Serum soluble programmed cell death 1 levels predict spontaneous functional cure in inactive carriers with chronic hepatitis B

BACKGROUND

Hepatitis B surface antigen (HBsAg) seroclearance is the most important milestone indicating favourable clinical outcomes in patients with chronic hepatitis B (CHB). However, it is difficult to achieve due to the impaired HBV-specific immunity, such as programmed cell death 1 (PD-1)-associated T cell exhaustion. We assessed soluble PD-1 (sPD-1) as a novel seromarker for predicting spontaneous HBsAg loss.

METHODS

Serial serum levels of sPD-1 were evaluated in 1046 untreated hepatitis B e antigen (HBeAg)-seronegative individuals who had achieved undetectable serum HBV DNA. Multiple regression analyses were applied to assess associations among baseline and subsequent sPD-1 levels, HBsAg decline during follow-up, and spontaneous HBsAg seroclearance.

RESULTS

A total of 390 individuals achieved spontaneous HBsAg seroclearance during 6464.4 person-years of follow-up. Baseline sPD-1 levels were inversely associated with baseline HBsAg levels (qHBsAg) as well as a greater decline in qHBsAg during follow-up. Incidence rates of HBsAg seroclearance were 11.5, 61.7, 96.7 and 151.0 per 1000 person-years for sPD-1 levels of ≥4000, 536-3999, 125-535 and <125 pg/mL, respectively (P_trend  < 0.0001). Compared with baseline sPD-1 levels ≥4000 pg/mL, the rate ratio (95% CI) of HBsAg seroclearance was 2.1 (1.1-3.9), 3.0 (1.6-5.5) and 5.1 (2.8-9.5), for baseline sPD-1 levels of 536-3999, 125-535 and <125 pg/mL, respectively, after adjustment for sex, age and serum alanine aminotransferase and HBsAg levels.

CONCLUSION

sPD-1 level is a novel marker which independently predicts spontaneous HBsAg seroclearance of HBeAg-negative inactive CHB patients with undetectable HBV DNA. (word count: 234, <250).

[Study on the hospitalization cost and its influencing factors of imported malaria patients in Guangxi Zhuang Autonomous Region and Yunnan Province]

OBJECTIVE

To analyze the hospitalization cost and its influencing factors of imported malaria patients in Guangxi Zhuang Autonomous Region and Yunnan Province, so as to provide insights into the evaluation of the economic burden due to imported malaria, and the guiding of malaria control and the rational allocation of medical resources.

METHODS

The data pertaining to the hospitalization costs of imported malaria patients admitted to Shanglin County People's Hospital in Guangxi Zhuang Autonomous Region during the period from January 1 through December 31, 2019, and Tengchong Municipal People's Hospital in Yunnan Province from January 1, 2015 to December 31, 2019, were collected, and the epidemiological data of these imported malaria patients were extracted from the Information Management System for Parasitic Diseases Control and Prevention, China. The composition of the hospitalization expenses was analyzed using a descriptive method. In addition, the factors affecting the hospitalization expenses of imported malaria patients were identified using a univariate analysis and a recursive system model.

RESULTS

A total of 206 imported malaria patients were included in this study, including 194 men (94.17%) and 12 women (5.83%). The mean length of hospital stay was 5.00 days per patient and the median hospitalization expenses were 2 813.07 Yuan per time, in which the expenses for laboratory examinations were the highest (45.31%, 1 274.62/2 813.07). Univariate analysis showed that hospital (z = 5.43, P < 0.01), type of malaria (χ² = 34.86, P < 0.01) and type of payment (χ² = 7.72, P < 0.05) were factors affecting the hospitalization expenses of imported malaria patients. Recursion system modeling revealed that the total effects on hospitalization expenses of imported malaria patients included length of hospital stay (0.78), selection of hospital (0.34), basic medical insurance for urban and rural residents (0.19), new rural cooperative medical care (0.17), Plasmodium falciparum malaria (0.15), gender (0.11) and P. vivax malaria (0.09).

CONCLUSIONS

The hospitalization expenses of imported malaria patients are affected by multiple factors in Guangxi Zhuang Autonomous Region and Yunnan Province, in which the length of hospital stay is the most predominant influencing factor. A reduction in the length of hospital stay is effective to decrease the hospitalization expenses of imported malaria patients.

