Alpha-fetoprotein as a tumor marker in hepatocellular carcinoma: investigations in south Indian subjects with hepatotropic virus and aflatoxin etiologies

OBJECTIVES

The prevalence of hepatitis B virus (HBV) is reportedly the main cause of hepatocellular carcinoma (HCC) in India, where hepatitis C virus (HCV)-associated HCC is believed to be relatively less prevalent. We verified the usefulness of alpha-fetoprotein (AFP) as a tumor marker and analyzed the influence of viral etiology on AFP levels in HCC.

METHODS

Of a total of 1012 cases with liver disease, 202 were investigated for the presence of AFP (142 HCC cases, 30 cirrhosis cases, and 30 chronic liver disease (CLD) cases). In addition, serum samples from 30 healthy patients, 30 hepatitis B surface antigen (HBsAg) carriers, and 30 acute viral hepatitis cases were included as controls. AFP was quantitatively determined using a commercial ELISA (Quorum Diagnostics, Canada). Out of the 142 HCC cases screened for AFP, aflatoxin B1 (AFB1) detection was carried out in 38 HCC cases using an in-house immunoperoxidase test.

RESULTS

In HBV and HCV co-infected HCC cases, the AFP positivity was 85.7%. In HBV alone-associated HCC, the positivity was 62.9%, and 54.5% of AFB1 positive HCC cases showed AFP positivity. In HBV and HCV negative HCC cases, the positivity was 20.5%, and in HCV-associated HCC it was 17.6%. The HBV/HCV co-infected group and HBV alone positive HCC cases had significantly elevated levels of AFP. When AFP positivity was analyzed based on the marker profile of HBV, 89.7% of AFP positive cases were HBV-DNA positive.

CONCLUSIONS

The overall positivity pattern of AFP in HCC does indicate that higher levels of AFP are observed with hepatitis virus positivity, especially with HBV. Further studies must be carried out to correlate the serum levels of AFP with the size, number, and degree of differentiation of HCC nodules.

Prevalence of aflatoxin B1 in liver biopsies of proven hepatocellular carcinoma in India determined by an in-house immunoperoxidase test

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death in the world. The incidence of HCC in India is reportedly low and varies from 0.2 to 1.9 %. Aflatoxins, secondary metabolites produced by Aspergillus flavus and Aspergillus parasiticus, are potent human carcinogens implicated in HCC. The prevalence of aflatoxin B1 (AFB1) as co-carcinogen was analysed using an in-house immunoperoxidase test in 31 liver biopsies and 7 liver-resection specimens from histopathologically proven HCC, and in 15 liver biopsies from cirrhosis patients (control group). Serum was tested for hepatitis B and C serological markers using commercial assays, and for AFB1 using an in-house ELISA with a sensitivity of approximately 1 ng ml(-1) for AFB1. In spite of positive AFB1 immunostaining in HCC cases, all serum specimens, from both HCC and the control groups, were AFB1-negative. There were 18 (58.1 %) HCC cases that revealed AFB1 in liver biopsies; 68.8 % (n=11) of non-B non-C hepatitis cases with HCC and 46.1 % (n=6) of the hepatitis B surface-antigen-positive subjects were positive for AFB1. Out of the two hepatitis B/hepatitis C virus co-infected cases, one was positive for AFB1. Of seven tumour-resection samples, six were positive for AFB1. Only one case revealed AFB1 in the non-tumour area of the resected material. Thus AFB1 staining was significantly associated with tumour tissue (P=0.03). Aflatoxins proved to have a significant association with HCC in this peninsular part of the subcontinent. The impact seems to be a cumulative process, as revealed by the AFB1 deposits in HCC liver tissue, even though the serum levels were undetectable.

Geographical difference in antimicrobial resistance pattern of Helicobacter pylori clinical isolates from Indian patients: Multicentric study

AIM

To assess the pattern of antimicrobial resistance of Helicobacter pylori isolates from peptic ulcer disease patients of Chandigarh, Delhi, Lucknow, Hyderabad and Chennai in India, and to recommend an updated anti-H. pylori treatment regimen to be used in these areas.

