miR-146 connects stem cell identity with metabolism and pharmacological resistance in breast cancer

Although ectopic overexpression of miRNAs can influence mammary normal and cancer stem cells (SCs/CSCs), their physiological relevance remains uncertain. Here, we show that miR-146 is relevant for SC/CSC activity. MiR-146a/b expression is high in SCs/CSCs from human/mouse primary mammary tissues, correlates with the basal-like breast cancer subtype, which typically has a high CSC content, and specifically distinguishes cells with SC/CSC identity. Loss of miR-146 reduces SC/CSC self-renewal in vitro and compromises patient-derived xenograft tumor growth in vivo, decreasing the number of tumor-initiating cells, thus supporting its pro-oncogenic function. Transcriptional analysis in mammary SC-like cells revealed that miR-146 has pleiotropic effects, reducing adaptive response mechanisms and activating the exit from quiescent state, through a complex network of finely regulated miRNA targets related to quiescence, transcription, and one-carbon pool metabolism. Consistent with these findings, SCs/CSCs display innate resistance to anti-folate chemotherapies either in vitro or in vivo that can be reversed by miR-146 depletion, unmasking a “hidden vulnerability” exploitable for the development of anti-CSC therapies.

p53 Loss in Breast Cancer Leads to Myc Activation, Increased Cell Plasticity, and Expression of a Mitotic Signature with Prognostic Value

Loss of p53 function is invariably associated with cancer. Its role in tumor growth was recently linked to its effects on cancer stem cells (CSCs), although the underlying molecular mechanisms remain unknown. Here, we show that c-myc is a transcriptional target of p53 in mammary stem cells (MaSCs) and is activated in breast tumors as a consequence of p53 loss. Constitutive Myc expression in normal mammary cells leads to increased frequency of MaSC symmetric divisions, extended MaSC replicative-potential, and MaSC-reprogramming of progenitors, whereas Myc activation in breast cancer is necessary and sufficient to maintain the expanding pool of CSCs. Concomitant p53 loss and Myc activation trigger the expression of 189 mitotic genes, which identify patients at high risk of mortality and relapse, independently of other risk factors. Altogether, deregulation of the p53:Myc axis in mammary tumors increases CSC content and plasticity and is a critical determinant of tumor growth and clinical aggressiveness.

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Myc is overexpressed and deregulated in breast tumors because of p53 signaling attenuation

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Myc activation favors SC symmetric divisions and SC reprogramming of progenitors

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Myc activation is necessary and sufficient to sustain the cancer SC phenotype

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Expression of 189 mitotic p53:Myc targets identifies high-risk breast cancer patients

Delivery of biologically active miR-34a in normal and cancer mammary epithelial cells by synthetic nanoparticles

Functional RNAs, such as microRNAs, are emerging as innovative tools in the treatment of aggressive and incurable cancers. In this study, we explore the potential of silica dioxide nanoparticles (SiO₂NPs) in the delivery of biologically active miRNAs. Focusing on the tumor-suppressor miR-34a, we evaluated miRNAs delivery by SiO₂NPs into the mammary gland, using in vitro as well as in vivo model systems. We showed that silica nanoparticles can efficiently deliver miR-34a into normal and cancer epithelial cells grown in culture without major signs of toxicity. Delivered miRNA retained the ability to silence artificial as well endogenous targets and can reduce the growth of mammospheres in 3D culture. Finally, miR-34a delivery through intra-tumor administration of SiO₂NPs leads to a reduced mammary tumor growth. In conclusion, our studies suggest that silica nanoparticles can mediate the delivery of miR-34a directly into mammary tumors while preserving its molecular and biological activity.

Abstract 4410: miRNA-34a sensitizes triple-negative breast cancer cells to paclitaxel reducing cancer stem cell population and lung colonization

Background: Cancer stem cells (CSCs) have inherent or developed drug resistance for which chemotherapy fails to eliminate all tumor cells, a property that is critically contributing to recurrence and metastasis. Here, we combine miR-34a, a well-known tumor suppressor miRNA that controls proliferation, apoptosis and self-renewal, with Paclitaxel (PTX), a commonly used first-line chemotherapy drug. Based on our preliminary observations (Bonetti et al., manuscript under revision), we hypothesized a combinatorial approach, coupling miRNA- and chemo- treatment, aimed at reducing CSCs in vitro and recurrence in vivo using triple-negative breast cancer (TNBC) as a model. Methodology: As a model, we exploited SUM159pt cells (TNBC mesenchymal-like, with CSC features) to mimic aggressive breast cancer, which harbor a vector for pLUC, which is induced by luciferin in vivo, to monitor tumor growth in real time. Furthermore, we used i) pSlik34a, with tunable expression of miR-34a by doxycycline; ii) treatment with PTX to select for resistant cells (RC); and combined the two, by treating RC with doxycycline. CSC content was evaluated by ALDH (Aldehyde Dehydrogenase) activity, sphere-forming efficiency (SFE) and qRT-PCR of known markers. A similar approach was followed for in vivo studies, with NSG female injected through tail vein injection with 500,000 SUM159/pLUC/pSlik34a cells, and separated into three groups: not treated (NT), PTX alone, and PTX+34a. Results: As observed for aggressive breast cancer, treatment of SUM159 with PTX generated resistant cells (RC) with increased CSC content (ALDH activity and spheres forming ability). When miR-34a was induced in the RC, cells changed morphology, slowed proliferation rate, and decreased CSC content (ALDH activity and spheres). Moreover, a second PTX treatment almost completely abolished the ALDH activity and SFE. The combined effect was evaluated in vivo, following by luminescence the growth of metastases after lung colonization, with PTX+34a mice reducing lung colonization than the PTX treatment or miR-34a treatment alone. Conclusions: Overall, these results indicate that miR-34a sensitize PTX-resistant cells reducing cancer stem-cell capacities, and in this preclinical setting limited the aggressive phenotype of breast cancer, including proliferation, drug resistance, relapse and metastasis causing in delay of lung colonization in vivo.

Citation Format: Montserrat Climent, Paola Bonetti, Francesco Nicassio. miRNA-34a sensitizes triple-negative breast cancer cells to paclitaxel reducing cancer stem cell population and lung colonization [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4410.

Degradation dynamics of microRNAs revealed by a novel pulse-chase approach

The regulation of miRNAs is critical to the definition of cell identity and behavior in normal physiology and disease. To date, the dynamics of miRNA degradation and the mechanisms involved in remain largely obscure, in particular, in higher organisms. Here, we developed a pulse-chase approach based on metabolic RNA labeling to calculate miRNA decay rates at genome-wide scale in mammalian cells. Our analysis revealed heterogeneous miRNA half-lives, with many species behaving as stable molecules (T_1/2 > 24 h), while others, including passenger miRNAs and a number (25/129) of guide miRNAs, are quickly turned over (T_1/2 = 4–14 h). Decay rates were coupled with other features, including genomic organization, transcription rates, structural heterogeneity (isomiRs), and target abundance, measured through quantitative experimental approaches. This comprehensive analysis highlighted functional mechanisms that mediate miRNA degradation, as well as the importance of decay dynamics in the regulation of the miRNA pool under both steady-state conditions and during cell transitions.

