Preventing arteriovenous shunt failure in hemodialysis patients: a population-based cohort study

Essentials Uncertainty remains about antiplatelets for vascular access patency in hemodialysis patients. 95 971 people under hemodialysis were followed in a claims database in Taiwan. Aspirin reduced vascular access failure rate and did not increase major bleeding rate. Clopidogrel, Aggrenox, and warfarin might increase major bleeding rate. SUMMARY: Background Dialysis adequacy is a major determinant of survival for patients with end-stage renal disease. Good vascular access is essential to achieve adequate dialysis. Objectives This study evaluated the impacts of different drugs on the vascular access failure rate of an arteriovenous fistula or an arteriovenous graft and the rate of major bleeding in hemodialysis patients. Patients and methods We studied patients with end-stage renal disease registered in the Taiwan National Health Insurance program from 1 January 1997 to 31 December 2012. A total of 95 971 patients were enrolled in our study. Vascular access dysfunction was defined as the need for thrombectomy or percutaneous angioplasty. Major bleeding was defined as emergency department visits or hospitalization with a primary diagnosis of gastrointestinal bleeding or intracerebral hemorrhage. The adjusted odds ratios between person-quarters with or without antiplatelet or oral anticoagulant use were calculated using a generalized estimating equation. Results The odds ratio of vascular access failure was 0.21 (0.11-0.39) for aspirin, 0.76 (0.74-0.79) for clopidogrel, 0.67 (0.59-0.77) for dipyridamole, 0.67 (0.53-0.86) for Aggrenox and 0.96 (0.90-1.03) for warfarin. The highest odds ratio for intracerebral hemorrhage was 5.33 (1.25-22.72) in younger patients using Aggrenox. The highest odds ratio for gastrointestinal bleeding was 1.34 (1.10-1.64) for clopidogrel. Conclusion Antiplatelet agents, but not warfarin, might reduce the vascular access thrombosis rate. The gastrointestinal bleeding rate was increased in the group using clopidogrel. Aggrenox should be used with caution in young individuals because it might increase the rate of intracerebral hemorrhage.

Abstract 5598: Adenosine signaling through A2AR limits the efficacy of anti-CTLA4 and chemotherapy in preclinical models

Elevated levels of extracellular adenosine within the tumor microenvironment create an immunosuppressive niche that promotes tumor growth and metastasis. Adenosine signaling via the A2A receptor (A2AR) on immune cells suppresses anti-tumor immunity and has been shown to limit the efficacy of immunotherapies such as anti-PD-L1 or anti-PD-1 monoclonal antibodies (mAbs).

CPI-444 is a potent and selective oral A2AR antagonist that is currently being investigated in Phase 1/1b clinical trials alone and in combination with an anti-PD-L1 antibody (Atezolizumab) in selected solid tumors. New preclinical data suggests that combining CPI-444 with anti-CTLA-4 mAbs as well as chemotherapy treatment are also promising therapeutic strategies in solid tumors, suggesting a broad role for adenosine as an immune suppressive mechanism.

The efficacy of CPI-444 + anti-CTLA-4 mAb treatment was evaluated in MC38 and CT26 syngeneic mouse tumor models. In CT26, combination treatment eliminated established tumors in up to 90% of mice approximately 2 weeks after treatment was initiated. In MC38, combination CPI-444 and anti-CTLA-4 mAb treatment prolonged survival of 80% of mice compared to only 40% of mice that received CPI-444 or anti-CTLA-4 mAbs alone. The effect of CPI-444 + anti-CTLA-4 treatment on T-cell proliferation, T cell activation, and TREG function will be discussed.

Chemotherapy releases adenosine and ATP into the tumor microenvironment (TME). Multiple chemotherapies have also been shown to up-regulate the ecto-enzymes CD39 and CD73 that produce adenosine and further suppress immune function. In the MC38 model, CPI-444 treatment synergized with doxorubicin and eliminated established tumors 80% of treated mice. CPI-444 treatment was also synergistic with cyclophosphamide, inhibiting the growth of RENCA tumors, a model that is considered resistant to chemotherapy. Ongoing studies are evaluating the effect of CPI-444 + chemotherapy on tumor infiltrating lymphocyte localization, activation, and expression of CD73 and CD39.

These results suggest that blockade of the adenosine signaling pathway may be vital for enhancing anti-tumor responses in solid tumors that show an incomplete response to anti-CTLA4 therapy or chemotherapy.

Citation Format: Po Ho, Meng-Yin Hsieh, Andrew Hotson, Richard Miller, Ian McCaffery, Stephen Willingham. Adenosine signaling through A2AR limits the efficacy of anti-CTLA4 and chemotherapy in preclinical models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5598. doi:10.1158/1538-7445.AM2017-5598

Characterization of patient-derived tumor xenografts (PDXs) as models for estrogen receptor positive (ER+HER2- and ER+HER2+) breast cancers

The research was to appraise the utility of the patient-derived tumor xenografts (PDXs) as models of estrogen receptor positive (ER+HER2- and ER+HER2+) breast cancers. We compared protein expression profiles by Reverse Phase Protein Array (RPPA) in tumors that resulted in PDXs compared to those that did not. Our overall PDX intake rate for ER+ breast cancer was 9% (9/97). The intake rate for ER+HER2+ tumors (3/16, 19%) was higher than for ER+HER2- tumors (6/81, 7%). Heat map analyses of RPPA data showed that ER+HER2- tumors were divided into 2 groups by luminal A/B signature [protein expression of ER, AR, Bcl-2, Bim (BCL2L11), GATA3 and INPP4b], and this expression signature was also associated with the rate of PDX intake. Cell survival pathways such as the PI3K/AKT signaling and RAS/ERK pathways were more activated in the specimens that could be established as PDX in both classes. Expression of the ER protein itself may have a bearing on the potential success of an ER+ PDX model. In addition, HER2 and its downstream protein expressions were up-regulated in the ER+HER2+ patient tumors that were successfully established as PDX models. Moreover, the comparison of RPPA data between original and PDX tumors suggested that the selection/adaptation process required to grow the tumors in mice is unavoidable for generation of ER+ PDX models, and we identified differences between patient tumor samples and paired PDX tumors. A better understanding of the biological characteristics of ER+PDX would be the key to using PDX models in assessing treatment strategies in a preclinical setting.

Abstract 4403: Antitumor properties of ouabain in lipid double emulsion integrated with tumor cell membrane fractions

Cell membrane proteins such as integrins are crucial for cell-cell recognition, binding and communication, cell-stromal interaction and adhesion, tumor invasion and metastasis. It was reported that cell-size hydrophobic beads coated with tumor membrane molecules could stimulate the lymphokine activated killer (LAK) cells to release IFN-alpha and TNF-alpha, and interrupted the recognition between LAK cells and tumor cells (Chong AS, 1988, 1991). Lipid double emulsion is a convenient formulation method to integrate lipid materials, hydrophilic and hydrophobic drugs in uniformed particles to achieve combinational chemotherapy. However the nonspecific uptake of double emulsion particles in vivo limits its targeting therapeutic potential. In current study, we sought to coat double emulsion particles with tumor cell membrane fraction to mimic the tumor cell surface in order to enhance the interaction and uptake of emulsion particles into tumor cells. Canine osteosarcoma cells and lymphoma cells were chosen for this study because canine cancers develop in immunocompetent environments and share many similar features observed in human cancers, such as long periods of latency for initiation, progression and development, metastasis, acquired drug resistance and recurrence. We use ouabain as therapeutic warhead in the emulsion particles because ouabain is known to have extremely high anticancer potential at nanomolar concentration level from our previous studies. The major obstacle of applying ouabain in vivo therapy is that the therapeutic dose window of ouabain is very narrow. Therefore in an attempt to mitigate such narrow therapeutic margin of safety, ouabain was formulated in lipid double emulsion by using microfluidic synthesis method and membrane emulsification method. The double emulsion particles were further coated with osteosarcoma cell membrane fraction. Our preliminary results showed enhanced antitumor activities of ouabain in tumor cell mimic-double emulsion or nanoemulsion against canine osteosarcoma cells and lymphoma cells in vitro and in orthotopic xenograft models in vivo, suggesting a promising therapeutic benefit in canine cancer targeting therapy.

