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Primary sclerosing cholangitis is associated to an extended
B8-DR3 haplotype including particular MICA and MICB alleles (*Human
Study*)
Kristine Wiencke, Anne Spurkland, Erik Schrumpf, Kirsten Muri
Boberg
Susceptibility to primary
sclerosing cholangitis (PSC) is associated with HLA-B8, -DR3,
-DR2, and -DR6. It is not established whether these HLA genes
or closely linked genes confer the primary disease susceptibility.
MICA and MICB genes are found in the class I region between HLA-B
and DRB. MICA is expressed in gastrointestinal epithelium and
activates T cells in the gut. Because PSC is strongly associated
with inflammatory bowel disease, we investigated whether MICA
and MICB contribute to the HLA-associated genetic susceptibility
to develop PSC. The study included 130 PSC patients and 306 healthy
controls, previously typed for HLA class I and II genes, typed
for 5 MICA and 15 MICB microsatellite alleles. The phenotype frequencies
of MICA5.1 and MICB24 were significantly increased among PSC patients
compared with controls (90% vs. 74%; odds ratio [OR] = 3.2; Pc
= 3 ¥ 103 and 58% vs. 29%; OR = 3.3; Pc < 1 ¥
107, respectively). When stratified for B8- or DR3-positive
and -negative individuals, the association of these markers to
PSC was no longer evident. However, we observed that B8 and DR3
were associated to PSC only in the presence of both MICA5.1
and MICB24 markers. The frequency of individuals carrying all
4 alleles was significantly increased among the PSC patients compared
with controls (49% vs. 18%; OR = 4.5; Pc < 1 ¥ 107).
Our data indicate that PSC is associated to the extended B8-MICA5.1-MICB24-DR3
haplotype. (HEPATOLOGY 2001;34:625-630.)
Immunoglobulin gene usage and immunohistochemical characteristics
of human monoclonal antibodies to the mitochondrial autoantigens
of primary biliary cirrhosis induced in the XenoMouse (*Human
Study*)
Motoko Sasaki, Judy Van De Water, Thomas P. Kenny, Michael L.
Gallo, Patrick S. C. Leung, Yasuni Nakanuma, Aftab A. Ansari,
Ross L. Coppel, James Neuberger, M. Eric Gershwin
The immunodominant antimitochondrial antibody
(AMA) response in primary biliary cirrhosis (PBC) is directed
against the E2 component of pyruvate dehydrogenase (PDC-E2). The
nature of the clonal selection process is unclear, and to address
this issue, we took advantage of a transgenic technology, XenoMouse,
that contains 80% of the human immunoglobulin (Ig) variable gene
repertoire and can produce high-affinity human antibodies to virtually
any immunogen without evidence of clonal bias. We immunized mice
with PDC-E2 to obtain 13 HmAbs, including 4 IgG2 and 9 IgM isotypes.
Immunoglobulin gene analysis was unique and demonstrated a clonal
bias; the immunoglobulin gene usage was considerably different
from other antibody responses analyzed in XenoMouse systems. Four
of the 13 mAbs recognized the inner lipoyl domain of PDC-E2, 2
of 13 recognized the entire PDC-E2 molecule, 4 of 13 recognized
PDC-E2 and OGDC-E2, 1 of 13 recognized OGDC only, 1 recognized
BCOADC-E2 only, and 1 recognized an unidentified 100-kd mitochondrial
protein. Immunohistochemical staining using these HmAbs produced
mitochondrial staining of septal bile ducts in both PBC and control
livers. Ig gene analysis showed that 7 of 13 HmAbs used the VH3
and 4 of 13 used VH4 gene repertoire, respectively. Three of 7
VH3 antibodies used the same Ig VH3-21 gene family found in human
AMA from patients with PBC. The CDRs of these autoantibodies were
slightly mutated when compared with the sequences present within
the Ig germline genes. In conclusion, the XenoMouse not only recapitulates
the unique specificity and restriction of PBC patients, but indicates
that the autoantibodies are derived from a restricted clonal selection
process. Such data suggest that the original immunogen leads to
somatic mutation without subsequent development of determinant
spreading. (HEPATOLOGY 2001;34:631-637.)
Differential expression of cyclooxygenase-2 (COX-2) in human
bile duct epithelial cells and bile duct neoplasm (*Human Study*)
Nobuyasu Hayashi, Hirofumi Yamamoto, Nobuaki Hiraoka, Keizo Dono,
Yasuhiro Ito, Jiro Okami, Motoi Kondo, Hiroaki Nagano, Koji Umeshita,
Masato Sakon, Nariaki Matsuura, Shoji Nakamori, Morito Monden
It is well known that chronic inflammatory conditions
involving the bile ducts predispose to the development of bile
duct carcinoma, although the relationship between chronic inflammation
and malignant transformation is unclear. In this study, by combining
immunohistochemistry and computer imaging techniques, we quantified
and compared the cyclooxygenase-2 (COX-2) protein expression levels
of epithelial cells according with their histopathological backgrounds.
This technique revealed that the highest levels of COX-2 were
expressed in bile duct carcinoma cells, mainly in cytoplasm, and
the expression pattern was homogenous and abundant. Moderate levels
of COX-2 protein expression were also observed in noncancerous
epithelial cells with inflammatory reaction, but the staining
intensity was heterogeneous among the positive cells exhibiting
inflammation. In contrast, only scattered weak reactivity of COX-2
protein was observed in the noncancerous bile duct epithelial
cells without inflammatory reaction. Moreover, bile duct epithelial
cells in primary sclerosing cholangitis (PSC) showed very strong
expression of COX-2 protein, that was comparable with carcinoma
cells. On the other hand, primary biliary cirrhosis (PBC) epithelial
cells showed moderate levels of COX-2 expression. In addition,
specific COX-2 inhibitors, JTE-522 and NS-398, directly inhibited
the growth of 4 bile duct carcinoma and 1 gall bladder carcinoma
cell lines that expressed COX-2 protein, in vitro. These data
suggest that COX-2 expression might regulate carcinogenesis of
bile duct epithelial cells in inflammatory regions and tumor progression
in this cancer. The data also suggest that COX-2 selective inhibitors
might have therapeutic effects not only on bile duct carcinoma,
but other hepatobiliary carcinomas. (HEPATOLOGY 2001;34:638-650.)
Intraductal papillary neoplasia of the liver associated
with hepatolithiasis (*Human Study*)
Tse-Ching Chen, Yasuni Nakanuma, Yoh Zen, Miin-Fu Chen, Yi-Yin
Jan, Ta-Sen Yeh, Cheng Tang Chiu, Tseng-Tong Kuo, Jun-ichi Kamiya,
Koji Oda, Michinari Hamaguchi, Yoshiyuki Ohno, Ling-Ling Hsieh,
Yuji Nimura
Intraductal papillary
growth of neoplastic biliary epithelia with a fine fibrovascular
stalk (intraductal papillary neoplasia of liver [IPN-L]) resembling
intraductal papillary mucinous neoplasm of pancreas is occasionally
associated with hepatolithiasis. In this study, 136 cases of hepatolithiasis
in Taiwan, between January 1998 and March 2000, and an additional
21 cases of IPN-L before December 1998, were examined histologically.
IPN-L was found in 41 of 136 hepatolithiasis cases (30.1%). Sixty-two
IPN-L cases (42 women and 20 men; age range, 59.8 ± 10
years) were divided into 4 types (type 1, IPN-L with low-grade
dysplasia, 23 cases; type 2, IPN-L with high grade dysplasia,
11 cases; type 3, IPN-L with in situ and microinvasive carcinoma,
13 cases; and type 4, IPN-L of types 2 and 3 with distinct invasive
carcinoma, 15 cases). Intraductal spreading and glandular involvement
were commonly observed in all types. About half of types 3 and
4 cases had mucobilia, and mucinous carcinoma was variably found
in two thirds of group 4 patients. IPN-L frequently showed variable
gastroenteric differentiation such as goblet cells and foveolar
and colon-like metaplasia. IPN-L with goblet cells and colon-like
metaplasia was frequently associated with overproduction of mucin
and mucobilia (P < .01). In Japan, IPN-L was not frequent
in hepatolithiasis (12 of 135 cases). In conclusion, IPN-L forms
a spectrum of biliary neoplasm in hepatolithiasis. It often displays
variable gastroenteric metaplasia and significant intraductal
spread. IPN-L tends to progress to mucinous carcinoma. Formerly
reported "mucin-producing intrahepatic cholangiocarcinoma"
with a favorable prognosis is included in IPN-L. (HEPATOLOGY 2001;34:651-658.)
Autoimmune hepatitis with incidental histologic features
of bile duct injury (*Human Study*)
Albert J. Czaja, Herschel A. Carpenter
Bile duct changes are atypical of autoimmune hepatitis.
Our aims were to assess the frequency and significance of these
changes in classical disease. Liver biopsy specimens were reviewed
under code from 84 patients who satisfied international scoring
criteria for autoimmune hepatitis, and the findings were correlated
with clinical features and outcome. Twenty patients (24%) had
biliary changes, including 6 with destructive cholangitis, 4 with
ductopenia, and 10 with nondestructive cholangitis. Patients with
and without bile duct changes had similar laboratory findings.
Diagnostic scores for autoimmune hepatitis were lower in patients
with bile duct changes (16.6 ± 0.6 vs. 19.1 ± 0.2,
P < .0001). The frequencies of scores sufficient for a definite
(80% vs. 97%, P = .03) or probable diagnosis (20% vs. 3%,
P = .03) were also less in this group. Patients with destructive
cholangitis and/or ductopenia responded as well to therapy as
patients with nondestructive cholangitis, and outcomes in each
group were similar to those of patients without biliary changes.
We concluded that biliary changes can occur in classic autoimmune
hepatitis, and they are not associated with distinctive clinical
features or treatment response. They may be coincidental findings
associated with classic disease or weak expressions of a variant
syndrome. In the absence of a cholestatic clinical syndrome, they
do not compel a different management strategy. (HEPATOLOGY 2001;34:659-665.)
Hereditary thrombophilia as a cause of Budd-Chiari syndrome:
A study from Western India (*Human Study*)
Dipika Mohanty, Shrimati Shetty, Kanjaksha Ghosh, Aruna Pawar,
Phillip Abraham
The inherited deficiencies of protein C, protein
S, antithrombin III, factor V Leiden mutation, prothrombin gene
polymorphism, and antiphospholipids were studied in 53 Budd-Chiari
syndrome (BCS) and 33 portal vein thrombosis (PVT) cases and compared
with 223 age- and sex-matched controls. Protein C deficiency was
detected in 7 (13.2%), protein S in 3 (5.7%), and antithrombin
III in 2 (3.8%) of the BCS cases. Factor V Leiden was the most
common risk factor, i.e., 14 of 53 (26.4%) in BCS cases followed
by protein C, as compared with PVT cases, i.e., 2 of 33 (6.06%)
and controls, i.e., 5 of 223 (2.3%). In PVT cases, protein
C deficiency was present in 3 (9.09%), protein S deficiency in
1 (3.03%), and factor V Leiden mutation in 2 (6.06%) of the cases.
The prothrombin gene polymorphism was not found in either the
controls or the patients. The antiphospholipids were seen in 11
(20.75%) of the BCS cases and 6 (18.18%) of the PVT cases. Other
acquired risk factors like pregnancy, surgery, and oral contraceptives
were present in 8 (15.09%) of BCS and 3 (9.09%) of PVT cases.
Thus overall, 59% of the BCS and 30% of the PVT cases could be
explained by at least one of the etiologic factors studied. (HEPATOLOGY
2001;34:666-670.)
Renal failure after upper gastrointestinal bleeding in cirrhosis:
Incidence, clinical course, predictive factors, and short-term
prognosis (*Human Study*)
Andrés Cárdenas, Pere Ginès, Juan Uriz, Xavier
Bessa, Joan Manuel Salmerón, Antoni Mas, Rolando Ortega,
Blas Calahorra, Dara De Las Heras, Jaime Bosch, Vicente Arroyo,
Juan Rodés
To assess the incidence, clinical course, predictive
factors, and prognosis of renal failure in patients with cirrhosis
and gastrointestinal bleeding, 175 consecutive episodes of gastrointestinal
bleeding in 161 patients were analyzed. Renal failure occurred
in 20 (11%) episodes and was transient in 8 episodes and nontransient
in 12. Renal failure was more common in patients with cirrhosis
than in a control population of bleeding patients without cirrhosis
matched by age and severity of the bleeding episode. Among 39
clinical and laboratory variables obtained at admission or during
hospitalization related with the bleeding episode or with liver
and renal function, the presence of hypovolemic shock, number
of packed red blood cells transfused, Child-Pugh class at admission,
and baseline platelet count were independent predictors of renal
failure. The development of renal failure and hypovolemic shock
was the only independent predictors of in-hospital mortality.
