Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma

Radiofrequency (RF) ablation is an alternative to percutaneous ethanol injection (PEI) for single nonsurgical hepatocellular carcinoma (HCC) and is currently used as adjuvant therapy before liver transplantation. This phase II study assesses the treatment-related complications and response rate of RF for the treatment of single HCC < or = 5 cm. Percutaneous RF was performed under conscious sedation and ultrasound (US) guidance with an electrical generator connected to a single cooled-tip electrode. Neoplastic cells in peripheral blood (reverse transcription-polymerase chain reaction for alpha fetoprotein [AFP] messenger RNA) were analyzed before and after RF. Treatment response was assessed by spiral computed tomography (CT) at 1 month and every 3 months by US or spiral CT thereafter. Thirty-two patients (20 men; age 67 +/- 4 years; 78% hepatitis C virus; 24 Child-Pugh A) with a mean tumor size of 2.8 cm (25 patients < or = 3 cm) were treated by RF (1.25 sessions; mean time, 22.1 +/- 2 minutes). Adjuvant PEI was performed in 9 cases. Complete response was achieved in 21 patients (65%), being significantly higher for HCC < or = 3 cm (76% vs. 29%, P = .03). After a median follow-up of 10 months, 8 patients showed treatment-related morbidity. Four of them (12.5%) showed biopsy-proven needle-track seeding detected between 4 to 18 months. Neoplastic seeding was related to subcapsular location (P = .009), poor differentiation degree (P = .02), and baseline AFP levels (P = .02). Thus, RF ablation with cooled-tip needle for HCC is associated with a high risk of neoplastic seeding. Iatrogenic dissemination was related to subcapsular location or an invasive tumoral pattern, and has to be considered when selecting curative treatments for HCC or adjuvant therapies before liver transplantation.

Etiology and microbial patterns of pulmonary infiltrates in patients with orthotopic liver transplantation

STUDY OBJECTIVE

To evaluate the etiology and microbial patterns of pulmonary infiltrates in liver transplant patients using a bronchoscopic diagnostic approach and the impact of diagnostic results on antimicrobial treatment decisions.

DESIGN

A prospective cohort study.

SETTING

A 1,000-bed tertiary-care university hospital.

PATIENTS AND METHODS

Fifty consecutive liver transplant patients with 60 episodes of pulmonary infiltrates (33 episodes during mechanical ventilation) were studied using flexible bronchoscopy with protected specimen brush (PSB) and BAL.

RESULTS

A definite infectious etiology was confirmed in 29 episodes (48%). Eighteen episodes corresponded to probable pneumonia (30%), 10 episodes had noninfectious etiologies (17%), and 3 remained undetermined (5%). Opportunistic infections were the most frequent etiology (16/29, 55%, including 1 mixed etiology). Bacterial infections (mainly Gram-negative) accounted for 14 of 29 episodes (48%), including 1 of mixed etiology. The majority of bacterial pneumonia episodes (n = 10, 71%) occurred in period 1 (1 to 28 days posttransplant) during mechanical ventilation, whereas opportunistic episodes were predominant in periods 2 and 3 (29 to 180 days and > 180 days posttransplant, respectively; n = 14, 82%). Microbial treatment was changed according to diagnostic results in 21 episodes (35%).

CONCLUSIONS

Microbial patterns in liver transplant patients with pulmonary infiltrates corresponded to nosocomial, mainly Gram-negative bacterial pneumonia in period 1, and to opportunistic infections in period 2 and, to a lesser extent, period 3. A comprehensive diagnostic evaluation including PSB and BAL fluid examination frequently guided specific antimicrobial therapy.

Endoscopic sclerotherapy to arrest uncontrolled variceal bleeding in cirrhotic patients with high surgical risk

BACKGROUND/AIMS

In 20-50% of patients bleeding from esophageal varices, conservative procedures fail to obtain hemostasis and prevent early recurrence.

METHODOLOGY

We retrospectively analyzed the efficacy and safety of endoscopic sclerotherapy in 66 cirrhotic patients with high surgical risk and persistence or recurrence of variceal bleeding in spite of adequate medical treatment (somatostatin and/or balloon tamponade).