The BET Bromodomain Inhibitor OTX015 Affects Pathogenetic Pathways in Preclinical B-cell Tumor Models and Synergizes with Targeted Drugs

PURPOSE

In cancer cells, the epigenome is often deregulated, and inhibition of the bromodomain and extra-terminal (BET) family of bromodomain-containing proteins is a novel epigenetic therapeutic approach. Preliminary results of an ongoing phase I trial have reported promising activity and tolerability with the new BET bromodomain inhibitor OTX015.

EXPERIMENTAL DESIGN

We assessed the preclinical activity of OTX015 as single agent and in combination in mature B-cell lymphoma models and performed in vitro and in vivo experiments to identify the mechanism of action and the genetic features associated with sensitivity to the compound.

RESULTS

OTX015 showed antiproliferative activity in a large panel of cell lines derived from mature B-cell lymphoid tumors with median IC50 of 240 nmol/L, without significant differences among the different histotypes. In vitro and in vivo experiments showed that OTX015 targeted NFKB/TLR/JAK/STAT signaling pathways, MYC- and E2F1-regulated genes, cell-cycle regulation, and chromatin structure. OTX015 presented in vitro synergism with several anticancer agents, especially with mTOR and BTK inhibitors. Gene expression signatures associated with different degrees of sensitivity to OTX015 were identified. Although OTX015 was mostly cytostatic, the compound induced apoptosis in a genetically defined subgroup of cells, derived from activated B-cell-like diffuse large B-cell lymphoma, bearing wtTP53, mutations in MYD88, and CD79B or CARD11.

CONCLUSIONS

Together with the data coming from the ongoing phase I study, the in vitro and in vivo data presented here provide the basis for further clinical investigation of OTX015 as single agent and in combination therapies.

Abstract 5528: The BET Bromodomain inhibitor OTX015 targets the NFKB, TLR and JAK/STAT pathways and shows pre-clinical activity as single agent and in combination in mature B-cell tumors

Background:

Lymphomas are still incurable in many patients and novel active compounds are actively being sought. We previously reported single agent activity of the BET bromodomain OTX015 in lymphoma cell lines and in vivo (AACR 2012; ICML 2013). Here, we report a study of the mechanism of action of OTX015 and its activity in combination with other anti-cancer compounds.

Methods:

Cell lines: 22 diffuse large B-cell lymphoma (DLBCL), 4 mantle cell lymphomas, 3 multiple myelomas, 3 splenic marginal zone lymphoma and 1 prolymphocytic leukemia. Anti-proliferative of OTX015 (OncoEthix SA, Switzerland) was assessed by MTT and its cytotoxic activity by Annexin V staining and gene expression profiling (GEP) with Illumina HumanHT-12 Expression BeadChips. Data mining was done with LIMMA, GSEA, Metacore. Synergy was assessed in cells (2-5 cell lines) exposed for 72 h to increasing doses of OTX015 alone or in combination with increasing doses of other agents. MTT assays were performed and Chou-Talalay combination index (CI) calculated.

Results:

OTX015 (500 nM, 72h) showed cytostatic activity in 29/33 (88%) cell lines and apoptosis in 3/22 (14%). Mutations in genes coding for MYD88 and components of BCR (P=0.027), and ABC signaling phenotypes (P=0.008) were significantly associated with apoptosis induction. We performed GEP on 2 cell lines (SU-DHL-6, SU-DHL-2), treated with DMSO or OTX015 (500 nM) for 1, 2, 4, 8 or 12 hours. Most upregulated genes were histones. MYC target genes were highly significantly enriched among all OTX015 regulated transcripts and MYC was the most frequently downregulated gene. OTX015 also downregulated MYD88, IRAK1, TLR6, IL6, STAT3, and TNFRSF17, members of the NFKB, TLR and JAK/STAT pathways. NFKB target genes (IRF4, TNFAIP3 and BIRC3) were also downregulated (PCR). Immunoblotting and immunohistochemistry showed a reduction of transcriptionally active pSTAT3 in 2 ABC cell lines, and a reduction in nuclear localization of p50 (NFKB1), indicating an inhibitory effect of OTX015 on the canonical NFKB pathway. Finally, IL10 and IL4 production was reduced after 24 hours OTX015 treatment.

Synergy was observed with everolimus (median CI=0.1; range 0.1-0.2), ibrutinib in ABC-DLBCL (CI=0.04; 0.02-0.1), idelalisib (CAL101) (CI=0.5; 0.04-2.4), vorinostat (CI=0.5; 0.3-0.6), rituximab (CI=0.5; 0.4-0.5), decitabine (CI=0.6; 0.6-0.7), lenalidomide (CI=0.7; 0.6-0.7), and all-trans retinoic acid (CI=0.4; .1-1.6). Additive effects were observed for combinations with romidepsin (CI=1.08; 1-1.22), bendamustine (CI=0.92; 0.83-1.1), and doxorubicin (CI=0.83; 0.71-0.96).

Conclusions:

OTX015 is a promising candidate for targeted combination therapies. A phase I study (NCT01713582) in patients with hematological neoplasias is underway and together with our preclinical data, may support further clinical investigations.

Citation Format: Eugenio Gaudio, Elena Bernasconi, Ivo Kwee, Michela Boi, Paola Bonetti, Chiara Tarantelli, Andrea Rinaldi, Monica Testoni, Maurilio Ponzoni, Anastasios Stathis, Georg Stüssi, Eugenia Riveiro, Patrice Herait, Emanuele Zucca, Francesco Bertoni. The BET Bromodomain inhibitor OTX015 targets the NFKB, TLR and JAK/STAT pathways and shows pre-clinical activity as single agent and in combination in mature B-cell tumors. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5528. doi:10.1158/1538-7445.AM2014-5528

Abstract 538: microRNAs as modifiers of stem cell properties in breast cancer: a whole genome approach

Cancer stem cells (CSCs) are cells with aberrantly regulated stem-like characteristics, such as self-renewal and quiescence. In breast cancer, CSCs have been shown to drive the tumorigenic process and to contribute to the emergence of therapeutic resistance and disease relapse. Based on this background, we decided to focus on the mechanisms that sustain CSC growth, namely self-renewal, to reveal molecules and pathways that control SC biology under physiological and pathological conditions.

Recent research suggests a key role for non-coding RNAs (microRNAs - miRNAs; and long non coding RNAs - lncRNAs) in the control of genetic program that specifies stem cell identity and properties. Nevertheless, we still do not know which non-coding RNAs are involved and how they influence self-renewal or differentiation properties of the normal as well the cancer SC pool in the breast tissue. Based on these premises we aimed at isolating those non-coding RNAs (either lncRNAs or miRNAs) that significantly associates with the self-renewal properties and the content of stem cells in the normal mammary gland and in human breast cancer to search for: i) “markers” that improve the stratification and prognosis of human breast cancer; and ii) “modifiers” (enhancing or suppressing) of self-renewal properties of breast normal and cancer stem cells.

In the long-term, our findings could serve as a basis to develop alternative strategies for the treatment of breast cancer that could radically improve the clinical management of breast cancer.

Note: This abstract was not presented at the meeting.