Mortality rate among the 20 episodes with renal failure was 55%
(11 deaths) as compared with only 3% (5 deaths) in the 155 episodes
without renal failure (P < .01). The development of nontransient
renal failure entailed a much greater mortality as compared with
transient renal failure (10 of 12 [83%] vs. 1 of 8 [12%]; P
< .01). In conclusion, renal failure is a common event in patients
with cirrhosis and gastrointestinal bleeding, the occurrence of
which is mainly related to the severity of bleeding and baseline
liver function. Renal failure is a strong predictor of mortality
in patients with cirrhosis and gastrointestinal bleeding. (HEPATOLOGY
2001;34:671-676.)
Adenosine reverses a preestablished CCL4-induced micronodular
cirrhosis through enhancing collagenolytic activity and stimulating
hepatocyte cell proliferation in rats
Rolando Hernández-Muñoz, Mauricio D¡az-Muñoz,
Juan A. Suárez-Cuenca, Cristina Trejo-Sol¡s, Verónica
López, Lourdes Sánchez-Sevilla, Luc¡a Yáñez,
Victoria Chagoya De Sánchez
Cirrhosis is one of the most common causes of
mortality worldwide, because hepatic dysfunction constitutes a
potentially lethal condition. Having demonstrated the hepatoprotective
effect of adenosine against CCl4-induced cirrhosis, the present
study was aimed at assessing adenosine's effect on an already-established
micronodular cirrhosis. Chronic administration of CCl4 (10 weeks)
induced a cirrhotic state, characterized by increased liver fibronectin
and collagen types I and III content, enhanced expression of -1
(I) collagen mRNA, portal hypertension, and liver dysfunction.
After CCl4 discontinuation (5 weeks), increased persitance of
-1 (I) collagen mRNA expression and deposition, enhanced proline
incorporation into collagen and prolyl hydroxylase activity evidenced
active fibrogenesis. Several weeks after CCl4 withdrawal, deposited
collagen showed an enhanced type I/III ratio, which was associated
with deficient collagenolytic activity in cirrhotic livers. Liver
expression of some metalloproteinases (MMPs) and of tissue inhibitors
of MMPs (TIMPs) also indicated decreased collagen breakdown in
cirrhotic livers. Parameters indicative of oxidative stress (mainly
protein oxidation) were persistently augmented. These events were
coincident with diminished regenerative capacity of the cirrhotic
liver. Intraperitoneal adenosine administration to CCl4-induced
cirrhotic rats blocked active fibrogenesis and increased the collagen
degradation (most probably by decreasing liver TIMPs levels),
normalizing collagen-type ratios. In addition, the nucleoside
promoted an effective hepatocyte's proliferation in the cirrhotic
liver and accelerated normalization of parameters indicative of
liver function and oxidative stress. Thus, adenosine readily reversed
an experimental cirrhosis through stimulating liver collagenolytic
and proliferative capacities, as well as by accelerating functional
recovery. (HEPATOLOGY 2001;34:677-687.)
The processing and utilization of hepatocyte growth factor/scatter
factor following partial hepatectomy in the rat
Peter Pediaditakis, Juan Carlos Lopez-Talavera, Bryon Petersen,
Satdarshan P. S. Monga, George K. Michalopoulos
Hepatocyte growth factor/scatter factor (HGF/SF)
is a pluripotent growth factor capable of acting as a motogen,
a morphogen, and a mitogen. Originally, HGF/SF was found as a
blood-borne mitogen for hepatocytes and has since been determined
to be very important in liver repair. Previous studies have established
that HGF/SF must be proteolytically cleaved to elicit its effects.
After liver injury by toxins such as carbon tetrachloride or after
surgical resection, partial hepatectomy (PHX), HGF/SF concentrations
increase in the blood. The aims of this study were to examine
(1) which form of HGF/SF is present in the normal liver, (2) which
form is present in the regenerating liver after PHX, and (3) if
the HGF/SF used after PHX is derived from existing liver reservoirs.
Both single-chain HGF/SF and active two-chain HGF/SF are present
in normal liver, with the former being the dominant form. After
PHX, the liver can be described as having two phases with regard
to the use of endogenous HGF/SF. The first phase from 0 to 3 hours
is the consumptive phase and is characterized by a decrease in
both single-chain HGF/SF and active two-chain HGF/SF. The second
phase is the productive phase. It is characterized by a pronounced
reappearance of both single-chain HGF/SF as well as two-chain
HGF/SF. The activation index shows a 5-fold increase over sham
operations during the productive phase. The use of radiolabeled
HGF/SF showed that during the first 3 hours, HGF/SF is used in
part from hepatic stores. Furthermore, during the first 3 hours
after PHX, only active two-chain HGF/SF is seen in the plasma.
(HEPATOLOGY 2001;34:688-693.)
Disrupted signaling and inhibited regeneration in obese
mice with fatty livers: Implications for nonalcoholic fatty liver
disease pathophysiology
Shi Qi Yang, Hui Zhi Lin, Aloke K. Mandal, Jiawen Huang, Anna
Mae Diehl
The impaired regenerative capacity of fatty livers
might promote the progression of nonalcoholic fatty liver disease
(NAFLD). To identify mechanisms involved, regenerative responses
were compared in normal mice and ob/ob mice (a model for NAFLD)
after partial hepatectomy (PH). We hypothesized that the usual
PH activation of oxidant-sensitive, growth-regulatory kinase cascades
would be abnormal in fatty hepatocytes, which have adapted to
chronic oxidant stress, and expected that this might interfere
with the induction of proliferative- and stress-related genes.
The normal coordinated induction of Jun N-terminal kinases (Jnks)
and extracellular regulated kinases (Erks) does not occur after
PH in ob/ob mice, which cannot activate Jnks but can superinduce
Erks. Jnk inhibition is associated with enhanced activation of
Akt, which inhibits phosphoenolpyruvate carboxykinase (PEPCK)
induction, causing severe hypoglycemia and increased lethality
in the ob/ob group. Activation of nuclear factor B (NF-B) is also
inhibited, but liver damage is increased only modestly, perhaps
because Akt-regulated survival factors are protective. Despite
enhanced Erk activity, induction of cyclin D-1, an NF-B target
gene, is abolished and this, together with hyperphosphorylated
signal transducer and activator of transcription-3 (Stat-3) and
reduced adenosine triphosphate (ATP) levels, arrests fatty hepatocytes
in G1. Thus, in mice with NAFLD that have adapted hepatocyte signaling
mechanisms to survive chronic oxidative stress, the cellular response
to an acute regenerative stimulus is altered. This contributes
to NAFLD pathophysiology by inhibiting proliferation, increasing
injury, and limiting function in fatty livers. (HEPATOLOGY 2001;34:694-706.)
Treatment strategy for small hepatocellular carcinoma: Comparison
of long-term results after percutaneous ethanol injection therapy
and surgical resection (*Human Study*)
Junji Yamamoto, Shuichi Okada, Kazuaki Shimada, Takushi Okusaka,
Susumu Yamasaki, Hideki Ueno, Tomoo Kosuge
This comparative study was conducted to clarify
the efficacy of percutaneous ethanol injection (PEI) and surgical
resection in the treatment of small hepatocellular carcinomas
(HCC). Thirty-nine patients treated by PEI and 58 who underwent
hepatic resection for small HCC (smaller than 3 cm and 3 or less
in number) during the same period were enrolled. The surgery group
included more patients with large and multiple bilobar nodules
than the PEI group. The histological differentiation of the treated
tumors became worse in the surgery patients than in those treated
by PEI. On the other hand, the PEI group included more patients
with a poor hepatic reserve, according to Child-Pugh grading,
the ICG test, and the serum total bilirubin value. The 1-, 3-,
and 5-year overall survival rates were almost identical between
the 2 cohorts (100%, 82.1%, and 59.0%, respectively, in the PEI
group; 96.6%, 84.4%, and 61.5%, respectively, in the surgery group)
(P = .96). During the follow-up period, 33 of 39 (85%) and
41 of 58 (71%) patients developed tumor recurrence after PEI and
surgery, respectively. Cumulative 1-, 3-, and 5-year tumor-free
survival rates in the PEI group were 63.4%, 30.3%, and 9.7 %,
whereas those in the surgery group were 75.5%, 44.7%, and 25.7%,
respectively (P = .10). Our overall findings show that local
therapy can achieve an actual 5-year survival rate of around 60%
for patients with small HCC with the proper selection of treatment.
A prospective randomized comparative trial is required to settle
this longstanding issue. (HEPATOLOGY 2001;34:707-713.)
The risk of liver and bile duct cancer in patients with
chronic viral hepatitis, alcoholism, or cirrhosis (*Human Study*)
Hannah Kuper, Weimin Ye, Ulrika Broomé, Anders Romelsjö,
Lorelei A. Mucci, Anders Ekbom, Hans-Olov Adami, Dimitrios Trichopoulos,
Olof Nyrén
No prospective study has analyzed simultaneously
chronic viral hepatitis and alcoholism as risk factors for liver
carcinogenesis, while taking into consideration the role of cirrhosis.
Nor has the risk for hepatocellular carcinoma among patients with
chronic viral hepatitis been prospectively evaluated in a low-risk
Western population. Last, the relationship between hepatocellular
carcinoma risk factors and bile duct cancer remains to be clarified.
We analyzed prospectively the risk for primary liver and extrahepatic
biliary tract cancer among 186,395 patients hospitalized with
either chronic viral hepatitis, alcoholism, cirrhosis, or any
combination of these conditions through linkages between national
Swedish registers. Compared with the general population, the relative
risk of hepatocellular carcinoma was 34.4 for chronic viral hepatitis
alone, 2.4 for alcoholism alone, and 40.7 for cirrhosis alone.
Among patients with combinations of these risk conditions, the
relative risk of hepatocellular carcinoma was 27.3 for chronic
viral hepatitis and alcoholism, 118.5 for chronic viral hepatitis
and cirrhosis, 22.4 for alcoholism and cirrhosis, and 171.4 for
all 3 conditions. We found limited evidence for an excess risk
of intrahepatic, but not for extrahepatic, biliary duct cancer.
Cirrhosis amplifies the risk of hepatocellular carcinoma among
patients with chronic viral hepatitis, but it is not a prerequisite
for liver carcinogenesis. In contrast, cirrhosis may be a necessary
intermediate for the development of hepatocellular carcinoma among
alcoholics. (HEPATOLOGY 2001;34:714-718.)
Targeting dexamethasone to Kupffer cells: Effects on liver
inflammation and fibrosis in rats
Barbro N. Melgert, Peter Olinga, Judith M. S. Van Der Laan, Betty
Weert, Jaejin Cho, Detlef Schuppan, Geny M. M. Groothuis, Dirk
K. F. Meijer, Klaas Poelstra
Kupffer cells (KC) play an important role in the
pathogenesis of inflammatory liver diseases leading to fibrosis.
Anti-inflammatory drugs are only effective when administered at
high doses that may cause side effects. Therefore, dexamethasone
coupled to mannosylated albumin (Dexa5-Man10-HSA) was designed
by us to selectively deliver this anti-inflammatory drug to the
KC. The effectiveness of Dexa5-Man10-HSA was studied both in organ
cultures and fibrosis induced by bile duct ligation (BDL) in rats.
Dexa5-Man10-HSA accumulated in livers of both healthy and fibrotic
rats (67% ± 5% and 70% ± 9% of the dose, respectively)
and uptake was found almost exclusively in KC. Active dexamethasone
was liberated from its carrier, because Dexa5-Man10-HSA could
effectively inhibit nitric oxide (NO) and tumor necrosis factor
(TNF-) release in endotoxin-activated liver slices. In vivo,
however, this was associated with increased collagen I and III
depositions and enhanced tissue inhibitor of metalloproteinase-1
(TIMP-1) mRNA expression. This was accompanied by a decreased
influx of reactive oxygen species (ROS) producing cells in the
livers of BDL animals treated with Dexa5-Man10-HSA as compared
with untreated BDL rats. Dexa5-Man10-HSA treatment also replenished
the depleted glycogen stores in hepatocytes of BDL livers. In
conclusion, our studies showed selective delivery of dexamethasone
to KC with Dexa5-Man10-HSA. This conjugate reduced intrahepatic
ROS in vivo and TNF- production in vitro and prevented
glycogen depletion in vivo, indicating effective pharmacologic
targeting. Dexa5-Man10-HSA, however, also accelerated fibrogenesis,
which was paralleled by TIMP-1 mRNA induction. Targeting of dexamethasone
to KC provides evidence for a dual role of this cell type in fibrogenesis
of BDL rats. (HEPATOLOGY 2001;34:719-728.)