RESULTS

Emergency sclerosis controlled bleeding in 46 out of 66 patients (70%). The remaining 20 patients underwent additional procedures to arrest the hemorrhage, and 6 died because of massive bleeding. Early rebleeding occurred in 5 patients (10%). The mortality within 2 days, 1 week, and 6 weeks was 9%, 17% and 32%, respectively. Death was attributed to hemorrhage in 9 cases. Sclerotherapy was associated with complications in 9 patients (14%).

CONCLUSION

These results suggest that emergency sclerotherapy is a safe and effective procedure in cirrhotic patients with high surgical risk and persistence or recurrence of bleeding after conservative hemostatic procedures.

Transgenic approaches to microbial disease resistance in crop plants

Recent progress in the genetic dissection of plant disease resistance signaling pathways has opened a number of new avenues towards engineering pathogen resistance in crops. Genes controlling race-specific and broad-spectrum resistance responses have been cloned, and novel induced resistance pathways have been identified in model and crop systems. Advances continue to be made in identification of antifungal proteins with effects inhibitory to either pathogen development or accumulation of associated mycotoxins.

Lack of renal effects of fish oil administration in patients with advanced cirrhosis and impaired glomerular filtration

The treatment of renal failure in cirrhotic patients with ascites remains unsatisfactory. Recent studies have shown that the dietary supplementation with fish oil improves the renal function of normal subjects, as well as that of patients with renal failure of different etiologies. We have investigated the renal effects of a daily supplementation for 1 month of 12 g fish oil (27% C20:5 n-3 eicosapentanoic acid [EPA], and 23% C22:6 n-3 docosahexanoic acid [DHA]) in a prospective study of cirrhotic patients with ascites, nine with normal renal function (group 1) and eight with renal failure (glomerular filtration rate [GFR] < 60 mL/min, group 2). Compliance with the dietary regimen was confirmed by fatty acid chromatography that showed increased plasma concentration of EPA (from 1.5 +/- 0.7% to 3.7 +/- 0.8%, P = .024, in group 1; and from 0.53 +/- 0.3% to 2.9 +/- 0.8%, P = .03, in group 2) and of DHA (from 2.1 +/- 0.4% to 3.4 +/- 0.3%, P = .008, in group 1; and from 1.45 +/- 0.5% to 3.8 +/- 0.4%, P = .05, in group 2). At the end of the study, in patients from group 1, the glomerular filtration rate increased by 19% (from 94 +/- 8 to 113 +/- 13 mL/min, P = .039), and the urine flow increased by 39% (from 0.85 +/- 0.14 to 1.12 +/- 0.2 mL/min, P = .039), while no changes occurred in the renal function of patients from group 2. No changes were observed in the urinary excretion of prostaglandin (PG) E2 or of 6-keto prostaglandin-1-alpha (6-K-PGF1-alpha) nor in plasma renin activity (PRA) or the plasma concentration of aldosterone (PA) or antidiuretic hormone (ADH) in both groups. As far as undesirable effects of fish oils were considered, the mean arterial pressure (MAP) decreased in both groups (group 1: from 88.6 +/- 2 to 85.3 +/- 2 mm Hg, P = .015; group 2: from 88.2 +/- 3 to 82.8 +/- 3 mm Hg, P = .05), and bleeding time displayed a significant increase when patients were considered collectively (from 744 +/- 89 to 872 +/- 106 seconds, P = .0068). In conclusion, the administration of fish oil for 1 month was unable to improve renal function in cirrhotic patients with ascites and renal failure. The occurrence of undesirable effects, such as the reduction of arterial pressure and the prolongation of bleeding time, argues against the use of fish oils in these patients.

Recurrent liver involvement in heatstroke

We report the case of a young patient who presented two self-limited episodes of acute jaundice that developed immediately following a long distance run. Zone 3 necrosis was the most prominent histologic change of the liver during the second episode. The diagnosis of heatstroke with liver damage was based on the exclusion of known causes of acute hepatitis, the histopathologic changes and the circumstances preceding the onset of liver disease. This seems to be the first case of severe and recurrent liver impairment due to heatstroke.