Citation Format: Paola Bonetti, Matteo J. Marzi, francesco nicassio. microRNAs as modifiers of stem cell properties in breast cancer: a whole genome approach. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 538. doi:10.1158/1538-7445.AM2014-538

Abstract 1017: The BRD-inhibitor OTX015 affects proliferation and gene expression of cells derived from mature lymphoid neoplasms

Inhibitors of the BET family members BRD2/3/4 are a promising new class of anti-cancer drugs. Here, we assessed the antitumor activity and the mechanism of action of OTX015, a selective orally bioavailable BRD2/3/4 inhibitor, in cells derived from human mature lymphoid neoplasms.

OTX015 was evaluated in 31 B-cell malignancies cell lines: 13 diffuse large B-cell lymphomas (DLBCL), 8 anaplastic large T-cell lymphomas (ALCL), 4 mantle cell lymphomas (MCL), 3 splenic marginal zone lymphomas (SMZL), and 3 multiple myelomas (MM). Anti-proliferative effect was seen in the majority of the cell lines. The median IC50s, calculated at 72h, were: DLBCL, 0.19μM (range 0.07-12.68); ALCL, 0.48μM (0.04-9.1); SMZL, 0.16μM (0.1-0.24); MM, 0.45μM (0.06-0.7); MCL, 2μM (1.22- >15). There were apparently no IC50 differences based on the cell of origin (DLBCL) or ALK-positivity status (ALCL). Apoptosis did not appear as the main effect of the drug, being not observed in 11 cell lines treated with the IC50 defined by MTT test after 72-hour exposure. However, OTX105 determined a dose-dependent G1 cell cycle arrest in 12/12 cell lines (DLBCL, MM and ALCL), and an increased percentage of senescent cells in 3/3 sensitive cell lines (DLBCL and ALCL).

MYC mRNA was suppressed in a dose-dependent manner in 4/5 DLBCL, 4/4 ALCL and 2/2 MM cell lines. Down-regulation was usually seen within 1h. Real-time PCR showed that MYC and also NFKB target genes were affected. Gene expression profiling (GEP), using the Illumina HumanHT-12 v4 Expression BeadChip array, was done in 3 sensitive DLBCL cell lines, exposed to DMSO or OTX015 (0.5μM) for 4h and 8h. MYC was the most down-regulated gene. Functional annotation of the down-regulated genes identified an over-representation of genes involved in RNA and DNA metabolism and cell cycle, putative MYC target genes and transcripts reported as down-regulated after treatment with aminopeptidase inhibitors and HDAC-inhibitors. Up-regulated transcripts were enriched of genes coding for proteins involved in chromatin structure, as well as putative MYC target genes and transcripts reported as up-regulated after treatment with HDAC-inhibitors, demethylating agents or aplidine. Also, GEP signature was similar to what reported for the BRD-inhibitor JQ1.

In conclusion, OTX015 showed in vitro anti-tumoral activity in a large series of mature lymphoid neoplasms. The activity was largely cytostatic, with cell cycle G1 arrest and induction of senescence. Down-regulation of MYC and its putative targets appeared as the main effect, but it might not be the only mechanism of action, since a few cell lines did not appear to down-regulate MYC after exposure to OTX015, which also induced down-regulation of NFKB target genes and modulation of transcripts similar to what observed with HDAC-inhibitors. The compound appears worth of further investigation as a new promising therapeutic agent in lymphomas.

Citation Format: Paola Bonetti, Michela Boi, Elena Bernasconi, Andrea Rinaldi, Ivo Kwee, Eugenio Gaudio, Maurilio Ponzoni, Maria Grazia Tibiletti, Anastasios Stathis, Eugenia Riveiro, Giorgio Inghirami, Emanuele Zucca, Francesco Bertoni. The BRD-inhibitor OTX015 affects proliferation and gene expression of cells derived from mature lymphoid neoplasms. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1017. doi:10.1158/1538-7445.AM2013-1017

Accuracy of botulinum toxin type A injection into the gastrocnemius muscle of adults with spastic equinus: manual needle placement and electrical stimulation guidance compared using ultrasonography

OBJECTIVE

To investigate the accuracy of manual needle placement and electrical stimulation guidance, compared using ultrasonography, for injection of botulinum toxin type A into the gastrocnemius muscle of adults with spastic equinus.

DESIGN

Prospective clinical study.

SUBJECTS

A total of 81 adults with stroke who were scheduled to receive botulinum toxin type A injection into the gastrocnemius muscle.

METHODS

After randomization into two groups, each patient was injected into two sites at each head of the gastrocnemius muscle. The manual needle placement group (n = 42) underwent injections using anatomical landmarks and palpation. The electrical stimulation guidance group (n = 39) underwent injections under electrical stimulation guidance. The accuracy of needle placement and muscle thickness at each injection site were compared by means of ultrasonography.

RESULTS

The overall accuracy of manual needle placement and electrical stimulation guidance, measured using ultrasonography, was significantly higher for the gastrocnemius medialis than for the lateralis (92.0% vs 79.0%). The gastrocnemius medialis was significantly thicker than the lateralis (mean 13.25 mm (standard deviation (SD) 1.86 mm) vs 10.84 mm (SD 1.52 mm).

CONCLUSION

Electrical stimulation guidance may be useful for injections into the gastrocnemius lateralis of adults with spastic equinus. However, neither manual needle placement nor electrical stimulation guidance showed complete accuracy, when measured using ultrasonography.

Applicability of a new robotic walking aid in a patient with cerebral palsy. Case report

BACKGROUND

Gait training with the help of assistive technological devices is an innovative field of research in neurological rehabilitation. Most of the available gait training devices do not allow free movement in the environment, which would be the most suitable natural and motivating condition for training children with neurological gait impairment.

AIM

To evaluate the potential applicability of a new robotic walking aid as a tool for gait training in non-ambulatory children with Cerebral Palsy.

DESIGN

Single case study

SETTING

Outpatient regimen

POPULATION

A 11-years-old child unable to stand and walk independently as a result of spastic tetraplegic cerebral palsy (CP).

METHODS

The experimental device was a newly actuated version of a dynamic combined walking and standing aid (NF-Walker®) available in the market which was modified by means of two pneumatic artificial muscles driven by a foot-switch inserted in the shoes. The child was tested at baseline (while maintaining the standing position aided by the non-actuated NF-Walker®) and in the experimental condition (while using the actuated robotic aid). The outcome measures were: 2-minute walking test, 10-metre walking test, respiratory and heart parameters, energy cost of locomotion.

RESULTS

At baseline, the child was unable to perform any autonomous form of locomotion. When assisted by the actuated aid (i.e. during the experimental condition), the child was successful in moving around in his environment. His performance was 19.63 m in the 2-minute walking test and 64 s in the 10-metre walking test. Respiratory and heart parameters were higher than healthy age-matched children both at baseline and in the experimental condition. The energy cost of gait, which was not valuable in the baseline condition, was significantly higher than normality during the experimental condition.

CONCLUSION

The new robotic walking aid may help children suffering from CP with severe impairment of gait to move around in their environment.

CLINICAL REHABILITATION IMPACT

This new robotic walking device may have a potential impact in stimulating the development and in training of gait in children with neurological gait impairment. Future studies are warranted in order to test this hypothesis.