Oxidized low-density lipoproteins bind to the scavenger
receptor, CD36, of hepatic stellate cells and stimulate extracellular
matrix synthesis (*Human Study*)
Wilhelm Schneiderhan, Alexandra Schmid-Kotsas, Jinshun Zhao, Adolf
Grünert, Andreas Nüssler, Hans Weidenbach, Andre Menke,
Roland M. Schmid, Guido Adler, Max G. Bachem
Cumulating evidence suggests that oxidative stress
resulting in lipid peroxidation and protein modification is involved
in the pathogenesis of chronic liver injury and fibrogenesis.
We investigated the effects of oxidized low-density lipoproteins
(oxLDL) on collagen and fibronectin synthesis of cultured human
and rat hepatic stellate cells (HSC). As shown on protein and
mRNA levels, oxLDL dose-dependently stimulated the synthesis of
collagen types I and III and fibronectin of cultured HSC. The
effect was biphasic, with a maximum between 5 and 25 µg/mL
oxLDL (c-fibronectin concentration in HSC supernatants increased
3.9-fold; collagen type I increased 4-fold). Higher oxLDL concentrations
were cytotoxic. LDL modified with malondialdehyde (MDA) was not
toxic, but stimulated extracellular matrix synthesis as well.
As demonstrated by immunofluorescence microscopy (double staining
of CD36 and iso--smooth muscle actin [iso--sm actin]), immunoblot,
and reverse-transcription polymerase chain reaction (RT-PCR),
respectively, cultured human HSC express the oxLDL receptor, CD36
(glycoprotein IIIb). Colocalization of CD36 and iso--sm actin
on sinusoidal lining cells was further demonstrated using sections
of human fibrotic liver. Preincubation of cultured human HSC with
the monoclonal antibody, OKM5, known to block CD36-mediated oxLDL
uptake, resulted in a reduction of the oxLDL-stimulated collagen
type I synthesis by 56%. In summary, our results demonstrate that
low concentrations of modified lipoproteins (oxLDL and MDA-LDL)
represent fibrogenic mediators that bind to CD36 and stimulate
matrix synthesis of HSC. (HEPATOLOGY 2001;34:729-737.)
High glucose and hyperinsulinemia stimulate connective tissue
growth factor expression: A potential mechanism involved in progression
to fibrosis in nonalcoholic steatohepatitis (*Human Study*)
Valerie Paradis, Gabriel Perlemuter, Franck Bonvoust, Delphine
Dargere, Beatrice Parfait, Michel Vidaud, Marc Conti, Stephane
Huet, Nathalie Ba, Catherine Buffet, Pierre Bedossa
Nonalcoholic steatohepatitis (NASH) may progress
to liver fibrosis and cirrhosis. Mechanisms directly involved
in the development of fibrosis have been poorly investigated.
Because connective tissue growth factor (CTGF) is an intermediate
key molecule involved in the pathogenesis of fibrosing chronic
liver diseases and is potentially induced by hyperglycemia, the
aims of this study were to (1) study the expression of CTGF in
vivo both in human liver biopsy specimens of patients with NASH
and in an experimental model of obesity and type II diabetes (Zucker
rats); and (2) analyze the effects of hyperglycemia and insulin
in vitro on hepatic stellate cells. In vivo, CTGF overexpression
was observed in the liver tissue of all of the 16 patients with
NASH. CTGF immunostaining was mild in 7 cases (44%) and moderate
or strong in 9 cases (56%). Staining was mainly detected in the
liver extracellular matrix in parallel with the amount of liver
fibrosis. Liver from fa/fa rats also showed CTGF overexpression
by comparison with Fa/fa rats both at the messenger RNA (mRNA)
level (3-fold increase) and protein level. In vitro, both
CTGF mRNA and protein were significantly increased when hepatic
stellate cells were incubated with either glucose or insulin.
A slight increase in type I procollagen mRNA level was also observed
in hepatic stellate cells incubated with glucose. In conclusion,
this study suggests that hyperglycemia and insulin are key-factors
in the progression of fibrosis in patients with NASH through the
up-regulation of CTGF. (HEPATOLOGY 2001;34:738-744.)
Angiotensin-II type 1 receptor interaction is a major regulator
for liver fibrosis development in rats
Hitoshi Yoshiji, Shigeki Kuriyama, Junichi Yoshii, Yasuhide Ikenaka,
Ryuichi Noguchi, Toshiya Nakatani, Hirohisa Tsujinoue, Hiroshi
Fukui
The renin-angiotensin system
(RAS) is frequently activated in patients with chronic liver diseases.
Angiotensin-II (AT-II) has been suggested to play an important
role in liver fibrogenesis. It induces hepatic stellate cell (HSC)
proliferation and up-regulates the transforming growth factor
1 (TGF-1) expression via AT-II type 1 receptor (AT1-R) in vitro.
The aim of the present study was to examine the in vivo effect
of candesartan (CA), a clinically used AT1-R blocker (ARB), and
perindopril (PE), an angiotensin-converting enzyme (ACE) inhibitor
(ACE-I), on pig serum-induced liver fibrosis development in rats.
The clinically available comparable doses of CA and PE significantly
attenuated the fibrosis development. These inhibitory effects
of PE and CA were also found in the on-going liver fibrosis model.
The hepatic hydroxyproline and serum fibrosis markers were significantly
suppressed by CA and PE treatment. Furthermore, the smooth muscle
actin (-SMA) positive cells in number were markedly suppressed
by CA and PE treatment. Similarly, the hepatic TGF-1 protein and
messenger RNA (mRNA) levels were significantly suppressed. Our
in vitro study showed that AT-II increased the TGF-1 mRNA expression
in the activated HSCs, and this effect was totally blocked by
CA. These results suggested that the RAS, especially AT-II and
AT1-R interaction plays a pivotal role in liver fibrosis development
through HSC activation. Because both CA and PE are widely used
in clinical practice without serious side effects, these drugs
may provide an effective new strategy for antiliver fibrosis
therapy. (HEPATOLOGY 2001;34:745-750.)
Enhanced expression of B7-1, B7-2, and intercellular adhesion
molecule 1 in sinusoidal endothelial cells by warm ischemia/reperfusion
injury in rat liver
Naosuke Kojima, Mitsuru Sato, Akira Suzuki, Takeya Sato, Shigeru
Satoh, Tetsuro Kato, Haruki Senoo
To elucidate a role of costimulatory molecule and cell adhesion
molecule in hepatic ischemia/reperfusion injury, we examined an
alteration in B7-1 (CD80), B7-2 (CD86), and intercellular adhesion
molecule 1 (ICAM-1; CD54) expression in the rat liver after warm
ischemia/reperfusion injury. To induce hepatic warm ischemia in
a rat model, both portal vein and hepatic artery entering the
left-lateral and median lobes were occluded by clamping for 30
minutes or 60 minutes, and then reperfused for 24 hours. B7-1,
B7-2, and ICAM-1 expressions in the liver were analyzed by immunofluorescence
staining and real-time reverse transcription polymerase chain
reaction (RT-PCR). Although B7-1 and B7-2 expressions were at
very low levels in the liver tissues from normal or sham-operated
control rats, both B7-1 and B7-2 expressions were enhanced at
protein and messenger RNA (mRNA) levels in the affected, left
lobes after warm ischemia/reperfusion. ICAM-1 protein and mRNA
were constitutively expressed in the liver of normal and sham-operated
control rats, and further up-regulated after warm ischemia/reperfusion.
Localization of increased B7-1, B7-2, and ICAM-1 proteins, as
well as von Willebrand factor as a marker protein for endothelial
cells, was confined by immunofluorescence staining to sinusoidal
endothelial cells in hepatic lobules. Data from quantitative real-time
RT-PCR analysis revealed that B7-1 and B7-2 mRNA levels were elevated
in hepatic lobes after warm ischemia/reperfusion (5.13- and 52.9-fold
increase, respectively), whereas ICAM-1 mRNA expression was rather
constitutive but further enhanced by warm ischemia/reperfusion
(4.24-fold increase). These results suggest that hepatic sinusoidal
endothelial cells play a pivotal role as antigen-presenting cells
by expressing B7-1 and B7-2 in warm hepatic ischemia/reperfusion
injury, and that B7-1 and/or B7-2 might be the primary target
to prevent early rejection and inflammatory reactions after hepatic
ischemia/reperfusion injury associated with liver transplantation.
(HEPATOLOGY 2001;34:751-757.)
Caspase activation correlates with the degree of inflammatory
liver injury in chronic hepatitis C virus infection
Heike Bantel, Andreas Lügering, Christopher Poremba, Norbert
Lügering, Jürgen Held, Wolfram Domschke, Klaus Schulze-Osthoff
Hepatitis C virus (HCV) infection is a major cause of liver disease
characterized by inflammation, cell damage, and fibrotic reactions
of hepatocytes. Apoptosis has been implicated in the pathogenesis,
although it is unclear whether proteases of the caspase family
as the central executioners of apoptosis are involved and how
caspase activation contributes to liver injury. In the present
study, we measured the activation of effector caspases in liver
biopsy specimens of patients with chronic HCV infection. The activation
of caspase-3, caspase-7, and cleavage of poly(ADP-ribose)polymerase
(PARP), a specific caspase substrate, were measured by immunohistochemistry
and Western blot analysis by using antibodies that selectively
detect the active truncated, but not the inactive precursor forms
of the caspases and PARP. We found that caspase activation was
considerably elevated in liver lobules of HCV patients in comparison
to normal controls. Interestingly, the immunoreactive cells did
yet not reveal an overt apoptotic morphology. The extent of caspase
activation correlated significantly with the disease grade, i.e.,
necroinflammatory activity. In contrast, no correlation was observed
with other surrogate markers such as serum transaminases and viral
load. In biopsy specimens with low activity (grade 0) 7.7% of
the hepatocytes revealed caspase-3 activation, whereas 20.9% of
the cells stained positively in grade 3. Thus, our results suggest
that caspase activation is involved in HCV-associated liver injury.
Moreover, measurement of caspase activity may represent a reliable
marker for the early detection of liver damage, which may open
up new diagnostic and therapeutic strategies in HCV infection.
(HEPATOLOGY 2001;34:758-767.)
Familial intrahepatic cholestasis 1: Studies of localization
and function (*Human Study*)
Peter Ujhazy, Daniel Ortiz, Suniti Misra, Shohua Li, James Moseley,
Hugh Jones, Irwin M. Arias
Mutations in the FIC1 gene constitute the molecular defect
in familial intrahepatic cholestasis I (Fic1 [Byler's disease])
and benign recurrent intrahepatic cholestasis. This report describes
the localization of Fic1 in rat liver and intestine, as well
as biochemical and transfection studies that support its function
as an energy-dependent aminophospholipid translocase. Immunocytochemistry
of rat liver and immunoblotting of membrane fractions localized
Fic1 to the canalicular, but not basolateral, plasma membrane
domain. In the small intestine, Fic1 was localized to the apical
membrane of epithelial cells. The distribution of Fic1 in liver
plasma membrane fractions from control and taurocholate-treated
rats correlated positively with adenosine triphosphate (ATP)-dependent
aminophospholipid (phosphatidyl-serine) translocase activity.
In canalicular membrane vesicles, translocase activity had an
initial velocity of 3.3 nmol phosphatidylserine (PS) translocated
per milligram of protein per minute and a Km (ATP) = 1.2 mmol/L;
was inhibited by vanadate, N-ethylmaleimide, sodium azide,
and calcium; and was unidirectional (i.e., from the outer to
the inner canalicular plasma membrane leaflet). Transient transfection
of CHOK1 cells with FIC1 cDNA resulted in appearance of FIC1
in membrane preparations and energy-dependent PS translocation
in cells. These studies indicate that FIC1 is a canalicular P-type
ATPase that participates in maintaining the distribution of aminophospholipids
between the inner and outer leaflets of the plasma membrane. How
this process produces cholestasis is under study. (HEPATOLOGY
2001;34:768-775.)