METHODS

Two hundred and fifty-nine H. pylori isolates from patients with peptic ulcer disease reporting for clinical management to the Post Graduate Institute of Medical Education and Research, Chandigarh; All India Institute of Medical Sciences, New Delhi; Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow; Deccan College of Medical Sciences and Allied Hospitals, Hyderabad; and hospitals in Chennai in collaboration with the Dr ALM Post Graduate Institute of Basic Medical Sciences were analyzed for their levels of antibiotic susceptibility to metronidazole, clarithromycin, amoxycillin, ciprofloxacin and tetracycline. The Epsilometer test (E-test), a quantitative disc diffusion antibiotic susceptibility testing method, was adopted in all the centers. The pattern of single and multiple resistance at the respective centers and at the national level were analyzed.

RESULTS

Overall H. pylori resistance rate was 77.9% to metronidazole, 44.7% to clarithromycin and 32.8% to amoxycillin. Multiple resistance was seen in 112/259 isolates (43.2%) and these were two/three and four drug resistance pattern to metronidazole, clarithromycin, amoxycillin observed (13.2, 32 and 2.56%, respectively). Metronidazole resistance was high in Lucknow, Chennai and Hyderabad (68, 88.2 and 100%, respectively) and moderate in Delhi (37.5%) and Chandigarh (38.2%). Ciprofloxacin and tetracycline resistance was the least, ranging from 1.0 to 4%.

CONCLUSION

In the Indian population, the prevalence of resistance of H. pylori is very high to metronidazole, moderate to clarithromycin and amoxycillin and low to ciprofloxacin and tetracycline. The rate of resistance was higher in southern India than in northern India. The E-test emerges as a reliable quantitative antibiotic susceptibility test. A change in antibiotic policy to provide scope for rotation of antibiotics in the treatment of H. pylori in India is a public health emergency.

Correlation of autoimmune reactivity with hepatitis B and C virus (HBV and HCV) infection in histologically proven chronic liver diseases

PURPOSE

To comprehensively study the possibility of autoimmune reactivity by hepatitis viruses B and C (HBV &HCV) in Indian chronic liver disease (CLD) patients.

METHODS

One hundred and sixty histopathologically proven CLD cases and 100 matched controls were analysed for viral serology for HBV and HCV and autoimmune serology for antinuclear antibody (ANA), anti smooth muscle antibody (ASMA) and Liver kidney microsomal antibody (LKM) using standard immunofluorescence technique.

RESULTS

43.7% of cases were chronic hepatitis B while 16.2% were positive for HCV. CLD-B cases showed ANA positivity in 27.1% and ASMA positivity in 25.7%. CLD-C cases revealed 26.9%, 46.1% and 11.1% positivity for ANA, ASMA and LKM antibodies respectively. These rates and titres of autoantibodies were statistically significant (p= or < 0.02) when compared with that of controls.

CONCLUSIONS

Based on the pattern of autoantibody positivity, it could be concluded that chronic HBV infection may induce autoimmune hepatitis (AIH) type I and chronic HCV infection might trigger AIH - Type II in Indian CLD cases.

Diagnosis of hepatitis C virus infection by ELISA, RIBA and RT-PCR: a comparative evaluation

OBJECTIVES

To evaluate the efficacy of second-generation ELISA (ELISA-2), third-generation ELISA (ELISA-3) and third-generation recombinant immunoblot assay (RIBA 3.0) for detection of antibodies to hepatitis C virus (anti-HCV) in comparison with reverse transcriptase-polymerase chain reaction (RT-PCR) to detect HCV RNA for the diagnosis of hepatitis C.