[Pier Luigi Viola and vinyl chloride: notes that were never published]

The name and work of Pier Luigi Viola (1917-1985) are unequivocally connected with the history of the discovery of the toxic effects of vinyl chloride, cancer in particular. A biography and a bibliography of Professor Viola are still lacking but his work is well documented; equally well known is his professional career as an occupational physician who spent his entire working life as an employee of one single industrial group, Solvay; his work was dedicated firstly to taking care of the health of the workers of the Corporation and not only in Italy, and secondly to organizing the occupational health departments of all Solvay's establishments in Italy. This positive connection between occupational physician and scientist has recently been challenged in certain historical reconstructions of the discovery of vinyl chloride's carcinogenicity: in particular, these reconstructions (which we do not consider to be coherent with the facts) depict Viola as in constant conflict with his employer. As crucial support to this view are offered on the one hand a statement by Viola, in 1980, that "At the basis of every discovery there is frequently the poetical imagination of a researcher who is always alone in facing the difficulties of the research, difficulties that rise up against him like a wall reaching up to the sky"; and on the other the supposed failure to find some of Professor Viola's notes which should reflect his spiritual testimony, and from which should emerge "the suffering, the torments, and the pressures of that initial period". The true history is very different: the notes do exist: they were personally delivered to one of the authors (PB) by Viola's widow a few months after his death; they are in fact the first pages of a planned book on vinyl chloride that Viola never actually succeeded in writing. In these pages Viola developed some personal reflections from which it is clear that he was conscious of having been in the centre ofa fantastic adventure in the field of scientific research in which he also played the principal role; there is no mention whatsoever of any conflict or contrast between Viola and Solvay. In fact, the backdrop to this story reflects the typical dynamics of scientific research. The article continues with the publication of Viola's handwritten notes: in this way the supposed "mistery of the missing notes" is solved.

Nucleophosmin and its AML-associated mutant regulate c-Myc turnover through Fbw7 gamma

Mutations leading to aberrant cytoplasmic localization of nucleophosmin (NPM) are the most frequent genetic alteration in acute myelogenous leukemia (AML). NPM binds the Arf tumor suppressor and protects it from degradation. The AML-associated NPM mutant (NPMmut) also binds p19Arf but is unable to protect it from degradation, which suggests that inactivation of p19Arf contributes to leukemogenesis in AMLs. We report here that NPM regulates turnover of the c-Myc oncoprotein by acting on the F-box protein Fbw7γ, a component of the E3 ligase complex involved in the ubiquitination and proteasome degradation of c-Myc. NPM was required for nucleolar localization and stabilization of Fbw7γ. As a consequence, c-Myc was stabilized in cells lacking NPM. Expression of NPMmut also led to c-Myc stabilization because of its ability to interact with Fbw7γ and delocalize it to the cytoplasm, where it is degraded. Because Fbw7 induces degradation of other growth-promoting proteins, the NPM–Fbw7 interaction emerges as a central tumor suppressor mechanism in human cancer.

Delocalization and Destabilization of the Arf Tumor Suppressor by the Leukemia-Associated NPM Mutant

One third of acute myeloid leukemias (AMLs) are characterized by the aberrant cytoplasmic localization of nucleophosmin (NPM) due to mutations within its putative nucleolar localization signal. NPM mutations are mutually exclusive with major AML-associated chromosome rearrangements and are frequently associated with a normal karyotype, suggesting that they are critical during leukemogenesis. The underlying molecular mechanisms are, however, unknown. NPM is a nucleocytoplasmic shuttling protein that has been implicated in several cellular processes, including ribosome biogenesis, centrosome duplication, cell cycle progression, and stress response. It has been recently shown that NPM is required for the stabilization and proper nucleolar localization of the tumor suppressor p19(Arf). We report here that the AML-associated NPM mutant localizes mainly in the cytoplasm due to an alteration of its nucleus-cytoplasmic shuttling equilibrium, forms a direct complex with p19(Arf), but is unable to protect it from degradation. Consequently, cells or leukemic blasts expressing the NPM mutant have low levels of cytoplasmic Arf. Furthermore, we show that expression of the NPM mutant reduces the ability of Arf to initiate a p53 response and to induce cell cycle arrest. Inactivation of p19(Arf), a key regulator of the p53-dependent cellular response to oncogene expression, might therefore contribute to leukemogenesis in AMLs with mutated NPM.

Nucleophosmin is required for DNA integrity and p19Arf protein stability

Nucleophosmin (NPM) is a nucleolar phosphoprotein that binds the tumor suppressors p53 and p19(Arf) and is thought to be indispensable for ribogenesis, cell proliferation, and survival after DNA damage. The NPM gene is the most frequent target of genetic alterations in leukemias and lymphomas, though its role in tumorigenesis is unknown. We report here the first characterization of a mouse NPM knockout strain. Lack of NPM expression results in accumulation of DNA damage, activation of p53, widespread apoptosis, and mid-stage embryonic lethality. Fibroblasts explanted from null embryos fail to grow and rapidly acquire a senescent phenotype. Transfer of the NPM mutation into a p53-null background rescued apoptosis in vivo and fibroblast proliferation in vitro. Cells null for both p53 and NPM grow faster than control cells and are more susceptible to transformation by activated oncogenes, such as mutated Ras or overexpressed Myc. In the absence of NPM, Arf protein is excluded from nucleoli and is markedly less stable. Our data demonstrate that NPM regulates DNA integrity and, through Arf, inhibits cell proliferation and are consistent with a putative tumor-suppressive function of NPM.

Premature arterial and venous events in three families. Effect of folate levels and MTHFR mutation mediated by family/generation and homocysteine levels

Plasma homocysteine levels result from the effect of genetic and environmental factors. We investigated the hypothesis of familial association between folates, methylenetetrahydrofolate reductase (MTHFR) and hyperhomocysteinemia with acute events, studying three families through pedigree analysis and log-linear graphical models. In 43 subjects, 13 had homocysteine levels of >15 micromol/l. In Family A, premature venous and arterial events occurred in father and son, respectively. In Family B, several arterial premature events occurred and very high homocysteine level was found in a healthy 18-year-old nephew. In Family C, stroke occurred at the age of 16 in a boy. In all three families, all subjects with premature cardiovascular events had high homocysteine level as well as MTHFR mutation, either homozygous or heterozygous. The present results underline that hyperhomocysteinemia has a direct conditional association with cardiovascular events. Moreover, homocysteine level is a variable that links the indirect association of folates, MTHFR mutation and cardiovascular event.

[Catch-up growth and final height in celiac disease]

BACKGROUND

Growth retardation resulting from celiac disease diagnosed in infancy or in early childhood is remediable after introduction of a gluten-free diet. The aim of this study was to evaluate long-term growth, catch-up growth and final height in a group of treated patients with celiac disease.

METHODS

The study population consisted of 35 patients (13 M, 22 F) with typical celiac disease. Age at diagnosis was 1.17 (+/- 0.69) years. For each patient, the standard deviation score (SDS) and centile of height at diagnosis, target height and final height were elaborated, and linear regression and correlations between SDS of final height and age at diagnosis, SDS of height at diagnosis and SDS of target height, respectively, were calculated.

RESULTS

At diagnosis patients had a general tendency to short stature: mean height was 81.8 cm +/- 22.9 cm (SDS -0.75 +/- 1.61), while target height was 164.3 cm +/- 13.5 cm (SDS -0.14 +/- 1.04) and final height 169.2 cm +/- 7.7 cm (SDS 0.41 +/- 1.04). Linear regression and correlations between SDS of final height and age at diagnosis, SDS of height at diagnosis and SDS of target height, respectively, proved nonsignificant.

