and anti-HCV ratio were lower (P = .001), and histological lesions had lower grade and stage in patients without detectable serum HCV RNA (P = .001). Liver HCV RNA was not detectable with PCR in the 12-serum HCV RNA-negative patients tested. During follow-up, all patients without detectable serum HCV RNA remained HCV RNA-negative and kept normal serum ALT; all patients with detectable serum HCV RNA remained HCV RNA-positive, 20 (21%) had a slight fluctuation of serum ALT above the upper limit of normal. No significant changes were observed in the liver lesions of the 24 patients who underwent a second liver biopsy. In anti-HCV-positive patients with persistently normal serum ALT, histological lesions are significantly lower in HCV RNA-negative than in HCV RNA-positive patients. During follow-up, the HCV RNA status of patients remained unchanged; 21% of the patients with detectable serum HCV RNA had slight increase in serum ALT levels, but histological lesions remained stable. (HEPATOLOGY 2001;34:1000-1005.)

Combination of interferon induction therapy and ribavirin in chronic hepatitis C (*Human Study*)
Peter Ferenci, Harald Brunner, Karin Nachbaur, Christian Datz, Michael Gschwantler, Harald Hofer, Rudolf Stauber, Franz Hackl, Wolfgang Jessner, Martha Rosenbeiger, Petra Munda-Steindl, Karin Hegenbarth, Alfred Gangl, Wolfgang Vogel, for the Austrian Hepatitis Study Group
The initial clearance of hepatitis C virus (HCV) during interferon-alfa therapy is dose-dependent. Therefore, higher initial interferon doses (induction therapy) may improve treatment results. This concept was tested in a prospective, randomized controlled trial. Previously untreated patients with chronic hepatitis C were randomized to receive 3 different interferon doses during the first 14 weeks of therapy (Group A, n = 130: 10 MU IntronA [AESCA-Schering Plough, Traiskirchen, Austria]/day for 2 weeks, followed by 10 MU/2 days for 12 weeks; Group B, n = 124: 5 MU/day for 14 weeks; Group C, n = 119; 5 MU/2 days for 14 weeks) followed in all by 5 MU/2 days for 24 weeks. Throughout the whole study all patients received 1 to 1.2 g ribavirin/day. On treatment, no differences in viral clearance rates were observed. Sustained response rates were also not different among the groups (A: 48.5%, B and C: 41.3%, intent to treat). When data were analyzed according to genotypes, sustained response was almost twice as high in patients with genotype 1 receiving high-dose interferon induction therapy (A: 44.2%, B: 28.6%, C: 27%, P < .05). In contrast, results were not different in genotype 3a patients (A: 61.3%, B: 75.9%, C: 56.3%; P > .1). These data indicate that high-dose interferon induction therapy may improve the outcome of interferon/ribavirin combination therapy in genotype 1 patients. (HEPATOLOGY 2001;34:1006-1011.)

Analysis of hepatitis B viral load decline under potent therapy: Complex decay profiles observed (*Human Study*)
Sharon R. Lewin, Ruy M. Ribeiro, Tomos Walters, George K. Lau, Scott Bowden, Stephen Locarnini, Alan S. Perelson
We used a new real-time polymerase chain reaction (PCR)-based assay that is sensitive, has a wide dynamic linear range, and is highly reproducible to quantify hepatitis B virus (HBV) DNA in the serum of infected individuals undergoing potent antiviral therapy. In addition, we made frequent measurements of viral load after initiation of treatment and maintained follow-up to about 12 weeks. To analyze the data we used a new model of HBV decay, which takes into account that existing drug treatments do not completely block de novo infection and the possibility of noncytolytic loss of infected cells. On initiation of therapy, there was a mean delay of 1.6 days followed by a biphasic or muliphasic decay of plasma HBV DNA. The slope of the first phase varied considerably, with one individual having rapid decay, corresponding to a virion half-life of 1 hour, but others showing half-lives of up to 92 hours. Individuals either had a slow second-phase decline (t12 = 7.2 ± 1.2 days) or a flat second phase. Some individuals exhibited a complex "staircase pattern" of decay, with further phases of viral DNA decline and phases with little change in viral load. (HEPATOLOGY 2001;34:1012-1020.)

Serum alanine aminotransferase flares during interferon treatment of chronic hepatitis B: Is sustained clearance of HBV DNA dependent on levels of pretreatment viremia? (*Human Study*)
Satheesh Nair, Robert P. Perrillo
During interferon treatment of chronic hepatitis B, an alanine aminotransferase (ALT) flare may herald a sustained loss of viral replication, but the relationship between virologic response, the extent of a flare, and pretreatment hepatitis B virus (HBV) DNA level has not been defined. We retrospectively examined the impact of an ALT flare on sustained virologic response in 121 interferon-treated patients and 42 untreated controls with either low-level (<100 pg/mL) or high-level (100 pg/mL) viremia. The degree of ALT flare was classified as mild (increase in ALT of 86-171 IU/L above baseline), moderate (increase of 172 to 343 IU/L above baseline), and severe (increase of 344 IU/L above baseline). Undetectable serum HBV DNA and hepatitis B e antigen (HBeAg) loss were significantly more likely at the end of follow-up in patients having a flare (P = .0001 and .001, respectively). In the high viremia group, a proportionate increase in virologic response was observed as the degree of flare increased. By multivariate analysis, high baseline HBV DNA, high pretreatment ALT, and both moderate and severe ALT flare were independently predictive of a virologic response with severe flare being the most powerful predictor for a sustained loss of serum HBV DNA (odds ratio, 5.3; P = .004). Severe flare was predictive of a virologic response in the high but not low viremia group. We conclude that a virologic response in patients with high-level viremia is dependent on the degree of ALT flare. Induction of a robust flare may enhance virologic response when high-level viremia is detected. (HEPATOLOGY 2001;34:1021-1026.)

Prevalence of naturally occurring surface gene variants of hepatitis B virus in nonimmunized surface antigen­negative Chinese carriers (*Human Study*)
Jinlin Hou, Zhanghui Wang, Jinjun Cheng, Yulong Lin, George K. K. Lau, Jian Sun, Fuyuan Zhou, Jenny Waters, Peter Karayiannis, Kangxian Luo
Previous studies have suggested that hepatitis B virus (HBV) variants may account for the presence of HBV DNA in hepatitis B surface antigen (HBsAg)-negative patients (occult HBV infection). However, it is not known how widespread these variants are and how they influence the course of liver disease. To determine the prevalence of variants within the major hydrophilic region (MHR) of HBsAg, we investigated 2,565 subjects, including subjects with chronic hepatitis, cryptogenic cirrhosis, hemodialysis patients, and blood donors. Fifty-one of them had occult HBV infection. The entire S gene from 46 of these patients was sequenced from amplified serum HBV DNA. Forty-three percent (20 of 46) had mutations in the MHR of HBsAg. Thirty-two amino acid substitutions between positions 100-160 of the MHR of HBsAg were detected in 18 patients, and these ranged from 1 to 4 per patient. These changes involved 11 positions inside and 5 outside of the historical first and second loops of the "a" determinant, and included the following: Q101K, T115A, K122N, T123A, T126N, Q129N, G130R, T131I, M133T, F134L, C138Y, K141E, P142S, G145R, N146S, and C147F/R. Combinations of mutations were detected in 9 patients, and 7 of these have not been described before. Two further patients had insertion mutations immediately before the "a" determinant. Monoclonal antibody binding tests with the Royal Free hepatitis B surface (RFHBs) panel of antibodies revealed decreased immunoreactivity in 6 novel variants of HBsAg. The existence of patients with occult HBV infection caused by HBsAg variants, therefore, has implications for their possible transmission through sexual contact and by blood transfusion. (HEPATOLOGY 2001;34:1027-1034.)

Interferon and ribavirin combination therapy for chronic hepatitis C in human immunodeficiency virus­infected patients with congenital coagulation disorders (*Human Study*)
Silvia Sauleda, Alberto Juárez, Juan I. Esteban, Carmen Altisent, Isabel Ruiz, Lluís Puig, Rafael Esteban, Jaime Guardia
We have conducted an open, prospective trial to assess the safety and efficacy of interferon alfa-2b and ribavirin in combination for the treatment of chronic hepatitis C in human immunodeficiency virus (HIV)-infected hemophiliacs. Twenty hemophiliacs coinfected with HIV and hepatitis C virus (HCV), 18 of them under highly active antiretroviral therapy (HAART), with a mean CD4+ cell count of 490 ± 176 cells/mm3 and undetectable (n = 9) or low-level HIV RNA (<10,000 copies/mL; n = 11), were treated with interferon-alfa2b (3 MU thrice weekly) and ribavirin (800 mg/d) for 6 or 12 months according to virologic response. Patients were monitored for tolerance and response at 4, 8, 12, 24, 36, and 48 weeks during treatment and every other month thereafter. All 20 patients enrolled completed at least 6 months of treatment with no major side effect requiring treatment withdrawal, dose reduction, or modification of HAART. Overall, 8 patients (40%) achieved a sustained virologic response at the end of the 6-month post-treatment follow-up. Sustained responders had lower baseline HCV-RNA levels (5.7 ± 0.8 vs. 6.3 ± 0.4 log10 IU/mL, P = .041) but were otherwise similar to nonresponders. All sustained responders had a decrease in HCV-RNA level of at least 1 log per month during the first 2 months and undetectable levels at 6 months. In conclusion, our results provide evidence that combination therapy with interferon and ribavirin is safe in HIV-infected hemophiliacs with stable CD4 cell count and undetectable or low-level HIV replication, and leads to eradication of HCV in 40% of these patients. (HEPATOLOGY 2001;34:1035-1040.)