Tomato Prf is a member of the leucine-rich repeat class of plant disease resistance genes and lies embedded within the Pto kinase gene cluster

In tomato, resistance to Pseudomonas syringae pv. tomato (Pst) strains expressing the avirulence gene avrPto requires the presence of at least two host genes, designated Pto and Prf. Here we report that Prf encodes a protein with leucine-zipper, nucleotide-binding, and leucine-rich repeat motifs, as are found in a number of resistance gene products from other plants. prf mutant alleles (4) were found to carry alterations within the Prf coding sequence. A genomic fragment containing Prf complemented a prf mutant tomato line both for resistance to Pst strains expressing avrPto and for sensitivity to the insecticide Fenthion. Prf resides in the middle of the Pto gene cluster, 24 kb from the Pto gene and 500 bp from the Fen gene.

Intergeneric transfer and functional expression of the tomato disease resistance gene Pto

Plant disease resistance loci have been used successfully in breeding programs to transfer traits from resistant germplasm to susceptible plant cultivars. The molecular cloning of plant disease resistance genes now permits the transfer of such traits across species boundaries by genetic transformation of recipient hosts. The tomato disease resistance gene Pto confers resistance to strains of the bacterial pathogen Pseudomonas syringae pv tomato expressing the avirulence gene avrPto. Transformation of Nicotiana benthamiana with Pto results in specific resistance to P. s. pv tabaci strains carrying avrPto. The resistant phenotype is manifested by a strong inhibition of bacterial growth and the ability to exhibit a hypersensitive response. Resistance cosegregates with the Pto gene in transgene selfings and testcrosses. Our results demonstrate the conservation of disease resistance functions across genus boundaries and suggest that the utility of host-specific resistance genes can be extended by intergeneric transfer.

Use of a gene expression system based on potato virus X to rapidly identify and characterize a tomato Pto homolog that controls fenthion sensitivity

A novel transient gene expression system was used to study both the tomato disease resistance gene Pto and a Pto homolog designated Fen. The gene expression system was based on potato virus X (PVX). Tomato plants that were both susceptible to strains of Pseudomonas syringae pv tomato carrying the corresponding avirulence gene avrPto and insensitive to the insecticide fenthion were infected with in vitro-generated transcripts of PVX derivatives containing either Pto or Fen. Expression of the Pto gene from the virus genome failed to elicit P.s. tomato resistance, indicating that the PVX system is not suitable for the study of Pto. However, expression of the Fen gene resulted in sensitivity to fenthion. The utility of the PVX gene expression system was further demonstrated through structure/function studies of the Fen gene. A correlation was shown between Fen protein kinase activity and the ability of this protein to confer fenthion sensitivity to tomato. Furthermore, it was demonstrated that mutation of a putative N-terminal myristoylation site, proposed to be involved in membrane targeting, rendered the Fen protein inactive. Analysis of a Pto-Fen chimeric gene allowed the fenthion sensitivity domain to be localized to the C-terminal part of the Fen protein. Interestingly, expression of the Fen kinase from the PVX genome in Nicotiana spp resulted in a fenthion-independent necrotic response. Our results support the involvement of the Fen gene in a signal transduction pathway(s).

Diabetes mellitus in patients with liver cirrhosis

In spite of the high prevalence of diabetes mellitus (DM) in patients with liver cirrhosis (LC) few studies have focused on the clinical implications of this association. We investigated the clinical and pancreatic-endocrine features of 34 patients who developed DM after LC (Group I). Results were compared with 34 carefully matched patients with only Type II DM (Group II). A standard meal test was performed in 26 patients with normal renal function from each group to assess beta-cell function. Group I patients, less frequently had retinopathy (14.7% vs. 45.5%, P < 0.05) and a family history of diabetes (23.5% vs. 58.8%, P < 0.01). Group I patients also showed signs of enhanced insulin resistance, reflected by higher insulin dose requirements in insulin-treated patients (0.87 +/- 0.10 vs. 0.62 +/- 0.05 IU/kg/day, P < 0.01) and increased basal C-peptide values (0.88 +/- 0.06 vs. 0.68 +/- 0.07 pmol/l, P < 0.05, respectively) than those in Group II. These results suggest that several clinical features, probably related to the hepatopathy, define DM occurring in patients with LC.