CONCLUSIONS

Irrespective of age and height at diagnosis, catch-up growth was complete in this group of patients, with satisfactory achievement of final height. Only one patient (age at diagnosis 13 years) failed to reach the target height.

[Current role of antidopaminergic drugs in pediatrics]

The treatment of gastrointestinal disorders in pediatrics is based on the use of prokinetic agents; amongst these prokinetic compounds, cholinomimetic drugs and dopamine antagonists (metoclopramide, domperidone) are principally available. Metoclopramide is an antidopaminergic benzamide with mainly antiemetic effects, due to the interaction with dopamine receptors in the central trigger zone. Another effect is to enhance the transit of material through the gastrointestinal tract. Disadvantages in the use of metoclopramide are neurological effects (asthenia, sleepiness), extrapyramidal dyskinetic reactions and/or neuroendocrine side effects (galactorrhea). Domperidone is a pure dopaminantagonist that accelerates gastric emptying. It is useful in the treatment of acute nausea and vomiting caused by different agents. There are adverse effects only if it is used in parenteral way.

BMI centile as an indicator of degree of obesity in childhood

OBJECTIVE

To evaluate body mass index (BMI centile) as an indicator of degree of obesity in childhood.

DESIGN

Random.

SETTING

Obese and nonobese healthy children were recruited in the Verona University Department of Pediatrics and Division of Pediatrics of the Verona City Hospital.

SUBJECTS AND METHODS

70 males aged 9.7 +/- 2.75 years and 55 females aged 9.9 +/- 3 years. Percentage fat mass was estimated by bioelectrical impedance analysis using Kushner's equation, and Italian BMI charts (A. Luciano et al. 1997) were used to calculate the BMI centile (BMI > 90 degrees in 76 subjects and BMI < 90 degrees in 59 subjects).

RESULTS

Linear regression analysis and correlations between percentage fat mass and BMI centile were significant in males (P = 0.000, r = 0.6) and females (P = 0.000, r = 0.7) in both obese and nonobese subjects.

CONCLUSIONS

BMI is a reliable, easy-to-use indicator of degree of obesity in childhood. Pediatricians should be encouraged to use BMI centiles to assess childhood obesity and particularly the onset of overweight, its evolution and its response to different types of management.

[Approach to constipation in children]

This article presents a diagnostic and therapeutic approach to children with constipation. Causes of constipation can be organic or non-organic (functional). Functional constipation may lead to functional fecal retention. The history and physical examination are most important. Laboratory and radiologic examinations are not warranted in the majority of children.

Serum from patients with severe heart failure downregulates eNOS and is proapoptotic: role of tumor necrosis factor-alpha

BACKGROUND

Cytokine activation and endothelial dysfunction are typical phenomena of congestive heart failure (CHF). We tested the hypothesis that incubating human umbilical vein endothelial cells with serum from patients with CHF will downregulate endothelial constitutive nitric oxide synthase (eNOS) and induce apoptosis.

METHODS AND RESULTS

We studied 21 patients with severe CHF. Levels of tumor necrosis factor-alpha (TNF-alpha) and several neuroendocrine parameters were assessed. eNOS was measured by Western Blot analysis and apoptosis by optical microscopy and flow cytometry. We observed (1) eNOS downregulation (difference versus healthy subjects at 24 hours [P<0.05] and 48 hours [P<0.001]), (2) nuclear morphological changes typical of apoptosis; and (3) a high apoptotic rate with propidium iodide (increasing from 2.1+/-0.4% to 11.3+/-1.2% at 48 hours; P<0.001 versus healthy subjects) and annexin V. An anti-human TNF-alpha antibody did not completely counteract these effects. A strong correlation existed between eNOS downregulation and apoptosis (r = -0.89; P<0.001).

CONCLUSIONS

Serum from patients with severe CHF downregulates eNOS expression and increases apoptosis. High levels of TNF-alpha likely play a role, but they cannot be the only factor responsible.

Efficacy of a second cycle of interferon therapy in patients with chronic hepatitis C

BACKGROUND & AIMS

Approximately 75%-85% of patients with chronic hepatitis C virus (HCV) infection do not have a sustained response when treated with interferon (IFN). Limited information exists on the efficacy of retreatment with IFN alone in these patients. The aim of this study was to define the efficacy of IFN retreatment in chronic hepatitis C.

METHODS

Ninety-two patients with chronic hepatitis C who had shown transient or no response to recombinant IFN-alpha were randomly retreated with different schedules of lymphoblastoid IFN-alpha and followed up for 12 months after therapy to define biochemical and virological response.

RESULTS

None of 26 initial nonresponders obtained a sustained response with retreatment, independent of the schedule used. Thirteen of 66 patients (20%; 95% confidence interval [CI], 10.9-31.3) with transient response during the primary cycle developed a sustained biochemical and virological response when retreated, including 3 of 41 (7%; 95% CI, 1.5-9.9) of those receiving the same schedule and 10 of 25 (40%; 95% CI, 21.1-61.3; P < 0.004) of those retreated with a higher dosage and for a longer period. Shorter disease duration (P = 0.02), higher alanine aminotransferase (P = 0.002) and lower gamma-glutamyltransferase levels (P = 0.004), HCV genotype other than HCV-1 (P = 0.03), and a negative serum HCV-RNA test at the end of the primary cycle (P = 0.000) were associated with sustained response.

CONCLUSIONS

Patients with chronic hepatitis C who have a relapse after a complete response to a 6-month IFN-alpha treatment should be retreated for 12 months. Nonresponders should not be retreated with IFN alone.

Treatment of chronic hepatitis C with interferon-alpha by monitoring the response according to viraemia

In chronic hepatitis C (HCV) infection, treatment with interferon is associated with a rather low rate of sustained response and many treated patients do not achieve significant benefit. Efforts have therefore been made to identify non-responders as early as possible to avoid unjustified costs and side-effects. We treated 106 cases of HCV with an algorithm based on the results of sequential alanine aminotransferase (ALT) and HCV RNA determinations, using an initial dose of 6 MU thrice weekly for 4 months, and modified the subsequent treatment according to the biochemical and virological profile. Thirty-three out of 48 patients (68.7%) who were HCV RNA negative with normal ALT at 4 months after initiation of treatment were sustained responders when treated for an additional 4-month period with a reduced 3 MU dose, while sustained response was achieved in 12.5% of HCV RNA positive patients treated with a higher dosage and for a more prolonged period of time. Our findings indicate that HCV RNA monitoring during interferon therapy may be useful in modifying of the treatment schedule for the individual patient.

Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients

BACKGROUND & AIMS

Few data are available concerning the long-term prognosis of chronic liver disease associated with hepatitis C virus infection. This study examined the morbidity and survival of patients with compensated cirrhosis type C.

METHODS

A cohort of 384 European cirrhotic patients was enrolled at seven tertiary referral hospitals and followed up for a mean period of 5 years. Inclusion criteria were biopsy-proven cirrhosis, abnormal serum aminotransferase levels, absence of complications of cirrhosis, and exclusion of hepatitis A and B viruses and of metabolic, toxic, or autoimmune liver diseases.