Analysis of rhythm variation during spontaneous cardioinhibitory neurally-mediated syncope. Implications for RDR pacing optimization: an ISSUE 2 substudy

BACKGROUND

Little is known of the variations of the heart rate during spontaneous cardioinhibitory neurally-mediated syncope. Their knowledge has both academic and practical implications for the optimization of rate drop response (RDR) pacing mode.

METHODS AND RESULTS

We describe variations of the rhythm occurring during 48 syncopal episodes documented by implantable loop recorder. The presyncopal phase of 18 s (interquartile range 9-65) was characterized by a fall in heart rate from 83 +/- 20 bpm to maximal bradycardia or (multiple) asystolic pauses which lasted a median of 19 s (10-30). The recovery phase lasted 22 s (7-52). The total duration of the cardioinhibitory reflex was 85 s (47-116). We then calculated the potential increase in benefit that an optimally programmed drop rate detection could provide compared with a reference Lower Rate detection. Compared with Lower Rate detection (defined as two consecutive beats at 40 bpm), drop rate detection (assumed to be drop size = 20 bpm, detection window = 1 min, and drop rate = 50 bpm) would have been able to introduce intervention pacing, a median of 5.7 s (interquartile range -5.1- -10.4) earlier in 28 cases (58%).

CONCLUSION

Cardioinhibitory neurally-mediated reflex varies widely from a few seconds to some minutes. In our data the total duration was <2 min. Optimal RDR programming, being potentially able to anticipate the detection of the cardioinhibitory reflex by a few seconds, could provide an increase in benefit for cardiac pacing therapy in prevention of syncope.

Prevalence and clinical implications of hepatitis B virus genotypes in southern Taiwan

BACKGROUND

Hepatitis B virus (HBV) infection is a major health problem. HBV genotypes may be associated with progression of liver disease. The distribution and clinical implications of HBV genotypes in southern Taiwan are evaluated.

METHODS

We used a polymerase chain reaction-restriction fragment length polymorphism genotyping method to determine HBV genotypes.

RESULTS

The genotype distribution for 265 patients with chronic HBV infection was as follows: A, 3 (1%); B, 158 (60%); C, 90 (34%); D, 7 (2.5%); E, 0: F, 0; and unclassified, 7 (2.5%). Compared with genotype B patients, genotype C patients had a higher hepatitis B e antigen positive rate and higher fibrosis score. There was no significant difference in the mean age between genotype B and genotype C patients with hepatocellular carcinoma (HCC). However, when patients were stratified by age, the prevalence of genotype C was significantly higher in young HCC patients (<50 years of age) than in age-matched asymptomatic carriers (40% versus 10%, P < 0.001). Using multivariate analysis, the significant risk factors for advanced liver disease (cirrhosis or HCC) for patients with chronic HBV infection were old age, male gender and genotype C.

CONCLUSIONS

These results suggest that genotype C is associated with more severe liver diseases than the B variant.

Fatal hepatic failure after emergence of the hepatitis B virus mutant during lamivudine therapy in a patient with liver cirrhosis

Lamivudine therapy for chronic hepatitis and decompensated liver cirrhosis related to the hepatitis B virus (HBV) resulted in improvement of liver function and inhibition of viral replication. Despite emergence of the HBV mutant, e-antigen seroconversion and improvement of liver function may be achieved with continuation of lamivudine therapy. Although hepatic decompensation has been reported in a few cases after the emergence of lamivudine-resistant mutants, fatal cases of non-transplant patients have only rarely been reported in the literature. Here, we describe a patient with HBV-related liver cirrhosis who died after a breakthrough infection with a lamivudine-resistant mutant. Hepatic failure and mortality developed after flare-up of severe hepatitis after 13 months of lamivudine treatment. Emergence of the HBV mutant with substitution of isoleucine for leucine at residue 426 (L4261) in combination with isoleucine for methionine at residue 550 (M5501) was observed at 10 and 13 months of treatment.