Nuclear factor-B in the liver of patients with chronic hepatitis C: Decreased RelA expression is associated with enhanced fibrosis progression (*Human Study*)
Patricia Boya, Esther Larrea, Iosu Sola, Pedro-Lorenzo Majano, Carlos Jiménez, María-Pilar Civeira, Jesús Prieto
The mechanisms of liver damage in chronic hepatitis C virus (HCV) infection are poorly understood. The transcription factor, nuclear factor-B (NF-B), regulates the expression of genes involved in apoptosis, inflammation, and antiviral response. It plays a protective role in several forms of liver damage. In this study, we analyzed NF-B by gel mobility shift assay and immunohistochemistry in liver biopsies from HCV-infected patients, and we have determined the hepatic levels of the components of the NF-B system by semiquantitative polymerase chain reaction (PCR). We found that NF-B was activated in the liver of patients with chronic hepatitis C. Neither NF-B activity nor the RNA levels of NF-B subunits showed correlation with liver inflammatory activity, viral load, or HCV genotype. By contrast, hepatic mRNA values of RelA, the main element of active NF-B, correlated inversely with apoptosis (r = ­.68; P < .05) and with the rate of fibrosis progression (r = ­.51; P < .04). In intermediate/rapid fibrosers, RelA mRNA levels were significantly decreased as compared with slow fibrosers (P < .003) and with normal livers (P < .03). In conclusion, we found that NF-B is activated in chronic HCV-infected livers, and that the expression of RelA is inversely correlated with liver cell apoptosis and with the rate of fibrosis progression. Our data thus suggest that RelA expression may protect against liver fibrosis and hepatocellular damage. (HEPATOLOGY 2001;34:1041-1048.)

Augmented hepatic interferon gamma expression and T-cell influx characterize acute hepatitis progressing to recovery and residual lifelong virus persistence in experimental adult woodchuck hepatitis virus infection
Paul D. Hodgson, Tomasz I. Michalak
Woodchucks infected with woodchuck hepatitis virus (WHV) have profiles of liver disease and age-dependent rates of progression to chronic hepatitis (CH) comparable with those seen in human hepatitis B. The mechanism of recovery from acute hepadnaviral infection or its evolution to chronicity remains unknown, although the liver immune responses are expected to play an important role. To determine the dynamics of intrahepatic cytokine expression and T-cell involvement, and to assess their value in predicting the outcome of acute hepatitis (AH) in the adult onset of WHV infection, we evaluated liver transcription of interferon gamma (IFN-); tumor necrosis factor (TNF-); interleukins (IL)-2, -4, and -6; and the T-cell influx in relation to disease histologic severity and virus load in serial liver biopsies collected during the life span of experimentally infected woodchucks. Our results show that recovery from viral AH in adulthood is preceded by a significantly greater hepatic expression of IFN- and CD3, an increased TNF- transcription, lower hepatic WHV load, and a greater degree of liver inflammation than those in acute infection with CH outcome. Furthermore, we have learned that the elevated IFN-, TNF-, and CD3 expression in the liver endures for years not only in CH, but also, although to a lesser extent, in apparently completely resolved infection. This is consistent with our previous findings that residual WHV replication and remnant liver inflammation continue for life after recovery from AH. This study indicates that antiviral cytokines, in particular IFN-, may play a central role in the long-term control of occult hepadnavirus persistence in the liver. (HEPATOLOGY 2001;34:1049-1059.)

GASTROENTEROLOGY

Table of Contents for November 2001 · Volume 121 · Number 5

Gene Therapy for Gastric Ulcers With Single Local Injection of Naked DNA Encoding VEGF and Angiopoietin-1
MICHAEL K. JONES, HIROFUMI KAWANAKA, DOLGOR BAATAR, IMRE L. SZABÓ, KOUJI TSUGAWA, RAMA PAI, GOU YOUNG KOH, INGUNE KIM, I. JAMES SARFEH, and ANDRZEJ S. TARNAWSKI
Background & Aims: Angiogenesis, formation of new capillary blood vessels, is crucial for gastroduodenal ulcer healing because it enables delivery of oxygen and nutrients to the healing site. Because angiogenesis is stimulated by vascular endothelial growth factor (VEGF) and angiopoietin-1 (Ang1), we studied whether local gene therapy with nonviral DNA encoding VEGF and/or Ang1 into the ulcer base could accelerate ulcer healing through enhanced angiogenesis. Methods: Gastric ulcers were induced in rats by acetic acid applied to the serosal surface of the stomach, and the site around the ulcer was injected with nonviral plasmid-encoding full-length complementary DNA (cDNA) of human recombinant (rh) VEGF165, rhAng1, or their combination. For some studies, neutralizing anti-VEGF antibody was administered. Results: Single local injection of plasmids encoding VEGF165 and Ang1 significantly increased neovascularization and accelerated ulcer healing. A neutralizing anti-VEGF antibody significantly reduced the acceleration of ulcer healing resulting from the treatment. Coinjection of both plasmids encoding rhVEGF165 and rhAng1 resulted in formation of more mature vessels and to more complete restoration of gastric glandular structures within the ulcer scar. However, this did not result in further reduction of ulcer size. Conclusions: VEGF and Ang1 gene therapy, with limited duration of target gene expression, significantly accelerates gastric ulcer healing. Coinjection of both plasmids leads to more complete structural restoration. Inhibition of accelerated healing by a neutralizing anti-VEGF antibody indicates an essential role for VEGF and enhanced angiogenesis in ulcer healing.
Gastroenterology 2001 121: 1040-1047. Published online Oct 16 2001.

Azathioprine Treatment and Male Fertility in Inflammatory Bowel Disease
CLEMENS DEJACO, CHRISTIAN MITTERMAIER, WALTER REINISCH, CHRISTOPH GASCHE, THOMAS WALDHOER, HEINZ STROHMER, and GABRIELE MOSER
Background & Aims: Long-term treatment with azathioprine (AZA) is well established in inflammatory bowel disease (IBD). AZA is metabolized to 6-mercaptopurine (6-MP), which interacts in purine metabolism and is therefore considered to have mutagenic potentials. This is the first study to examine the influence of AZA on semen quality. Methods: Semen quality was examined and compared with World Health Organization (WHO) standards regarding sperm density, motility, morphology, ejaculate volume, and total sperm count in 23 IBD patients treated with AZA. In 10 of these patients, a semen sample was assessed before and during AZA treatment; in another 5, semen analysis was performed twice during at least 2 years of AZA therapy. Results: In 18 patients treated with 1.5-2 mg/kg AZA daily for at least 3 months but without sulfasalazine, sperm density was 94 ± 84 Mio/mL (94% within WHO standard), motility was 60% ± 20% (67% within WHO standard), the proportion of sperm with normal morphology was 44% ± 21% (67% within WHO standard), ejaculate volume was 3.4 ± 1.5 mL (89% within WHO standard), and total sperm count was 297 ± 272 Mio (94% within WHO standard). No changes in semen parameters were noted after 11 ± 5 months of AZA administration or during long-term treatment (49 ± 14 months). Sulfasalazine administration in 5 patients was associated with markedly reduced semen morphology. During the study period, 6 patients fathered 7 healthy children. Conclusions: Our data show that AZA does not reduce semen quality and thereby male fertility in IBD.
Gastroenterology 2001 121: 1048-1053. Published online Oct 24 2001.

Impaired Drinking Capacity in Patients With Functional Dyspepsia: Relationship With Proximal Stomach Function
GUY E. BOECKXSTAENS, DAVID P. HIRSCH, BRAM D. J. VAN DEN ELZEN, SIEM H. HEISTERKAMP, and GUIDO N. J. TYTGAT
Background & Aims: Impaired fundic accommodation to a meal and hypersensitivity to distention are increasingly recognized as important mechanisms underlying functional dyspepsia (FD). In the present study, we evaluated whether a drink test can predict such abnormalities and thus represent a noninvasive tool to study proximal stomach motor function. Methods: Healthy volunteers (HV), nonconsulters with mild dyspeptic symptoms (MS), and patients with FD filled out a disease-specific questionnaire and underwent a drink test with either water or with a high calorie fluid. The maximal ingested volume and the subsequent symptoms were meticulously recorded. In addition, all subjects underwent a gastric barostat study assessing meal-induced relaxation and sensation to distention. Results: Drinking capacity was not significantly related to any particular dyspeptic symptom. FD were able to consume less water (893 ± 70 mL) and caloric liquid (767 ± 50 mL) compared with HV (water, 1764 ± 120 mL; caloric liquid, 1308 ± 96 mL) or MS (water, 1645 ± 120 mL; caloric liquid, 973 ± 45 mL). Approximately half of the FD had an abnormal water or Nutridrink test compared with 9% of MS and 4% of HV. Furthermore, FD developed significantly more symptoms than MS or HV after both drink tests. The drinking capacity did not predict impaired fundic accommodation or visceral hypersensitivity. Conclusions: FD, but not MS, have an impaired drinking capacity to both water and a nutrient liquid. The drinking capacity is not related to a specific dyspeptic symptom and does not predict proximal stomach motor function.
Gastroenterology 2001 121: 1054-1063. Published online Oct 24 2001.

A Comparison of Endoscopic Ultrasound, Magnetic Resonance Imaging, and Exam Under Anesthesia for Evaluation of Crohn's Perianal Fistulas
DAVID A. SCHWARTZ, MAURITS J. WIERSEMA, KIKA M. DUDIAK, J. G. FLETCHER, JONATHAN E. CLAIN, WILLIAM J. TREMAINE, ALAN R. ZINSMEISTER, IAN D. NORTON, LISA A. BOARDMAN, RICHARD M. DEVINE, BRUCE G. WOLFF, TONIA M. YOUNG-FADOK, NANCY N. DIEHL, JOHN H. PEMBERTON, and WILLIAM J. SANDBORN
Background & Aims: To determine accuracy of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) for evaluation of Crohn's disease perianal fistulas. Methods: Thirty-four patients with suspected Crohn's disease perianal fistulas were prospectively enrolled in a blinded study comparing EUS, MRI, and examination under anesthesia (EUA). Fistulas were classified according to Parks' criteria, and a consensus gold standard was determined for each patient. Acceptable accuracy was defined as agreement with the consensus gold standard for 85% of patients. Results: Three patients did not undergo MRI; 1 did not undergo EUS or EUA; and consensus could not be reached for 1. Thirty-two patients had 39 fistulas (20 trans-sphincteric, 5 extra-sphincteric, 6 recto-vaginal, 8 others) and 13 abscesses. The accuracy of all 3 modalities was 85%: EUS 29 of 32 (91%, confidence interval [CI] 75%-98%), MRI 26 of 30 (87%, CI 69%-96%), and EUA 29 of 32 (91%, CI 75%-98%). Accuracy was 100% when any 2 tests were combined. Conclusions: EUS, MRI, and EUA are accurate tests for determining fistula anatomy in patients with perianal Crohn's disease. The optimal approach may be combining any 2 of the 3 methods.
Gastroenterology 2001 121: 1064-1072. Published online Oct 24 2001