METHODS

Sera of 108 patients with chronic liver disease (CLD) were analyzed by ELISA-2, ELISA-3, RIBA 3.0 and RT-PCR in the first part of the study; in the second part, sera of 105 patients with non-chronic liver disease were evaluated with ELISA-3, RIBA 3.0 and RT-PCR.

RESULTS

In the CLD group, anti-HCV was positive in 4.6%, 14.8% and 16.6% by ELISA-2, ELISA-3 and RIBA 3.0, respectively. Among these anti-HCV positive cases, HCV RNA was positive in 100%, 58.9% and 64%, respectively. ELISA-2 did not give false-positive results, but missed substantial number of anti-HCV positive cases (p < 0.001). In the second group, anti-HCV was positive in 76.3% by ELISA-3 and 68.6% by RIBA 3.0 (p:ns). HCV-RNA was positive in 88.7% of ELISA- and RIBA-positive cases; in 60% of ELISA-positive, RIBA-indeterminate cases; and in 46.4% of ELISA-negative, RIBA-negative cases.

CONCLUSIONS

ELISA-2 is not a suitable assay for routine screening. ELISA-3 was at par with RIBA 3.0 and it can be recommended for routine screening for anti-HCV. RT-PCR for HCV is of value in detecting early viremic, anti-HCV negative cases; this may be of importance in the treatment of hepatitis C.

Randomised controlled clinical trial of short course chemotherapy in abdominal tuberculosis: a five-year report

OBJECTIVES

To assess and compare the efficacy of a 6-month short-course chemotherapy regimen (SCC) with that of a 12-month standard regimen in the treatment of abdominal tuberculosis.

DESIGN AND SUBJECTS

A total of 193 adult patients with evidence of abdominal tuberculosis were randomly allocated to one of two daily regimens: 1) a 6-month SCC regimen with rifampicin, isoniazid and pyrazinamide for 2 months followed by rifampicin with isoniazid for another 4 months (6R series) and 2) and 12-month standard regimen of ethambutol and isoniazid with streptomycin supplemented for 2 weeks (12E series). Surgery was undertaken only for patients suspected to have obstruction or perforation of the intestine.

RESULTS

A total of 163 (85 6R, 78 12E) patients were available for efficacy analysis after exclusion of 30 patients for various reasons. At the end of treatment clinical status was normal in 84 (99%) in 6R patients and in 73 (94%) in 12E patients. Of these, 147 patients completed follow-up for 5 years; none had relapsed requiring treatment for abdominal tuberculosis.

CONCLUSION

A 6-month SCC regimen has been found to be as effective as the standard 12-month regimen in the treatment of all forms of abdominal tuberculosis.

Heriditary pattern of cancer

Three thousand nine hundred and twelve patients with cancer in various sites reporting to the out patient department were questioned for history of cancer among blood relatives. A positive history of cancer was obtained in 154 of whom 89 were male and 65 female. Thirty nine patients gave history of cancer among siblings and five gave history of cancer among spouses related by consanguneous marriage. The other 110 gave history of cancer among second and third generation relatives. Sixty one percent maternal relatives of the female patients had cancer as compared to only 33 percent of paternal relatives. This difference was not seen among male patients where there were about 45 percent of maternal and 47 paternal relatives giving history of cancer. Further it was found that 6 of 20 patients with cancer of the breast, 7 of 22 with stomach cancer and 4 of 12 with cervix cancer had blood relatives with the same type of cancer.

Mapping of the hepatitis B virus genome in hepatocellular carcinoma using PCR and demonstration of a potential trans-activator encoded by the frequently detected fragment