The hepatic mitochondrial DNA depletion syndrome: Ultrastructural
changes in liver biopsies (*Human Study*)
Hanna Mandel, Corina Hartman, Drora Berkowitz, Orli N. Elpeleg,
Irena Manov, Theodore C. Iancu
Mitochondrial respiratory chain disorders are an established cause
of liver failure in early childhood. In some patients, the levels
of mitochondrial DNA are markedly reduced, a condition referred
to as mtDNA depletion syndrome (MDS). We report here on the ultrastructural
changes in the livers of 10 infants with the hepatic form of this
syndrome. All patients displayed progressive liver failure, neurological
abnormalities, hypoglycemia, and lactic acidosis that warranted
investigation of respiratory chain disorder in liver tissue, specifically
expressing the disease. Decreased activity of respiratory chain
complexes containing mtDNA-encoded subunits (complexes I, III,
IV) was shown in 5 patients. Mitochondrial DNA depletion was confirmed
by Southern blot analysis in the livers of 6 patients. We found
hepatocytes filled with mitochondria having aspects of "oncocytic
transformation," associated with numerous changes in shape,
size, cristae, and matrix. The changes were virtually identical
in all specimens. In many hepatocytes, microvesicular steatosis
was the salient feature. Additional findings included cholestasis
and focal cytoplasmic biliary necrosis (CBN), as well as cytosiderosis
in hepatocytes and sinusoidal cells. In some hepatocytes the damage
appeared extreme, but fibrosis was identified only in the few
patients who died beyond 6 months of age. Although individual
ultrastructural findings are not specific, when taken together,
they show a diagnostic pattern highly suggestive of a respiratory
chain disorder. In the appropriate clinical context, these findings
can direct the clinician towards the diagnosis of hepatic MDS.
(HEPATOLOGY 2001;34:776-784.)
Factors associated with hepatitis B virus DNA breakthrough
in patients receiving prolonged lamivudine therapy (*Human Study*)
Man-Fung Yuen, Erwin Sablon, Chee-Kin Hui, He-Jun Yuan, Hilde
Decraemer, Ching-Lung Lai
Factors associated with hepatitis B virus (HBV) DNA breakthrough
and the significance of YMDD variants without the presence of
wild-type YMDD during prolonged lamivudine treatment are unknown.
We studied the amino acid sequence of codon 552 (YMDD motif) and
codon 528 by means of a line probe assay in 159 chronic HBV patients
(median follow-up 29.6 months). Pretreatment HBV DNA levels and
alanine transaminase (ALT) levels correlated inversely with the
time to HBV DNA breakthrough with YMDD variants (r = 0.46,
P = .001; r = 0.45, P = .001 respectively). Patients
harboring YMDD variants 3 months before HBV DNA breakthroughs
had higher HBV DNA breakthrough levels compared with those without
YMDD variants 3 months before HBV DNA breakthroughs (18.9 ¥
106 vs. 5.4 ¥ 106 copies/mL, P = .007). Patients with HBV
DNA breakthroughs had higher percentages of YMDD variants without
the presence of wild-type YMDD compared with patients without
HBV DNA breakthrough (25.6% vs. 9%, P = .007 for single M552I
variant; 20.9% vs. 8.1%, P = .026 for single M552V variant;
30.2% vs. 9.9%, P = .004 for M552I/M552V variants). Patients
with HBV DNA levels of more than 103 copies/mL after 6 months
of lamivudine therapy had a 63.2% chance of subsequently developing
YMDD variants. HBeAg seroconversion occurred in 2 patients after
the emergence of YMDD variants. Only one patient developed YMDD
variant after HBeAg seroconversion. There was no increase in the
rate of development of YMDD variants or L528M mutation in patients
receiving lamivudine 25 mg daily or famciclovir 500 mg 3 times
a day before being given lamivudine 100 mg daily. (HEPATOLOGY
2001;34:785-791.)
Chronic ethanol consumption stimulates hepatitis B virus
gene expression and replication in transgenic mice
Jonathan Larkin, Marcia M. Clayton, Jie Liu, Mark A. Feitelson
Epidemiologic observations show a
higher frequency of hepatitis B virus (HBV) serologic markers
in chronic alcoholics compared with the general population. This
may be the result of an increased susceptibility of alcoholics
to infection and/or to an ethanol-mediated stimulation of HBV
gene expression and replication. To test the latter hypothesis,
HBV transgenic SCID mice, which support consistent levels of virus
replication, were fed with a standard Lieber-DiCarli or isocaloric
diet for 5 weeks. In ethanol-fed mice, the levels of hepatitis
B surface antigen (HBsAg) and viral DNA in serum increased by
up to 7-fold compared with mice fed the control diet. Ethanol-treated
mice also had elevated HBV-RNA levels, and increased expression
of surface, core, and X antigens in the liver, especially in the
pericentral regions. None of these changes were observed in transgenic
mice fed isocaloric diets. Thus, chronic alcohol consumption alters
the patterns of HBV gene expression and replication in the serum
and liver of HBV transgenic SCID mice, and may provide a partial
explanation for the increased frequency of HBV markers among alcoholics.
(HEPATOLOGY 2001;34:792-797.)
Evaluation of a new hepatitis B triple-antigen vaccine in
inadequate responders to current vaccines (*Human Study*)
Jane N. Zuckerman, Arie J. Zuckerman, Ian Symington, Wei Du, Anthony
Williams, Brian Dickson, Michael D. Young, for the UK Hepacare
Study Group
In this double-blind, randomized, controlled study,
healthcare professionals with a history of inadequate response
to currently available single-antigen hepatitis B vaccines confirmed
by measuring hepatitis B surface antibody titer before entry to
the study were revaccinated with a 20-µg dose either of
a novel triple-antigen (S, pre-S1, and pre-S2) recombinant vaccine
or of a present single-antigen (S only) vaccine. Hepatitis B surface
antibody titers were measured 8 weeks' post revaccination. A total
of 925 individuals were randomized and vaccinated, of whom 915
(98.9%) completed the study and were included in the efficacy
analysis. A single dose of the new triple-antigen hepatitis B
vaccine (Hepacare) produced a successful response in over three
quarters of these subjects who had not mounted an adequate response
to current vaccines. The antibody response was statistically significantly
superior (P = .002) to that after a single dose of current
vaccines. An evaluation of the overall response showed that only
the triple-antigen vaccine was able to raise the average antibody
response (geometric mean titer [GMT]) to over 100 IU/L. The superior
effect of the new vaccine was most pronounced in subjects who
were previously complete nonresponders to currently available
hepatitis B vaccines. Both vaccines were well tolerated and had
similar safety profiles. This study demonstrated that in healthcare
workers who had responded inadequately to at least a full course
of immunization (median, 5 doses), a single 20-µg dose of
a new triple-antigen vaccine induced protective antibody level
in more vaccinees (P = .002) and increased the average antibody
titer (GMT) in those protected successfully to a greater degree
(P < .001) than a further attempt with a current vaccine
(Engerix-B). (HEPATOLOGY 2001;34:798-802.)
Endothelial cellmediated uptake of a hepatitis B virus:
A new concept of liver targeting of hepatotropic microorganisms
Klaus M. Breiner, Heinz Schaller, Percy A. Knolle
The liver is a target for many infectious agents,
most notably hepatitis viruses. However, several receptor molecules
identified so far for hepatitis viruses were found to be ubiquitously
expressed and can thus not account for efficient liver targeting.
Using a model hepatitis B virus, the duck hepatitis B virus (DHBV),
we have obtained data indicating that scavenging liver sinusoidal
endothelial cells (LSEC), rather than hepatocytes themselves,
play the key role in the initial uptake of viral pathogens into
the liver. Experiments with fluorescent viral particles and coated
gold particles in test animals, as well as in primary liver cell
culture, demonstrated a preferential uptake of the viral substrates
into LSEC. Intracellularly, fluorescent virus particles internalized
by LSEC colocalized with the DHBV receptor, carboxypeptidase D,
suggesting receptor-mediated rescue from lysosomal degradation.
To comply with the high efficiency by which hepatitis B viruses
infect hepatocytes in vivo, we propose that viruses initially
scavenged by LSEC are thereafter released to infect adjacent hepatocytes,
the only cells capable of replicating these viruses. Such a model
of primary uptake into LSEC may illustrate a general mechanism
by which blood-borne hepatotropic agents are targeted to the hepatocytes
in the liver. (HEPATOLOGY 2001;34:803-808.)
Estimating progression to cirrhosis in chronic hepatitis
C virus infection (*Human Study*)
Anthony J. Freeman, Gregory J. Dore, Matthew G. Law, Max Thorpe,
Jan Von Overbeck, Andrew R. Lloyd, George Marinos, John M. Kaldor
To gain a clearer understanding of the rate of
progression to cirrhosis and its determinants in chronic hepatitis
C virus (HCV) infection, a systematic review of published epidemiologic
studies that incorporated assessment for cirrhosis has been undertaken.
Inclusion criteria were more than 20 cases of chronic HCV infection,
and information on either age of subjects or duration of infection.
Of 145 studies examined, 57 fulfilled the inclusion criteria.
Least-squares linear regression was employed to estimate rates
of progression to cirrhosis, and to examine for factors associated
with more rapid disease progression in 4 broad study categories:
1) liver clinic series (number of studies = 33); 2) posttransfusion
cohorts (n = 5); 3) blood donor series (n = 10); and 4) community-based
cohorts (n = 9). Estimates of progression to cirrhosis after 20
years of chronic HCV infection were 22% (95% CI, 18%-26%) for
liver clinic series, 24% (11%-37%) for posttransfusion cohorts,
4% (1%-7%) for blood donor series, and 7% (4%-10%) for community-based
cohorts. Factors that were associated with more rapid disease
progression included older age at HCV infection, male gender,
and heavy alcohol intake. Even after accounting for these factors,
progression estimates were much higher for cross-sectional liver
clinic series. Selection biases probably explain the higher estimates
of disease progression in this group of studies. Community-based
cohort studies are likely to provide a more representative basis
for estimating disease progression at a population level. These
suggest that for persons who acquire HCV infection in young adulthood,
less than 10% are estimated to develop cirrhosis within 20 years.
(HEPATOLOGY 2001;34:809-816.)
Acute exacerbations of chronic hepatitis B are rarely associated
with superinfection of hepatitis B virus (*Human Study*)
Jia-Horng Kao, Pei-Jer Chen, Ming-Yang Lai, Ding-Shinn Chen
There are 7 genotypes of hepatitis B virus (HBV).
Whether superinfection of HBV carriers with different HBV genotypes
occurs remains unknown. We therefore determined the HBV genotype
and association between superinfection and acute exacerbation
of disease in a cohort of 244 patients with chronic HBV infection
who had elevated serum aminotransferase levels for at least 1
year. Within this group, 103 patients experienced acute exacerbation
with an annual incidence of 13%, and 20 of the 103 patients had
IgM antibody to hepatitis B core antigen (IgM anti-HBc). These
20 patients had a higher prevalence of genotype C infection (65%)
than the remaining 83 anti-core IgMnegative patients (40%)
who also had acute exacerbations (P < .05). Detailed analysis
of HBV genotypes and sequences of the variable pre-S gene were
determined in serial samples from 20 patients with IgM anti-HBcpositive
acute exacerbations (group A), 20 patients with IgM anti-HBcnegative
acute exacerbations (group B), and 20 patients without exacerbations
(group C). Two (10%) of the group A patients had virologic evidence
of HBV superinfection during acute exacerbation, one superinfected
with heterotypic virus and the other with homotypic virus. The
newly introduced virus disappeared after the exacerbation and
the original virus resumed thereafter. The calculated prevalence
of HBV superinfection in the hepatitis B carriers and those with
acute exacerbations was 0.8% (2 of 244) and 1.9% (2 of 103), respectively.
In conclusion, superinfection of HBV on hepatitis B carriers indeed
occurs and may cause acute exacerbations, albeit at a low frequency
even in hyperendemic areas of HBV infection. (HEPATOLOGY 2001;34:817-823.)
Woodchuck hepatocytes remain permissive for hepadnavirus
infection and mouse liver repopulation after cryopreservation
Maura Dandri, Martin R. Burda, Andreas Gocht, Eva Török,
Jörg M. Pollok, Charles E. Rogler, Hans Will, Jörg Petersen
Isolated hepatocytes represent a relevant model
of the liver and are highly required both for research and therapeutic
applications. However, sources of primary liver cells from human
beings and from some animal species are limited. Therefore, cryopreservation
of hepatocytes could greatly facilitate advances in various research
areas. The aim of this study was to evaluate whether cryopreserved
primary woodchuck hepatocytes could be used for woodchuck hepatitis
B virus (WHV) infection studies, and whether they could maintain
their regenerative potential in vivo after thawing. Critical
steps for good quality of cryopreserved hepatocytes included the
use of University of Wisconsin (UW) solution as a main component
of the freezing medium, stepwise reduction of dimethylsulfoxide
(DMSO) to avoid osmotic shock, and maintenance of low concentrations
of DMSO in the culture medium. After cryopreservation, cell viability
was still high (70% to 80%), and 50% to 60% of thawed cells attached
to the plates. The appearance of covalently closed circular (ccc)DNA
and of WHV-replicative forms a few days after in vitro infection
demonstrated that thawed woodchuck hepatocytes were still susceptible
to viral infection, thus proving maintenance of a very high hepatocyte-specific
differentiation status. Furthermore, transplantation of woodchuck
hepatocytes into the liver of urokinase-type plasminogen activator
(uPA)/recombination activation gene-2 (RAG-2) mice, a model of
liver regeneration, demonstrated that cryopreserved cells retained
the ability to divide and to extensively repopulate a xenogenic
liver. Notably, in vivo susceptibility to infection with WHV
and proliferative capacity of frozen/thawed woodchuck hepatocytes
in recipient mice were identical to those observed by transplanting
fresh hepatocytes. (HEPATOLOGY 2001;34:824-833.)