A Multicenter, Randomized, Clinical Trial of Hormonal Therapy in the Prevention of Rebleeding From Gastrointestinal Angiodysplasia
FÉLIX JUNQUERA, FAUST FEU, MICHEL PAPO, SEBASTIÁN VIDELA, JOSÉ RAMÓN ARMENGOL, JOSEP MARÍA BORDAS, ESTEBAN SAPERAS, JOSEP M. PIQUÉ, and JUAN-RAMÓN MALAGELADA
Background & Aims: The efficacy of hormonal therapy for recurrent bleeding from gastrointestinal angiodysplasia remains uncertain. We investigated the efficacy of long-term estrogen-progestagen therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. Methods: Seventy-two noncirrhotic patients bleeding from gastrointestinal angiodysplasia confirmed by endoscopy or angiography were randomized to receive in double-blind conditions treatment with ethinylestradiol (0.01 mg) plus norethisterone (2 mg) (1 tablet/d), or placebo (1 tablet/d) for a minimum period of 1 year (range: 1-2 years). Results: Four patients could not be assessed because they did not attend the first follow-up visit. Failure of treatment occurred in 13 of 33 (39%) patients in the treatment group and in 16 of 35 (46%) patients in the placebo group (P = NS). No significant differences between groups were found according to number of bleeding episodes (0.7 ± 1.0 vs. 0.9 ± 1.5) and transfusional requirements (0.9 ± 1.9 vs. 0.7 ± 1.5 units). Treatment received was not an independent predictor for rebleeding prevention in the multivariate regression analysis. Severe adverse events (2 vs. 1) and mortality (0 vs. 1 patient, respectively) were similar between the treatment and placebo groups. Conclusions: Continuous estrogen-progestagen treatment is not useful in the prevention of rebleeding from gastrointestinal angiodysplasia.
Gastroenterology 2001 121: 1073-1079. Published online Oct 24 2001.

Inflammatory Bowel Disease Is Not Associated With an Increased Risk of Lymphoma
JAMES D. LEWIS, WARREN B. BILKER, COLLEEN BRENSINGER, JULIUS J. DEREN, DAVID J. VAUGHN, and BRIAN L. STROM
Background & Aims: Previous studies of the risk of lymphoma in inflammatory bowel disease patients have provided conflicting results. This study examines the risk of Hodgkin's and non-Hodgkin's lymphoma among patients with inflammatory bowel disease. Methods: The authors performed a retrospective cohort study using the General Practice Research Database. Inflammatory bowel disease patients were matched to randomly selected controls on age, sex, and primary care practice. Lymphoma rates were also compared with published age- and sex-specific rates. Results: The study included 6605 patients with Crohn's disease, 10,391 with ulcerative colitis, and 60,506 controls followed for an average of 3.7, 3.9, and 4.4 years, respectively. The incidence of lymphoma was not increased in patients with inflammatory bowel disease (relative risk = 1.20; 95% CI, 0.67-2.06). In subgroup analyses, an increased risk was not observed among patients with Crohn's disease (relative risk = 1.39; 95% CI, 0.50-3.40) or ulcerative colitis (relative risk = 1.11; 95% CI, 0.51-2.19). Compared with inflammatory bowel disease patients not treated with azathioprine or 6-MP, the relative risk of lymphoma among the 1465 inflammatory bowel disease patients treated with these medications (average, 106 mg/day for 2.0 years) was 1.27 (95% CI 0.03-8.20). Conclusions: Patients with inflammatory bowel disease do not have an increased risk of lymphoma as compared with the general population. Although we cannot completely rule out a modest increased risk of lymphoma with azathioprine or 6-MP therapy, an increased risk was not observed in this cohort.
Gastroenterology 2001 121: 1080-1087. Published online Oct 24 2001.

Etanercept for Active Crohn's Disease: A Randomized, Double-Blind, Placebo-Controlled Trial
WILLIAM J. SANDBORN, STEPHEN B. HANAUER, SEYMOUR KATZ, MICHAEL SAFDI, DOUGLAS G. WOLF, RICHARD D. BAERG, WILLIAM J. TREMAINE, THERESE JOHNSON, NANCY N. DIEHL, and ALAN R. ZINSMEISTER
Background & Aims: We evaluated etanercept, a human soluble tumor necrosis factor receptor: Fc fusion protein, for the treatment of active Crohn's disease. Methods: Forty-three patients with moderate to severe Crohn's disease were enrolled in an 8-week placebo-controlled trial. Patients were randomized to subcutaneous etanercept 25 mg or placebo twice weekly. The primary outcome measure was clinical response at week 4, defined as a decrease in the baseline Crohn's Disease Activity Index score 70 points or a Crohn's Disease Activity Index score <150 points. Results: At week 4, 39% of etanercept-treated patients had clinical response as compared with 45% of placebo-treated patients (P = 0.763). The frequency of common adverse events including headache, new injection site reaction, asthenia, abdominal pain, Crohn's disease-related anemia, and skin disorders was similar in both groups. Likewise, the frequency of severe or serious adverse events was similar in both groups. Conclusions: Subcutaneous etanercept at a dose of 25 mg twice weekly is safe, but not effective, for the treatment of patients with moderate to severe Crohn's disease. The dose of etanercept administered in this study is that approved for rheumatoid arthritis. Higher doses or more frequent dosing may be required to attain a response in patients with active Crohn's disease.
Gastroenterology 2001 121: 1088-1094. Published online Oct 24 2001

Step-Down Management of Gastroesophageal Reflux Disease
JOHN M. INADOMI, ROULA JAMAL, GLEN H. MURATA, RICHARD M. HOFFMAN, LAURENCE A. LAVEZO, JUSTINA M. VIGIL, KATHLEEN M. SWANSON, and AMNON SONNENBERG
Background & Aims: As the economic burden of gastroesophageal reflux disease (GERD) is largely weighted to maintenance as opposed to initial therapy, switching from more potent to less expensive medication once symptoms are alleviated (step-down therapy) may prove to be most cost-effective. This study aimed to prospectively evaluate the feasibility of step-down therapy in a cohort of patients with symptoms of uncomplicated GERD. Methods: Patients whose GERD symptoms were alleviated by proton pump inhibitors (PPIs) were recruited from outpatient general medicine clinics. After baseline demographic and quality of life information were obtained, PPIs were withdrawn from subjects in a stepwise fashion. Primary outcome was recurrence of symptoms during follow-up that required reinstitution of PPIs. Secondary outcomes included changes in quality of life and overall cost of management. Predictors of nonresponse to step-down were assessed. Results: Seventy-one of 73 enrolled subjects completed the study. Forty-one of 71 (58%) were asymptomatic off PPI therapy after 1 year of follow-up. Twenty-four of 71 (34%) required histamine 2-receptor antagonists, 5/71 (7%) prokinetic agents, 1/71 (1%) both, and 11/71 (15%) remained asymptomatic without medication. Quality of life did not significantly change, whereas management costs decreased by 37%. Multivariable analysis revealed younger age and a dominant symptom of heartburn to predict PPI requirement. Conclusions: Step-down therapy is successful in the majority of patients and can decrease costs without adversely affecting quality of life.
Gastroenterology 2001 121: 1095-1100. Published online Oct 24 2001.

Apolipoprotein B48 Glycosylation in Abetalipoproteinemia and Anderson's Disease
NATHALIE BERRIOT-VAROQUEAUX, A. HAYSSAM DANNOURA, ALAIN MOREAU, NICOLE VERTHIER, AGNÈS SASSOLAS, GUILLAUME CADIOT, ALAIN LACHAUX, ANNE MUNCK, JACQUES SCHMITZ, LAWRENCE P. AGGERBECK, and MARIE-ELISABETH SAMSON-BOUMA
Background & Aims: Abetalipoproteinemia and Anderson's disease are hereditary lipid malabsorption syndromes. In abetalipoproteinemia, lipoprotein assembly is defective because of mutations in the microsomal triglyceride transfer protein. Here, we evaluated the intracellular transport of apolipoprotein B48 to localize the defect in Anderson's disease. Methods: Asparagine-linked oligosaccharide processing of apolipoprotein B48 in normal and affected individuals was determined by the endoglycosidase H and F sensitivities of the protein after metabolic labeling of intestinal explants in organ culture. Cell ultrastructure was evaluated with electron microscopy. Results: In Anderson's disease as in normal individuals, there was a time-dependent transformation of high mannose endoglycosidase H-sensitive oligosaccharides, of endoplasmic reticulum origin, to complex endoglycosidase H-resistant oligosaccharides, added in the Golgi network. In contrast, despite the translocation of apolipoprotein B48 into the endoplasmic reticulum in patients with abetalipoproteinemia and in biopsies treated with Brefeldin A, which blocks anterograde transport between the endoplasmic reticulum and the Golgi network, there was no transformation of endoglycosidase H-sensitive oligosaccharides. Conclusions: In abetalipoproteinemia and Anderson's disease, apolipoprotein B48 is completely translocated into the endoplasmic reticulum, but only in Anderson's disease is the protein transported to the Golgi apparatus. This suggests that Anderson's disease is caused by a post-Golgi cargo-specific secretion defect.
Gastroenterology 2001 121: 1101-1108. Published online Oct 24 2001.