A real-time ST-segment monitoring algorithm for implantable devices

Continuous ST-segment monitoring by implantable devices may lead to clarification of the substrate of arrhythmias, clarification of the origin of nonspecific chest pain, and titration or preventative application of established anti-ischemic therapies. Although ST-segment monitoring algorithms are available for surface electrocardiogram, the computational demand of algorithms for implantable devices must be minimized for considerations of device longevity. The new algorithm first locates a fiducial point (FPT) at the dominant peak of each QRS complex. The ST-segment deviation (measured at 2 rate-adaptive delays after FPT, eg, FPT + 96 ms and FPT + 152 ms at 60 BPM) with respect to the isoelectric level (measured at the minimum slope preceding the QRS) is then measured. The following features are also quantified by simple operations: R-R interval, R-wave slope, R-wave amplitude, ST-segment slope, and noise content during the isoelectric segment. Inconsistencies in these features relative to their adaptive normal ranges are used to reject noisy or ectopic beats and sudden morphology changes. Finally, the ST-segment deviation over time is filtered to reject rates of change that are not likely attributable to human ischemia. Performance of the algorithm was evaluated on the European Society of Cardiology ST-T Database, which contains 180 hours of ambulatory electrocardiogram with 250 expert-annotated ischemic episodes. The sensitivity was 79% [74% 84%] (mean [95% CI]) and positive predictivity was 81% [76% 86%]. This performance is statistically equivalent to that of published electrocardiogram algorithms that were validated on the same dataset. Estimates of computational burden suggest that the algorithm could process two channels of electrogram continuously for more than 5 years with current implanted device technology. In conclusion, we have developed an algorithm for ST-segment monitoring that can be implemented in current implantable devices with sensitivity and positive predictivity that are comparable with the state-of-the-art.

Hepatitis C virus infection among teenagers in an endemic township in Taiwan: epidemiological and clinical follow-up studies

The aim of the study was to elucidate the epidemiological features of Hepatitis C virus (HCV) infection among teenagers in an endemic area by conducting a mass screening study. We also investigated the clinical outcome of the anti-HCV-positive subjects by conducting subsequent short-term and long-term follow-up studies. All 2837 students of two junior middle schools in Tzukuan, aged 13-16 years, were invited to be screened for anti-HCV, HBsAg, AST and ALT in October 1995. A total of 2726 (96%) students responded. Anti-HCV, HCV RNA and aminotransferase levels were evaluated among anti-HCV-positive students 1 month and 30 months later, respectively. A total of 38 (1.4%; M/F = 22/16) participants were anti-HCV-positive. The anti-HCV-positive students had higher rates of exposures to transfusion, anti-HCV-positive families and surgery. The prevalence (2.8%) of the 7 maritime villages was markedly higher than that (0.7%) of the other 8 villages (P < 0.001). Subsequent follow-up studies demonstrated that there might be 5 cases of acute or recent HCV infection, and 6 cases who had recovered from chronic HCV infection.

Persistent hyperendemicity of hepatitis C virus infection in Taiwan: the important role of iatrogenic risk factors

The purpose of this study was to investigate determinants of endemic hepatitis C virus (HCV) infection within communities in Taiwan. A two-phase study, including a seroprevalence survey and a prevalent case-control study at the first phase, which has been published previously, and a follow-up seroconversion determination and an incident case-control study during the second phase, was carried out to evaluate correlates of persistent endemic HCV infection. At the first phase, a total of 12,021 men and 1,819 women who were 30-64 years old and living in seven townships in Taiwan were tested for the seroprevalence of antibodies to HCV (anti-HCV). In addition, a prevalent case-control study involving 272 HCV-positive cases and 282 seronegative controls identified from the anti-HCV testing was conducted to investigate risk factors associated with HCV prevalence. During the second phase, a total of 2,728 men and 834 women who were seronegative at recruitment participated in the 1-year prospective study on anti-HCV seroconversion. Subsequently, an incident case-control study based on 39 seroconverters and 81 persistently seronegative controls were carried out to elucidate determinants of HCV seroconvertion. Antibodies to HCV were tested by the second-generation enzyme immunoassay. Information on risk factors of HCV infection was collected from subject interviews. The prevalence of anti-HCV consistently increased with age (range 2.9-5.4%), whereas no apparent age trend was observed for anti-HCV seroconversion rate (range 0.9-1.7%). A striking geographical variation in seroprevalence and seroconversion rates of anti-HCV was observed in the study townships. Furthermore, a significant geographical correlation between HCV seroprevalence and seroconversion rates was noted (r = 0.962, P = 0.001). From the results of both prevalent and incident case-control comparisons, medical injections were found to be the main mode to sustain the persistent endemic state of HCV infection within a community (odds ratios for prevalent and incident case-control studies were 2.5 (95% CI = 1.7-3.6) and 3.1 (95% CI = 1.4-7.1), respectively. The data indicate that the basis for HCV transmission has already been existed in study areas and the iatrogenic risk factor tended to be the major determinant for sustaining persistent endemicity within a community.