Citation Format: Jun Wu, Mariele Mondala, Meng-Yin Hsieh, Eugene Roberts, Richard Ermel. Antitumor properties of ouabain in lipid double emulsion integrated with tumor cell membrane fractions. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4403. doi:10.1158/1538-7445.AM2015-4403

Targeting JAK1/STAT3 signaling suppresses tumor progression and metastasis in a peritoneal model of human ovarian cancer

JAK/STAT3 is one of the major signaling pathways that is aberrantly activated in ovarian cancer and associated with tumor progression and poor prognosis in patients with ovarian cancer. In this study, we evaluated the therapeutic potential of targeting JAK/STAT3 signaling in ovarian cancer using a peritoneal dissemination mouse model. We developed this mouse model by injecting a metastatic human ovarian cancer cell line, SKOV3-M-Luc, into the peritoneal cavity of immunodeficient mice. This model displayed a phenotype similar to late-stage ovarian cancer, including extensive peritoneal metastasis and ascites production. The constitutive activation of STAT3 in human ovarian cancer cells appeared to be mediated by an autocrine cytokine loop involving the IL6 family of cytokines and JAK1 kinase. shRNA-mediated knockdown of JAK1 or STAT3 in ovarian cancer cells led to reduced tumor growth, decreased peritoneal dissemination, and diminished ascites production, suggesting a critical role of STAT3 in ovarian cancer progression. Similar results were obtained when a small-molecule inhibitor (JAKi) of the JAK1 kinase was used to treat ovarian cancer in this model. In addition, we found that the expression level of IL6 was correlated with activation of STAT3 in ovarian cancer cells both in vitro and in vivo, suggesting a potential application of IL6 as a biomarker. Altogether, our results demonstrate that targeting JAK1/STAT3, using shRNA knockdown or a small-molecule inhibitor, effectively suppressed ovarian tumor progression and, therefore, could be a potential novel therapeutic approach for treating advanced ovarian cancer.

Acute disseminated encephalomyelitis that meets modified McDonald criteria for dissemination in space is associated with a high probability of conversion to multiple sclerosis in Taiwanese patients

BACKGROUND

Patients with acute disseminated encephalomyelitis (ADEM) may relapse and some may ultimately convert to multiple sclerosis (MS); however, no criteria that can predict MS conversion are available to date. Our aim was to describe the clinical and magnetic resonance imaging (MRI) features of patients with an initial ADEM attack and evaluate which MRI criteria can predict conversion to MS.

METHODS

We retrospectively reviewed the records of 36 patients diagnosed with ADEM. We determined clinical signs/symptoms, examined the cerebrospinal fluid (CSF), and performed brain MRI scans and compared the findings between patients who did and did not convert to MS.

RESULTS

Clinical signs/symptoms, and CSF analysis show no significant difference between the two groups. The rate of conversion to MS from ADEM in Taiwanese patients is low (11%) after a mean follow-up period of 28.36 months. Modified McDonald criteria were fulfilled in 19/36 patients: 21% (4/19) of those patients developed MS according to Poser criteria subsequently. Of the other patients (17/36) who did not fulfill these criteria, none converted to MS. (log rank test; P=0.027).

CONCLUSIONS

It is difficult to predict from initial clinical presentations to address which patients with ADEM will convert to MS. Patients with ADEM whose brain MRI findings met the modified McDonald criteria may have clinically isolated syndrome because they have a significantly higher probability of conversion to MS. In contrast, patients whose brain MRI findings did not meeting these criteria may be considered as having classic ADEM because they have a lower probability of conversion to MS.

Identification by machine vision of the rate of motor activity decline as a lifespan predictor in C. elegans

One challenge in aging research concerns identifying physiological parameters or biomarkers that can reflect the physical health of an animal and predict its lifespan. In C. elegans, a model organism widely used in aging research, motor deficits develop in old worms. Here we employed machine vision to quantify worm locomotion behavior throughout lifespan. We confirm that aging worms undergo a progressive decline in motor activity, beginning in early life. Importantly, the rate of motor activity decline rather than the absolute motor activity in the early-to-mid life of individual worms in an isogenic population inversely correlates with their lifespan, and thus may serve as a lifespan predictor. Long-lived mutant strains with deficits in insulin/IGF-1 signaling or food intake display a reduction in the rate of motor activity decline, suggesting that this parameter might also be used for across-strain comparison of healthspan. Our work identifies an endogenous physiological parameter for lifespan prediction and healthspan comparison.

Serum insulin-like growth factor-II as a serologic marker of small hepatocellular carcinoma

OBJECTIVE

Alpha-fetoprotein (AFP) is not a useful tumor marker for diagnosis of small hepatocellular carcinoma (HCC). There is over-expression of insulin-like growth factor (IGF)-II in HCC tissue. This study investigates the diagnostic application of IGF-II in small HCC.

MATERIAL AND METHODS

Serum levels of IGF-II and AFP were determined in 41 patients with small cirrhotic HCC (< or = 3 cm), 41 sex- and age-matched patients with cirrhosis alone (LC), and 41 healthy adults. The optimal cut-off values for diagnosing HCC were determined with receiver operating characteristics (ROC) curve.

RESULTS

Both IGF-II and AFP levels in HCC were higher than those in LC patients or controls (each p = 0.0001). The IGF-II levels in LC patients were lower than those in controls (p = 0.001). In HCC patients, multivariate analysis indicated that that both IGF-II (odds ratio, 4.54; 95% confidence interval, 2.15-9.55; p = 0.0001) and AFP (odds ratio, 1.05; 95% confidence interval, 1.01-1.08; p = 0.003) were found to be associated with an increased risk of presence of HCC. The optimal cut-off values of IGF-II (4.1 mg/g prealbumin) and AFP (50 ng/ml) were determined with ROC curves. The sensitivity, specificity, and diagnostic accuracy values for IGF-II were 63%, 90%, and 70%, respectively. Those for AFP were 44%, 95%, and 70%, respectively. Determination of both markers in parallel significantly increase the diagnostic accuracy (88%) and sensitivity (80%), with a high specificity (90%).

CONCLUSIONS

Serum IGF-II level can be used as an independent serologic marker or a complementary tumor marker to AFP for diagnosis of small HCC.

The juvenile variant of papular-purpuric gloves and socks syndrome and its association with viral infections

BACKGROUND

Papular-purpuric gloves and socks syndrome (PPGSS) occurs mostly in adults and has been shown to be related to several possible viral infections. However, childhood-onset PPGSS seems to be not so rare as previously thought in our clinical experience.

OBJECTIVES

To survey the general characteristics of childhood-onset PPGSS and to determine the possible association between this juvenile variant of PPGSS and various viral infections.

PATIENTS AND METHODS

Thirty-three children with erythematopurpuric papular eruptions on the hands and/or feet were enrolled. Detailed history-taking and physical examination were performed on all of them. Blood samples were obtained from 25 patients about 1-5 weeks after the appearance of cutaneous eruptions to check complete blood counts, differential white blood cell counts, and IgM and IgG antibodies to parvovirus B19, cytomegalovirus (CMV), viral capsid antigen of Epstein-Barr virus (EBV) and measles.

RESULTS

The median age of these 33 patients was 23 months. The mean duration of the skin eruption was 4.8 weeks (SD 2.7, 95% CI 3.9-5.0). Lymphocytosis was present in 13 patients (52%) while mild eosinophilia occurred in only three patients (12%). Five patients (20%) were positive for IgM antibodies against CMV and seven (28%) were positive for IgM antibodies against EBV. Only one patient (4%) was detected to have IgM antibodies against parvovirus B19.

CONCLUSIONS

Childhood-onset PPGSS shows somewhat different clinical features from the adult type. It may represent a nonspecific manifestation of several viral infections, including CMV, EBV and parvovirus B19 infections.

Serum insulin-like growth factor-II and alpha-fetoprotein as tumor markers of hepatocellular carcinoma

To evaluate the diagnostic application of serum insulin-like growth factor-II (IGF-II) and alpha-fetoprotein (AFP) levels in hepatocellular carcinoma (HCC), IGF-II and AFP were determined in 100 cirrhotic patients with HCC, 100 sex- and age-matched patients with cirrhosis alone and 50 healthy controls. The results indicated that IGF-II and AFP levels in patients with HCC were higher than in those with cirrhosis alone (p = 0.0001). There is an inverse correlation between IGF-II and (log)AFP (r = -0.410, p = 0.0001) in patients with HCC. Multivariate analysis indicated that IGF-II and AFP were closely associated, in a dose-related fashion, with the presence of HCC. Receiver operating characteristic curves were used to determine the optimal cutoff values of IGF-II (4.5 mg/g prealbumin) and AFP (100 ng/ml), respectively. Both IGF-II and AFP show a high specificity and positive likelihood ratio. The sensitivity was 42.0% for IGF-II and 73.0% for AFP. Determination of both markers in parallel significantly increased the diagnostic accuracy (96.5%) and sensitivity (97.9%), with a high specificity (95.1%) and positive likelihood ratio (19.9). In conclusion, IGF-II and AFP may be used as complementary tumor markers to discriminate HCC from cirrhosis.