Cerebral Metabolism of Ammonia and Amino Acids in Patients With Fulminant Hepatic Failure
GITTE IRENE STRAUSS, GITTE MOOS KNUDSEN, JENS KONDRUP, KIRSTEN MØLLER, and FIN STOLZE LARSEN
Background & Aims: High circulating levels of ammonia have been suggested to be involved in the development of cerebral edema and herniation in fulminant hepatic failure (FHF). The aim of this study was to measure cerebral metabolism of ammonia and amino acids, with special emphasis on glutamine metabolism. Methods: The study consisted of patients with FHF (n = 16) or cirrhosis (n = 5), and healthy subjects (n = 8). Cerebral blood flow was measured by the 133Xe washout technique. Blood samples for determination of ammonia and amino acids were drawn simultaneously from the radial artery and the internal jugular bulb. Results: A net cerebral ammonia uptake was only found in patients with FHF (1.62 ± 0.79 µmol · 100 g1 · min1). The cerebral glutamine efflux was higher in patients with FHF than in the healthy subjects and cirrhotics, 6.11 ± 5.19 vs. 1.93 ± 1.17 and 1.50 ± 0.29 µmol · 100 g1 · min1, respectively (P < 0.05). Patients with FHF who subsequently died of cerebral herniation (n = 6) had higher arterial ammonia concentrations, higher cerebral ammonia uptake, and higher cerebral glutamine efflux than survivors. Intervention with short-term mechanical hyperventilation in FHF reduced the net cerebral glutamine efflux, despite an unchanged net cerebral ammonia uptake. Conclusions: Patients with FHF have an increased cerebral glutamine efflux, and short-term hyperventilation reduces this efflux. A high cerebral ammonia uptake and cerebral glutamine efflux in patients with FHF were associated with an increased risk of subsequent fatal intracranial hypertension.
Gastroenterology 2001 121: 1109-1119. Published online Oct 24 2001

Helicobacter pylori Eradication Does Not Exacerbate Reflux Symptoms in Gastroesophageal Reflux Disease
PAUL MOAYYEDI, CHANDU BARDHAN, LYNNE YOUNG, MICHAEL F. DIXON, LORNA BROWN, and ANTHONY T.R. AXON
Background & Aims: Observational studies have suggested that Helicobacter pylori may protect against gastrointestinal reflux disease (GERD), but these results could be due to bias or confounding factors. We addressed this in a prospective, double blind, randomized, controlled trial. Methods: H. pylori-positive patients with at least a 1-year history of heartburn with a normal endoscopy or grade A esophagitis were recruited. Patients were randomized to 20 mg omeprazole, 250 mg clarithromycin, and 500 mg tinidazole twice a day for 1 week or 20 mg omeprazole twice a day and identical placebos. A second concurrently recruited control group of H. pylori-negative patients were given open label 20 mg omeprazole twice a day for 1 week. All patients received 20 mg omeprazole twice a day for the following 3 weeks and 20 mg omeprazole once daily for a further 4 weeks. Omeprazole was discontinued at 8 weeks and patients were followed up for a further 10 months. A relapse was defined as moderate or severe reflux symptoms. H. pylori eradication was determined by 13C-urea breath test. Results: The H. pylori-positive cases were randomized to antibiotics (n = 93) or placebo (n = 97). Relapse of GERD occurred in 83% of each of the antibiotic, placebo, and H. pylori-negative groups during the 12-month study period. Life tables revealed no statistical difference between the 2 H. pylori-positive groups (log rank test, P = 0.84) or between the 3 groups (log rank test, P = 0.94) in the time to first relapse. Two patients in each group developed grade B esophagitis at 12 months. Conclusions: H. pylori eradication therapy does not seem to influence relapse rates in GERD patients.
Gastroenterology 2001 121: 1120-1126. Published online Oct 24 2001.

Periampullary Adenomas and Adenocarcinomas in Familial Adenomatous Polyposis: Cumulative Risks and APC Gene Mutations
JAN BJÖRK, HELENA ÅKERBRANT, LENNART ISELIUS, ANNIKA BERGMAN, YVONNE ENGWALL, JAN WAHLSTRÖM, TOMMY MARTINSSON, MARGARETA NORDLING, and ROLF HULTCRANTZ
Background & Aims: Patients with familial adenomatous polyposis (FAP) have a high prevalence of duodenal adenomas, and the region of the ampulla of Vater is the predilection site for duodenal adenocarcinomas. This study assessed the risk of stage IV periampullary adenomas according to the Spigelman classification and periampullary adenocarcinomas in Swedish FAP patients screened by esophagogastroduodenoscopy (EGD). The genotype of patients with stage IV periampullary adenomas and periampullary adenocarcinomas was also investigated. Methods: A retrospective study of 180 patients screened by EGD in 1982-1999 was undertaken. Kaplan-Meier analysis was performed to evaluate cumulative risk. Mutation analysis was carried out in patients with periampullary adenocarcinomas diagnosed outside the screening program, in addition to patients in the screening group with stage IV periampullary adenomas and adenocarcinomas. Results: Periampullary adenoma stage IV was diagnosed in 14 patients (7.8%), with a cumulative risk of 20% at age 60 years. Periampullary adenocarcinoma was diagnosed in 5 patients (2.8%), with a cumulative risk of 10% at age 60. Three of the adenocarcinomas occurred in patients with stage IV periampullary adenomas compared with 2 in patients with less severe periampullary adenomatosis at screening (odds ratio, 31; 95% confidence interval, 4.6-215). Fifteen (88%) of the APC gene mutations were detected; 12 of these were located downstream from codon 1051 in exon 15. Conclusions: The life time risk of severe periampullary lesions in FAP patients is high, and an association between stage IV periampullary adenomas and a malignant course of the periampullary adenomatosis is strongly suggestive. Mutations downstream from codon 1051 seem to be associated with severe periampullary lesions.
Gastroenterology 2001 121: 1127-1135. Published online Oct 24 2001.

Genetic Link of Hepatocellular Carcinoma With Polymorphisms of the UDP-Glucuronosyltransferase UGT1A7 Gene
ARNDT VOGEL, SUSANNE KNEIP, AYSE BARUT, URSULA EHMER, ROBERT H. TUKEY, MICHAEL P. MANNS, and CHRISTIAN P. STRASSBURG
Background & Aims: Hepatocellular carcinoma is associated with risk factors including hepatitis C, hepatitis B, cirrhosis, genetic liver diseases, and environmental carcinogens. Uridine 5'-diphosphate-glucuronosyltransferases are a superfamily of detoxifying enzymes capable of tobacco-borne carcinogen detoxification and cellular protection. This study examines the association of UGT1A7 and UGT1A9 gene polymorphisms with hepatocellular carcinoma. Methods: Genomic DNA from the blood of 59 patients with hepatocellular carcinoma and 70 control subjects without evidence of cancer was analyzed by UGT1A7- and UGT1A9-specific PCR, sequencing analysis, and temperature gradient gel electrophoresis. Results: Three UGT1A7 missense mutations were detected defining the UGT1A7*2, UGT1A7*3, and UGT1A7*4 alleles. Wild-type UGT1A7 alleles were present in 41.4% of controls but only in 6.8% of cancer patients (P < 0.001; odds ratio [OR], 9.73; 95% confidence interval [CI], 3.17-29.83). UGT1A7 polymorphisms were present in 93.2% of hepatocellular cancer patients, 74.5% carried the UGT1A7*3 allele (P < 0.001; OR, 10.76; 95% CI, 4.75-24.38), which combines the W208R, N129K, and R131K mutations and encodes a protein with low carcinogen detoxification activity. No UGT1A9 polymorphisms were detected. Conclusions: The significant association of hepatocellular carcinoma with the UGT1A7*3 allele encoding a low detoxification activity protein is identified and implicates UGT1A7 as a risk gene of hepatocarcinogenesis in addition to a role as potential marker for cancer risk assessment in chronic liver disease.
Gastroenterology 2001 121: 1136-1144. Published online Oct 24 2001.

Infliximab Induces Apoptosis in Monocytes From Patients With Chronic Active Crohn's Disease by Using a Caspase-Dependent Pathway
ANDREAS LÜGERING, MICHAEL SCHMIDT, NORBERT LÜGERING, HANS-GERD PAUELS, WOLFRAM DOMSCHKE, and TORSTEN KUCHARZIK
Background & Aims: Treatment with a chimeric anti-tumor necrosis factor (TNF) antibody (infliximab) has been shown to be highly efficient for patients with steroid-refractory Crohn's disease (CD). However, the mechanism of action remains largely unknown. As monocytopenia is commonly observed after treatment with infliximab, we investigated the role of infliximab-induced monocyte apoptosis. Methods: Peripheral blood monocytes from healthy volunteers and patients with chronic active CD (CDAI > 250) were isolated by density gradient centrifugation methods. Apoptosis was determined by annexin V staining DNA-laddering, and transmission electron microscopy. Activation of caspases and mitochondrial release of cytochrome C was determined by immunoblotting. Transcriptional activation of members of the Bcl-2 family have been analyzed by ribonuclease protection assay. Results: Treatment with infliximab at therapeutic concentrations resulted in monocyte apoptosis in patients with chronic active CD in a dose-dependent manner. Infliximab-induced monocyte-apoptosis required the activation of members of the caspase-family since activation of caspase-8, -9, and -3 could be determined. Caspase activation was induced by a CD95/CD95L independent signaling pathway with mitochondrial release of cytochrome C. Cytochrome C release seemed to be triggered by transcriptional activation of Bax and Bak. Monocyte apoptosis in vivo as determined by annexin-V binding and caspase-3 activation could be shown in patients with chronic active CD as soon as 4 hours after treatment with infliximab. Conclusions: Monocyte apoptosis induced by infliximab may be an important mechanism that could explain the powerful anti-inflammatory properties of infliximab in patients with chronic active CD.
Gastroenterology 2001 121: 1145-1157. Published online Oct 24 2001.

Oral Immunization With HCV-NS3-Transformed Salmonella: Induction of HCV-Specific CTL in a Transgenic Mouse Model
HEINER WEDEMEYER, SARA GAGNETEN, ANTHONY DAVIS, RALF BARTENSCHLAGER, STEPHEN FEINSTONE, and BARBARA REHERMANN
Background & Aims: The ability to induce cytotoxic T cells is considered an important feature of a candidate hepatitis C virus (HCV) vaccine. We used an oral immunization strategy with attenuated HCV-NS3-transformed Salmonella typhimurium to deliver DNA directly to the gut-associated lymphoid tissue. Methods: HLA-A2.1 transgenic mice were immunized once with transformed attenuated Salmonella. HCV-specific CD8+ T cells were analyzed in vitro as well as in vivo by challenge of mice with recombinant HCV-NS3 vaccinia virus. Results: Salmonella (108 colony-forming units; 20 µg plasmid DNA) induced cytotoxic and IFN--producing CD8+ T cells specific for the immunodominant epitope NS3-1073 in 26 of 30 mice (86%) that persisted for at least 10 months. A second epitope (NS3-1169) was also recognized by cytotoxic and IFN--producing T cells, whereas a third one (NS3-1406) stimulated IFN- production without cytotoxicity. The minimal amount of plasmid DNA required to induce CTLs was 2 ng. Upon challenge with recombinant HCV-NS3-expressing vaccinia virus, vaccinia titers were significantly lower in mice immunized with Salmonella-NS3 than in mice immunized with control Salmonella, demonstrating the in vivo function of CTLs. Conclusions: Oral immunization with attenuated Salmonella typhimurium as a carrier for HCV DNA induces long-lasting T-cell responses.
Gastroenterology 2001 121: 1158-1166. Published online Oct 24 2001.