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.

Clinical characteristics of double pylorus

BACKGROUND

Double pylorus can occur as either a congenital abnormality or an acquired complication of peptic ulcer disease. There has been no report of long-term follow-up of a large series of patients treated for double pylorus. The objective of this study was to determine the course of double pylorus in 20 patients by serial endoscopic examination.

METHODS

Among 102,958 endoscopic examinations conducted from 1987 to 1999, a diagnosis of double pylorus was made in 20 patients, 18 of whom were followed from 2 months to 10 years. The demographics, clinical presentations, and outcome, as well as endoscopic patterns of double pylorus, were retrospectively reviewed. The rates of ulcer recurrence and symptoms were estimated and compared.

RESULTS

Most fistulous rings were located on the lesser curve of the gastric antrum (75%). Evolution from an original ulcer to fistula was observed in 9 patients. The fistula disappeared in 1 patient, remained open in 12, and converged with the normal pyloric ring in 5 patients. One or more associated systemic diseases and extensive treatment with various drugs were noted in 12 patients. Eradication of Helicobacter pylori in infected patients resulted in a lower percentage of patients with symptoms (36% vs. 100%) and ulcer recurrence (55% vs. 100%) compared with uninfected patients, but the differences were not statistically significant.

CONCLUSION

In this study, fistula closure did not occur in the majority of patients. Associated systemic diseases and extensive use of medications might be important factors in persistence of double pylorus. Eradication of Helicobacter pylori was not beneficial in terms of relief of symptoms, prevention of ulcer recurrence, and fistula closure. Surgical intervention should be considered for patients with refractory symptoms, recurrent ulcers, and other complications.

Sonographic features of hepatic adenomas with pathologic correlation

BACKGROUND

We compared the sonographic characteristics of hepatic adenomas with pathologic findings.

METHODS

Information over 10 years was collected on 12 patients (six men, six women; mean age = 47 years) with surgically proven hepatic adenomas. Clinical data, sonographic features, and histopathologic findings were reviewed.

RESULTS

The tumors in males were smaller and simpler than those in women (p < 0.05, Fisher's exact test). Four of the six larger tumors (>5 cm) showed mixed-echoic patterns corresponding with pathologically intratumoral hemorrhage and necrosis. Four homogeneously hypoechoic tumors had less change in tumor composition. Three homogeneously hyperechoic tumors had evident fatty changes inside. One isoechoic tumor had a hypoechoic rim, that correlated mostly to the tumor itself and compressed liver parenchyma. Seven of the 12 tumors had thin fibrous capsules that were not seen on sonography.

CONCLUSION

Hepatic adenomas have variable sonographic appearances depending on changes in the tumor. Hypoechoic, hyperechoic, and mixed-echoic patterns represent simple adenoma, adenoma with fatty metamorphosis, and hemorrhagic necrosis, respectively, in tumors.

Famotidine versus omeprazole, in combination with amoxycillin and tinidazole, for eradication of Helicobacter pylori infection

BACKGROUND

Eradication regimens combining two antibiotics with a proton pump inhibitor have been studied intensively. In contrast, only a few studies have focused on the possible role of H2-receptor antagonists in eradication therapy. The mechanism involved in the synergy between antibiotics and proton pump inhibitors is still controversial.

OBJECTIVES

To compare the results of two triple-therapy regimens, different only in the antisecretory drugs used, in patients with Helicobacter pylori infection, and to assess the impact of primary resistance to metronidazole on treatment outcome.

METHODS

A total of 120 patients with peptic ulcer and non-ulcer dyspepsia were randomly assigned to a 2-week course of either: famotidine 40 mg twice a day, amoxycillin 1 g twice a day and tinidazole 500 mg twice a day (FAT group; n = 60); or omeprazole 20 mg twice a day, amoxycillin 1 g twice a day and tinidazole 500 mg twice a day (OAT group; n = 60). Upper endoscopy was performed prior to treatment and at least 4 weeks after completion of treatment and discontinuation of the antisecretory therapy. H. pylori status was assessed by a biopsy urease test, histology and culture.