The prevalence of TT virus and GB virus C/hepatitis G virus infection in individuals with raised liver enzymes but without HBV or HCV infection in Taiwan

The prevalence of TT virus (TTV) and GB virus-C/hepatitis G virus (GBV-C/HGV) infection and the association with raised liver function tests in 546 Taiwanese with negative HBsAg, anti-HCV and HCV RNA was elucidated. They were tested for serum alanine aminotransferase (ALT), GBV-C/HGV RNA, anti-envelope protein 2 antibody (anti-E2) and TTV DNA. Direct sequencing and phylogenetic analyses were performed on 58 isolates for TTV genotype determination. The prevalence of TTV DNA, GBV-C/HGV RNA, anti-E2 and over all GBV-C/HGV exposure was 24.9, 3.4, 8.2 and 11.1%, respectively. Using uni- and multi-variate analyses, male gender and TTV viremia were associated significantly with raised ALT values. Sixty-nine percent of TTV isolates were deduced to be TTV genotype 1 and they had significantly lower mean age than genotype non-1 isolates. In the population, raised ALT may be related to male gender and be attributable to TTV infection but not to GBV-C/HGV among individuals with no evidence of current HBV and HCV infection. TTV genotype 1 is the most prevalent genotype and associated with younger age.

GB virus C/hepatitis G virus infection in chronic hepatitis C patients with and without interferon-alpha therapy

GB virus C/hepatitis G virus (GBV-C/HGV) RNA, detected by polymerase chain reaction, and antibodies to the GBV-C/HGV envelope protein (anti-E2), detected by an enzyme-linked immunosorbent assay, were used to evaluate both the impact of GBV-C/HGV on the coexistent hepatitis C virus (HCV) infection and the course of GBV-C/HGV infection in chronic hepatitis C patients with and without interferon-alpha (IFN-alpha) treatment. Of the 162 chronic hepatitis C patients treated with INF-alpha, 17.9% were GBV-C/HGV RNA-positive and 18.5% anti-E2-positive (total exposure, 35.2%). Neither present nor past GBV-C/HGV infection had impact on the clinical features, HCV virological characteristics and response to IFN-alpha treatment in chronic hepatitis C patients. Among patients with ongoing HCV/GBV-C/HGV coinfection, 20.7% (6/29) in IFN-alpha-treated patients lost GBV-C/HGV RNA concomitant with anti-E2 seropositivity, which was significantly higher than 4.8% (2/42) in patients without INF-alpha treatment (P<0.05). Based on multivariate analyses, the significant factors associated with clearance of GBV-C/HGV viremia combined with anti-E2 seropositivity were baseline anti-E2 seropositivity and IFN-alpha treatment. In summary, GBV-C/HGV did not alter the course of coexistent HCV. IFN-alpha treatment was effective in some patients against GBV-C/HGV and might facilitate anti-E2 seroconversion in chronic hepatitis C patients with GBV-C/HGV viremia.

Changing prevalence of hepatitis C virus genotypes: molecular epidemiology and clinical implications in the hepatitis C virus hyperendemic areas and a tertiary referral center in Taiwan

To determine the hepatitis C virus (HCV) genotype distribution in Taiwan and to clarify the relationship between genotype and the pathogenesis of HCV infection, 1,164 subjects positive for serum HCV antibodies and HCV RNA from three HCV hyperendemic areas (Masago, Tzukuan, and Taoyuan) and a tertiary referral center in Taiwan were studied during 1995-1997. HCV genotypes and viral loads were determined using Okamoto's method and branched DNA assay, respectively. Genotype 1b was the most prevalent in Tzukuan (61.9%), Taoyuan (76.9%), and the referral center (47.0%). By contrast, genotype 2a was the major HCV type in Masago (63.5%). Prevalence of genotype 1b positively and that of genotype 2a negatively correlated to age, regardless of study populations (P < 0.01). Based on multivariate analysis, the significant factors associated with the presence of cirrhosis, with or without hepatocellular carcinoma, in chronic hepatitis C patients were genotype 1b and age. In conclusion, these results underline that independent HCV outbreaks continue in HCV hyperendemic areas in Taiwan, concomitant with a changing relative prevalence of HCV genotypes in relation to age. Both the correlation of genotype 1b with age (cohort effect) and intrinsic properties of HCV genotypes are probably responsible for the association between genotype and the pathogenesis of HCV infection.

Ultrasonic characteristics of periportal collateral circulation in hepatocellular carcinoma with portal vein invasion

Real-time ultrasound (US) was used to analyze the morphological characteristics of periportal collateral circulation (PPCC) and the hepatic artery in hepatocellular carcinoma (HCC) patients with portal vein invasion (PVI). During a 5-year interval, a total of 17 HCC patients with main portal vein thrombosis and detectable periportal vessels were collected: 14 men and 3 women, aged 27 to 76 years old. We examined these patients' periportal vessels by real-time US, then differentiated PPCC from hepatic artery by duplex Doppler US. We analyzed the morphological appearances of real-time US imaging of PPCC and the hepatic artery. Our results showed that the PPCC was always torturously worm-like in appearance on real-time US, and the hepatic artery usually had a linear channel appearance on real-time US. When these two kinds of vessels were seen simultaneously along the pathway of a thrombosed portal vein, the inner vessel was always the hepatic artery with linear channel structure, and the outer vessel was always PPCC with a torturously worm-like structure. In conclusion, real-time US is a useful and reliable modality in detecting periportal vessels and differentiating PPCC from the hepatic artery.

Influence of hepatitis C virus on the profiles of patients with chronic hepatitis B virus infection

BACKGROUND

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are the most common causes of chronic liver disease, cirrhosis and hepatocellular carcinoma. The influence of HCV infection on the clinicopathological and virological profiles of chronic HBV infection was investigated.

METHODS

A total of 100 chronic HBV carriers with histopathological diagnoses by liver biopsy were studied. Hepatitis B e antigen (HBeAg) and anti-HCV antibody were tested. Serum HCV-RNA was detected by using a nested reverse transcription-PCR assay. A branched DNA (bDNA) assay was used to detect HBV-DNA and quantitate the serum levels.

RESULTS

Eighteen (18%) of 100 patients were positive for anti-HCV and HCV-RNA. Patients with concurrent HCV and HBV infection were significantly older than those without HCV infection (P < 0.05). The positive rates of HBeAg and HBV-DNA as well as the serum levels of HBV-DNA in patients with concurrent HCV and HBV infection were significantly lower than those without concurrent HCV and HBV infection (P < 0.01, P < 0.05, and P < 0.001, respectively). By using multivariate analysis, the factors of seroconversion of HBeAg and decreasing level of HBV-DNA were significantly correlated to concurrent HCV and HBV infection in chronic HBV carriers. The factors of increasing age and concurrent HCV and HBV infection were significantly correlated to seroconversion of HBeAg.

CONCLUSIONS

The concurrent HCV and HBV infection in chronic HBV carriers might result in a suppression of HBV replication that presented with a lower level of serum HBV-DNA and HBeAg seroconversion. Nevertheless, neither more obvious increase in biochemical parameters nor histopathological progression to more advanced liver diseases was observed.

Sex differences in relation to serum hepatitis B e antigen and alanine aminotransferase levels among asymptomatic hepatitis B surface antigen carriers

This study aimed to investigate sex differences in relation to hepatitis B e antigen (HBeAg) and serum alanine aminotransferase (ALT) levels in chronic asymptomatic hepatitis B virus (HBV) infection. HBeAg and ALT level were determined in 636 asymptomatic hepatitis B surface antigen carriers. There was no significant sex differences in the age-adjusted prevalence of HBeAg. Abnormal ALT level (>45 IU/l) was more frequent in carriers with HBeAg (17.5% vs 7.6%; P = 0.001). Multivariate analysis indicated that male sex (odds ratio, 2.0; 95% confidence interval, 1.1-3.6) and HBeAg (odds ratio, 2.6; 95% confidence interval, 1.6-4.3) were independent risk factors for abnormal ALT levels. Male sex and HBeAg-positivity are independent risk factors for abnormal ALT activity in chronic HBV infection. This observation may be related to sex differences in chronic HBV infection.