The Pattern of Intestinal Substrate Oxidation Is Altered by Protein Restriction in Pigs
SOPHIE R. D. VAN DER SCHOOR, JOHANNES B. VAN GOUDOEVER, BARBARA STOLL, JOE F. HENRY, JUDY R. ROSENBERGER, DOUGLAS G. BURRIN, and PETER J. REEDS
Background & Aims: Previous studies indicate that amino acids and glucose are the major oxidative substrates for intestinal energy generation. We hypothesized that low protein feeding would lower the contribution of amino acids to energy metabolism, thereby increasing the contribution of glucose. Methods: Piglets, implanted with portal, arterial, and duodenal catheters and a portal flow probe, were fed isocaloric diets of either a high protein (0.9 g/[kg/h] protein, 1.8 g/[kg/h] carbohydrate, and 0.4 g/[kg/h] lipid) or a low protein (0.4 g/[kg/h] protein, 2.2 g/[kg/h] carbohydrate, and 0.5 g/[kg/h] lipid) content. They received enteral or intravenous infusions of [1-13C]leucine (n = 17), [U-13C]glucose (n = 15), or enteral[U-13C]glutamate (n = 8). Results: CO2 production by the splanchnic bed was not affected by the diet. The oxidation of leucine, glutamate, and glucose accounted for 82% of the total CO2 production in high protein-fed pigs. Visceral amino acid oxidation was substantially suppressed during a low protein intake. Although glucose oxidation increased to 50% of the total visceral CO2 production during a low protein diet, this increase did not compensate entirely for the fall in amino acid oxidation. Conclusions: Although low protein feeding increases the contribution of enteral glucose oxidation to total CO2 production, this adaptation is insufficient. To compensate for the fall in amino acid oxidation, other substrates become increasingly important to intestinal energy generation.
Gastroenterology 2001 121: 1167-1175. Published online Oct 24 2001.

Alterations in Vesicle Transport and Cell Polarity in Rat Hepatocytes Subjected to Mechanical or Chemical Cholestasis
NATALIE J. TÖRÖK, ELIZABETH M. LARUSSO, and MARK A. McNIVEN
Background & Aims: The molecular mechanisms that contribute to the cholestatic condition in hepatocytes are poorly defined. It has been postulated that a disruption of normal vesicle-based protein trafficking may lead to alterations in hepatocyte polarity. Methods: To determine if vesicle motility is reduced by cholestasis, hepatocytes cultured from livers of bile duct ligation (BDL)- or ethinyl estradiol (EE)-injected rats, were viewed and recorded by high-resolution video microscopy. Cholestatic hepatocytes were analyzed by phalloidin staining and electron microscopy. Functional analysis was done by the sodium fluorescein sequestration assay. Results: In cholestatic hepatocytes, there was a significant decrease in the number of motile cytoplasmic vesicles observed compared with control cells. Further examination of cells from BDL- or EE-treated livers revealed the presence of numerous large intracellular lumina. More than 24% of cells in BDL-treated livers and 19% of cells in EE-treated livers displayed these structures, compared with 1.1% found in control hepatocytes. Phalloidin staining of hepatocytes showed a prominent sheath of actin surrounding the lumina, reminiscent of those seen about bile canaliculi. Electron microscopy revealed that these structures were lined by actin-filled microvilli. Further, these pseudocanaliculi perform many of the functions exhibited by bona fide canaliculi, such as sequestering sodium fluorescein. Conclusions: Both mechanically and chemically induced cholestasis have substantial effects on vesicle-based transport, leading to marked disruption of hepatocellular polarity.
Gastroenterology 2001 121: 1176-1184. Published online Oct 24 2001.

Hepatic Uptake of Cholecystokinin Octapeptide by Organic Anion-Transporting Polypeptides OATP4 and OATP8 of Rat and Human Liver
MANFRED G. ISMAIR, BRUNO STIEGER, VALENTINO CATTORI, BRUNO HAGENBUCH, MICHAEL FRIED, PETER J. MEIER, and GERD A. KULLAK-UBLICK
Background & Aims: Cholecystokinin (CCK) is a major gastrointestinal peptide hormone that is released postprandially from the small intestine and exerts marked effects on gallbladder and gastrointestinal motility. The smaller isoforms CCK-8 and CCK-4 are rapidly taken up into hepatocytes, metabolized, and excreted into bile. Our aim was to identify and characterize the hepatocellular CCK-8 uptake system. Methods: CCK-8 uptake was measured in Xenopus laevis oocytes expressing the organic anion-transporting polypeptides of rat liver (Oatp1, Oatp2, Oatp3, or Oatp4) and of human liver (OATP-A, OATP-B, OATP-C, or OATP8) and in primary cultured rat hepatocytes. Results: Rat Oatp4 and human OATP8 efficiently mediated CCK-8 uptake in oocytes, with Michaelis constant (Km) values of 14.9 ± 2.9 µmol/L and 11.1 ± 2.9 µmol/L, respectively. CCK-8 uptake by hepatocytes was also saturable, with a Km of 6.7 ± 2.1 µmol/L. The Km value in rat hepatocytes is consistent with Oatp4-mediated transport. Conclusions: CCK-8 is selectively transported by rat Oatp4 and human OATP8, both of which are exclusively expressed at the basolateral membrane of hepatocytes. These 2 transporters are the first and probably the predominant hepatic uptake systems for CCK-8 and may be critical for the rapid clearance of this hormone from the circulation.
Gastroenterology 2001 121: 1185-1190. Published online Oct 24 2001.

Increases in Guanylin and Uroguanylin in a Mouse Model of Osmotic Diarrhea Are Guanylate Cyclase C-Independent
KRIS A. STEINBRECHER, ELIZABETH A. MANN, RALPH A. GIANNELLA, and MITCHELL B. COHEN
Background & Aims: Guanylin and uroguanylin are peptide hormones that are homologous to the diarrhea-causing Escherichia coli enterotoxins. These secretagogues are released from the intestinal epithelia into the intestinal lumen and systemic circulation and bind to the receptor guanylate cyclase C (GC-C). We hypothesized that a hypertonic diet would result in osmotic diarrhea and cause a compensatory down-regulation of guanylin/uroguanylin. Methods: Gut-to-carcass weights were used to measure fluid accumulation in the intestine. Northern and/or Western analysis was used to determine the levels of guanylin, uroguanylin, and GC-C in mice with osmotic diarrhea. Results: Wild-type mice fed a polyethylene glycol or lactose-based diet developed weight loss, diarrhea, and an increased gut-to-carcass ratio. Unexpectedly, 2 days on either diet resulted in increased guanylin/uroguanylin RNA and prohormone throughout the intestine, elevated uroguanylin RNA, and prohormone levels in the kidney and increased levels of circulating prouroguanylin. GC-C-deficient mice given the lactose diet reacted with higher gut-to-carcass ratios. Although they did not develop diarrhea, GC-C-sufficient and -deficient mice on the lactose diet responded with elevated levels of guanylin and uroguanylin RNA and protein. A polyethylene glycol drinking water solution resulted in diarrhea, higher gut-to-carcass ratios, and induction of guanylin and uroguanylin in both GC-C heterozygous and null animals. Conclusions: We conclude that this model of osmotic diarrhea results in a GC-C-independent increase in intestinal fluid accumulation, in levels of these peptide ligands in the epithelia of the intestine, and in prouroguanylin in the kidney and blood.
Gastroenterology 2001 121: 1191-1202. Published online Oct 24 2001.

Expression and Localization of the Multidrug Resistance Proteins MRP2 and MRP3 in Human Gallbladder Epithelia
DANIEL ROST, JÖRG KÖNIG, GUNTER WEISS, ERNST KLAR, WOLFGANG STREMMEL, and DIETRICH KEPPLER
Background & Aims: The multidrug resistance protein (MRP) isoforms MRP2 (ABCC2) and MRP3 (ABCC3) play a decisive role in the hepatic secretion of endogenous and xenobiotic conjugates and are differentially expressed in hepatocytes and cholangiocytes. The epithelium of the gallbladder considerably modifies the composition of primary hepatic bile by absorption and secretion; however, the underlying transport mechanisms were largely unknown. Localization of MRP2 and MRP3 may provide an explanation of how the products of phase II conjugation are effluxed from gallbladder epithelia. Methods: Expression and localization of MRP2 and MRP3 were analyzed by reverse-transcription polymerase chain reaction (RT-PCR) and immunofluorescence microscopy of human gallbladder tissue. Results: Expression of MRP2 and MRP3 was identified in all gallbladders by RT-PCR followed by sequencing of the amplified fragments. Double immunofluorescence microscopy using 2 specific antibodies for the respective MRP isoform showed the simultaneous expression of MRP2 in the apical membrane and MRP3 in the basolateral membrane of gallbladder epithelia. MRP1 protein expression was not detectable. Conclusions: Our findings show the expression of MRP2 and MRP3 in distinct plasma membrane domains of gallbladder epithelia and provide evidence for the capacity of the gallbladder to secrete xenobiotic and endogenous anionic conjugates into blood via MRP3 and into bile via MRP2.
Gastroenterology 2001 121: 1203-1208. Published online Oct 24 2001.

Altered Cellular Calcium Regulatory Systems in a Rat Model of Cirrhotic Cardiomyopathy
CHRISTOPHER A. WARD, HONGQUN LIU, and SAMUEL S. LEE
Background & Aims: Decreased cardiac contractility has been observed in cirrhosis, but the cause remains unclear. Because cardiomyocyte contraction depends on Ca2+ influx entering via L-type Ca2+ channels (ICa,Ls) to activate Ca2+ release from the sarcoplasmic reticulum, we postulated that the Ca2+ transients may be abnormal in cirrhotic cardiomyocytes. We aimed to investigate the status of the cellular Ca2+-regulatory system in a rat model of cirrhotic cardiomyopathy. Methods: Cirrhosis was induced by bile duct ligation. The ICa,L protein expression was detected by Western blotting. Ca2+ currents were measured electrophysiologically. The intracellular Ca2+ system, which includes the ryanodine receptor 2 (RYR2), sarcoplasmic reticulum Ca2+-pump adenosine triphosphatase (SERCA2), and Ca2+-binding protein were quantitatively assayed by reverse-transcription polymerase chain reaction and Western blots and functionally by 3H-ryanodine binding and radiolabeled Ca2+ uptake. Results:ICa,L protein expression was reduced in cirrhotic rats compared with controls, and the peak inward Ca2+ current was significantly less. At all membrane potentials examined, ICa,Ls current densities from cirrhotic animals were consistently lower, and the response to maximal isoproterenol stimulation was also significantly lower. Protein expression and messenger RNA transcription for RYR2, SERCA2, and calsequestrin were quantitatively unchanged, and 3H-ryanodine binding characteristics and Ca2+ uptake were also unaltered. Conclusions: We conclude that the decreased cardiac contractility in cirrhotic cardiomyocytes is caused by dysfunction of the Ca2+-regulatory system. Plasma membrane ICa,Ls are quantitatively reduced and functionally depressed, whereas intracellular systems are intact.
Gastroenterology 2001 121: 1209-1218. Published online Oct 24 2001.