Neural Stem Cells Express RET, Produce Nitric Oxide, and
Survive Transplantation in the Gastrointestinal Tract
MARIA-ADELAIDE MICCI,* RANDALL D. LEARISH, HUI LI,* BINCY P. ABRAHAM,*
and PANKAJ JAY PASRICHA*
Background & Aims: Transplantation of
neural stem cells (NSC) has been shown to be successful in a variety
of experimental models of nongastrointestinal diseases. The aim
of this study was to assess the potential of NSC transplantation
as a therapeutic strategy for neuronal replacement in disorders
of the enteric nervous system. Methods: Central nervous
system-derived NSC (CNS-NSC) were obtained from the subventricular
zone of rat brain (E17). Expression of RET, GFR1, and neuronal
nitric oxide synthase (nNOS) was assessed by Western blot and
immunocytochemistry. Nitric oxide (NO) production was assessed
using the NO-sensitive fluorescent indicator DAF-2. CNS-NSC (labeled
with CM-DiI) were transplanted into the pylorus of mice and fluorescent
double-labeling immunostaining for III-tubulin or PGP 9.5 and
nNOS was performed at 2, 4, and 8 weeks after transplantation.
Results: Our results show that CNS-NSC express both the
receptors (RET and GFR1) for the enteric neurotrophin, GDNF; GDNF,
in turn, induces expansion of the RET-expressing CNS-NSC population.
Furthermore, CNS-NSC express nNOS and produce NO in vitro. When
transplanted into the gut, CNS-NSC differentiate into neurons,
continue to express nNOS and survive at least 8 weeks. Conclusions:
We conclude that transplantation of CNS-NSC bears promise as a
potential cellular replacement strategy for enteric neurons. GASTROENTEROLOGY
2001;121:757-766
Cannabinoids Inhibit Emesis Through CB1 Receptors in the
Brainstem of the Ferret
MARJA D. VAN SICKLE,* LORRAINE D. OLAND,* WINNIE HO,* CECILIA
J. HILLARD, KEN MACKIE,§ JOSEPH S. DAVISON,* and KEITH A.
SHARKEY*
Background & Aims: Marijuana and other cannabinoids
are effective anti-emetics. Despite ongoing controversy over their
usage, the receptor distribution and the site of the anti-emetic
action of these compounds are not known. Our aim was to investigate
whether the cannabinoid 1 receptor (CB1r) and endocannabinoids
play a role in the anti-emetic action of cannabinoids. Methods:
Ferrets were given an emetic stimulus and the number of episodes
of retching and vomiting were observed after administration of
CB1r agonists and a CB1r antagonist. CB1r and fatty acid amide
hydrolase (FAAH), which degrades endocannabinoids, were localized
by immunohistochemistry. Results: CB1r and FAAH were localized
in the dorsal vagal complex, consisting of the area postrema,
nucleus of the solitary tract, and the dorsal motor nucleus of
the vagus in the brainstem. CB1r was found in the myenteric plexus
of the stomach and duodenum. Activation of CB1r by the agonists
(delta)9-tetrahydrocannabinol, WIN 55,212-2, and methanandamide
inhibited emesis and their action was reversed by a selective
CB1r antagonist, which alone had no effect, but potentiated vomiting
in response to an emetic stimulus. Conclusions: CB1r mediates
the anti-emetic action of cannabinoids in the dorsal vagal complex.
Endocannabinoids are a novel neuroregulatory system involved in
the control of emesis. GASTROENTEROLOGY 2001;121:767-774
Unbuffered Highly Acidic Gastric Juice Exists at the Gastroesophageal
Junction After a Meal
JONATHAN FLETCHER,* ANGELA WIRZ,* JOANNE YOUNG,* RAMSEY VALLANCE,
and KENNETH E. L. McCOLL*
Background & Aims: Gastroesophageal reflux
typically occurs after meals. During dual gastric and esophageal
pH monitoring, we observed that postprandial refluxate was often
more acidic than the gastric contents. This study aimed to investigate
this phenomenon. Methods: Dual gastric and esophageal pH
tracings were analyzed from 40 dyspeptic patients. Dual pH
electrode pull-through studies were performed in healthy volunteers
to document regional variation in intragastric pH under both fasting
and postprandial conditions. The squamocolumnar junction was identified
using radio-opaque endoscopic clips. We also examined in vitro
partitioning of gastric juice added to a homogenized fatty meal.
Results: The dual pH traces confirmed that esophageal refluxate
was frequently more acidic than the body of the stomach after
meals but not during fasting. The pull-through studies showed
a pocket of acid at the gastroesophageal junction that escaped
the buffering effect of meals, remaining highly acidic (median
pH 1.6) compared with the body of the stomach (pH 4.7; P < 0.001).
This proximal acid pocket extended from the cardia across the
squamocolumnar junction 1.8 cm into the distal esophagus.
The in vitro studies showed that acidic gastric juice could partition
on top of a homogenized fatty meal. Conclusions: After
eating, highly acidic unbuffered gastric juice is present at the
gastroesophageal squamocolumnar junction and is likely to contribute
to the high prevalence of disease at this site. GASTROENTEROLOGY
2001;121:775-783
Helicobacter pylori in Gastric Cancer Established
by CagA Immunoblot as a Marker of Past Infection
ANNA MIA EKSTRÖM,* MARIA HELD,* LARS-ERIK HANSSON, LARS ENGSTRAND,*,§
and OLOF NYRÉN*
Background & Aims: Helicobacter pylori
may disappear spontaneously with progressing precancerous changes
and invalidate serologic studies of its association with gastric
cancer. We reestimated the strength of the H. pylori-gastric
cancer relationship, using both conventional immunoglobulin (Ig)
G enzyme-linked immunosorbent assay (ELISA) and immunoblot (against
cytotoxin-associated antigen A [CagA] antibodies that prevail
longer after eradication) to detect past H. pylori
exposure more relevant for time at cancer initiation. Methods:
In our population-based case-control study, the seroprevalence
among 298 gastric adenocarcinoma cases was 72% (IgG ELISA)
and 91% (immunoblot) vs. 55% and 56% among 244 controls frequency-matched
for age and gender. Results: Using IgG ELISA only, the
adjusted OR for noncardia gastric cancer among H. pylori-positive
subjects was 2.2 (95% confidence interval [CI], 1.4-3.6).
When ELISA/CagA+ subjects (odds ratio [OR], 68.0) were removed
from the reference, the OR rose to 21.0 (95% CI, 8.3-53.4)
and the previous effect modification by age disappeared. ELISA+/CagA
subjects had an OR of 5.0 (95% CI, 1.1-23.6). There were
no associations with cardia cancer. Conclusions: The weaker
H. pylori-cancer relationships in studies based on
IgG ELISA rather than CagA may be caused by misclassification
of relevant exposure. A much stronger relationship emerges with
more accurate exposure classification. In the general Swedish
population, 71% of noncardia adenocarcinomas were attributable
to H. pylori. GASTROENTEROLOGY 2001;121:784-791
Recrudescence and Reinfection With Helicobacter pylori
After Eradication Therapy in Bangladeshi Adults
PIUS HILDEBRAND,* PRADIP BARDHAN,,§ LIVIO ROSSI,*, SHAHANA
PARVIN, ANISUR RAHMAN, MOHAMED S. AREFIN,¶ MAHMUD HASAN,¶
MIAN M. AHMAD,# KATHARINA GLATZ-KRIEGER,** LUIGI TERRACCIANO,**
PETER BAUERFEIND,§ CHRISTOPH BEGLINGER,*, NIKLAUS GYR, and
ABUL K. AZAD KHAN
Background & Aims: In developing countries
where Helicobacter pylori infection is widespread, posttherapeutic
recurrence rates may be high. Many of the limited studies available
have methodological problems and show varied recurrence rates.
We determined late recrudescence rates, true reinfection, and
ulcer recurrence. Methods: One hundred five Bangladeshi
patients with H. pylori infection and duodenal ulcer
disease were treated with a triple therapy. Follow-up included
13C-urea breath tests, endoscopy, and biopsy-based tests. In reinfected
patients, genomic typing compared pretherapeutic and posttherapeutic
strains. Results: Recrudescence, associated with nitroimidazole-based
treatment, occurred in 15 of 105 patients (14%) within
the first 3 months, but only 8 of 105 patients
tested positive 4 weeks after therapy ended. True reinfection
was diagnosed in 11 of 105 patients between 3 and
18 months after therapy. The annual reinfection rate was
13%, based on a total follow-up of 84.7 patient years. Ulcer
relapse occurred in 2 of 15 (13%) recrudescence cases
and in 6 of 11 (55%) reinfection cases, but also in
4 of 73 (5%) H. pylori-negative patients.
Conclusions: In Bangladesh, late recrudescence of H. pylori
after eradication therapy occurs within the first 3 months.
The reinfection rate is high and might influence cost-benefit
analyses for determining diagnostic and therapeutic procedures.GASTROENTEROLOGY
2001;121:792-798
Irritable Bowel Syndrome in Twins: Heredity and Social Learning
Both Contribute to Etiology
RONA L. LEVY,* KENNETH R. JONES, WILLIAM E. WHITEHEAD, SHARA I.
FELD,§ NICHOLAS J. TALLEY, and LINDA A. COREY¶
Background & Aims: Heredity has been suggested
to explain the finding that irritable bowel syndrome (IBS) tends
to run in families. Research in this area has been limited. The
aim of the present study was to assess the relative contribution
of genetic and environmental (social learning) influences on the
development of IBS by comparing concordance rates in monozygotic
and dizygotic twins to concordance between mothers and their children.
Methods: Questionnaires soliciting information on the occurrence
of more than 80 health problems, including IBS, in self and
other family members were sent to both members of 11,986 twin
pairs. Results: Analysis is based on 10,699 respondents
representing 6060 twin pairs. Concordance for IBS was significantly
greater (P = 0.030) in monozygotic (17.2%) than
in dizygotic (8.4%) twins, supporting a genetic contribution to
IBS. However, the proportion of dizygotic twins with IBS who have
mothers with IBS (15.2%) was greater than the proportion of dizygotic
twins with IBS who have co-twins with IBS (6.7%, P < 0.001),
and logistic regression analysis showed that having a mother with
IBS and having a father with IBS are independent predictors of
irritable bowel status (P < 0.001); both are
stronger predictors than having a twin with IBS. Addition of information
about the other twin accounted for little additional predictive
power. Conclusions: Heredity contributes to development
of IBS, but social learning (what an individual learns from those
in his or her environment) has an equal or greater influence.
GASTROENTEROLOGY 2001;121:799-804
The Interleukin 1 Receptor Antagonist Gene Allele 2 as
a Predictor of Pouchitis Following Colectomy and IPAA in Ulcerative
Colitis
MARTYN J. CARTER,*, FRANCESCO S. DI GIOVINE, ANGELA COX, PETER
GOODFELLOW,§ SIMON JONES,*, ANDREW J. SHORTHOUSE,§ GORDON
W. DUFF, and ALAN J. LOBO*,
Background & Aims: The interleukin 1 receptor
antagonist gene allele 2 has been suggested as a determinant
of both disease susceptibility and extent in ulcerative colitis.
The aim of this study was to assess the allele as a predictor
of both the indication for colectomy and the occurrence of pouchitis
after ileal pouch-anal anastomosis formation. Methods:
Genotyping for the +2018 single nucleotide polymorphism in the
interleukin 1 receptor antagonist gene was performed in 109 patients
who had undergone colectomy, including 82 patients who had
been followed prospectively after ileal pouch-anal anastomosis
formation. Results: Patients with pouchitis had a higher
allele 2 carriage rate compared with those without pouchitis
(72% vs. 45%) and Kaplan-Meier survival analysis showed that allele
2 carriers had a significantly increased incidence of pouchitis
compared with noncarriers (log-rank test, 6.5). After adjustment
for confounding covariates in a Cox proportional hazards model,
the relative hazard was 3.1 (95% confidence interval [CI],
1.2-7.8; P = 0.02). Although there was a higher
allele 2 carriage rate in patients with chronic refractory
compared with acute severe ulcerative colitis (63% vs. 48%), this
difference was not significant (odds ratio, 1.9; 95% CI, 0.9-4.1;
P = 0.1). Conclusions: The interleukin
1 receptor antagonist gene allele 2 predicts pouchitis
after ileal pouch-anal anastomosis in ulcerative colitis. GASTROENTEROLOGY
2001;121:805-811
Colonic Transit Influences Deoxycholic Acid Kinetics
MARTIN J. VEYSEY,* LINZI A. THOMAS,* ANTHONY I. MALLET, PAUL J.