Morphology of glass fibers in electronics workers with fiberglass dermatitis--a scanning electron microscopy study

BACKGROUND

Fiberglass is used as a reinforcement filler material in printed circuit boards (PCBs) which are widely used in the electronics industry. In a recent survey, we demonstrated that fiberglass dermatitis is the most common occupational dermatosis among electronics industry workers in Taiwan. Little is known, however, about the morphologic structures of the glass fibers which induce dermatitis. The purpose of this study was to assess the morphology of fiber spicules and to determine the relationship of this structure to fiberglass dermatitis.

METHODS

Fourteen female patients with a diagnosis of fiberglass dermatitis were selected for study. The diagnosis was confirmed in all patients by positive skin stripping for glass fibers and matching with glass fibers from dust collected in work areas and from samples collected by scraping the edge of PCBs. Samples of collected glass fibers were analyzed by scanning electron microscopy (SEM).

RESULTS

SEM of the fiberglass samples revealed that fibers were approximately 10 microm in diameter. In samples from both the edge of PCBs and from dust collected in work areas, SEM revealed that most of the fibers were in bundles of various sizes and lengths. All fibers collected from patients' skin by tape stripping showed a singular spicule, most had a sharp free end, and the lengths were in the range 50-150 microm .

CONCLUSIONS

Singular glass fibers with a sharp free end and a length of 50-150 microm are most likely to induce fiberglass dermatitis.

Betel quid chewing as a risk factor for hepatocellular carcinoma: a case-control study

The role of betel quid chewing in the aetiology of hepatocellular carcinoma (HCC) was evaluated in a case-control study including 263 pairs of age- and sex-matched HCC patients and healthy controls. Serum hepatitis B surface antigen (HBsAg), and antibodies to hepatitis C virus (anti-HCV) were determined, and standardized personal interview conducted using a structured questionnaire. Multivariate analysis indicated that betel quid chewing (odds ratio (OR), 3.49; 95% confidence interval (CI), 1.74-6.96), HBsAg (OR, 16.69; 95% CI, 9.92-28.07), anti-HCV (OR, 38.57; 95% CI, 18.15-81.96), and educational duration of less than 10 years (OR, 1.71; 95% CI, 1.05-2.78) are independent risk factors of HCC. In addition, there was an additive interaction between betel quid chewing and chronic infection with either hepatitis B virus (synergy index, 5.37) or hepatitis C virus (synergy index, 1.66). Moreover, risk on HCC increased as duration of betel quid chewing increased, or amount of betel quid consumed (each P for trend < 0.0001).

The molecular epidemiology and clinical significance of TT virus (TTV) infection in healthy blood donors from southern Taiwan

To evaluate the molecular epidemiology and clinical significance of th

The serological and molecular epidemiology of GB virus C/hepatitis G virus infection in a hepatitis C and B endemic area

OBJECTIVES

To investigate the serological and molecular characteristics of GB virus C/hepatitis G virus (GBV-C/HGV) infection in the hepatitis C virus (HCV)/hepatitis B virus (HBV)-endemic areas in Taiwan.

METHODS

Sera from 200 residents from Masago, an HCV/HBV-endemic community in Taiwan, and 400 blood donors were tested for GBV-C/HGV RNA by using nested reverse transcription-polymerase chain reaction and for antibodies to GBV-C/HGV E2-protein (anti-E2) by an enzyme-linked immunosorbent assay. Phylogenetic analysis of GBV-C/HGV was performed.

RESULTS

The prevalence of GBV-C/HGV viraemia, anti-E2 and GBV-C/HGV exposure among residents of Masago was significantly higher than that among donors (17.0%, 25.5% and 39.5% vs. 3.3%, 7.5% and 10.3%, respectively; all P < 0.0001). In Masago, the prevalence of GBV-C/HGV exposure was significantly higher in residents exposed to HCV than in those without HCV exposure (45.8% vs. 24.1%;P< 0.005). Based on multivariate analyses, HCV viraemia was the only significant factor associated with elevated levels of alanine aminotransferase in Masago. Phylogenetic analysis showed all 34 GBV-C/HGV isolates from Masago clustered within genotype 3.

CONCLUSIONS

GBV-C/HGV was highly prevalent in Masago, an HCV/HBV-endemic community in Taiwan. HCV viraemia played the most important clinical hepatopathic role in the area. Infections with other hepatitis viruses did not influence the anti-E2 seroconversion from GBV-C/HGV infections.

Incidence and associated factors of neutralizing anti-interferon antibodies among chronic hepatitis C patients treated with interferon in Taiwan

BACKGROUND

The administration of interferon (IFN) could be complicated by the development of neutralizing anti-interferon antibodies (NA). This study evaluates the frequency and associated factors of NA among chronic hepatitis C patients treated with different IFNs.

METHODS

Ninety-five chronic hepatitis C patients were randomized to be treated with recombinant IFN-alpha2a (n = 28), IFN-alpha2b (n = 39) or lymphoblastoid IFN-alpha1 (n = 28) given intramuscularly, 3-6 million units, thrice weekly for 24 weeks. Serum samples collected before, during and after the cessation of treatment were checked for NA.

RESULTS

Three patients were withdrawn from treatment. All patients were negative for NA before treatment and 13 (14%) patients developed neutralizing antibodies. Of the 26 patients treated with IFN-alpha2a, 6 (23.1%) developed NA. whereas NA were detected in only 6 (15.4%) of 39 and 1 (3.7%) of 27 patients treated with IFN-alpha2b and IFN-alphanl, respectively. Age, gender, HCV genotype, ALT level, IFN total dose and liver histology were not associated with the development of NA. By using multivariate logistic regression it was shown that pretreatment HCV RNA level and IFN preparation were the two major factors related to the production of NA. The response of treatment was related to pretreatment viremia but not to the presence of NA.

CONCLUSIONS

The frequency of development of NA among Taiwanese patients with chronic hepatitis C might be related to different IFN preparations and pretreatment HCV RNA level. The response of treatment was related to pretreatment HCV RNA level but not to the presence of NA.

The epidemiology of TT virus (TTV) infection in a hepatitis C and B virus hyperendemic area of southern Taiwan

TT virus (TTV) is a newly isolated DNA virus from the serum of a patient with posttransfusion hepatitis of unknown etiology in 1997. To evaluate the clinical and molecular characteristics of TT virus (TTV) in a hepatitis C virus (HCV) and B (HBV) hyperendemic area (Masago), 200 residents were enrolled in the study. The sera were tested for alanine aminotransferase (ALT), HCV RNA and GB virus C/Hepatitis G virus (HGV) RNA, TTV DNA, HBsAg, anti-HCV and antibodies to HGV E2-protein (anti-E2). TTV DNA was positive in 99 of the 200 sera with a prevalence rate of 49.5%. The prevalence of HBsAg, anti-HCV, HCV RNA, HGV RNA, anti-E2 and HGV exposure (defined as positive for serum HGV RNA and/or anti-E2) was 38.9%, 69.5%, 64.5%, 17.0%, 25.5% and 39.5%, respectively. Neither clinical nor virological factors were associated with TTV viremia. The rate of ALT abnormality was significantly elevated in HCV RNA-positive (34.9%) than -negative (7.0%) residents (p < 0.001). HCV viremia was the only factor significantly associated with ALT elevation by multiple logistic regression (odds ratio: 6.96; 95% C.I.: 2.60-18.7). We concluded that in this HCV/HBV hyperendemic area, the prevalence of TTV DNA was high. No significant clinical factor was observed to be associated with TTV infection. TTV infection is not related to abnormal ALT levels and ALT abnormality was mainly attributable to HCV but not TTV, HBV or HGV infection.

Clinical evaluation of the automated COBAS AMPLICOR HCV MONITOR test version 2.0 for quantifying serum hepatitis C virus RNA and comparison to the quantiplex HCV version 2.0 test

A second-generation hepatitis C virus (HCV) quantitative assay (COBAS AMPLICOR HCV MONITOR Test, version 2.0; COBAS HCM-2) has been developed, with the intention of achieving equivalent quantification of all HCV genotypes and improving assay performance. To evaluate the clinical performance of COBAS HCM-2 and its utility in predicting the response to alpha interferon treatment, sera from 215 chronic hepatitis C patients were analyzed and the results were compared with those obtained by the Quantiplex bDNA HCV RNA, version 2.0, assay (bDNA-2). The COBAS HCM-2 had significantly greater sensitivity than bDNA-2 (94.9 versus 88.4%; P < 0.001) when performed with sera from chronic hepatitis C patients who were viremic by a qualitative PCR test. The standard deviations for the within-run and between-run reproducibilities of COBAS HCM-2 were <0. 1 and <0.2, respectively, and it showed an improved linear range between genotypes with the threefold serial dilutions tested (r(2) = 0.986 to 0.995). The COBAS HCM-2 results were positively correlated with the bDNA-2 results, but the values for COBAS HCM-2 were on average 0.96 log lower than the values for bDNA-2. The mean difference in quantification values between these two assays did not differ among samples with different genotypes (0.70 to 1.00 log). No genotype-dependent difference in viral load was observed. The pretreatment viral load was significantly lower in complete responders. By using multivariate analysis, the viral load 2 weeks after the initiation of alpha interferon treatment was the strongest predictor of a complete response. In conclusion, COBAS HCM-2 demonstrated good sensitivity, linearity, and reproducibility and efficiency equal to that of bDNA-2 for the quantification of HCV genotypes 1 and 2. Hence, this assay provides a rapid and reliable method for the quantification of HCV RNA in serum and is useful for the planning of interferon treatment.