Inactivating Mutations of KILLER/DR5 Gene in Gastric Cancers
WON SANG PARK, JONG HEUN LEE, MIN SUN SHIN, JIK YOUNG PARK, HONG SUG KIM, YOUNG SIL KIM, CHO HYUN PARK, SANG KYU LEE, SUG HYUNG LEE, SHI NAE LEE, HYANG KIM, NAM JIN YOO, and JUNG YOUNG LEE
Background & Aims: The KILLER/death receptor (DR)5 has been identified as a potent inducer of apoptosis, and mapped to chromosome 8p21-22, showing frequent allelic loss in gastric cancer. The p53-induced apoptosis is an important biological process to prevent the development of cancer, and is mediated in part by expression of KILLER/DR5 only in cells with wild-type p53 protein, but not in those lacking p53 function. The aim of this study was to determine whether genetic alterations of KILLER/DR5 could be involved in the tumorigenesis of gastric cancer. Methods: We analyzed the genetic alterations of KILLER/DR5 and p53 in 43 gastric cancers and the loss of function of KILLER/DR5 mutants, detected in this study. Results: We found 3 KILLER/DR5 missense mutations (7%), and 2 of them showed allelic loss in the remaining allele. Interestingly, all the mutants inhibit apoptotic cell death in transfection studies. We also found 6 p53 mutations (14%). Interestingly, the tumors containing the KILLER/DR5 mutation did not carry the p53 mutation. Conclusions: These results suggest that inactivation of KILLER/DR5 caused by mutations of KILLER/DR5 may be one of the possible escaping mechanisms against KILLER/DR5-mediated apoptosis and that inactivating mutation of KILLER/DR5 may contribute to the development or progression of a subset of gastric cancers.
Gastroenterology 2001 121: 1219-1225. Published online Oct 24 2001.

Emergence of a Distinct Pattern of Viral Mutations in Chimpanzees Infected With a Homogeneous Inoculum of Hepatitis C Virus
MICHAEL THOMSON, MICHELINA NASCIMBENI, SOPHIA GONZALES, KRISHNA K. MURTHY, BARBARA REHERMANN, and T. JAKE LIANG
Background & Aims: Prospective, long-term study of viral evolution and immunologic responses in chimpanzees infected with a homogeneous hepatitis C virus (HCV) population is crucial in understanding the pathogenesis of HCV-host interactions. Methods: A molecular clone was constructed of HCV genotype 1b and RNA transcribed from this clone inoculated intrahepatically into chimpanzee X0142. Serum was taken from X0142 at week 2 and inoculated intravenously into a second chimpanzee (X0234). Detailed virologic, serologic, and immunologic analyses of these 2 chimpanzees were performed. Results: Both chimpanzees developed persistent viremia, with titers of 103 to 105 genomes/mL, for 80 weeks (X0142) and 55 weeks (X0234) of follow-up. A late antibody response against the nonstructural proteins and a weak, transient T-helper proliferative response were detected in both animals. In X0142, 25 mutations emerged in the virus population by week 78 and 15 in X0234 by week 35. A relatively large proportion of mutations affecting protein sequences appeared in the NS5A gene (33% in X0142 and X0234 combined), and 5 mutations were common to both chimpanzees. Conclusions: In this long-term study of the molecular evolution of HCV genotype 1b from a cloned source, the appearance of a distinct pattern of mutations is suggestive of an adaptive response of HCV in vivo. In addition, a limited virus-specific immunity may contribute to HCV persistence.
Gastroenterology 2001 121: 1226-1233. Published online Oct 24 2001.

Liver and Kidney Foreign Bodies Granulomatosis in a Patient With Malocclusion, Bruxism, and Worn Dental Prostheses
MARCO BALLESTRI, ALBERTO BARALDI, ANTONIETTA M. GATTI, LUCIANA FURCI, ALBERTO BAGNI, PAOLA LORIA, RENATO M. RAPANÀ, NICOLA CARULLI, and ALBERTO ALBERTAZZI
Granulomatous reactions caused by foreign bodies have been described in drug abusers, in subjects exposed to occupational pollutants, and more rarely, in association with the use of prosthetic devices. We describe a 62-year-old patient with multiorgan parenchymal granulomatosis caused by inorganic debris of unknown origin. The patient presented with fever, hepatosplenomegaly, progressive cholestasis, and acute renal failure. Liver and kidney biopsies showed the presence of noncaseating epithelioid giant-cell granulomas containing scattered polarizable particles. Similar particles were also present in stools. Studies by innovative scanning electron microscopy and energy-dispersive microanalytical techniques showed that the particles isolated in liver, kidney, and stools were made by feldspars, the main component of porcelain. No occupational or environmental exposure to these materials could be identified in this patient and the only reliable source of the porcelain debris turned out to be constituted by 2 dental bridges evidently worn because of a possible inappropriate construction, malocclusion, and bruxism. The porcelain of the dental prostheses had the same elemental spectrum of the particles isolated from stool specimens and liver-kidney granuloma. After identification of the dental prostheses as the most likely source of ceramic debris, and after their removal, the particles from stool specimens disappeared. The patient was then treated with steroids leading to a remission of the clinical symptoms and a decrease in granulomatous inflammatory reaction in both liver and kidney. This is the first report suggesting that a foreign body systemic granulomatosis can be associated with worn dental prostheses.
Gastroenterology 2001 121: 1234-1238. Published online Oct 24 2001.

BRITISH MEDICAL JOURNAL

24 November 2001 (Volume 323, Issue 7323)

Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in entrants to Irish prisons: a national cross sectional survey Commentary: efficient research gives direction on prisoners' and the wider public health---except in England and Wales
Jean Long, Shane Allwright, Joseph Barry, Sheilagh Reaper Reynolds, Lelia Thornton, Fiona Bradley, John V Parry, and Sheila M Bird
BMJ 2001;323 1209 [Full text]
Objectives: To determine the prevalence of antibodies to hepatitis B core antigen, hepatitis C virus, and HIV in entrants to Irish prisons and to examine risk factors for infection.
Design: Cross sectional, anonymous survey, with self completed risk factor questionnaire and oral fluid specimen for antibody testing.
Setting: Five of seven committal prisons in the Republic of Ireland.
Participants: 607 of the 718 consecutive prison entrants from 6 April to 1 May 1999.
Main outcome measures: Prevalence of antibodies to hepatitis B core antigen, hepatitis C virus, and HIV in prison entrants, and self reported risk factor status.
Results: Prevalence of antibodies to hepatitis B core antigen was 37/596 (6%; 95% confidence interval 4% to 9%), to hepatitis C virus was 130/596 (22%; 19% to 25%), and to HIV was 12/596 (2%; 1% to 4%). A third of the respondents had never previously been in prison; these had the lowest prevalence of antibodies to hepatitis B core antigen (4/197, 2%), to hepatitis C (6/197, 3%), and to HIV (0/197). In total 29% of respondents (173/593) reported ever injecting drugs, but only 7% (14/197) of those entering prison for the first time reported doing so compared with 40% (157/394) of those previously in prison. Use of injected drugs was the most important predictor of antibodies to hepatitis B core antigen and hepatitis C virus.
Conclusions: Use of injected drugs and infection with hepatitis C virus are endemic in Irish prisons. A third of prison entrants were committed to prison for the first time. Only a small number of first time entrants were infected with one or more of the viruses. These findings confirm the need for increased infection control and harm reduction measures in Irish prisons.

ABC of the upper gastrointestinal tract: Indigestion and non-steroidal anti-inflammatory drugs
J M Seager and C J Hawkey
BMJ 2001;323 1236-1239 [Full text]
Non-steroidal anti-inflammatory drugs (NSAIDs) are usually thought to pose a dilemma for doctors wishing to prescribe them. Their anti-inflammatory and analgesic properties have led to their widespread use for rheumatoid and (much more commonly) other conditions often regarded as more trivial. However they are ulcerogenic to the stomach and duodenum and lead to a threefold to 10-fold increase in ulcer complications, hospitalisation, and death from ulcer disease......

17 November 2001 (Volume 323, Issue 7322)

ABC of the upper gastrointestinal tract: Upper abdominal pain: Gall bladder
C D Johnson
BMJ 2001;323 1170-1173 [Full text]
Gall stones are common but often do not give rise to symptoms. Pain arising from the gall bladder may be typical of biliary colic, but a wide variety of atypical presentations can make the diagnosis challenging. After a period of uncertainty in the 1980s, when operative techniques were challenged by drug treatment and lithotripsy, it is now widely accepted that symptomatic gallbladder stones should be treated by laparoscopic cholecystectomy. Clinical judgment and local expertise will greatly influence the management of bile duct stones, particularly if cholecystectomy is also required......

Interferon alfa with or without ribavirin for chronic hepatitis C: systematic review of randomised trials
Lise L Kjaergard, Kim Krogsgaard, and Christian Gluud
BMJ 2001;323 1151-1155 [Full text]
Objective: To assess the efficacy and safety of interferon alfa with or without ribavirin for treatment of chronic hepatitis C.
Design: Systematic review of randomised trials on interferon alfa plus ribavirin combination therapy versus interferon alfa. Patients were naive (not previously treated with interferon), relapsers (transient response to previous interferon therapy), or non-responders (no response to previous interferon therapy).
Studies reviewed: Of 1155 references identified, 48 trials with 6585 patients met the inclusion criteria. Patients were followed to the end of treatment in 20 trials and in 28 trials for 12-96 weeks after treatment.
Main outcome measures: Virological response and morbidity plus mortality.
Results: Compared with interferon, combination therapy reduced the risk of not having a sustained virological response for 6 months by 26% in naive patients (relative risk 0.74, 95% confidence interval 0.70 to 0.78), 33% in relapsers (0.67, 0.57 to 0.78), and 11% in non-responders (0.89, 0.83 to 0.96). Morbidity and mortality showed a non-significant trend in favour of combination therapy (Peto odds ratio 0.45, 0.19 to 1.06). Combination therapy significantly reduced the risk of not having improvement in results of histology by 17% in naive patients (0.83, 0.74 to 0.93) and by 27% in relapsers and non-responders (0.73, 0.66 to 0.82). The risk of treatment discontinuations was significantly higher after combination therapy (1.28, 1.07 to 1.52).
Conclusion: Treatment with interferon alfa plus ribavirin has a significant beneficial effect on the virological and histological responses of patients with chronic hepatitis C, irrespective of previous treatment. Combination therapy may therefore also be considered appropriate for relapsers and non-responders.