The association of hepatitis B virus (HBV) infection with hepatocellular carcinoma (HCC) is well established. Insertional mutagenesis, trans-activation by truncated X or preS2/S regions and activation of growth regulatory genes or oncogenes have all been suggested as possible mechanisms for this carcinogenesis. However, no consensus regarding the mechanism or region of the HBV genome involved has been established. Of the 36 HCC tissues analysed for the presence and extent of the HBV genome, using multiple overlapping PCR, 22 (61%) were found to be positive. Twenty of these showed the presence of a fragment (nucleotides 636 to 746) that covered part of the surface antigen gene. The recognized trans-activators, X and preS2/S, were present in only seven (31.8%) and 12 (54.5%) cases, respectively. In two cases the entire viral genome was detected. The trans-activation potential of the cloned S fragment (nucleotides 426 to 851) covering the frequently detected fragment (nucleotides 636 to 746) was investigated in cotransfection experiments. This fragment was able to trans-activate the HBV enhancer-X promoter target. To define the specificity of the trans-activation and the sequences involved, frameshift and deletion mutants of this fragment were constructed and analysed. The trans-activation activity was lost in the frameshift mutants. The deletion mutants that retained nucleotide sequences 436 to 679 showed trans-activation activity whereas the other ones (nucleotide sequences 436 to 611) did not show any activity. It is suggested that the frequently detected HBV genome fragment belonging to the S gene frame has a trans-activation potential. This may explain the mechanism for pathogenicity of HBV-associated HCC.

Association between obesity and hypertension in south Indian patients

Two hundred and forty four newly diagnosed hypertensives (cases) of age 40 years and above, attending the hypertensive clinic of the Government General Hospital during one year and three hundred and twelve normotensives (controls) belonging to the same age group and attending the outpatient department during the same period for other minor ailments formed the subjects for this case control study. There were 18 (7.4%) obese subjects among hypertensives and 6 (1.9%) among controls. In spite of these low proportions, there was a strong association between obesity and hypertension with an overall odds ratio of 4 and there appeared to be a significant increasing trend in the proportion of cases of hypertension (37%, 63%, 75%) observed according to the different grades (underweight or normal, overweight, obese) of nutrition.

Combination of anticholinergic agent and H2 receptor antagonist in duodenal ulcer treatment--a randomized, double blind multicenter study

BACKGROUND

The acid suppressive abilities of H2 receptor antagonists and anticholinergics have been claimed to be additive.

METHODS

A multicenter, double-blind, randomized trial comparing ranitidine (150 mg) plus propantheline bromide 15 mg at bedtime to ranitidine 300 mg alone at bedtime was conducted in 161 patients with endoscopically confirmed uncomplicated duodenal ulcer.

RESULTS

After six weeks of therapy, ulcer healing rates in the two groups were comparable ie 80% in the combination group (ranitidine + propantheline) and 79.4% in the ranitidine group. Pain relief after one, two and four weeks of treatment was also comparable in the two groups. Side effects to drugs were minor and comparable in both the groups.

CONCLUSION

A combination of 150 mg ranitidine and 15 mg propantheline bromide is as efficacious as 300 mg ranitidine in inducing healing of uncomplicated duodenal ulcers, with similar side-effects but at greatly reduced cost.

A dipstick immunobinding enzyme-linked immunosorbent assay for serodiagnosis of hepatitis B and delta virus infections

A simple, specific and economical dipstick immunobinding enzyme-linked immunosorbent assay (DIA) for detecting hepatitis B surface antigen (HBsAg) and antibodies to hepatitis delta virus (anti-HDV), utilizing cellulose nitrate membrane is described. Screening of 815 serum specimens for HBsAg by DIA and micro ELISA revealed a positivity of 22.69% and 22.94% respectively. In the detection of antibodies to delta antigen, DIA was compared with an indirect immunofluorescence technique using A3 cell line as antigen substrate and a commercial macro ELISA. Of the 143 HBsAg positive sera tested for anti-HDV, 59 (41.25%) were positive by both immunofluorescence and macro ELISA and 61 (42.65%) by DIA. While the positive and negative predictive values of DIA for HBsAg were 100% and 99.6%, for anti-HDV by DIA these were 96.7% and 100% respectively. Based on the simplicity of performance and the economical nature of the test system, DIA is recommended as a diagnostic tool for field surveys and small laboratories in developing countries.