Percutaneous ethanol injection of the supplying artery to hepatocellular carcinoma that is not amenable to conventional treatment

The purpose of this study was to evaluate the clinical usefulness of ultrasound-guided percutaneous ethanol injection of the supplying artery (PEISA) to the tumour in the palliative management of hepatocellular carcinoma (HCC) that is not amenable to conventional treatments. A total of 23 cases of HCC, measuring from 3.1 cm to larger than 15 cm (median 5.4 cm) in 17 cirrhotic patients, were treated by PEISA. PEISA was used to control rapid growth of the tumour in seven patients and to reduce abdominal discomfort caused by rapid expansion of the tumour in 10 patients. Tumours with arterial Doppler signals persisting after PEISA underwent repeated treatment. The follow-up period ranged from 2-48 months. PEISA was achieved in 69 out of 76 attempts (90.8%). The amount of ethanol injected on each occasion ranged from 2.5-33 ml. Follow-up colour Doppler scanning showed complete elimination of tumour Doppler signals in 22 out of 23 lesions (95.7%). Following treatment, one tumour disappeared, 13 tumours shrank and nine tumours were unchanged in size. All patients with abdominal discomfort had relief after treatment. The common complications of PEISA were local pain and fever. In conclusion, PEISA is effective at treating painful HCC unsuitable for conventional treatment.

Serotyping and genotyping of hepatitis C virus in Taiwanese patients with type C chronic liver disease and uraemic patients on maintenance haemodialysis

BACKGROUND

To evaluate a recombinant immunoblot hepatitis C virus (HCV) serotyping assay, which determines HCV serotypes 1, 2, and 3 by detecting type-specific antibodies to core-and NS-4-derived peptides.

METHODS

Immunoreactivity of type-specific antibodies among 173 chronic hepatitis C patients and 43 haemodialysis patients in Taiwan was examined and the serotyping results were compared with genotyping by Okamoto's method. Serial specimens from 29 patients undergoing interferon-alpha therapy were also evaluated.

RESULTS

Of the 205 specimens for which genotyping data were available, 51.2% were of serotype 1, 31.7% of serotype 2, 1.0% of serotype 3, 2.4% of either serotype 1 or 3, and the remaining 13.7% were untypable. The serotypable rate was significantly lower in haemodialysis patients than in chronic hepatitis C patients (70.0% vs 94.9%; P < 0.001). Serotyping of genotype 2b specimens was significantly more dependent on core peptide bands than other genotypes. Using genotyping as the reference, the overall sensitivity, specificity and concordance of the recombinant immunoblot HCV serotyping assay were 86.3%, 97.2% and 83.9%, respectively. However, the serotyping assay had significantly lower sensitivity (69.2%), specificity (77.8%) and concordance (53.8%) for genotype 2b specimens. Of nine HCV complete responders, one lost type-specific antibodies 6 months after the cessation of interferon-alpha treatment.

CONCLUSIONS

These results suggest that, except for less than optimal performance with immunocompromised or genotype 2b patients, the HCV serotyping assay is a practical and useful method for HCV typing in the clinical setting in Taiwan.

Virologic factors related to interferon-alpha-induced thyroid dysfunction in patients with chronic hepatitis C

OBJECTIVE

Hepatitis C virus (HCV), being reported to be associated with a high prevalence of serological markers of autoimmunity in HCV-infected patients, and possibly sharing partial sequences in amino acid segments with thyroid tissue antigens, may be associated with interferon-alpha (IFN-alpha)-induced thyroid dysfunction in chronic hepatitis C patients. We conducted this study to clarify the issue.

DESIGN AND METHODS

One hundred and fifty chronic hepatitis C patients with normal baseline thyroid function were treated with IFN-alpha 2a, 2b and n1 (3-6 million Units three times weekly for 24 weeks). Pretreatment sera were tested for HCV genotype and HCV RNA levels. Serum thyrotropin, total thyroxine and free thyroxine index were performed every 4 weeks for 24 weeks followed by every 8 weeks for another 24 weeks.

RESULTS

Twenty-one (14.0%) patients developed early thyroid dysfunction (abnormal thyroid function during the first 3 months of therapy). Female gender, lower HCV RNA levels, IFN-alpha n1 and a lower IFN-alpha dose were significantly associated with early thyroid dysfunction. On multivariate analysis, gender, IFN-alpha preparation and HCV RNA levels were the significant factors associated with early thyroid dysfunction. Seven (4.7%) patients developed thyroid dysfunction during the second 3 months of IFN-alpha therapy. Taken together, 18.7% patients developed thyroid dysfunction. Female, mixed HCV genotype infection and lower HCV RNA levels were significantly associated with thyroid dysfunction. However, only gender remained significantly associated with IFN-alpha-induced thyroid dysfunction in multivariate analysis.

CONCLUSIONS

The virologic features of HCV may be associated with thyroid dysfunction in chronic hepatitis C patients treated with IFN-alpha. Nevertheless, gender still plays the most important role in IFN-alpha-induced thyroid dysfunction.

Role of serum C-reactive protein as a marker of hepatocellular carcinoma in patients with cirrhosis

BACKGROUND

The usefulness of C-reactive protein (CRP) as a tumour marker in patients with hepatocellular carcinoma (HCC) is controversial. The purpose of this study was to determine whether CRP estimation could be used to identify patients with HCC among those with cirrhosis.

METHODS

Serum levels of CRP and alpha-fetoprotein (AFP) were investigated in 122 previously untreated patients with cirrhosis and HCC. Another 76 patients with cirrhosis alone were also investigated as controls.

RESULTS

Of the subjects tested, 47.5% of patients with HCC and 39.5% of controls had elevated CRP values (> 6 microg/mL). Although using elevated CRP and/or AFP (> 20 ng/mL) as a criterion showed a significant difference between controls and patients with multiple nodular, massive, or diffuse type HCC (all P < 0.005), the clinical application of this criterion was limited because of low specificity (58%) and accuracy (all < 73%). By using receiver-operating characteristic curves no valuable threshold value of CRP was found to discriminate various types of HCC, except for distinguishing the diffuse type from controls. The CRP value of 12 microg/mL could be used as the cut-off value to differentiate diffuse-type HCC from controls (sensitivity 82.4%, specificity 82%, accuracy 82.1%, P<0.005).

CONCLUSIONS

Serum CRP is not a good marker for HCC. However, very high values of CRP in patients with cirrhosis may suggest the presence of a diffuse-type HCC.

Clinical application of the Quantiplex HCV RNA 2.0 and Amplicor HCV Monitor assays for quantifying serum hepatitis C virus RNA

AIM

To compare the performance characteristics and clinical application of two different technologies for quantifying serum hepatitis C virus (HCV) RNA levels.

METHODS

HCV RNA was quantified by Amplicor HCV Monitor assay (Amplicor) and Quantiplex HCV RNA 2.0 assay (bDNA-2) in 119 sera from 107 HCV infected patients.

RESULTS

Both assays had similar sensitivity (79.4% for Amplicor; 86.0% for bDNA-2), acceptable coefficients of variation (5.3% in Amplicor; 2.6% in bDNA-2), and good linearity (r2 > or = 0.98). There was a positive correlation between quantification values of both methods (r = 0.683, p < 0.001). The Amplicor values were on an average 1.76 log lower than bDNA-2 results. Male subjects and HCV genotype 1b were significantly associated with higher viral load determined by Amplicor, but not with viral load measured by bDNA-2. In 70 chronic HCV infected patients treated with interferon alfa, mean (SD) pretreatment viral load in 27 complete responders (3.47 (0.84) logs for Amplicor, 5.63 (0.58) for bDNA-2) was significantly lower than in non-responders (4.43 (1.01) logs for Amplicor, 6.10 (0.67) logs for bDNA-2; p < 0.001). Cut off points of 3.9 logs for Amplicor and 5.8 logs for bDNA-2 were determined to be the best for predicting response to interferon alfa, giving acceptable sensitivity (70.4%, 74.1%), specificity (72.1%, 65.1%), and accuracy (71.4%, 68.6%), respectively.