RESULTS

Antibodies against hepatitis C virus were positive in 98% of 361 patients tested. The 5-year risk of hepatocellular carcinoma was 7% and that of decompensation was 18%. Death occurred in 51 patients (13%), with 70% dying of liver disease. Survival probability was 91% and 79% at 5 and 10 years, respectively. Two hundred five patients (53%) were treated with interferon alfa. After adjustment for clinical and serological differences at baseline between patients treated or not treated with interferon, the 5-year estimated survival probability was 96% and 95% for treated and untreated patients, respectively.

CONCLUSIONS

In this cohort of patients, life expectancy is relatively long, in agreement with the morbidity data showing a slowly progressive disease.

Persistent hepatitis C viremia predicts late relapse after sustained response to interferon-alpha in chronic hepatitis C. TriVeneto Viral Hepatitis Group

OBJECTIVE

To define long-term outcome in patients with chronic hepatitis C who remain viremic after sustained biochemical response to interferon-alpha therapy.

DESIGN

Prospective evaluation of an outpatient cohort.

SETTING

University hospital.

PATIENTS

107 patients with chronic hepatitis C who maintained normal aminotransferase levels as long as 12 months after interferon-alpha therapy. Patients were followed prospectively for an additional 6 to 36 months.

MEASUREMENTS

Aminotransferase levels were monitored at 3-month intervals. Serum hepatitis C virus (HCV) RNA was tested by polymerase chain reaction before therapy, at the end of therapy, and 12 months after therapy. The HCV genotype was defined by spot hybridization using serum specimens obtained before treatment.

RESULTS

Hepatitis C virus RNA was detected in 27 (25%) patients with sustained biochemical response; 80 (75%) patients were negative for HCV RNA. Patients positive for HCV RNA were older (P < 0.001), had received a smaller interferon-alpha dose (P = 0.02), and were more frequently infected with HCV genotype 2 (P < 0.01). Liver histologic findings were active in 57% of patients positive for HCV RNA, despite normal alanine aminotransferase levels, compared with only 12% of patients who were negative for HCV RNA (P = 0.01). The estimated probability of hepatitis relapse by 4 years after therapy was 53% in viremic patients and 0% in patients negative for HCV RNA (P < 0.001).

CONCLUSION

Patients with chronic hepatitis C should be tested for serum HCV RNA 1 year after a sustained biochemical response to interferon-alpha therapy to determine whether the response is complete and permanent.

[Brief notes on the evolution of the legal position of immigrants from outside the European Community in Italy in 1995-1996]

"In 1995/96 Italian immigration decrees on the legal status of non-EC citizens have maintained a confused and, in some cases, an unconstitutional character. Government decree n.489/November 1995, issued on the grounds of an alleged emergency, did not succeed in regulating incoming flows for seasonal work and enforcing restrictive measures on illegal immigration. Hopefully, it will manage to clear the position of 250,000 illegal entries. This latter provision is likely to prove a further incentive for illegal immigrants, the...opposite of what the government had in mind." (SUMMARY IN ENG AND FRE)

Prevalence of Helicobacter pylori infection in elderly inpatients and in institutionalized old people: correlation with nutritional status

Helicobater pylori plays an important role in the aetiology and development of peptic ulcer disease. The prevalence of H. pylori infection increases with age, and is influenced by low socioeconomic status and poor hygiene owing to person-to-person transmission of the organism by the oral-faecal route. The aim of this study was to investigate the prevalence of H. pylori infection, detected serologically, in elderly patients admitted to a geriatric rehabilitation ward and in a sample of institutionalized old subjects. Nutritional status was also evaluated in order to examine its relation to H. pylori infection. The overall prevalence of H. pylori infection was 70.8%, the prevalence in hospitalized patients being 72.9% and in institutionalized subjects 68.7%. No significant correlation was observed between anti-H. pylori IgG levels and either age or length of stay in the institution. We found no difference between H. pylori positive and negative patients as regards their self-sufficiency and cognitive functions. The prevalence of anti-H. pylori antibodies in the serum was not related to blood variables (including nutritional indices), history of drug consumption (in particular nonsteroidal anti-inflammatory drugs), dyspeptic symptoms, or alcohol and smoking habits.

Randomized trial comparing three different regimens of alpha-2a-interferon in chronic hepatitis C. The TriVeneto Viral Hepatitis Group

Alpha-interferon (IFN-alpha) is an effective treatment for chronic hepatitis C, but only 20% to 30% of patients are apparently cured with the current recommended schedule of 3 MU given three times a week for 6 months. To evaluate the efficacy of more aggressive treatment regimens, we have conducted a randomized trial in 174 patients with chronic hepatitis C using three different schedules: (1) 12-month treatment starting with 6 MU/ three times a week and decreasing the dose on the basis of serum alanine transaminase (ALT) activities (group A: 59 cases); (2) fixed dose of 3 MU three times a week for 12 months (Group B: 61 cases), (3) fixed dose of 6 MU three times of week for 6 months (Group C: 54 cases). Patients were evaluated during therapy for biochemical and virological response and followed for at least 12 months after therapy to assess long-term efficacy and liver histological outcome. The genotype of infecting HCV was also analyzed in all patients, and predictors of response were determined by multivariate analysis. Serum ALT became normal during therapy in 76% of patients (95% confidence interval [CI]: 63 to 86), 65% (CI: 52 to 77), and 74% (CI: 60 to 85) in groups A, B, and C, respectively (P = NS). The corresponding figures for sustained response 12 months after therapy were 49% (CI: 36 to 62), 31% (CI: 20 to 44), and 28% (CI: 16 to 42)(A vs. B, P = .06; A vs. C, P = 0.03). Eighty-six percent of patients with sustained response cleared HCV-RNA from serum, and 72% improved histologically.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of sustained response, relapse and no response in patients with chronic hepatitis C treated with interferon-alpha

Three main patterns of response are seen when interferon-alpha (IFN-alpha) is used for the treatment of chronic hepatitis C: 1 sustained response with alanine-aminotransferase (ALT) normalization that is maintained after cessation of therapy, with or without clearance of serum hepatitis C virus (HCV) RNA; 2 transient response with ALT normalization during therapy followed by relapse after its withdrawal, and 3 no response with no or only partial reduction in ALT levels. In order to define variables that could predict each of these three types of response we studied 321 cases of chronic hepatitis C treated with IFN-alpha in two consecutive trials conducted in our Unit. By univariate analysis, age < 45 years (P < 0.01), known disease duration < 60 months (P < 0.01), normal gamma-glutamyl-transpeptidase (gamma GT) levels (P < 0.01) and infection by HCV genotype 2 or HCV genotype 3 (P < 0.01) were found to be statistically associated with sustained response while age > 45 years (P < 0.01), body weight (P = 0.05), cirrhosis (P < 0.01) and elevated gamma GT levels (P < 0.01) were associated with no response. By multivariate analysis sustained response was predicted by HCV genotype 2 (P < 0.01) and HCV genotype 3 (P < 0.01), known disease duration (P < 0.01), patient's age (P < 0.05) and associated with the use of a more aggressive treatment schedule (P < 0.05). Transient response with relapse was predicted by known duration of disease (P < 0.05), HCV genotype 1 (P < 0.05) and female sex (P < 0.05). No response was statistically associated with elevated gamma GT levels (P < 0.01), higher body weight (P < 0.05) and with the less aggressive regimen of 3 MU of natural IFN-alpha given three times weekly for 6 months (P < 0.05). These results indicate that the HCV genotype as well as the schedule of treatment greatly affect the pattern of response to IFN in chronic hepatitis C and allow us to define criteria to predict which type of response is more likely in individual patients.