RESULTS

In the intention-to-treat analysis, eradication of H. pylori was achieved in 48 of the 60 patients (80%; 95% confidence interval: 70-90%) in the FAT group, compared to 50 of the 60 patients (83.3%; 95% confidence interval: 74-93%) in the OAT group. In the per protocol analysis, eradication therapy was achieved in 48 out of 53 patients (90.6%; 95% confidence interval: 83-98%) treated with FAT and 50 out of 57 patients (87.7%; 95% confidence interval: 79-96%) treated with OAT (not significant). The primary metronidazole resistance was present in 28.8% of strains. Overall, per protocol eradication rates in strains resistant and susceptible to metronidazole were 83.3% and 91.3% respectively (P > 0.05).

CONCLUSIONS

Two-week courses of either high-dose famotidine or omeprazole, both combined with amoxycillin and tinidazole, are equally effective for eradication of H. pylori infection. In a 2-week triple therapy, metronidazole resistance has no significant impact on eradication rates.

Genetic polymorphisms of glutathione S-transferases M1 and T1 associated with susceptibility to aflatoxin-related hepatocarcinogenesis among chronic hepatitis B carriers: a nested case-control study in Taiwan

This study was conducted to investigate the modifying effect of glutathione S-transferase (GST) M1 and T1 polymorphisms on aflatoxin-induced hepatocarcinogenesis among chronic hepatitis B virus surface antigen (HBsAg) carriers. A total of 79 HBsAg-positive cases of hepatocellular carcinoma (HCC) diagnosed between 1991 and 1997 were identified and individually matched to one or two HBsAg-positive controls on age, gender, residence and date of recruitment from the same cancer screening cohort in Taiwan. Blood samples were tested for hepatitis B and C viral markers by enzyme immunoassay and for aflatoxin B(1) (AFB(1))-albumin adducts by competitive enzyme-linked immunosorbent assay. GSTM1 and GSTT1 genotypes were determined by PCR. There was a statistically significant relationship between detectable levels of AFB(1)-albumin adducts in serum and risk of HCC among chronic HBsAg carriers, with an adjusted odds ratio (OR) of 2.0 [95% confidence interval (CI) 1.1-3.7]. In addition, the effect of aflatoxin exposure on HCC risk was more pronounced among chronic HBsAg carriers with the GSTT1 null genotype (OR 3.7, 95% CI 1.5-9.3) than those who were non-null (OR 0.9, 95% CI 0.3-2.4). The interaction between serum AFB(1)-albumin adduct level and GSTT1 genotype was statistically significant (P = 0.03). For GSTM1 the effect of aflatoxin exposure on HCC risk in those with the null genotype was also greater (adjusted OR 2.8, 95% CI 1.0-7.8) than in those with the gene present (adjusted OR 1.8, 95% CI 0.8-4.5), but the difference was not significant (P = 0.91). Notably, when the interaction between aflatoxin exposure and GSTT1 genotype was considered, aflatoxin exposure by itself was not a significant determinant of HCC risk among chronic HBsAg carriers. These results demonstrate the importance of gene-environment interactions in the multifactorial development of HCC.

Flash echo gray scale imaging with subtraction in assessment of small hepatocellular carcinoma treated with percutaneous ethanol injection: preliminary report

OBJECTIVE

To assess the therapeutic effect of percutaneous ethanol injection on small hepatocellular carcinoma by using a flash echo imaging system, a newly developed technique for detecting echoes from microbubble contrast agents more efficiently.

METHODS

Six patients with 7 small nodular hepatocellular carcinomas, proved by fine-needle aspiration cytologic or pathologic examination, were included. Percutaneous ethanol injection was performed until there was no intratumoral color signal on conventional color and power Doppler ultrasonography. A bubble contrast agent was then injected, and flash echo imaging in the subtraction mode was performed for assessment of the therapeutic effect. Dynamic computed tomography, magnetic resonance imaging, and hepatic angiography were also used for evaluation of the therapeutic effect.

RESULTS

Five tumors had perfusion defects that were equal in size to or larger than the tumors. No tumor stain was shown on hepatic angiography. Two tumors had partial perfusion defects. Viable tumors were confirmed by tumor resection in 1 case and cytologic examination in the other.

CONCLUSIONS

Our preliminary results show that flash echo imaging with subtraction has potential value in evaluation of the therapeutic effect of percutaneous ethanol injection on small hepatocellular carcinoma.

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.

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.

The association between Helicobacter pylori infection and functional dyspepsia in patients with irritable bowel syndrome

OBJECTIVE

Irritable bowel syndrome (IBS) is associated with an exaggerated response to a variety of physiological and nonphysiological gastrointestinal stimuli. Many patients with IBS also have functional dyspepsia. Our aim was to examine the hypothesis that Helicobacter pylori (H. pylori) infection may predispose IBS patients to functional dyspepsia.