Tomato mutants altered in bacterial disease resistance provide evidence for a new locus controlling pathogen recognition

We have employed a genetic approach to study the resistance of tomato to the phytopathogenic bacterium Pseudomonas syringae pv tomato. Resistance to P. s. tomato depends upon expression of the Pto locus in tomato, which encodes a protein with similarity to serine/threonine protein kinases and recognizes pathogen strains expressing the avirulence gene avrPto. Eleven tomato mutants were isolated with altered resistance to P. s. tomato strains expressing avrPto. We identified mutations both in the Pto resistance locus and in a new locus designated Prf (for Pseudomonas resistance and fenthion sensitivity). The genetic approach allowed us to dissect the roles of these loci in signal transduction in response to pathogen attack. Lines carrying mutations in the Pto locus vary 200-fold in the degree to which they are susceptible to P. s. tomato strains expressing avrPto. The pto mutants retain sensitivity to the organophosphate insecticide fenthion; this trait segregates with Pto in genetic crosses. This result suggested that contrary to previous hypotheses, the Pto locus controls pathogen recognition but not fenthion sensitivity. Interestingly, mutations in the prf locus result in both complete susceptibility to P. s. tomato and insensitivity to fenthion, suggesting that Prf plays a role in tomato signaling in response to both pathogen elicitors and fenthion. Because pto and prf mutations do not alter recognition of Xanthomonas campestris strains expressing avrBsP, an avirulence gene recognized by all tested tomato cultivars, Prf does not play a general role in disease resistance but possibly functions specifically in resistance against P. s. tomato. Genetic analysis of F2 populations from crosses of pto and prf homozygotes indicated that the Pto and Prf loci are tightly linked.

Molecular characterization and hrp dependence of the avirulence gene avrPto from Pseudomonas syringae pv. tomato [corrected]

The avrPto avirulence gene from Pseudomonas syringae pv. tomato (Pst) race 0 governs race-specific resistance to bacterial speck disease in tomato cultivars containing the Pto resistance gene. The avrPto gene encodes 0.7 and 0.75 kb mRNAs whose predicted translation product is a mostly hydrophilic 164 amino acid protein of 18.3 kD a that reveals no homology to protein sequences in GenBank or EMBL databases. Highest expression of avrPto in cell culture is observed in minimal media containing sugars and sugar alcohols as carbon sources and lowest expression in minimal media containing tricarboxylic acid intermediates and in complex media. Expression of avrPto in planta is induced within 1 h following infection of both resistant and susceptible tomato plants by Pst, and increases over the first 6 h. Transcription of avrPto requires the hrpSR pathogenicity functions, but is independent of other Pst hrp genes. A region of the avrPto promoter shows homology to hrp box sequences upstream of other P. syringae genes that require the hrpSR locus for expression, and both avirulence activity and avrPto mRNA accumulation are abolished by deletions extending into this region. The avrPto transcription start site maps 31 nucleotides downstream of the hrp box motif.

Genetic evidence that an activation domain of GAL4 does not require acidity and may form a beta sheet

Regulation of gene expression in eukaryotes relies on intricate protein-protein interactions. Transcription of the galactose genes in yeast has been a productive model for this type of interaction. The positive activator in this system, GAL4, has a bifunctional C-terminus. It contains both a prototypic acidic activation domain and a region that binds the negative regulator, GAL80. We have taken advantage of this colocalization of functions to subject the region to a constrained mutagenesis analysis: one function was maintained, while the other one was altered. This analysis and the experiments it suggested have led us to two conclusions: first, the acidic amino acids are not, as commonly thought, required for activation; second, this region is not unstructured or alpha helical, but its function may require a beta sheet.