Relationship between serum HCV markers and response to interferon therapy in chronic hepatitis C. Evaluation of HCV genotypes during and after long-term follow-up

Hepatitis C virus is the most frequent cause of chronic non-A, non-B hepatitis, and the antibodies to structural and nonstructural proteins encoded by viral genome have been suggested to be markers of ongoing HCV infection. We studied the behavior of these antibodies during interferon therapy in 18 patients with chronic hepatitis C and also during a follow-up period of at least four years. A significant decrease of anti-HCV titer was found only in patients who had shown positive response to therapy and all of them were anti-HCV negative at the end of follow-up. Analysis by recombinant immunoblotting assay showed that only anti-c100 were affected by interferon therapy, whereas anti-c22 and anti-c33 were not modified. Using polymerase chain reaction to detect small amounts of HCV genome in serum, we could confirm that the behavior of HCV-RNA during and after interferon therapy is similar to that of anti-HCV and the loss of anti-c100 seems to be closely related to HCV-RNA disappearance from serum. Our patients with chronic hepatitis C were found to be of type 1b and 2, according to the recent score of Simmonds, and the clearance of serum HCV-RNA during treatment and its sustained negative status are closely related to genotype 2 and to long-term positive response to interferon.

Interferon antibodies in patients with chronic hepatitic C virus infection treated with recombinant interferon alpha-2 alpha

Patients treated with alpha-2a interferon for chronic hepatitis C may produce anti-interferon antibodies whose effect, if any, on the individual response to therapy has not been fully clarified. The prevalence and kinetics of anti-interferon, including those of neutralizing type, have been studied in 60 patients with chronic hepatitis C enrolled in a randomized controlled trial of recombinant alpha-2a interferon. Thirty patients received interferon while 30 were untreated controls. Two different methods, an enzyme immunoassay and an antiviral neutralization bioassay, were used and serial serum samples from each patient were analyzed. Enzyme immunoassay-positive anti-interferon appeared in 60.7% of treated patients within 6 months of therapy; antiviral neutralization bioassay-positive anti-interferon appeared in 52.9% of these enzyme immunoassay-positive patients, and was associated with high enzyme immunoassay reactivity and long-term persistence. Anti-interferon was detected in 75% of patients showing no response to interferon. Antibodies were also detected in three out of six patients who showed alanine aminotransferase normalization persisting up to the end of treatment and in 8 out of 14 patients who showed an initial marked reduction or even normalization of alanine aminotransferase, followed by reactivation of liver damage during treatment. Interestingly, patients who became anti-interferon positive before complete alanine aminotransferase normalization later showed reactivation of liver damage independently of interferon dose reduction, while patients who became positive for anti-interferon after complete alanine aminotransferase normalization either did not reactivate or did so only after interferon dose reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of chronic hepatitis C with recombinant human interferon-alpha 2a: results of a randomized controlled clinical trial

Sixty consecutive patients with chronic hepatitis C were included in a randomized controlled trial of recombinant human interferon-alpha 2a vs. no treatment. Treated patients received tapering doses of interferon thrice weekly for 1 yr. Twenty treated cases (66.7%) normalized serum aminotransferase levels within the first 4 mo of treatment, but reactivation or breakthrough frequently occurred afterward (20% in both cases). Only one of the untreated patients showed spontaneous normalization of serum aminotransferase levels. Liver histology did not improve in patients without a biochemical response or with breakthrough during therapy, whereas it did not worsen in long-term responders and reactivating patients. Lack of response does not appear to be related to serum interferon antibodies, although their early appearance is more frequent in patients who showed reactivation later on. No biochemical parameter was found to be predictive for positive response to treatment. Antibody to c100 became negative in 62.5% of long-term responders, whereas no change was recorded in other treated patients or controls. Reactivation and breakthrough often occur during treatment, and further studies are needed to determine the most effective schedule (dose and time) of interferon treatment. Loss of c100 antibody during therapy may be a marker of long-term maintenance of response to interferon therapy.

Treatment with interferon(s) of community-acquired chronic hepatitis and cirrhosis type C. The TVVH Study Group

Two hundred and thirty-four patients with chronic non-A, non-B hepatitis, 86% positive for anti-HCV by ELISA, were treated with recombinant interferon-alpha 2a or with natural (human-leukocytes-derived) interferon-alpha using different dosage and periods of administration. Interim analysis of follow-up data indicate that 65-70% of patients treated initially with 6 MU, thrice weekly, of recombinant interferon-alpha 2a achieved a complete biochemical response (normalization of alanine aminotransferase: ALT) during therapy compared to 56-58% of those treated with 3 MU, thrice weekly, of recombinant or natural interferon-alpha. A 12-month schedule of interferon administration appeared superior to a 6-month schedule in reducing the probability of reactivation of liver disease after therapy withdrawal, although further data are needed to confirm such a conclusion. The probability of response to interferon in terms of maintaining normal ALT after withdrawal did not appear to be influenced by sex, while it was significantly higher in patients aged below 45 years and in those without cirrhosis.

Serum alanine aminotransferase levels among volunteer blood donors: effect of sex, alcohol intake and obesity

Serum alanine aminotransferase (ALT) activity and antibody to hepatitis B core antigen (anti-HBc) were proposed as surrogate markers of non-A, non-B (NANB) infection. In this study we analyzed 649 consecutive repeat blood donors to define the possible exclusion rate if both surrogate markers were implemented in our Blood Service, and to assess risk factors associated with elevated ALT levels. One hundred and seven blood donors (16.5%) had slightly elevated ALT levels (higher than the upper reference value, but less than twice this level), but only 15 (2.3%) had a level higher than mean log + 2.25 SD. Seventy-seven (11.8%) resulted anti-HBc positive. Blood donors with elevated ALT levels and those who were anti-HBc positive belonged to different populations, being only 6 (0.9%) positive for both surrogate markers. Only two known donors (0.3%) resulted anti-HCV positive, and each of them was implicated in one of the four post-transfusion hepatitis (PTH) cases observed in 200 recipients of blood from these 649 donors. Both were negative for anti-HBc but one had elevated ALT levels. Male sex, age, alcohol use and obesity resulted all independently and significantly associated with elevated ALT levels. For both alcohol use and body weight we observed a significant linear relationship with serum ALT levels. These findings suggest that in our Region the exclusion of blood donors with ALT levels above the reference value, or those anti-HBc positive, would exclude an unacceptably high rate of blood donors without proven evidence of post-transfusion hepatitis prevention.(ABSTRACT TRUNCATED AT 250 WORDS)

[Is flexible sigmoidoscopy as preventive measure for colorectal carcinoma in asymptomatic patients over 45 practicable?]