METHODS

In 69 IBS patients, dyspeptic symptoms, H. pylori status, and sociodemographic and psychological variables (perceived stress, trait anxiety, and depression) were assessed. Sociodemographic and psychological variables were also evaluated in 52 control subjects.

RESULTS

Mean scores for perceived stress (17.1 +/- 6.0 vs 14.9 +/- 6.0, p = 0.05), trait anxiety (45.6 +/- 9.1 vs 41.1 +/- 7.8, p = 0.004) and depression (9.9 +/- 8.4 vs 5.0 +/- 5.5, p = 0.0002) were higher in IBS patients than in controls. In all, 33 of the 69 patients (47.8%) had H. pylori infection, and this was associated with relevant symptoms of epigastric pain (odds ratio [OR] = 6.77, 95% confidence interval [CI] 1.89-24.3) and postprandial upper abdominal fullness (OR = 4.23, 95% CI 1.38-13.2). H. pylori infection and female gender were independent predictors of the presence of relevant dyspepsia (OR = 8.31, 95% CI 2.35-29.5 and 6.06, 95% CI 1.71-21.5, respectively). Symptom intensity was associated with the level of perceived stress (total relevant symptom number > or =3 vs <3, OR = 1.16 per point on a 40-point perceived stress scale, 95% CI 1.01-1.34).

CONCLUSIONS

In IBS patients, the presence of dyspepsia is associated with H. pylori infection, female gender, and perceived stress.

Contact fluorescence imaging of reentry in monolayers of cultured neonatal rat ventricular myocytes

INTRODUCTION

We present a novel contact fluorescence imaging (CFI) approach to monitor transmembrane potentials in monolayers of cultured neonatal rat ventricular cells. We apply CFI to demonstrate, for the first time, long-term recordings as well as electrical induction and termination of reentrant activity in this in vitro model.

METHODS AND RESULTS

CFI was performed in confluent cell monolayers stained with di-8-ANEPPS. An anatomic obstacle (6 x 0.5 mm) was created in the center of the monolayers. Reentry was induced with a premature stimulus after pacing at 2 Hz (both via field stimulation). Seven sustained (>3 min) reentrant episodes, anchored to the anatomic obstacle, were observed in three monolayers. Field stimulation (30 V/cm) was applied to successfully terminate 6 of the 7 reentries. Analysis of reentrant activity showed similarities with anatomic reentry in tissue preparations, such as reduced conduction velocity around the core, variable conduction velocity along the reentrant pathway due to wavefront curvature effects, and field-induced activation at the obstacle borders leading to reentry termination (cardioversion).

CONCLUSION

This study demonstrates the feasibility of CFI for macroscopic optical mapping of transmembrane potentials in a single layer of cultured cells. Our results suggest that the monolayer cell culture model is an attractive complement to tissue models of reentry and cardioversion.

Conformal radiation therapy for hepatoma with portal vein thrombosis

A 43-year-old male patient was diagnosed as having hepatocellular carcinoma with portal vein thrombosis and arterioportal shunts. Three-dimensional conformal radiation therapy (3DCRT) with high focal dose was given to the left portal venous area. Shrinkage of the tumour and thrombus, disappearance of the arterioportal shunts and restoration of the hepatopedal flow of the portal vein was noted 3 months after treatment. The patient received further transarterial embolisation and achieved successful tumour control. No serious complications were encountered. 3DCRT is technically feasible and effective to treat a small volume of liver tissue with a high dose of radiation in this advanced disease.

Adult intussusception: a 12-year experience, with emphasis on etiology and analysis of risk factors

BACKGROUND

To determine the incidence, causes, and associated risk factors of adult intussusception.

METHODS

Forty-five cases of adult intussusception proven by surgery were collected from 58,000 surgeries performed from December 1986 through December 1998. The condition leading to intussusception, imaging studies, and clinical risk factors were analyzed.

RESULTS

Nineteen men and 26 women, 18 to 83 years of age (mean, 52.6 years), experienced intussusception. The incidence of adult intussusception was 0.08% of abdominal surgeries and 3.0% of intestinal obstructions. A benign process was diagnosed in 25 cases (55.6%), malignancy in 16 cases (35.6%), surgery-related intussusception in 1 case (2.2%), and an idiopathic condition existed in 3 cases (6.6%). The major cause of adult intussusception due to benign lesions was polyps (12/25) and for malignancy, it was colonic adenocarcinoma (14/16). The diagnostic imaging rates were 52% for computed tomography, 41% for barium studies and 32% for abdominal ultrasound. There was no mortality due to intussusception; 4 patients (8.9%) died of colon cancer with liver metastasis. No definite risk factor was identified, but leukocytosis and a shorter preoperative duration tended to increase the risk of complications (p = 0.084, 0.082 respectively).