10 November 2001 (Volume 323, Issue 7321)

General outbreaks of infectious intestinal diseases linked with private residences in England and Wales, 1992-9: questionnaire study
Iain A Gillespie, Sarah J O'Brien, and Goutam K Adak
BMJ 2001;323 1097-1098 [Full text]
The inception of the Food Standards Agency in April 2000 has given food safety issues a high public and political profile. Recently, concerns about food hygiene have focused on the home and, in particular, the possible transmission of infection via household items.1 To determine the causes of gastrointestinal infection associated with the home, we reviewed general outbreaks (outbreaks affecting more than one household) of infectious intestinal disease in England and Wales reported to the Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre from 1992 to 1999....

ABC of the upper gastrointestinal tract: Upper gastrointestinal haemorrhage
Helen J Dallal and K R Palmer
BMJ 2001;323 1115-1117 [Full text]
Acute upper gastrointestinal haemorrhage accounts for about 2500 hospital admissions each year in the United Kingdom. The annual incidence varies from 47 to 116 per 100 000 of the population and is higher in socioeconomically deprived areas......

3 November 2001 (Volume 323, Issue 7320)

ABC of the upper gastrointestinal tract: Management of Helicobacter pylori infection
Adam Harris and J J Misiewicz
BMJ 2001; 323: 1047-1050 [Full text]  
This article discusses the current management of Helicobacter pylori infection in patients with dyspepsia with or without endoscopic abnormalities. We take an evidence based approach when possible and consider recent guidelines from national and international bodies pertaining to primary and secondary care. In patients who are not taking non-steroidal anti-inflammatory drugs (NSAIDs) duodenal ulcer will be due to H pylori infection in 95% of cases, and eradication treatment can be prescribed without testing for H pylori. If there is any doubt about the diagnosis, such as a possible ulcer crater on a barium meal, endoscopic confirmation of duodenal ulcer and H pylori infection should be sought before prescribing treatment......

27 october 2001 (Volume 323, Issue 7319)

ABC of the upper gastrointestinal tract: Pathophysiology of duodenal and gastric ulcer and gastric cancer
John Calam and J H Baron
BMJ 2001; 323: 980-982. [Full text]  
Duodenal and gastric ulcers and gastric cancer are common and serious diseases but occur in only a minority of people infected with Helicobacter pylori. Mass eradication of H pylori is impractical because of the cost and the danger of generating antibiotic resistance, so we need to know how to target prophylaxis. Knowledge of the mechanisms that lead to ulcer formation or to gastric cancer in the presence of H pylori infection is therefore valuable.....

NEW ENGLAND JOURNAL

15 November 2001 (Volume 345, Issue20)

Treatment of Acute Hepatitis C with Interferon Alfa-2b
E. Jaeckel and Others

Background In people who are infected with the hepatitis C virus (HCV), chronic infection often develops and is difficult to eradicate. We sought to determine whether treatment during the acute phase could prevent the development of chronic infection. Methods Between 1998 and 2001, we identified 44 patients throughout Germany who had acute hepatitis C. Patients received 5 million U of interferon alfa-2b subcutaneously daily for 4 weeks and then three times per week for another 20 weeks. Serum HCV RNA levels were measured before and during therapy and 24 weeks after the end of therapy. Results The mean age of the 44 patients was 36 years; 25 were women. Nine became infected with HCV through intravenous drug use, 14 through a needle-stick injury, 7 through medical procedures, and 10 through sexual contact; the mode of infection could not be determined in 4. The average time from infection to the first signs or symptoms of hepatitis was 54 days, and the average time from infection until the start of therapy was 89 days. At the end of both therapy and follow-up, 43 patients (98 percent) had undetectable levels of HCV RNA in serum and normal serum alanine aminotransferase levels. Levels of HCV RNA became undetectable after an average of 3.2 weeks of treatment. Therapy was well tolerated in all but one patient, who stopped therapy after 12 weeks because of side effects. Conclusions Treatment of acute hepatitis C with interferon alfa-2b prevents chronic infection.

LANCET

Volume 358, Number 9294 17 November 2001

Eradication of Helicobacter pylori and improvement of hereditary angioneurotic oedema 
Henriette Farkas, George Füst, Béla Fekete, István Karádi, Lilian Varga [Full Text] 

Helicobacter pylori infection is thought to be a causal factor in various dermatological disorders. We assessed the frequency of H pylori infection in 65 patients with hereditary angioneurotic oedema. We measured the serum concentration of antibodies against H pylori and did the carbon-14-urease breath test in patients with positive H pylori serology. 19 of 65 patients had H pylori infection. All patients with infection, and 11 of 46 without infection, had a history of recurrent episodes of acute abdominal pain. We successfully eradicated H pylori infection in 18 patients. The frequency of abdominal symptoms was significantly higher in the infected group (p=0·002 after adjustment for age). In nine of 19 patients with dyspepsia, the frequency of oedematous episodes decreased from 100 over 10 months before eradication to 19 during the 10-month follow-up period. Screening for, and eradication of, H pylori infection seems to be justified in patients with hereditary angioneurotic oedema. Lancet 2001; 358: 1695-96

Helicobacter pylori and reflux disease
Kenneth E L McColl, Derek Gillen  [Full Text] 
Sir--W Schwizer and colleagues (June 2, p 1738)1 conclude that eradication of Helicobacter pylori prolongs the disease-free interval in patients with gastro-oesophageal reflux disease (GORD). However, we are concerned that the outcome has been affected by the small numbers of participants studied and consequent poor matching of the randomised groups..The number of patients followed up in the three randomised groups were only 14, 15, and 29. The group that had a high relapse rate was the H pylori-positive group assigned placebo, which consisted of only 14 patients. These patients' symptoms were of longer duration and alcohol intake was higher than in those in the other groups. The mismatching at the point of randomisation for symptom duration was of sufficient magnitude to be significant, despite the small numbers available for analysis. Because of this mismatching, the higher symptomatic relapse rate in the H pylori-positive group might have been due to characteristics of the group at randomisation rather than to any effect of the eradication therapy......

Volume 358, Number 9293 10 November 2001

Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial
J P Neoptolemos, J A Dunn, D D Stocken, J Almond, K Link, H Beger, C Bassi, M Falconi, P Pederzoli, C Dervenis, L Fernandez-Cruz, F Lacaine, A Pap, D Spooner, D J Kerr, H Friess, M W Büchler for the members of the European Study Group for Pancreatic Cancer*
Background Stroke units reduce mortality and dependence, but the reasons are unclear. We have compared differences in management and complications of patients with acute stroke who were admitted to a stroke unit or to a general ward as part of a previously reported randomised trial. Methods 304 patients had been randomly assigned to stroke units (n=152) or to general wards supported by a specialist stroke team (152). We used a structured format to gather prospective data on the frequency of prespecified interventions in each of the major aspects of stroke care. Observations were undertaken daily for the first week and every week for the next 3 months by independent observers. The effect of differences in management on outcome at 3 months was assessed with the modified Rankin score, dichotomised to good (0-3) and poor (4-6) outcome. Findings Patients in the stroke unit were monitored more frequently (odds ratio 2·1 [1·3-3·4]) and more patients received oxygen (2·0 [1·3-3·2]), antipyretics (6·4 [1·5-27·5]), measures to reduce aspiration (6·0 [2·3-15·5]), and early nutrition (14·4 [5·1-40·9]) than those in general wards. Complications were less frequent in patients in the stroke unit than those in general wards (0·6 [0·2-0·7]), with fewer patients having progression of stroke, chest infection, or dehydration. Measures to prevent aspiration, early feeding, stroke unit management, and frequency of complications independently affected outcome. Interpretation Differences in management and complications between the stroke unit and general wards differ substantially, even when specialist support is provided. Such differences could be responsible for the more favourable outcome seen in patients on stroke units than those on general wards. Lancet 2001; 358: 1586-92

Volume 358, Number 9292, 3 November 2001

Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial
F Bozzetti, M Braga, L Gianotti, C Gavazzi, L Mariani
Background Although current opinion favours the use of enteral over parenteral nutrition, the clinical benefits of early postoperative nutrition in patients undergoing elective surgery have never been clearly shown. We aimed to test the hypothesis that postoperative enteral nutrition is better (fewer postoperative complications) than parenteral nutrition containing similar energy and nitrogen amounts (112 kJ kg-1day-1 and 1.4 g aminoacid kg-1day-1). Methods We did a randomised multicentre clinical trial in patients with gastrointestinal cancer who were malnourished and candidates for major elective surgery. 159 patients were assigned to enteral nutrition and 158 to parenteral nutrition. The primary endpoint was the occurrence of postoperative complications, and secondary endpoints were length of postoperative hospital stay, adverse effects, and treatment crossover. Analysis was by intention to treat. Findings Postoperative complications occurred in 54 (34%) patients fed enterally versus 78 (49%) fed parenterally (relative risk 0·69, 95% CI 0·53-0·90, p=0·005). Length of postoperative stay was 13·4 days and 15·0 days in the enteral nutrition and parenteral nutrition groups, respectively (p=0·009). Adverse effects occurred in 56 (35%) patients fed enterally versus 22 (14%) patients fed parenterally (2·50, 1·61-3·86, p<0·0001). 14 (9%) patients on enteral nutrition had to switch to parenteral nutrition, whereas none of those fed parenterally crossed over to enteral feeding. Interpretation We conclude that early enteral nutrition significantly reduces the complication rate and duration of postoperative stay compared with parenteral nutrition, although parenteral nutrition is better tolerated than enteral nutrition. Lancet 2001; 358: 1487-92