The cloned avirulence gene avrPto induces disease resistance in tomato cultivars containing the Pto resistance gene

Resistance of tomato plants to the bacterial pathogen Pseudomonas syringae pv. tomato race 0 is controlled by the locus Pto. A bacterial avirulence gene was cloned by constructing a cosmid library from an avirulent P. syringae pv. tomato race, conjugating the recombinants into a strain of P. syringae pv. maculicola virulent on a tomato cultivar containing Pto, and screening for those clones that converted the normally virulent phenotype to avirulence. The cloned gene, designated avrPto, reduced multiplication of P. syringae pv. tomato transconjugants specifically on Pto tomato lines, as demonstrated by bacterial growth curve analyses. Analysis of F2 populations revealed cosegregation of resistance to P. syringae pv. tomato transconjugants carrying avrPto with resistance to P. syringae pv. tomato race 0. Surprisingly, mutation of avrPto in P. syringae pv. tomato race 0 does not eliminate the avirulent phenotype of race 0, suggesting that additional, as yet uncharacterized, avirulence genes and/or resistance genes may contribute to specificity in the avrPto-Pto interaction. Genetic analysis indicates that this resistance gene(s) would be tightly linked to Pto. Interestingly, P. syringae pv. glycinea transconjugants carrying avrPto elicit a typical hypersensitive resistant response in the soybean cultivar Centennial, suggesting conservation of Pto function between two crop plants, tomato and soybean.

Vasopressin/nitroglycerin infusion vs. esophageal tamponade in the treatment of acute variceal bleeding: a randomized controlled trial

Vasopressin infusion and esophageal tamponade are still widely used to arrest variceal bleeding, but no objective evidence exists on the superiority of either of the two procedures. In this study, 108 cirrhotic patients bleeding from varices were included in a prospective, randomized trial to investigate the comparative effectiveness and safety of balloon tamponade (using the Sengstaken-Blakemore tube for esophageal varices and the Linton-Nachlas tube for gastric varices) (n = 52) and intravenous vasopressin infusion (0.4 to 0.8 mu/min) plus intravenous nitroglycerin infusion (40 to 400 micrograms/min) (n = 56). Both treatments were maintained for 24-hr. The hemostatic efficacy according to the intention to treat was 86.5% for tamponade and 66% for pharmacological therapy (p less than 0.01). No significant differences were found with respect to rebleeding during the first 72 hr after treatment, mortality rate or side effects. These results suggest that esophageal tamponade is more effective than vasopressin/nitroglycerin infusion in the treatment of variceal bleeding in cirrhotic patients.

GAL4 mutations that separate the transcriptional activation and GAL80-interactive functions of the yeast GAL4 protein

The carboxy-terminal 28 amino acids of the Saccharomyces cerevisiae transcriptional activator protein GAL4 execute two functions--transcriptional activation and interaction with the negative regulatory protein, GAL80. Here we demonstrate that these two functions are separable by single amino acid changes within this region. We determined the sequences of four GAL4C-mutations, and characterized the abilities of the encoded GAL4C proteins to activate transcription of the galactose/melibiose regulon in the presence of GAL80 and superrepressible GAL80S alleles. One of the GAL4C mutations can be compensated by a specific GAL80S mutation, resulting in a wild-type phenotype. These results support the idea that while the GAL4 activation function tolerates at least minor alterations in the GAL4 carboxyl terminus, the GAL80-interactive function is highly sequence-specific and sensitive even to single amino acid alterations. They also argue that the GAL80S mutations affect the affinity of GAL80 for GAL4, and not the ability of GAL80 to bind inducer.