CONCLUSIONS

Both the Amplicor and bDNA-2 assays are clinically useful methods for HCV RNA quantification and are reliable for predicting the outcome of treatment, despite differences in absolute quantification values and in the correlation between HCV genotypes and viral load.

Immunoglobulin- and hepatitis B surface antigen-specific circulating immune complexes in chronic hepatitis B virus infection

For assessing the role of circulating immune complexes (CIC) in chronic hepatitis B virus (HBV) infection, CICs containing IgM, IgG, and HBsAg were determined by C1q and conglutinin (K) assays in 216 patients with chronic HBV infection and 54 healthy controls. The concentration of each type of CIC in patients is higher than in controls (P = 0.0001). CIC is a common feature of chronic HBV infection with 95.8% of cases having at least one abnormal test result. At least one type of HBsAg-CIC is positive in 54.2% of patients. HBsAg-CIC positivity is associated with HBeAg positivity (P = 0.0001), higher aminotransferase levels (P < 0.002), and younger age (P = 0.001). IgG-CIC or IgM-HBsAg-CIC correlates with higher aminotransferase activity (P = 0.001). In conclusion, HBsAg-CIC correlates with HBV replication. IgG-CIC and/or IgM-HBsAg-CIC correlate with disease activity. Immune-mediated injury may play a role in the pathogenesis of chronic HBV infection.

Clinical relevance of transforming growth factor-beta 1 in the urine of patients with hepatocellular carcinoma

To assess the clinical relevance of transforming growth factor-beta 1 (TGF-beta 1) in the urine of patients with hepatocellular carcinoma (HCC), TGF-beta 1 was measured, by radioimmunoassay, in 140 patients with HCC, 50 cirrhotic patients, 30 patients with chronic active hepatitis, and 50 healthy controls. The results indicate that there were significantly increased urinary TGF-beta 1 levels in patients with HCC. Raised TGF-beta 1 levels were associated, in a dose-related fashion, with increased risk for development of HCC (odds ratio, 1.05, 95% confidence interval, 1.03-1.07). HCC patients with raised TGF-beta 1 levels had shorter survival than those with normal TGF-beta 1 levels (p = 0.038). TGF-beta 1 levels decreased after successful anticancer therapy (p < 0.0001). There was an inverse correlation between TGF-beta 1 and serum alpha-fetoprotein (AFP) (r = -0.199, p < 0.04). Receiver operating characteristics (ROC) curve analysis indicated that parallel determination of TGF-beta 1 and AFP significantly increased the sensitivity and diagnostic accuracy, with a high specificity. In conclusion, raised urinary TGF-beta 1 was associated with HCC development. It is a predictor of poor prognosis, and a tumor marker for diagnosis and therapeutic follow-up of HCC.

Urinary transforming growth factor-beta 1 in relation to serum alpha-fetoprotein in hepatocellular carcinoma

BACKGROUND

Our aim was to assess the relationship between transforming growth factor beta 1 (TGF-beta 1) and alpha-fetoprotein (AFP) levels in hepatocellular carcinoma (HCC).

METHODS

Urinary TGF-beta 1 and serum AFP were determined in 123 HCC patients, 50 patients with chronic liver disease (CLD), and 50 healthy controls.

RESULTS

Both TGF-beta 1 and AFP levels were higher in HCC patients than in CLD patients or controls (each, P = 0.0001). There was a negative correlation between TGF-beta 1 and logAFP (r = -0.196, P = 0.029). Multivariate analysis indicated that TGF-beta 1 and AFP were associated with an increased risk of HCC development. By receiver-operating characteristic curve analysis, determination of AFP and TGF-beta 1 in parallel significantly increased the sensitivity and diagnostic accuracy in detecting HCC.

CONCLUSION

Increased urinary TGF-beta 1 level can be used as a complementary marker to AFP for detection of HCC with low AFP production.

Serum alanine aminotransferase level in relation to hepatitis B and C virus infections among blood donors

To assess the serum alanine aminotransferase (ALT) activity in relation to hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among blood donors, antibodies to HCV (anti-HCV) and hepatitis B surface antigen (HBsAg) were detected in 400 blood donors with normal ALT level (< or = 750 mumol/s per liter), and 76 blood donors with raised ALT level. The prevalence of anti-HCV (10.5%) and HBsAg (28.9%) in the latter was higher than that (2.0% and 17.5%, respectively) in the former (p < 0.001 and p < 0.03, respectively). There was a trend that indicated that the risk of anti-HCV positivity increased with increasing age (p < 0.001). Thirty of 76 (39.5%) donors with raised ALT level were positive for anti-HCV or HBsAg. Compared with HBsAg-positive donors, donors with anti-HCV had higher serum ALT levels (p < 0.01) and greater mean age (p < 0.01). Multivariate analysis indicated that both anti-HCV (odds ratio: 6.2; 95% confidence interval: 2.2-17.8) and HBsAg (odds ratio: 2.2; 95% confidence interval: 1.3-3.9) were significantly associated with raised serum ALT activity. The estimated population-attributable risk was 8.6% for anti-HCV, and 13.8% for HBsAg. In conclusion, although HBV and HCV infections are independent risk factors of raised ALT activity among blood donors, they play a minor role in the etiology of raised ALT activity.

Effect of hepatitis C and B virus infection on risk of hepatocellular carcinoma: a prospective study

To assess whether there is an additive effect between chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection on the development of hepatocellular carcinoma (HCC), 400 consecutive cirrhotic patients were followed prospectively with periodic abdominal ultrasound examination and measurement of serum alpha-fetoprotein (AFP) level every 4 months. During a follow-up of 1185 person-years, 80 (20%) patients developed HCC, with an annual incidence of 6.8%. The annual incidence was 2.0% in patients negative for hepatitis B surface antigen (HBsAg) and antibodies to HCV (anti-HCV), 6.6% in patients with HBsAg alone, 7.0% in patients with anti-HCV alone and 13.3% in patients co-infected with HBV and HCV. There was a positive linear trend in the annual incidence of HCC among patients without either marker, patients with single viral infection and patients with dual viral infection (P[for trend] < 0.0001). Cox's proportional hazard model indicated that HCV/HBV co-infection [hazard ratio (HR), 6.41; 95% confidence interval (CI), 1.80-22.80], anti-HCV alone (HR, 3.74; 95% CI, 1.07-13.07) and HBsAg alone (HR, 4.06; 95% CI, 1.23-13.34) were independently risk factors of HCC. In conclusion, there is an additive and independent effect modification of HCV and HBV infection on HCC development.

Elevated urinary transforming growth factor-beta1 level as a tumour marker and predictor of poor survival in cirrhotic hepatocellular carcinoma

To assess the clinical relevance of transforming growth factor-beta1 (TGF-beta1) in hepatocellular carcinoma (HCC), urinary TGF-beta1 and serum alpha-fetoprotein (AFP) were determined in 94 patients with cirrhotic HCC, 94 age- and sex-matched patients with cirrhosis alone and 50 healthy adults. TGF-beta1 level in HCC was higher than in cirrhosis alone or in healthy controls (each P = 0.0001). There is an inverse correlation between TGF-beta1 and AFP levels (r = -0.292, P = 0.004). Significantly higher TGF-beta1 level was found in HCC patients with worsening Child-Pugh stages, diffuse HCC, tumour size > 3 cm, multilobular tumour and AFP < or = 20 ng ml(-1). TGF-beta1 level decreased after complete treatment with transcatheter arterial chemoembolization (P = 0.0001). The median survival in HCC patients with raised TGF-beta1 was shorter than those with normal TGF-beta1 (P = 0.018). Multivariate analysis indicated that TGF-beta1 and AFP were significantly correlated with the presence of HCC. In addition, TGF-beta1 could be used as a diagnostic marker for HCC, particularly in tumours with low AFP production. In conclusion, elevated urinary TGF-beta1 level is a tumour marker and predictor of poor survival for cirrhotic HCC.

Clinical utility of color Doppler sonography in the differentiation of hepatocellular carcinoma from metastases and hemangioma

The clinical utility of color Doppler sonography in the differentiation of hepatocellular carcinoma from metastases and hemangioma was investigated in 72 hepatocellular carcinomas (80 lesions), 30 metastases (82 lesions), and 39 hemangiomas (54 lesions). Overlaps of color patterns were found among hepatocellular carcinoma, metastases and hemangioma. Pulsatile waves from lesions with the basket, vessels within tumor, or spot patterns, or lesions measuring less than 3 cm with detectable signals, did not favor the diagnosis of hemangioma. In conclusion, color Doppler sonography can aid in the differentiation of hepatocellular carcinoma from hemangioma but may be unreliable in the differentiation of hepatocellular carcinoma from hypervascular metastases.