CONCLUSION

Malignancy was the major cause of colonic intussusception, as was a benign process the primary cause of intestinal intussusception. These adult patients with intussusception received adequate surgical care and had a good prognosis except for those with colon cancer and liver metastasis.

Secular trends of HBeAg prevalence among HBsAg-positive delivery mothers in a hepatitis B endemic area

A high prevalence of HBeAg among HBsAg-positive mothers at the time of delivery results in a high prevalence of hepatitis B vertical transmission. From 1990 to 1995, 896 pregnant HBsAg-positive women, including 411 (46 per cent) HBeAg-positive subjects, were enrolled in our study to analyse the secular change in HBeAg prevalence. Their mean age, number of pregnancies and parity were 29.5 +/- 4.1 years, 2.0 +/- 1.2, and 0.6 +/- 0.7, respectively. The prevalence rates of HBeAg were 48, 54, 49, 47, 40, and 40 per cent among the subjects enrolled in 1990, 1991, 1992, 1993, 1994, and 1995, respectively. In univariate analyses, prevalence of HBeAg decreased by the calendar year of pregnancy (p = 0.01), and also by age (p < 0.00001), number of pregnancies (p < 0.0001) and parity (p < 0.0002). After adjusting for age in multiple logistic regression, the calendar year of pregnancy was still the independent variable, while gravida and parity became insignificant. The odd ratios (95 per cent confidence interval) of HBeAg negative-seroconversion in the equations were 1.09 (1.00-1.19) per calendar year and 1.14 (1.10-1.18) per year of age. Our results have shown a secular decrease in HBeAg-prevalence among pregnant HBsAg-positive women in Taiwan.

Excess mortality from hepatocellular carcinoma in an HCV-endemic township of an HBV-endemic country (Taiwan)

Taiwan is an endemic area of hepatitis B virus (HBV). All previous studies have concluded that HBV is the major cause of hepatocellular carcinoma (HCC) in Taiwan. An HBV- and hepatitis C virus (HCV)-endemic township, Tzukuan, in southern Taiwan has been identified with the prevalence of 24% for HB surface antigen (HBsAg) and 37% for anti-HCV antibodies. To elucidate the aetiology of HCC and impact of HCV in this township, we conducted a case-control study and compared HBV-related liver cancer mortality in Tzukuan and Taiwan as a whole. Based on cancer registration datasets of 2 medical centres from 1991 to 1995, we recruited 18 male and 9 female HCC cases from the study township. Their mean age (+/- standard deviation) was 60.3 (+/- 7.3) years. Randomly sampled from a community-based survey, 4 age- (+/- 2 years) and sex-matched residents were selected as community controls for each HCC case. The HBsAg carrier rate was 40.7% in cases and 25.0% in controls (P = 0.1). Anti-HCV positive rate was 88.9% in cases and 53.7% in controls (P = 0.008). Age-adjusted liver cancer mortality in Tzukuan (36.5 per 10(5)) was significantly higher than that of Taiwan as a whole (20 per 10(5)). Based on the HBsAg-positive rate among HCC patients (40.7% in Tzukuan and 77.4-86.6% in Taiwan), the estimated HBV-related liver cancer mortality was similar in Tzukuan (14.9 per 10(5)) and Taiwan (15.8-17.3 per 10(5)). We concluded that HCV was the major risk factor for excess liver cancer mortality in this HCV-endemic township of the HBV-endemic country.

Age, gender, and local geographic variations of viral etiology of hepatocellular carcinoma in a hyperendemic area for hepatitis B virus infection

BACKGROUND

There are etiologic variations of hepatocellular carcinoma (HCC) in different geographic areas. Taiwan is a hyperendemic area for hepatitis B virus (HBV) infection. Hepatitis C virus (HCV) infection also plays an important role in HCC development in Taiwan. Identification of local HCV-endemic areas is important to keep HCV from spreading. This study investigated the etiologic variations of HCC in different geographic areas of Taiwan.