The efficacy of flexible sigmoidoscopy as a screening method for colorectal cancer is still undetermined, and a reduction in mortality due to this cancer by mass screening has not been demonstrated so far. An important precondition for the practicability of screening sigmoidoscopy is its acceptability by the persons to be screened. Acceptability was tested in 294 volunteers without abdominal symptoms from a general medical outpatients clinic. Mean age of participants was 58 years (45-86), 65% were men and 35% women. Sigmoidoscopy was judged harmless by 221 persons (75.1%), painful by 62 (21.1%), very painful by 11 (3.7%), and unacceptable by none. Every participant would have agreed to repeat the examination. In 36 patients 52 polyps were detected, comprising one carcinoma, 18 adenomas (in 15 patients), 32 hyperplastic polyps and one lipoma. We conclude that sigmoidoscopy was well accepted in this study and should be evaluated further as a mass screening method for colorectal cancer.

Interferon therapy of cryptogenic chronic active liver disease and its relationship to anti-HCV

In a randomized controlled trial of Interferon (IFN) in 60 patients (30 treated and 30 controls) with cryptogenic chronic active liver disease, 70% of treated patients showed complete response, but a high rate of biochemical relapse (62%) was noted. In these cases, a second response to higher doses of IFN has been more difficult and less frequent. A response to IFN was found in 88.5% of anti-HCV positive treated patients and only in 25% of anti-HCV negative. We suggest that serum anti-HCV is a suitable test to predict the response to IFN.

Antibody to hepatitis C virus in cryptogenic chronic liver disease

The prevalence of antibody to hepatitis C virus (HCV) was studied in 207 patients with chronic liver disease of unknown etiology, in relation to clinical, epidemiological and histological features. Serum antibody to C-100 epitope of HCV was detected by ELISA in 82.6% of patients, with a significant difference compared with a group of patients with primary biliary cirrhosis (10%). The presence of anti-HCV antibody in serum did not correlate with age, sex, histological diagnosis, and activity and duration of the disease, nor with serum anti-HBc, used as a marker of exposure to hepatitis B virus infection. These results strongly support the view that most cases that were previously defined as cryptogenic forms of chronic liver disease are in fact related to HCV infection. There was a correlation between serum anti-HCV antibody and history of risk for parenteral exposure or of acute hepatitis. This correlation was particularly evident for transmission by parenteral route, suggesting that HCV infection may be transmitted often by this route (36.8% among anti-HCV antibody-positive patients and 11.1% among anti-HCV-negative patients). Liver disease in patients without risk factors for parenteral transmission and with lower prevalence of anti-HCV antibody may be caused by other as yet unidentified non-A, non-B (non-C) agents or may be of nonviral origin.

Cryptogenic chronic active liver disease. Evaluation of serum aminoterminal peptide of type III procollagen as a marker of histological activity

Sera from 64 patients with HBsAg-negative chronic liver disease with or without cirrhosis were investigated for aminoterminal peptide of type III procollagen (sP-III-P) as a suitable marker of hepatic fibrosis; 244 healthy control subjects were included in the study. A close correlation (p less than 0.01) between sP-III-P levels and histological activity was observed; on the contrary, no correlation was found between the same serum marker of liver fibroplasia and biochemical activity or clinical severity of the disease. We conclude that sP-III-P as a suitable marker of liver overload of collagen fibers is strongly correlated with the histological activity of the disease. Local immune reactions produce soluble substances that might stimulate fibroblastic activity. The test has a significant sensitivity and a very high specificity as a marker of chronic liver disease with histological activity.

[Treatment of cryptogenic chronic liver diseases with recombinant alpha-2a interferon. Preliminary results of a randomized controlled clinical trial]

Fifty-six consecutive patients with cryptogenic chronic active liver disease were enrolled in a randomized controlled clinical trial of alpha-2a interferon and randomly assigned to a control group (28 patients) and to a treated one (28 patients). All had a histologic diagnosis of chronic active hepatitis (with superimposed cirrhosis in 50% of them) and presented a persistent elevation in aminotransferases, during the last year. Ad-interim analysis shows that 19 out of 28 treated patient (68%) have normalized the aminotransferases during the eight months of therapy, with a statistically significant difference (p less than 0.01) between treated and control group; nevertheless, in 58% of them, we noted rising aminotransferases at low doses of interferon with subsequent normalization when the dose was increased to previous effective levels. Retrospectively, the antibody directed to virus C (anti-HCV) was found positive in 84% of our patients, and its presence was strongly associated with response to interferon treatment. Our preliminary results seem to demonstrate that interferon is truly effective, mainly at high doses, in cryptogenic chronic active liver disease; these data with the high prevalence of anti-HCV and the association between anti-HCV and response to therapy, may confirm a possible etiologic role of virus C in causing this subgroup of liver disease.

Recombinant human interferon alfa-2a in community-acquired non-A, non-B chronic active hepatitis. Preliminary results of a randomized, controlled trial

A randomized, controlled trial was undertaken to evaluate the response to recombinant interferon alfa-2a in patients with hepatitis B surface antigen negative chronic active hepatitis of unknown aetiology (community-acquired non-A, non-B hepatitis). Thirty patients were treated with thrice weekly interferon in a dose of 6 million units for 1 month, followed by 3 million units for 3 months and 1 million units maintenance therapy for 8 months. Patients who relapsed were returned to the previously effective dose. A control group of 30 patients received no treatment and were followed up for 12 months. Overall, 21/30 (70%) of treated patients had a complete response, with normalization of serum aminotransferase levels, and a further three (10%) had a partial response (a decrease to less than 50% of baseline levels). No significant changes were observed in the control patients. Five (24%) of the 21 complete responders relapsed during months 2-4 and 8/21 (38%) relapsed during maintenance therapy. Three (23%) of these 13 patients had a return to normal serum aminotransferase levels when the dose was increased and 7/13 (54%) demonstrated a significant decrease. In a retrospective analysis of patients' sera for antibody to hepatitis C virus, 23/26 patients testing positive were treatment responders compared to 1/4 antibody negative patients. Our results suggest that interferon alfa-2a is an effective treatment for community-acquired non-A, non-B hepatitis, but reactivation during treatment occurred in 62% of patients. We recommend use of a higher dose of interferon for at least 1 year with long-term follow up in order to exclude early or late reactivation after treatment withdrawal.

Cryptogenic chronic liver disease and serum or liver hepatitis B virus markers. Their possible correlations and etiologic significance

In an attempt to evaluate a possible correlation between cryptogenic chronic liver disease and a present or past hepatitis B virus (HBV) infection, we studied 17 patients with hepatitis B surface antigen (HBsAg)-negative, nonalcoholic chronic liver disease; 9 of them were positive for serum HBsAg detected by a solid-phase enzyme immunoassay with monoclonal antibody (M-EIA) and 8 were negative for the same marker. Liver hepatitis B core antigen (HBcAg), studied by an indirect immunofluorescence technique, was present in 55.5% of the patients positive for serum HBsAg by M-EIA. In the same group of patients, liver HBV-DNA was found in 66.6% of the patients. On the other hand, only 1 patient without serum positivity for HBsAg by M-EIA was positive for liver HBcAg and HBV-DNA. None of our patients showed serum positivity for HBV-DNA sequences. We conclude that HBV infection may be a possible cause of cryptogenic chronic liver disease; this HBV-related, HBsAg-negative chronic liver disease seems to have no viral replication or undetectable levels of HBV-DNA in serum. HBsAg, detected by a monoclonal assay, seems to be a suitable marker to identify this subgroup of patients with HBsAg-negative chronic liver disease.