Clinical evaluation of urinary transforming growth factor-beta1 and serum alpha-fetoprotein as tumour markers of hepatocellular carcinoma

To evaluate the diagnostic application of urinary transforming growth factor-beta1 (TGF-beta1) and serum alpha-fetoprotein (AFP) levels in hepatocellular carcinoma (HCC), TGF-beta1 and AFP were determined in 94 patients with cirrhotic HCC and in 94 sex- and age-matched patients with cirrhosis alone. TGF-beta1 and AFP levels in HCC were higher than in cirrhosis alone (P = 0.0001). There is an inverse correlation between TGF-beta1 and log AFP (r = -0.292, P = 0.004). Multivariate analysis indicated that TGF-beta1 and AFP were closely associated, in a dose-related fashion, with the development of HCC. Receiver-operating characteristic (ROC) curves were used to determine the optimal cut-off values of TGF-beta1 (50 microg g(-1) creatinine) and AFP (100 ng ml(-1)). Both TGF-beta1 and AFP showed a high specificity (99%) and positive likelihood ratio. The sensitivity was 53.1% for TGF-beta1 and 55.3% for AFP. The determination of both markers in parallel significantly increased the diagnostic accuracy (90.1%) and sensitivity (84%), with a high specificity (98%) and positive likelihood ratio (40.0). In conclusion, TGF-beta1 and AFP are independent tumour markers of HCC and may be used as complementary tumour markers to discriminate HCC from cirrhosis.

The genotypes of hepatitis C virus in patients with chronic hepatitis C virus infection in southern Taiwan

To investigate the genotype distribution of hepatitis C virus (HCV) in southern Taiwan, the sera from 56 patients with chronic HCV infection were studied. Twenty-nine patients were men and 27 were women. Age ranged from 22 to 65 years (mean, 47.3 +/- 11.4). Eighteen of them had chronic persistent hepatitis, 27 had chronic active hepatitis, and 11 had liver cirrhosis. HCV RNA was detected by reverse transcription-nested polymerase chain reaction using primers derived from the 5'-noncoding region. The genotypes of HCV were determined by amplification of the core region with the type-specific primers as described by Okamoto et al.. All sera were positive for HCV RNA. The prevalence rates of genotypes were as follows: 1b/II, 44.6%(25/56); 2a/III, 41.1%(23/56); 2b/IV, 3.6%(2/56); mixed 1b/I + 2a/III, 5.4%(3/56): mixed 1b/II + 2b/IV, 1.8%(1/56) and type unclassified 3.6%(2/56). The distribution of genotypes was not related to the patients' age, sex, and histological changes. Nevertheless, patients having past history of blood transfusion had a significantly higher rate of HCV type 2a/III infection (72.2% versus 34.2%, p < .05, chi-square test). We concluded that both of the HCV genotypes 1 b/II and 2a/III are predominant types in southern Taiwan and regional HCV genotype distribution may differ even within this island. Selective transmission of specific genotypes may pass along different infectious routes.

Treatment of chronic hepatitis C with interferon-alpha: a preliminary report

Interferon alpha (IFN-alpha) has been indicated to be dramatically effective in some but not all patients with chronic hepatitis C virus (HCV) infection. We investigated prospectively 27 patients of chronic hepatitis C, 12 females and 15 males, treated with IFN-alpha for a better regimen of the therapy and for any effective predictor of response to the treatment. All patients were treated with 3 to 6 million units (MU) of recombinant IFN-alpha 2b (n = 15) or lymphoblastoid IFN-alpha (n = 12) given 3 times weekly for 12 to 36 weeks. Patients with normal alanine aminotransferase (ALT) value during therapy, who sustained this response throughout 6 months follow-up after treatment was completed, were grouped into the complete responders. Patients with normal ALT value during therapy but who relapsed after treatment completed, were grouped as partial responders. Non-responders were defined as patients without normal ALT value during therapy. The rates of complete response, partial response, and non-response were 29.6%, 40.8%, and 29.6%, respectively. The degree of response to IFN-alpha therapy was not related to age, sex, type of IFN-alpha, history of blood transfusion, the state of liver pathology, or pretreatment level of ALT value. The complete responsive rate to IFN-alpha was higher in patients treated with total dose above 215 MU [38.1% (8/21) vs. 0% (0/6), p = 0.06], in patients treated for at least 24 weeks [40% (8/20) vs. 0% (0/7), p < 0.05], and in patients with non-genotype 1b/II HCV infection [40% (8/20) vs. 0% (0/7), p < 0.05]. We concluded that IFN-alpha was effective in the treatment of chronic HCV infection, particularly in those other than HCV genotype 1b/II. A high-dose, and long-duration regimen may be recommended for better response of chronic hepatitis C to IFN-alpha therapy.

Hepatitis B surface antigen- and immunoglobulin-specific circulating immune complexes in acute hepatitis B virus infection

For assessing the role of circulating immune complexes (CICs) in acute hepatitis B, CICs containing HBsAg, IgM, and IgG were determined, by C1q and conglutinin (K) assays, in 242 patients with acute hepatitis B and 60 healthy controls. CIC is a common feature of acute hepatitis B with 90.9% of cases having at least one abnormal test result. Patients with shorter interval (< 1 week) between onset of symptoms and patient presentation have significantly higher frequency of abnormal IgM class CIC, HBsAg-specific CIC, and higher frequency of raised alanine aminotransferase activity (> 30-fold upper limit of normal). The prevalence of raised alanine aminotransferase in patients with CIC containing HBsAg and IgM is higher than those without (P = 0.001). There is significant association between HBsAg-CIC and C1q-CIC. In conclusion, HBsAg-CIC and IgM class CIC correlate with disease activity. C1q-binding CIC is the predominant CIC that may play a role in the pathogenesis of acute hepatitis B.

Changes in intrahepatic portal hemodynamic in early stage hepatic abscesses

Color Doppler sonography was used to investigate the changes in intrahepatic portal hemodynamics in early stage hepatic abscesses (21 lesions). At time of patients' admission, 10 lesions measuring over 6 cm showed reverse flow from at least one of their corresponding segmental portal branches, but 11 lesions measuring 6 cm or less did not show this phenomenon. All portal branches with reverse flow eventually returned to a normal direction of flow after successful medication. In conclusion, a large early stage hepatic abscess may show temporary reverse portal flow on color imaging. Thus, a differential diagnosis of hepatic tumors with reverse portal flow should include early stage hepatic abscesses.

The status of serum hepatitis B virus DNA in HBSAG-positive hepatocellular carcinoma

To elucidate the status of serum hepatitis B virus (HBV) DNA in HBsAg-positive hepatocellular carcinoma (HCC), 100 type B chronic liver disease (CLD) patients and 19 HCC patients were studied. The positive rate of serum HBV DNA in HBeAg-positive CLD patients was significantly higher than that in HBeAg-negative CLD patients, and the correlation between the presence of serum HBV DNA and patients' age showed a negative trend. In contrast, the positive rates of serum HBV DNA in HCC patients were not related to the status of HBeAg and age, and the positive rate of serum HBV DNA in HBeAg-negative HCC patients was significantly higher than that in HBeAg-negative CLD patients. Nevertheless, the serum concentrations of HBV DNA in HCC patients were significantly lower than those in CLD patients. These results suggest that replication of HBV in HCC patients might differ from that in CLD patients, and that persistent low-level HBV replication might be related to the presence of HCC.

Longitudinal study of intrahepatic portal flow: a novel approach using Doppler technique

The present study investigates whether the application of the summation of portal blood flow (SPBF), measured from the left umbilical portion and the right anterior branch by Doppler, could be of use in the longitudinal study of intrahepatic portal flow or not. Forty-five subjects were divided into two groups. Group I subjects included males and post-menopausal females. Thirty-seven subjects (19 normal volunteers, 12 subjects with chronic hepatitis, six cirrhotics) were investigated by the more experienced doctor A at 9 day intervals for an intra-observer study. Among them, seven subjects (four normal volunteers, three with chronic hepatitis) were also investigated consecutively at 10 min apart by doctor B on days 1 and 10 for an interobserver study. Group II subjects included eight normal subjects with a regular menstrual cycle. They were investigated by doctor A during menstruation, mid-follicular, ovulatory and mid-luteal phases of the menstrual cycle to evaluate the possible impact of the menstrual cycle on SPBF measurement. The reproducibility of measurements was assessed by the coefficient of variation (CV) and the reproducibility coefficient. Data are expressed as mean +/- s.d. The CV of the SPBF for intra-observer and interobserver study were 4.88 +/- 3.36 and 4.19 +/- 2.53, respectively. All differences of SPBF were within their corresponding reproducibility limits. The results of SPBF measurements obtained from different phases of the menstrual cycle were variable. Only the comparison between the data obtained from mid-follicular and mid-luteal phases could demonstrate acceptable CV values (3.98 +/- 3.12%) and all the differences in SPBF measurements were within the repeatability limit. In conclusion, Doppler SPBF measurement may be useful in the longitudinal evaluation of intrahepatic portal flow changes.