JENKINS,§ G. MICHAEL BESSER,§ GERARD M. MURPHY,* and
R. HERMON DOWLING*
Background & Aims: Prolonged large bowel
transit, and an increase in the proportion of deoxycholic acid
(DCA), have been implicated in the pathogenesis of cholesterol
gallstonesincluding those developing in acromegalics treated with
octreotide. However, there are few data on the effects of intestinal
transit on bile acid kinetics. Methods: We therefore measured
the kinetics of DCA and cholic acid (CA) using stable isotopes,
serum sampling, and mass spectrometry. The results were related
to mouth-to-caecum (MCTT) and large bowel transit times (LBTTs)
in 4 groups of 8 individuals: (1) non-acromegalic controls,
(2) acromegalics untreated with octreotide, (3) acromegalics on
long-term octreotide, and (4) patients with constipation. Paired,
before and during octreotide, studies were performed in 5 acromegalics.
Results: In the unpaired and paired studies, octreotide
significantly prolonged MCTT and LBTT. In the paired studies,
the octreotide-induced prolongation of LBTT caused an increase
in the DCA input rate (6.4 ± 2.8 to 12 ± 2.6 µmol
· kg · d, P < 0.05)
and pool size (18 ± 12 to 40 ± 13 µmol/kg,
P < 0.05), and a decrease in CA pool size
(45 ± 15 to 25 ± 11 µmol/kg,
P < 0.05). Furthermore, during octreotide
treatment, the mean conversion of 13C-CA to 13C-DCA (micromoles)
was greater (P < 0.05) on study days 3, 4, and
5. There were also positive linear relationships between
LBTT and DCA input rate (r = 0.78), pool size
(r = 0.82, P < 0.001),
and a weak(r = 0.49) negative linear relationship
between LBTT and CA pool size (P < 0.01).
Conclusions: These data support the hypothesis that, by
increasing DCA formation and absorption, prolongation of large
bowel transit is a pathogenic factor in the formation of octreotide-induced
gallstones. GASTROENTEROLOGY 2001;121:812-822
Interleukin 1B and Interleukin 1RN Polymorphisms Are Associated
With Increased Risk of Gastric Carcinoma
JOSÉ CARLOS MACHADO,* PAUL PHAROAH,,§ SÓNIA
SOUSA,* RALPH CARVALHO,* CARLA OLIVEIRA,*, CÉU FIGUEIREDO,*
ANTÓNIO AMORIM,*, RAQUEL SERUCA,* CARLOS CALDAS, FÁTIMA
CARNEIRO,*,¶ and MANUEL SOBRINHO-SIMÕES*,¶
Background & Aims: Interleukin
(IL)-1 gene cluster proinflammatory polymorphisms
have been associated with development of gastric atrophy and with
increased risk of gastric carcinoma. We aimed to determine the
association between IL-1 loci polymorphisms and increased
risk of gastric carcinoma in samples from a Portuguese population,
and to find whether there was any relationship with the histologic
types of gastric carcinoma. Methods: In a case-control
study including 220 controls and 152 patients with gastric
carcinoma (intestinal, 76; diffuse, 37; and atypical, 39), both
the IL-1B-511 biallelic polymorphism and the IL-1RN
penta-allelic variable number of tandem repeats were genotyped.
Results: We found a significant association between the
IL-1 polymorphisms and increased risk for tumor development
in patients with intestinal-type gastric carcinoma. A trend towards
an increased risk of tumor development was also observed in patients
with diffuse-type gastric carcinoma. No significant relationship
was observed in patients with atypical carcinoma. Carriers of
IL-1B-511T and IL-1RN*2 homozygotes had increased
risk for developing intestinal-type gastric carcinoma with odds
ratios of 2.7 (95% confidence interval [CI], 1.5-4.9) and
3.1 (95% CI, 1.5-6.5), respectively. Statistical analysis
showed an interaction between the 2 loci with the risk conferred
by the IL-1B-511T allele substantially increased (odds
ratio, 9.0; 95% CI, 3.5-23.0) in individuals homozygous for the
IL-1RN*2 allele. Conclusions: Our results provide
further support to the association between IL-1 gene cluster
proinflammatory polymorphisms and increased risk of gastric carcinoma.
Furthermore, we found evidence pointing to the existence of a
synergistic interaction between the IL-1B and IL-1RN
polymorphisms. GASTROENTEROLOGY 2001;121:823-829
The Colon Cancer Burden of Genetically Defined Hereditary Nonpolyposis
Colon Cancer
WADE S. SAMOWITZ,* KAREN CURTIN, HEATHER H. LIN,§ MARGARET
A. ROBERTSON,§ DONNA SCHAFFER, MELANIE NICHOLS,¶ KRISTEN
GRUENTHAL,¶ MARK F. LEPPERT,¶ and MARTHA L. SLATTERY
Background & Aims: Estimates of the frequency
of hereditary nonpolyposis colon cancer (HNPCC) based on clinical
criteria have varied widely. Recent studies of germline mismatch
repair gene mutations have suggested that HNPCC accounts for close
to 3% of all colon cancer, but this estimate may have been inflated
by inclusion of founder effects peculiar to Finland. We therefore
determined by genetic criteria the colon cancer burden associated
with HNPCC in a population-based study of 1066 individuals
from Utah and California. Methods: The coding regions of
mismatch repair genes hMSH2 and hMLH1 were sequenced
from the germline of those individuals whose tumors exhibited
microsatellite instability. Results: Microsatellite instability
was present in 16% (171/1066) of tumors. Pathogenic germline mismatch
repair gene mutations were identified in 7 individuals, and
missense amino acid changes of uncertain significance were identified
in another 6 individuals. After adjusting for the availability
of sufficient germline DNA for sequencing, the 7 clearly
pathogenic mutations accounted for 0.86% of colon cancer at the
population level. Individuals with these mutations were significantly
younger, more likely to have a family history of colon and endometrial
cancer, and more likely to have first-degree relatives with a
young-age onset of colon cancer than individuals with unstable
tumors but without germline mutations (P < 0.01).
Conclusions: We conclude that genetically defined HNPCC
accounts for a very small percentage of colon cancer at the population
level, a percentage less than that estimated by most previous
clinical studies. GASTROENTEROLOGY 2001;121:830-838
Multicellular Gastric Cancer Spheroids Recapitulate Growth
Pattern and Differentiation Phenotype of Human Gastric Carcinomas
BARBARA MAYER,* GIANNOULA KLEMENT,* MAYUMI KANEKO, SHAN MAN,*
SERGE JOTHY, JANUSZ RAK,§ and ROBERT S. KERBEL*
Background & Aims: Advanced gastric cancer
has a poor prognosis and is largely unresponsive to currently
available chemotherapeutic drugs. The development of more effective
therapies would be aided by better preclinical models. Methods:
An in vitro multicellular gastric cancer spheroid model was established
using the liquid overlay technique and compared with the corresponding
xenografts in immunodeficient mice. Results: Twelve of
17 (71%)gastric cancer cell lines reflected growth characteristics
of their parental gastric carcinomas in three-dimensional culture.
Thus, cell lines derived from peritoneal and pleural carcinomatosis
grew as single cells (HSC-39, KATO-II, KATO-III) and cell aggregates
(SNU-5, SNU-16). Cell lines representing adenosquamous (MKN-1)
and tubular differentiation (MKN-28, MKN-74, N87) formed partly
compact multicellular spheroids recapitulating the tumor architecture
of the respective original tumor. The differentiated phenotype
was lost after subcutaneous implantation of the in vitro spheroids
in mice. The degree of morphologic differentiation was reflected
by the levels of mucin and constitutive E-cadherin expression.
Heterogeneous changes of other adhesion molecules (EpCAM, 21,
CD44s, Lex, sLex) were observed. In contrast, cell lines derived
from poorly differentiated gastric carcinomas (Hs-746T, RF-1,
RF-48) formed fully compact spheroids mimicking the poorly differentiated
phenotype, were E-cadherin negative, and showed only CD44s up-regulation.
Conclusions: Recapitulating some complexity of their in
vivo counterparts, multicellular gastric cancer spheroids may
represent a physiologically valid model for studying the biology
of this cancer, and testing new therapeutic strategies. GASTROENTEROLOGY
2001;121:839-852
Immune Cell Trafficking in Uterus and Early Life Is Dominated
by the Mucosal Addressin MAdCAM-1 in Humans
MARKO SALMI,* KALLE ALANEN, SEIJA GRENMAN,§ MICHAEL BRISKIN,
EUGENE C. BUTCHER,¶ and SIRPA JALKANEN*
Background & Aims: In adults, binding
of mucosal addressin cell adhesion molecule 1 (MAdCAM-1)
to lymphocyte 47 integrin directs cell trafficking to gut, whereas
interaction of peripheral node addressins (PNAd) with lymphocyte
L-selectin targets immune cells to peripheral lymph nodes (PLNs).
Because nothing is known about these addressins during human development,
we studied the expression and function of MAdCAM-1 (and PNAd for
comparison) in fetuses and children. Methods: Series of
human tissue samples obtained from fetuses (7-40 weeks), children
(2 months-7 years), and adults were immunostained with monoclonal
antibodies. The function of the addressins and their lymphocyte
counter-receptors was tested in in vitro binding assays on fetal
and adult tissues. Results: Unlike in adults, MAdCAM-1
is widely expressed from embryonic week 7 onwards, and it
only gradually becomes polarized to mucosal vessels after birth.
In utero MAdCAM-1 functionally governs lymphocyte adhesion to
vessels both in the gut and PLNs by binding to 47 integrin. The
later induction of PNAd gradually starts to dominate the binding
of lymphocytes to PLNs during childhood. Conclusions: There
are striking age-dependent switches and species-specific variation
in the molecular mechanisms of lymphocyte migration. In utero
and during early childhood, the mucosal addressin MAdCAM-1 plays
a dominant role in lymphocyte-endothelial cell adhesion at mucosal
and nonmucosal sites. GASTROENTEROLOGY 2001;121:853-864
Glutathione S-Transferase- Overexpression Is Closely
Associated With K-ras Mutation During Human Colon Carcinogenesis
KOJI MIYANISHI, TETSUJI TAKAYAMA, MOTOH OHI, TSUYOSHI HAYASHI,
ATSUSHI NOBUOKA, TAKAHARU NAKAJIMA, RISHU TAKIMOTO, KATSUHISA
KOGAWA, JUNJI KATO, SUMIO SAKAMAKI, and YOSHIRO NIITSU
Background & Aims: In colorectal adenoma
and carcinoma, glutathione S-transferase- (GSTP1-1) is highly
expressed. K-ras mutation is also known to occur frequently
in colorectal adenoma and carcinoma, as well as in the putative
precursor of adenoma, aberrant crypt foci (ACF). Further, forced
expression of v-H-ras in rat liver epithelial cells has
been shown to enhance rat -class GST expression. The aim of the
present study is, therefore, to investigate the causative relationship
between GSTP1-1 overexpression and K-ras mutation in these
lesions. Methods: Twenty-seven specimens of colorectal
carcinoma, 24 of adenoma, and 28 of ACF were examined
in this study. The expression of GSTP1-1 or p21K-ras was examined
by immunohistochemistry. The GSTP1-1 messenger RNA levels were
measured by TaqMan reverse-transcription polymerase chain reaction
(PCR). K-ras mutation was detected by two-step PCR restriction
fragment length polymorphism. v-K-ras transfection to RPMI-4788
colon carcinoma cells was carried out by the lipofection method.