Independent effects of intestinal parasite infection and domestic allergen exposure on risk of wheeze in Ethiopia: a nested case-control study Full Text
Sarah Scrivener, Haile Yemaneberhan, Mehila Zebenigus, Daniel Tilahun, Samuel Girma, Seid Ali, Paul McElroy, Adnan Custovic, Ashley Woodcock, David Pritchard, Andrea Venn, John Britton
Background Why asthma is rare in rural subsistence societies is not clear. We tested the hypotheses that the risk of asthma is reduced by intestinal parasites or hepatitis A infection, and increased by exposure to dust-mite allergen or organophosphorus insecticides in urban and rural areas of Jimma, Ethiopia. Methods From 12 876 individuals who took part in a study of asthma and atopy in urban and rural Jimma in 1996, we identified all who reported wheeze in the previous 12 months, and a random subsample of controls. In 1999, we assessed parasites in faecal samples, Der p 1 levels in bedding, hepatitis A antibodies, serum cholinesterase (a marker of organophosphorus exposure), total and specific serum IgE, and skin sensitisation to Dermatophagoides pteronyssinus in 205 cases and 399 controls aged over 16 years. The effects of parasitosis, Der p 1 level, hepatitis A seropositivity, and cholinesterase concentration on risk of wheeze, and the role of IgE and skin sensitisation in these associations, were analysed by multiple logistic regression. Findings The risk of wheeze was independently reduced by hookworm infection by an odds ratio of 0·48 (95% CI 0·24-0·93, p=0·03), increased in relation to Der p 1 level (odds ratio per quartile 1·26 [1·00-1·59], p=0·05), and was unrelated to hepatitis A seropositivity or cholinesterase concentration. In the urban population, D pteronyssinus skin sensitisation was more strongly related to wheeze (9·45 [5·03-17·75]) than in the rural areas (1·95 [0·58-6·61], p for interaction=0·017), where D pteronyssinus sensitisation was common, but unrelated to wheeze in the presence of high-intensity parasite infection. Interpretation High degrees of parasite infection might prevent asthma symptoms in atopic individuals. Lancet 2001; 358: 1493-99

Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care
David S Sanders, Martyn J Carter, David P Hurlstone, Alison Pearce, Anthony Milford Ward, Mark E McAlindon, Alan J Lobo
Background Irritable bowel syndrome has a high prevalence. Consensus diagnostic criteria (ROME II) based on symptoms have been established to aid diagnosis. Although coeliac disease can be misdiagnosed as irritable bowel syndrome, no prospective study has been published in which patients with this disorder are investigated for coeliac disease. We aimed to assess the association of coeliac disease with irritable bowel syndrome in patients fulfilling ROME II criteria. Methods We undertook a case-control study at a university hospital. 300 consecutive new patients who fulfilled Rome II criteria for irritable bowel syndrome, and 300 healthy controls (age and sex matched) were investigated for coeliac disease by analysis of serum IgA antigliadin, IgG antigliadin, and endomysial antibodies (EMA). Patients and controls with positive antibody results were offered duodenal biopsy to confirm the possibility of coeliac disease. Findings 66 patients with irritable bowel syndrome had positive antibody results, of whom 14 had coeliac disease (11 EMA positive, three EMA negative). Nine patients with positive antibody results were lost to follow-up or refused biopsy (only one EMA-positive patient refused biopsy), and 43 had normal duodenal mucosa. Two controls, both of whom were EMA positive, had coeliac disease. Compared with matched controls, irritable bowel syndrome was significantly associated with coeliac disease (p=0·004, odds ratio=7·0 [95% CI 1·7-28·0]). Interpretation Patients with irritable bowel syndrome referred to secondary care should be investigated routinely for coeliac disease. With only EMA, three of 14 cases would have been missed. Lancet 2001; 358: 1504-08

Volume 358, Number 9291, 26 October 2001

Prevalence of hereditary haemochromatosis in late-onset type 1 diabetes mellitus: a retrospective study Full Text
Christina Ellervik, Thomas Mandrup-Poulsen, Børge G Nordestgaard, Lisbeth Enggaard Larsen, Merete Appleyard, Merete Frandsen, Pia Petersen, Poul Schlichting, Torben Saermark, Anne Tybjaerg-Hansen, Henrik Birgens
Background Although genotyping studies suggest that hereditary haemochromatosis is one of the most common genetic disorders in white people, it is still thought of as an uncommon disease. Our aim was to test the hypothesis that hereditary haemochromatosis is a disease often overlooked in patients with late-onset type 1 diabetes mellitus, a late manifestation of untreated iron overload. Methods We did a retrospective study in which we genotyped for the C282Y and H63D mutations in the haemochromatosis gene in 716 unselected Danish patients who developed type 1 diabetes mellitus after age 30 years and 9174 controls from the general Danish population. We also screened for hereditary haemochromatosis by assessment of transferrin saturation. Findings More patients with diabetes (n=9, relative frequency 1·26%, 95% CI 0·58-2·37) than controls (23, 0·25%, 0·16-0·38) were homozygous for C282Y (odds ratio 4·6, 2·0-10·1, p=0·0001). These patients had unrecognised signs of haemochromatosis. Transferrin saturation and ferritin concentrations ranged from 57% to 102% and 17 µg/L to 8125 µg/L, respectively. Frequency of compound heterozygosity (C282Y/H63D) did not differ between patients with diabetes (eight) and controls (131) (odds ratio 0·8, 95% CI 0·4-1·7). Positive and negative predictive values of transferrin saturation greater than 50%, in identification of C282Y homozygosity, were 0·26 and 1·00, respectively. A saturation of less than 50% therefore excluded C282Y homozygosity, whereas a saturation of more than 50% suggested C282Y homozygosity. Interpretation Measurement of transferrin saturation followed by genetic testing could prevent liver and heart problems and improve life expectancy in patients with diabetes. Population screening before the onset of diabetes might improve the outlook of patients even further, but will be less cost effective. Lancet 2001; 358: 1405-09

Safety and efficacy of imatinib (STI571) in metastatic gastrointestinal stromal tumours: a phase I study
Allan T van Oosterom, Ian Judson, Jaap Verweij, Sigrid Stroobants, Eugenio Donato di Paola, Sasa Dimitrijevic, Marc Martens, Andrew Webb, Raf Sciot, Martine Van Glabbeke, Sandra Silberman, Ole S Nielsen, for the European Organisation for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group
Background Gastrointestinal stromal tumours (GISTs) are rare tumours of the gastrointestinal tract characterised by cell-surface expression of the tyrosine kinase KIT (CD117). No effective systemic treatment is available. Imatinib (STI571) inhibits a similar tyrosine kinase, BCR-ABL, leading to responses in chronic myeloid leukaemia, and has also been shown to inhibit KIT. We did a phase I study to identify the dose-limiting toxic effects of imatinib in patients with advanced soft tissue sarcomas including GISTs. Methods 40 patients (of whom 36 had GISTs) received imatinib at doses of 400 mg once daily, 300 mg twice daily, 400 mg twice daily, or 500 mg twice daily. Toxic effects and haematological, biochemical, and radiological measurements were assessed during 8 weeks of follow-up. 18Fluorodeoxy- glucose positron-emission tomography (PET) was used for response assessment in one centre. Findings Five patients on 500 mg imatinib twice daily had dose-limiting toxic effects (severe nausea, vomiting, oedema, or rash). Inhibition of tumour growth was seen in all but four patients with GISTs, resulting in 19 confirmed partial responses and six as yet unconfirmed partial responses or more than 20% regressions. 24 of 27 clinically symptomatic patients showed improvement, and 29 of 36 were still on treatment after more than 9 months. PET scan responses predicted subsequent computed tomography responses. Interpretation Imatinib at a dose of 400 mg twice daily is well tolerated during the first 8 weeks, side-effects diminish with continuing treatment, and it has significant activity in patients with advanced GISTs. Our results provide evidence of a role for KIT in GISTs, and show the potential for the development of anticancer drugs based on specific molecular abnormalities present in cancers. Lancet 2001; 358: 1421-23

JAMA

Volume 286, Number 16, 24/31 October 2001

 
Process of Care and Outcomes for Elderly Patients Hospitalized With Peptic Ulcer Disease Results From a Quality Improvement Project Full Text
Jane Brock, MD, MSPH; Angela Sauaia, MD, PhD; Dennis Ahnen, MD; William Marine, MD, MPH; William Schluter, MD, MSPH; Beth R. Stevens, MS; Jeanne D. Scinto, PhD, MPH; Herbert Karp, MD; Dale Bratzler, DO, MPH Context  Since publication in 1994 of guidelines for management of peptic ulcer disease (PUD), trends in physician practice and outcomes related to guideline application have not been evaluated.Objectives  To describe changes in process of care that occurred in a quality improvement program for patients hospitalized with PUD and to evaluate associations between in-hospital treatment of PUD and 1-year rehospitalization for PUD and mortality in a subset of these patients.Design, Setting, and Patients  Cohort study of 4292 sequential Medicare beneficiaries hospitalized at acute care hospitals with a principal diagnosis of PUD in 5 states (Colorado, Georgia, Connecticut, Oklahoma, and Virginia) in 1995 (baseline) and 1997 (remeasurement); outcomes were evaluated for 752 patients in Colorado.Main Outcome Measures  Changes in rates of screening for Helicobacter pylori infection, treatment for H pylori infection, screening for nonsteroidal anti-inflammatory drug (NSAID) use, counseling about NSAID use; outcomes included rehospitalization for PUD and all-cause mortality within 1 year of discharge in Colorado.Results  Screening for H pylori infection increased significantly (12%-19% increase; P<.001) in each of the 5 states. Treatment of H pylori infection increased in each state and was significantly increased for the entire group of hospitalizations examined (8% increase overall; P = .001). Despite increased screening, detection of H pylori infection was less frequent than expected in every state, (13%-24%) and did not increase in any state. Screening for and counseling about NSAIDs did not significantly increase overall or in any state. In the Colorado cohort, the proportion of patients rehospitalized was unchanged in 1995 (8.9%) and 1997 (6.8%), and 124 patients (16%) in the combined 1995 and 1997 cohorts died within 1 year. Treatment for H pylori was not associated with a reduction in rehospitalization within 1 year (adjusted odds ratio [OR], 1.24; 95% confidence interval [CI], 0.65-2.36) or with a reduction in mortality (adjusted OR, 1.08; 95% CI, 0.68-1.71). Counseling about NSAID use was associated with a decrease in risk of 1-year rehospitalization for PUD (adjusted OR, 0.47; 95% CI, 0.22-0.99) and risk of all-cause mortality (adjusted OR, 0.44; 95% CI, 0.26-0.75).Conclusions  This quality improvement program for elderly patients with PUD resulted in increased screening for H pylori and increased treatment of H pylori infection but no change in counseling about NSAID use. However, with the low prevalence of H pylori detected, treatment of H pylori infection was not associated with a reduction in repeat hospitalization for PUD or subsequent mortality, whereas counseling about the risks of using NSAIDs was associated with a reduction in the risk of both outcomes.JAMA. 2001;286:1985-1993

---