Interaction between transcriptional activator protein LAC9 and negative regulatory protein GAL80

In Saccharomyces cerevisiae, transcriptional activation mediated by the GAL4 regulatory protein is repressed in the absence of galactose by the binding of the GAL80 protein, an interaction that requires the carboxy-terminal 28 amino acids of GAL4. The homolog of GAL4 from Kluyveromyces lactis, LAC9, activates transcription in S. cerevisiae and is highly similar to GAL4 in its carboxyl terminus but is not repressed by wild-type levels of GAL80 protein. Here we show that GAL80 does repress LAC9-activated transcription in S. cerevisiae if overproduced. We sought to determine the molecular basis for the difference in the responses of the LAC9 and GAL4 proteins to GAL80. Our results indicate that this difference is due primarily to the fact that under wild-type conditions, the level of LAC9 protein in S. cerevisiae is much higher than that of GAL4, which suggests that LAC9 escapes GAL80-mediated repression by titration of GAL80 protein in vivo. The difference in response to GAL80 is not due to amino acid sequence differences between the LAC9 and GAL4 carboxyl termini. We discuss the implications of these results for the mechanism of galactose metabolism regulation in S. cerevisiae and K. lactis.

Comparative study of aminoglycoside nephrotoxicity in normal rats and rats with experimental cirrhosis

Several authors have suggested that the risk of developing aminoglycoside nephrotoxicity is greater in cirrhotic patients than in the noncirrhotic population. However, this has not been confirmed by other investigators. To compare the intensity and characteristics of aminoglycoside nephrotoxicity in cirrhotic and normal rats, 31 rats with carbon tetrachloride-induced cirrhosis with ascites and 35 control rats were treated with gentamicin. Each group of rats was divided into two subgroups in order to receive 10 or 40 mg per kg per day of gentamicin, and different subsets of animals were killed on Days 4, 8 and 12 of treatment for renal histological examination and determination of renal tissue gentamicin concentration. Urine volume, osmolality, sodium excretion and N-acetyl-beta-D-glucosaminidase activity were measured daily throughout the study. Creatinine clearance and trough plasma concentration of gentamicin were determined in each animal immediately before killing. There were no significant differences between cirrhotic and control rats in relation to the magnitude of changes in urine volume, osmolality, sodium excretion and N-acetyl-beta-D-glucosaminidase activity and creatinine clearance during gentamicin administration. The values of a histopathological score semiquantitatively assessing the renal morphological changes observed by light microscopy were not significantly different in cirrhotic and control rats. In addition, similar trough plasma and renal cortical tissue concentrations of gentamicin were observed in both groups of animals. These results suggest that, in this experimental model, cirrhosis does not increase the risk for aminoglycoside nephrotoxicity.

Interaction of positive and negative regulatory proteins in the galactose regulon of yeast

Transcriptional regulation in the galactose regulon of yeast is determined by an interplay between a positive regulatory protein, GAL4, and a negative regulatory protein, GAL80. We show that derivatives of GAL4 missing as few as 28 carboxy-terminal amino acids are not responsive to GAL80 regulation, implying that the carboxyl terminus of GAL4 is required for interaction with GAL80. Furthermore, a lesion in GAL4 that genetically defines the GAL80-interactive region maps to the 3' end of the gene. Since the carboxyl terminus of GAL4 has also been implicated in interaction with a transcriptional factor, we propose a model for negative regulation in which GAL80 and this factor compete for binding a common region of GAL4, and the on/off state of transcription is determined by the relative affinities of the negative regulator and the transcriptional factor for this region.

Analysis of the Kluyveromyces lactis positive regulatory gene LAC9 reveals functional homology to, but sequence divergence from, the Saccharomyces cerevisiae GAL4 gene

The galactose metabolism positive regulatory gene from Kluyveromyces lactis, LAC9, has been isolated through its ability to activate expression of galactose metabolism enzyme genes in Saccharomyces cerevisiae. The LAC9 gene also activates expression of the S. cerevisiae alpha-galactosidase (MEL1) and K. lactis beta-galactosidase (LAC4) genes in S. cerevisiae. Although LAC9-activated gene expression in K. lactis is not glucose repressed, activation of MEL1 gene expression by LAC9 in S. cerevisiae is. The LAC9 gene is expressed at an extremely low level as a approximately 2.9-kb mRNA, and encodes a protein of 865 amino acids. Although the LAC9 gene is functionally analogous to the S. cerevisiae GAL4 gene, the bulk of its protein sequence shows little homology to that of GAL4. Two of the three regions of homology that do exist, however, are restricted to areas of GAL4 protein already implicated in nuclear localization, DNA binding, and transcriptional activation.