Additive effect modification of hepatitis B surface antigen and e antigen on the development of hepatocellular carcinoma

To assess the role of hepatitis B e antigen (HBeAg) and its interaction with hepatitis B surface antigen (HBsAg) on the development of hepatocellular carcinoma (HCC), this case-control study included 361 age- and sex-matched pairs of patients with histologically proven HCC and healthy control subjects. HBsAg, HBeAg and antibody to HBeAg (anti-HBe) were detected by radioimmunoassay. Antibodies to hepatitis C virus (anti-HCV) were detected by second-generation enzyme immunoassay. The prevalences of HBeAg (20.2%), HBsAg (80.3%) and anti-HCV (29.5%) in cases were higher than in controls (1.9%, 20.7%, and 2.7% respectively; each P < 0.0001). Using patients negative for HBsAg, HBeAg and anti-HBe as a referent group, univariate analysis indicated that HBsAg alone or HBsAg and HBeAg were risk factors for HCC (P for trend < 0.0001). Calculation of incremental odds ratio indicated that there was additive interaction between HBsAg and HBeAg. Multivariate analysis indicated that HCC development was strongly associated with the presence of HBeAg (odds ratio, 8.1; 95% confidence interval, 2.4-27.1), HBsAg (odds ratio, 68.4; 95% confidence interval, 20.5-227.8) and anti-HCV (odds ratio, 59.3; 95% confidence interval, 13.6-258.4). In conclusion, HBsAg, HBeAg and anti-HCV are independent risk factors for HCC. There is additive and independent effect modification between HBsAg and HBeAg on the development of HCC.

Treatment of hepatocellular carcinoma smaller than 5 cm by transcatheter arterial chemoembolization

To assess the effectiveness of transcatheter arterial chemoembolization (TACE) in the treatment of small hepatocellular carcinoma (HCC) and to analyze the prognostic factors, a total of 77 patients with histologically proven HCC, < or = 5 cm in diameter, were enrolled for the study and followed for more than 2 years, The overall cumulative 1-, 2-, and 3-year survival rates were 79.2%, 50.6% and 36.7%, respectively. The median survival time of Child-Pugh's A patients was 990 +/- 146 days, which was significantly better than the median survival time of Child-Pugh's B patients (450 +/- 82 days) Furthermore, positive HBeAg and alpha-Fetoprotein (AFP) were factors close to statistically significant. In contrast, sex, age, HBsAg, Anti-HCV, tumor type, tumor size and tumor number were not related to the prognosis in small HCC who received TACE.

Increased IgM class circulating immune complexes in acute hepatitis A virus infection

For assessing the role of circulating immune complexes (CIC) in acute hepatitis A, IgM- and IgG-specific CIC were determined, by C1q and conglutinin (K) assays, in 205 patients with acute hepatitis A and 60 healthy controls. The concentration of each type of CIC in patients was higher than healthy controls (P=0.0001). CIC was a common feature of acute hepatitis A with 95.6% of cases having at least one abnormal test result. The prevalence of abnormal IgM class CIC was significantly higher than IgG class CIC. There were significantly inverse correlations between levels of IgM class CIC and interval between onset of symptoms and patient presentation. The prevalence of abnormal IgM CIC was higher in patients with higher alanine aminotransferase (P=0.001) and patients with jaundice (P=0.0002). In conclusion, IgM class CIC is the predominant CIC in acute hepatitis A and correlated with disease activity. CIC may play a role in the pathogenesis of acute hepatitis A.

Percutaneous intravascular ethanol injection of the supplying tumor vessel in the treatment of hepatocellular carcinoma larger than 3 cm

Percutaneous intravascular ethanol injection of the supplying vessel of the tumor using color Doppler imaging was performed in three patients (three lesions) with hepatocellular carcinoma measuring more than 3 cm. Intravascular injection was achieved in six out ot seven attempts. The total amount of ethanol injected intravascularly was small (10, 15,0 and 26 ml for each patient). One attempt failed and the ethanol was injected perivascularly. No serious complication was noted. After treatment, two patients showed remarkable decrease in tumor size and one showed massive tumor necrosis. In conclusion, ethanol injection using the intravascular approach may be of value in the palliative management of large hepatocellular carcinomas.

Prevalence and size of simple hepatic cysts in Taiwan: community- and hospital-based sonographic surveys

Simple hepatic cysts are now being diagnosed more frequently with the widespread availability of sonographic imaging. Among the general population, the prevalence was reported to be between 0.1 and 2.5%, more so in women, and more often in the right lobe. We conducted this large scale community-based sonographic screening on simple hepatic cysts to explore the age- and sex-specific prevalence in Taiwan. We also conducted another hospital-based study to record the size of simple hepatic cysts. A total of 3,600 subjects in 8 communities were recruited and 156 simple hepatic cysts in 132 study subjects were detected. The overall prevalence is 3.60%. An increasing prevalence with age is demonstrated, ranging from 0.83% from below the age of 40 up to 7.81% of patients over 60 years old. The sizes of 219 simple hepatic cysts of 167 patients out of the hospital-based 5,893 patients were recorded in detail; 53% of cysts were of a diameter of between 1 and 3 cm, and only 7% were larger than 5 cm.

Expression pattern and partial sequence analysis of a fetal bovine myosin heavy-chain gene

A fragment of a bovine myosin heavy-chain (MHC) gene approximately 15 kbp in size (designated MHC 67) was isolated from a bovine genomic DNA library. The direction of transcription was determined, and preliminary experiments indicated that the gene was expressed in fetal skeletal muscle. The expression pattern of this gene was, therefore, evaluated in detail using northern blots containing RNA from eleven different bovine muscle and nonmuscle tissues at three developmental ages. A restriction fragment of clone MHC 67 containing the 3' untranslated sequence (which is specific for each MHC gene) was used as a probe. This gene fragment hybridized predominantly to RNA from fetal skeletal muscles and did not hybridize to RNA from either neonatal or adult skeletal muscles (red or white), smooth muscle tissue, or nonmuscle tissue. A 7-kb EcoRI fragment containing both translated and untranslated regions surrounding the 3' end of the gene was subcloned into pBluescript II KS+ and partially sequenced. When these bovine sequences were aligned to that of the human and rat skeletal and cardiac MHC genes, we found that these sequences corresponded to exons 31, 32, and 33, and that they had homology with human perinatal and fetal MHC as high as 90% at the nucleotide level and 97% at the amino acid level. Comparison of the nucleotide sequences of isoform-specific 3' nontranslated regions from bovine, human, and rat genes further verify that the MHC 67 clone encodes the bovine fetal or perinatal MHC isoform.

Reappraisal of gastroduodenal lesions after transcatheter arterial chemoembolization of liver neoplasms--selective versus superselective method

Twenty-six patients with liver neoplasm receiving transcatheter arterial chemoembolization (TAE) therapy underwent gastroduodenal endoscopic examinations before and after TAE. The balloon was inflated in the common hepatic artery before chemoembolization if superselective cannulation beyond the gastroduodenal artery could not be done. Sixteen of the 26 patients (61.5%) showed new gastroduodenal lesions, with superficial gastritis in six, one or more erosions in nine, and hemorrhagic gastritis in five. The frequency of lesions detected was no different when the common hepatic artery was obstructed (60.0%) than when superselective embolization was done in more peripheral branch(es) (60.0%). No clinical events indicating upper gastrointestinal bleeding were noticed after TAE. The presence of esophageal and/or gastric varices and session(s) of TAE performed before did not affect the occurrence of gastroduodenal lesion(s). We conclude that TAE produces erosive gastroduodenal lesions that are detected by endoscopic examination but are clinically unimportant; balloon catheter occlusion of the common hepatic artery did not result in more frequent gastroduodenal complications than the ordinary superselective chemoembolization method.