Activities of GSTP1-1 promoters containing AP-1 and Sp1
responsive elements in the v-K-ras transfectants were measured
by a secreted form of human placental alkaline phosphatase (SEAP)
assay. Nuclear protein from these transfectants bound to the GSTP1-1
promoter was analyzed by electrophoretic mobility shift assay
(EMSA). Results: In human colorectal carcinoma, adenoma,
and ACF, close association of increased expression of GSTP1-1
with K-ras mutation was observed. v-K-ras transfectants
showed significantly higher SEAP activity than that of mock-transfectant
activity. EMSA showed specific interaction of AP-1 with promoter
of GSTP1-1. Conclusions: It is highly plausible
that GSTP1-1 overexpression in ACF, colorectal adenoma, and carcinoma
is induced by K-ras mutation via AP-1 activation. GASTROENTEROLOGY
2001;121:865-874
Macrophage-Derived IL-18-Mediated Intestinal Inflammation in
the Murine Model of Crohn's Disease
TAKANORI KANAI,* MAMORU WATANABE,* AKIRA OKAZAWA, TOSHIRO SATO,
MOTOMI YAMAZAKI,* SUSUMU OKAMOTO, HIROMASA ISHII, TERUJI TOTSUKA,*
RYOICHI IIYAMA,* RYUICHI OKAMOTO,* MASAO IKEDA,§ MASASHI
KURIMOTO,§ KIYOSHI TAKEDA, SHIZUO AKIRA, and TOSHIFUMI HIBI,¶
Background & Aims: Crohn's disease (CD)
is associated with an increased number of infiltrating macrophages,
which release a variety of proinflammatory cytokines. Interleukin
(IL)-18 has been implicated in the modulation of mucosal CD4+
T cells towards Th1 responses, which are implicated in the pathogenesis
of CD. Here we assess the role of macrophages and of IL-18 in
the murine model of intestinal inflammation that mimics the immunologic
characteristics of human CD. Methods: Colitis was induced
in C57BL/6 mice immunized with 2,4,6-trinitrobenzene sulfonic
acid (TNBS) followed by rectal administration of TNBS in ethanol.
Mice were treated with either an antibody directed against macrophages
conjugated to the ribosome-inactivating protein saporin (anti-Mac-1-saporin)
or with a neutralizing antibody against IL-18. In addition, we
assessed whether an identical TNBS immunization/challenge protocol
could induce colitis in IL-18/ mice. Results: The colonic
mucosa of TNBS-treated mice was marked by infiltration of Mac-1-positive
macrophages and up-regulation of IL-18. The administration of
the anti-Mac-1-saporin antibody or the neutralizing anti-IL-18
antibody resulted in a dramatic attenuation of mucosal inflammation
in this model. In addition, TNBS was unable to induce significant
colitis in the IL-18/ mice. Conclusions: Our data underscore
the pivotal role of macrophages, and the macrophage-derived IL-18,
in the establishment of TNBS-induced colitis in mice. Our results
highlight the potential use of therapy directed against IL-18
in the treatment of patients with CD. GASTROENTEROLOGY 2001;121:875-888
Lack of Inducible Nitric Oxide Synthase Promotes Intestinal
Tumorigenesis in the ApcMin/+ Mouse
DANIEL J. SCOTT,* MARK A. HULL,* ELIZABETH J. CARTWRIGHT,* WAI
K. LAM,* ALISON TISBURY,* RICHARD POULSOM, ALEXANDER F. MARKHAM,*
CONSTANZE BONIFER,* and P. LOUISE COLETTA*
Background & Aims: The role of the inducible
isoform of nitric oxide synthase (Nos2 or iNOS) in intestinal
tumorigenesis is unclear. Conflicting data also exist regarding
the ability of Nos2 to modulate expression and/or activity of
cyclooxygenase 2 (Cox-2), which promotes intestinal tumorigenesis.
Therefore, we determined the effect of a null Nos2 genotype
on intestinal tumorigenesis and Cox-2 expression/activity in the
ApcMin/+ mouse model of familial adenomatous polyposis.
Methods: ApcMin/+Nos2/ mice were generated
by successive crosses between C57BL/6-ApcMin/+ andC57BL/6-Nos2tm1Lau
mice. Adenoma characteristics of age-matched ApcMin/+Nos2+/+
and ApcMin/+Nos2/ mice were compared. The level
and cellular localization of Nos2 messenger RNA (mRNA)
expression in ApcMin/+Nos2+/+ mouse intestine was
determined. Cox-2 expression and activity were measured in both
intestinal tissue and bone marrow-derived macrophages in vitro.
Results: ApcMin/+Nos2/ mice developed significantly
more intestinal adenomas than ApcMin/+Nos2+/+ littermates.
Epithelial cell Nos2 mRNA expression was decreased in adenomas
compared with histologically normal ApcMin/+Nos2+/+
intestine. There was no significant difference in Cox-2 expression
or activity in either intestine or bone marrow-derived macrophages
from ApcMin/+Nos2+/+ and ApcMin/+Nos2/
animals. Conclusions: Nos2 plays an antineoplastic
role in the ApcMin/+ mouse model of familial adenomatous
polyposis. Nos2 does not modulate Cox-2 expression or activity
in the ApcMin/+ mouse. GASTROENTEROLOGY 2001;121:889-899
A Preliminary Trial of High-Dose Ursodeoxycholic Acid in Primary
Sclerosing Cholangitis
STEPHEN A. MITCHELL,* DAVINDER S. BANSI,* NICHOLAS HUNT, KLAUS
VON BERGMANN,§ KENNETH A. FLEMING, and ROGER W. CHAPMAN*
Background & Aims: Ursodeoxycholic acid
(UDCA) is used for the treatment of cholestatic liver diseases
including primary biliary cirrhosis (PBC) for which it has a positive
effect on laboratory values, may delay the development of liver
failure and prolong the transplant-free disease period. Standard
doses of UDCA (8-15 mg/kg daily) have been shown to be ineffective
in the treatment of primary sclerosing cholangitis (PSC). We report
on the findings (clinical, biochemical, histological, and cholangiographic)
and side effects of a 2-year double-blind placebo-controlled preliminary
study of high-dose UDCA in PSC patients. Methods: Twenty-six
patients with PSC were randomized to high-dose (20 mg/kg
daily) UDCA or placebo. Cholangiography and liver biopsy were
performed at entry and after 2 years. Symptoms, clinical
signs, and liver biochemical tests were recorded at 3 monthly
intervals. Results: High-dose UDCA did not influence symptoms,
but there was a significant improvement in liver biochemistry
(serum alkaline phosphatase, P = 0.03; -glutamyl transferase,
P = 0.01) and a significant reduction in progression in
cholangiographic appearances (P = 0.015) and liver fibrosis
as assessed by disease staging (P = 0.05). In the treatment
group, a significant increase in total bile acids and saturation
with UDCA >70% confirmed patient compliance. No significant
side effects were reported. Conclusions: High-dose UDCA
may be of clinical benefit in PSC, but trials with a larger number
of participants and of longer duration are required to establish
whether the effect of high-dose UDCA on liver biochemistry, histology,
and cholangiography in patients with PSC is translated into improved
long-term survival. GASTROENTEROLOGY 2001;121:900-907
Isosorbide Mononitrate in the Prevention of First Variceal
Bleed in Patients Who Cannot Receive -blockers
JUAN CARLOS GARCÍA-PAGÁN,* CANDIDO VILLANUEVA, MARIA
CARME VILA,§ AGUSTIN ALBILLOS,# JOAN GENESCÀ,¶
LUIS RUIZ-DEL-ARBOL,# RAMÓN PLANAS,** MANUEL RODRIGUEZ,
JOSE LUIS CALLEJA, ANTONIO GONZÁLEZ,¶ RICARD SOLÀ,§
JOAQUIM BALANZÓ, JAUME BOSCH,* and MEMBERS OF THE MOVE
GROUP
Background & Aims: Nonselective beta-blockers
(-blockers) are very effective in preventing first variceal bleeding
(FVB) in patients with cirrhosis. However, 15%-25% of patients
have contraindications or develop severe side effects precluding
its use. The present study evaluates whether isosorbide-5-mononitrate
(Is-MN) effectively prevents variceal bleeding in patients with
contraindications or who could not tolerate -blockers. Methods:
One hundred thirty-three consecutive cirrhotic patients with gastro-esophageal
varices and contraindications or intolerance to -blockers were
included in a multicenter, prospective, double-blind randomized
controlled trial. Sixty-seven were randomized to receive Is-MN,
and 66 to receive placebo. Results: There were no
significant differences in the 1- and 2-year actuarial probability
of experiencing a FVB between the 2 treatment groups. Presence
of variceal red signs at endoscopy was the only variable independently
associated with an increased risk of variceal bleeding on follow-up
(relative risk 3.4; P < 0.01). Survival and
adverse events were similar in the 2 groups. There were no
significant differences in the incidence of ascites or changes
in renal function. Conclusions: Is-MN does not reduce the
incidence of FVB in patients with cirrhosis and esophageal varices
who cannot be treated with -blockers because contraindications
or intolerance to these drugs, suggesting that Is-MN has no place
in the primary prophylaxis of variceal bleeding. GASTROENTEROLOGY
2001;121:908-914
Somatostatin Suppresses Endothelin-1-Induced Rat Hepatic Stellate
Cell Contraction via Somatostatin Receptor Subtype 1
HENDRIK REYNAERT,*, FREYA VAEYENS,* HONG QIN,* KARINE HELLEMANS,*
NIRJHAR CHATTERJEE,§ DOMINIQUE WINAND,§ ERIK QUARTIER,
FRANS SCHUIT, DANIEL URBAIN, UJENDRA KUMAR,¶ YOGESH C. PATEL,¶
and ALBERT GEERTS*,#
Background & Aims: Hepatic stellate cells
(HSCs) are considered therapeutic targets to decrease portal hypertension.
To elucidate some of the hemodynamic effects of somatostatin (SST)
on portal pressure, the presence and function of SST receptors
(SSTRs) on HSCs were investigated. Methods: SSTR messenger
RNA expression, and SSTR presence was investigated using reverse-transcription
polymerase chain reaction, real-time quantitative polymerase chain
reaction, Western blotting, and immunohistochemistry. The function
of SSTRs was studied by examining the effects of SST and specific
SSTR agonists on endothelin-1(ET-1)-induced HSC contraction. Results:
Specific amplicons for SSTR subtypes 1, 2, and 3 were
demonstrated in rat liver and in activated HSCs. The presence
of SSTR subtypes 1, 2, and 3 was confirmed by Western
blotting. With immunohistochemistry, a strong staining of HSCs
was obtained for SSTR subtypes 1, 2, and 3 in CCl4-treated
rats, but not in normal rat liver. Incubation of HSCs on collagen
gels with buffer, 108 mol/L SST, and 2 ¥ 108 mol/L
ET-1 resulted in collagen surface area decreases of 5.5% ± 3.3%,
6.8% ± 4.4%, and 49.8% ± 8.3%,
respectively. Relative contraction of gels preincubated with 108
mol/L SST followed by 2 ¥ 108 mol/L ET-1 or vice
versa as compared with maximal contraction (100%) with 2 ¥ 108
mol/L ET-1 were 72.6% ± 17.9% and 76.2% ± 12.6%,
respectively (P < 0.05). SSTR agonist 1, but
not SSTR agonist 2 or 3, was able to counteract the
contractile effect of ET-1. Conclusions: Activated rat
HSCs bear SSTR subtypes 1, 2, and 3. SST causes
significant partial inhibition of ET-1-induced contraction of
activated HSCs, mainly by stimulation of SSTR subtype 1. GASTROENTEROLOGY
2001;121:915-930
Immunotherapy Directed Against -Fetoprotein Results in Autoimmune
Liver Disease During Liver Regeneration in Mice
MICHAEL GEISSLER,* LEONHARD MOHR,* ROBERT WETH,* GABRIELE KÖHLER,
CHRISTIAN F. GRIMM,* TIM U. KROHNE,* FRITZ VON WEIZSÄCKER,*
and HUBERT E. BLUM*
Background & Aims: Priming immune responses
against -fetoprotein (AFP) highly expressed in the majority of
hepatocellular carcinomas results in significant antitumoral T-cell
responses. Liver regeneration in humans and mice, however, is
also associated with increased AFP expression. Therefore, we evaluated
the risk of AFP-directed immunotherapeutic approaches to induce
autoimmunity against the regenerating liver. Methods: Mice
were immunized with DNA encoding mouse AFP. For induction of liver
regeneration, partial hepatectomy was performed and mice were
monitored by serial histopathologic examinations and measurements
of serum ALT activities (U/L), and by determination of the kinetics
of AFP-specific T-cell responses. Results: Livers of AFP
immune mice without partial hepatectomy were characterized by
minor lymphocytic infiltrations without transaminase elevations.
By contrast, a significant hepatocyte damage was observed in regenerating
liver that correlated well with the number of AFP-specific CD8+
T cells, the activity of liver regeneration, and the level of
AFP synthesis. Autoimmune liver damage was mediated by CD4+ T
cell-dependent CD8+ cytotoxic T lymphocytes. Conclusions:
These results show that priming of T-cell responses against shared
tumor-specific self antigens may be accompanied by induction of
autoimmunity dependent on the level of expression of the self
antigen and have important implications for the development of
antitumoral vaccines targeted against antigens that are not strictly
tumor-specific. GASTROENTEROLOGY 2001;121:931-939
Mitogenic Effect of Gastrin and Expression of Gastrin Receptors
in Duct-like Cells of Rat Pancreas
ILSE ROOMAN,* JESSY LARDON,* DAISY FLAMEZ, FRANS SCHUIT, and LUC
BOUWENS*
Background & Aims: Ductular metaplastic
cells are observed during pancreas injury. Growth control by gastrin
and expression of gastrin/cholecystokinin (CCK) B receptors were
evaluated in these cells. Methods: Acinoductal transdifferentiation
was induced in vitro by culturing of acinar cells, and ductular
metaplasia was obtained in vivo by ligation of the pancreatic
ducts. Mitogenic effects of gastrin I on ductal complexes in vivo
and of tetragastrin, pentagastrin, and gastrin I and II, with
or without the CCK-B receptor antagonist L-365,260, on duct-like
cells in vitro were analyzed by 5-bromo-2'-deoxyuridine labeling.
Immunocytochemistry, Western blotting, and reverse-transcription
polymerase chain reaction were applied for detection of the CCK-B
receptor. Results: Gastrin analogues induced a mitogenic
stimulus in the duct-like cells in vitro and in ductal complexes
in duct-ligated rat pancreas. Immunocytochemistry showed expression
of CCK-B receptors in these models and in fetal but not normal
adult exocrine pancreas. Additionally, up-regulation of CCK-B
receptors during ductular metaplasia was shown by Western blotting
and reverse-transcription polymerase chain reaction. Conclusions:
Duct-like pancreatic epithelial cells in vitro and ductal complexes
in vivo express gastrin/CCK-B receptors and proliferate in response
to gastrin. GASTROENTEROLOGY 2001;121:940-949
Pancreatic Acinar Cell Dysfunction in CFTR/ Mice Is
Associated With Impairments in Luminal pH and Endocytosis
STEVEN D. FREEDMAN,* HORST F. KERN, and GEORGE A. SCHEELE§
Background & Aims: We have previously shown
that endocytosis at the apical plasma membrane in pancreatic acinar
cells is coupled to ductal bicarbonate secretion into the lumen.
We hypothesized that decreased bicarbonate secretion in cystic
fibrosis (CF) inhibits apical endocytosis. The aim of this study
was to determine in cftr/ mice (1) if the pH of the pancreatic
juice is acidic compared with wild-type (WT) controls, (2) if
there is a selective block in endocytosis, and (3) if alkalinization
of the luminal fluid reverses this defect. Methods: Fluid
secretion and pH of pancreatic juice were measured. Exocytosis,
endocytosis, and morphology were compared in pancreatic lobules
from cftr/ and WT mice. Results: Pancreatic juice pH was
8.12 ± 0.06 in WT mice compared with 6.60 ± 0.04 in
cftr/ mice. Although cholecystokinin-stimulated amylase secretion
was not significantly different, endocytosis was markedly inhibited
in cftr/ compared with WT mice. Cleavage of GP2, a GPI-anchored
protein tightly associated with activation of endocytosis, was
also decreased. Incubation of lobules from cftr/ mice at pH 8.3 reversed
the luminal dilatation. Conclusions: These data indicate
that apical endocytosis is selectively impaired in cftr/ mice,
which explains, in part, the luminal dilatation observed at the
apical plasma membrane. In vitro alkalinization of luminal fluid
led to reversal of defects in membrane dynamics, restored coupled
exocytosis and endocytosis, and abolished the luminal dilatation
in this animal model of CF. Acidic pH changes in luminal secretions
may play a role in the pancreatic membrane dysfunction observed
in CF. GASTROENTEROLOGY 2001;121:950-957
Dysfunctional LAD-1 Neutrophils and Colitis
GÜLBÛ UZEL,* DAVID E. KLEINER, DOUGLAS B. KUHNS,§
and STEVEN M. HOLLAND
Leukocyte adhesion deficiency 1 (LAD-1) is characterized
by absent or dysfunctional 2 integrin (CD18), leading to defective
chemotaxis, adherence, phagocytosis, and bacterial killing. Colitis,
except for rare intestinal necrotizing events, is not a well-recognized
feature of this immunodeficiency. A case of nonspecific colitis
clinically resembling Crohn's disease in a patient with the severe
form of LAD-1 (0.5% < CD18) has been previously reported.
We describe an adult patient with the moderate form of LAD-1 and
chronic colitis characterized by extensive inflammation and ulceration
of the right colon and terminal ileum, leading to adhesions and
strictures. The chronic colitis described in this article associated
with the dysfunctional neutrophils of LAD-1 represents a distinct
pathology from the commonly encountered forms of inflammatory
bowel disease (IBD). The existence of active IBD in the presence
of dysfunctional CD18/CD11a-b intercellular adhesion molecules
(ICAM-1) interaction is relevant to the proposed targeting of
ICAM-1 for the treatment of Crohn's disease. GASTROENTEROLOGY
2001;121:958-964
ABC of the upper gastrointestinal tract: Epidemiology and
diagnosis of Helicobacter pylori infection
Robert P H Logan and Marjorie M Walker
BMJ 2001; 323: 920-922. [Full
text]
ABC of the upper gastrointestinal tract: Dysphagia
William Owen
BMJ 2001; 323: 850-853. [Full
text]
Postoperative starvation after gastrointestinal surgery
D B A Silk and N Menzies Gow
BMJ 2001; 323: 761-762. [Full
text]
Early enteral feeding versus "nil by mouth" after
gastrointestinal surgery: systematic review and meta-analysis
of controlled trials
Stephen J Lewis, Matthias Egger, Paul A Sylvester, and Steven
Thomas
BMJ 2001; 323: 773. [Full
text]
Objective: To determine whether a period of starvation (nil
by mouth) after gastrointestinal surgery is beneficial in terms
of specific outcomes.
Design: Systematic review and meta-analysis of randomised controlled
trials comparing any type of enteral feeding started within 24 hours
after surgery with nil by mouth management in elective gastrointestinal
surgery. Three electronic databases (PubMed, Embase, and the Cochrane
controlled trials register) were searched, reference lists checked,
and letters requesting details of unpublished trials and data
sent to pharmaceutical companies and authors of previous trials.
Main outcome measures: Anastomotic dehiscence, infection of any
type, wound infection, pneumonia, intra-abdominal abscess, length
of hospital stay, and mortality.
Results: Eleven studies with 837 patients met the inclusion
criteria. In six studies patients in the intervention group were
fed directly into the small bowel and in five studies patients
were fed orally. Early feeding reduced the risk of any type of
infection (relative risk 0.72, 95% confidence interval 0.54 to
0.98, P=0.036) and the mean length of stay in hospital (number
of days reduced by 0.84, 0.36 to 1.33, P=0.001).
Risk reductions were also seen for anastomotic dehiscence (0.53, 0.26 to
1.08, P=0.080), wound infection, pneumonia, intra-abdominal
abscess, and mortality, but these failed to reach significance
(P>0.10). The risk of vomiting was increased among patients
fed early (1.27, 1.01 to 1.61, P=0.046).
Conclusions: There seems to be no clear advantage to keeping patients
nil by mouth after elective gastrointestinal resection. Early
feeding may be of benefit. An adequately powered trial is required
to confirm or refute the benefits seen in small trials.
ABC of the upper gastrointestinal tract: Oesophagus: Atypical
chest pain and motility disorders
John Bennett
BMJ 2001; 323: 791-794. [Full
text]
Volume 345:1091-1097 October 11, 2001 Number 15
A Pooled Analysis of Adjuvant Chemotherapy for Resected
Colon Cancer in Elderly Patients
Daniel J. Sargent, Ph.D., Richard M. Goldberg, M.D., Stacy
D. Jacobson, M.D., John S. Macdonald, M.D., Roberto Labianca,
M.D., Daniel G. Haller, M.D., Lois E. Shepherd, M.D., Jean François
Seitz, M.D., and Guido Francini, M.D.
Background Adjuvant chemotherapy is standard treatment for patients with resected colon cancer who are at high risk for recurrence, but the efficacy and toxicity of such treatment in patients more than 70 years of age are controversial.
Methods We performed a pooled analysis, based on the intention to treat, of individual patient data from seven phase 3 randomized trials (involving 3351 patients) in which the effects of postoperative fluorouracil plus leucovorin (five trials) or fluorouracil plus levamisole (two trials) were compared with the effects of surgery alone in patients with stage II or III colon cancer. The patients were grouped into four age categories of equal size, and analyses were repeated with 10-year age ranges (50, 51 to 60, 61 to 70, and >70 years), with the same conclusions. The toxic effects measured in all trials were nausea or vomiting, diarrhea, stomatitis, and leukopenia. Patients in the fluorouracil-plus-leucovorin and fluorouracil-plus-levamisole groups were combined for the efficacy analysis but kept separate for toxicity analyses.
Results Adjuvant treatment had a significant positive effect on both overall survival and time to tumor recurrence (P<0.001 for each, with hazard ratios of death and recurrence of 0.76 [95 percent confidence interval, 0.68 to 0.85] and 0.68 [95 percent confidence interval, 0.60 to 0.76], respectively). The five-year overall survival was 71 percent for those who received adjuvant therapy, as compared with 64 percent for those untreated. No significant interaction was observed between age and the efficacy of treatment. The incidence of toxic effects was not increased among the elderly (age >70 years), except for leukopenia in one study.
Conclusions Selected elderly patients with colon cancer can receive the same benefit from fluorouracil-based adjuvant therapy as their younger counterparts, without a significant increase in toxic effects.
Treatment of Acute Hepatitis C with Interferon Alfa-2b
Elmar Jaeckel, M.D., Markus Cornberg, M.D., Heiner Wedemeyer,
M.D., Teresa Santantonio, M.D., Julika Mayer, M.D., Myrga Zankel,
D.V.M., Giuseppe Pastore, M.D., Manfred Dietrich, M.D., Christian
Trautwein, M.D., Michael P. Manns, M.D., and the German Acute
Hepatitis C Therapy Group
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, 42 of the 43 patients who have completed follow-up (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.
Adjuvant radiotherapy for rectal cancer: a systematic overview
of 8507 patients from 22 randomised trials [Full
Text]
Colorectal Cancer Collaborative Group*
Background At least 28 randomised, controlled trials have compared outcomes of surgery for rectal cancer combined with preoperative or postoperative radiotherapy with those of surgery alone. We have done a collaborative meta-analysis of these results to give a more balanced view of the total evidence and to increase statistical precision.
Methods We centrally checked and analysed individual patient data from 22 randomised comparisons between preoperative (6350 patients in 14 trials) or postoperative (2157 in eight trials) radiotherapy and no radiotherapy for rectal cancer.
Findings Overall survival was only marginally better in patients who were allocated to radiotherapy than in those allocated to surgery alone (62% vs 63% died; p40·06). Rates of apparently curative resection were not improved by preoperative radiotherapy (85% radiotherapy vs 86% control). Yearly risk of local recurrence was 46% (SE 6) lower in those who had preoperative radiotherapy than in those who had surgery alone (p=0·00001), and 37% (10) lower in those who had postoperative treatment than those who had surgery alone (p=0·002). Fewer patients who had preoperative radiotherapy died from rectal cancer than did those who had surgery alone (45% vs 50%, respectively, p=0·0003), but early (1 year after treatment) deaths from other causes increased (8% vs 4% died, p<0·0001).
Interpretation Preoperative radiotherapy (at biologically effective doses 30 Gy) reduces risk of local recurrence and death from rectal cancer. If safety can be improved without compromising effectiveness, then overall survival would be moderately improved by use of preoperative radiotherapy, especially for young, high risk patients. Postoperative radiotherapy also reduces local recurrence, but short preoperative radiation schedules seem to be at least as effective as longer schedules.
Lancet 2001; 358: 1291-304
Primary interferon resistance and treatment response in
chronic hepatitis C infection: a pilot study [Full
Text]
Wolfgang Jessner, Michael Gschwantler, Petra Steindl-Munda, Harald
Hofer, Thomas Watkins-Riedel, Friedrich Wrba, Christian Mueller,
Alfred Gangl, Peter Ferenci
Only 30% of patients with chronic hepatitis C virus genotype 1 (HCV-1) infection achieve a sustained virological response to interferon and ribavirin combination therapy. We prospectively assessed decline in viral load 24 h after one dose of interferon alfa as a predictor of non-response to 6 months of treatment with interferon and ribavirin. Interferon sensitivity was measured before initiation of combination therapy. We measured viral load in 29 consecutive patients, who had not previously been treated with interferon and who were chronically infected with HCV-1 within 24 h after one dose of 5 MU or 10 MU interferon alfa-2b, and 14 days of daily 5 MU interferon alfa-2b. A 24 h viral load decline by less than 70% of baseline after 5 MU interferon was the best pretreatment measure to identify non-responders (specificity 100%, n=10, 95% CI 74-100], sensitivity 83% [15/18], 59-96]).
Metastasis in colorectal cancer associated with phosphatase
expression [Full
Text]
Jane Bradbury
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