METHODS

The authors evaluated the hepatitis B surface antigen (HBsAg) and antibodies to HCV (anti-HCV) status of 284 patients (232 male, 52 female) with HCC. They also evaluated the gender ratio and mean age of these patients.

RESULTS

The mean age of HBsAg positive patients was significantly lower than the mean age of HBsAg negative patients (52.6 +/- 12.3 vs. 61.3 +/- 11.2 years) (P < 0.05). The male-to-female ratio was 4.5:1 for all HCC patients, 7:1 for HBsAg positive HCC patients, and 2.8:1 for anti-HCV positive HCC patients. In Chaiyi County in southern Taiwan, the prevalence of anti-HCV in male HCC patients was 52%, significantly greater than that of Taiwan as a whole (27.6%) (P = 0.07). However, the prevalence of anti-HCV in male HCC patients in Taipei County in northern Taiwan was 8.7%, significantly less than that of Taiwan as a whole (P = 0.043). Of a total of 65 Chiayi-based HCC patients, 55.4% were anti-HCV positive and 46.2% were HBsAg positive. In the Chiayi area, results of multiple logistic regression showed that the HCC patients who were age 60 years or older or who were living in the city area both had highly HCV-related disease.

CONCLUSIONS

The mean age of patients with HBV-related HCC was significantly lower than that of patients with non-HBV-related HCC. The male-to-female ratio for patients with HBV-related HCC was significantly higher than that of patients with HCV-related HCC. The authors identified an area of Taiwan in which HCV-related HCC was prevalent.

Age, gender, and local geographic variations of viral etiology of hepatocellular carcinoma in a hyperendemic area for hepatitis B virus infection

BACKGROUND

There are etiologic variations of hepatocellular carcinoma (HCC) in different geographic areas. Taiwan is a hyperendemic area for hepatitis B virus (HBV) infection. Hepatitis C virus (HCV) infection also plays an important role in HCC development in Taiwan. Identification of local HCV-endemic areas is important to keep HCV from spreading. This study investigated the etiologic variations of HCC in different geographic areas of Taiwan.

METHODS

The authors evaluated the hepatitis B surface antigen (HBsAg) and antibodies to HCV (anti-HCV) status of 284 patients (232 male, 52 female) with HCC. They also evaluated the gender ratio and mean age of these patients.

RESULTS

The mean age of HBsAg positive patients was significantly lower than the mean age of HBsAg negative patients (52.6 +/- 12.3 vs. 61.3 +/- 11.2 years) (P < 0.05). The male-to-female ratio was 4.5:1 for all HCC patients, 7:1 for HBsAg positive HCC patients, and 2.8:1 for anti-HCV positive HCC patients. In Chaiyi County in southern Taiwan, the prevalence of anti-HCV in male HCC patients was 52%, significantly greater than that of Taiwan as a whole (27.6%) (P = 0.07). However, the prevalence of anti-HCV in male HCC patients in Taipei County in northern Taiwan was 8.7%, significantly less than that of Taiwan as a whole (P = 0.043). Of a total of 65 Chiayi-based HCC patients, 55.4% were anti-HCV positive and 46.2% were HBsAg positive. In the Chiayi area, results of multiple logistic regression showed that the HCC patients who were age 60 years or older or who were living in the city area both had highly HCV-related disease.

CONCLUSIONS

The mean age of patients with HBV-related HCC was significantly lower than that of patients with non-HBV-related HCC. The male-to-female ratio for patients with HBV-related HCC was significantly higher than that of patients with HCV-related HCC. The authors identified an area of Taiwan in which HCV-related HCC was prevalent.

Phylogenetic analysis to document a common source of hepatitis D virus infection in a mother and her child

BACKGROUND

Spread of hepatitis D virus (HDV) from mother to infant is rare and nucleotide evidence to document such transmission is lacking. The aim of this study was to screen the children of HDV-infected parents and compare the HDV nucleotide sequence between children and parents by phylogenetic analysis.

METHODS

Fifty-seven children of 28 HDV-infected parents (23 fathers and 5 mothers, including two couples) were enrolled. HDV genomes from sera of HDV-infected parents and their children were cloned and sequenced. Comparison and phylogenetic analysis of HDV genomes were based on a region from nucleotide 911 to 1260. The homology to nucleotide sequence among different genotypes was estimated by phylogenetic analysis.

RESULTS

One of the eight children whose mothers were anti-HDV positive was positive for anti-HDV. Mean heterogeneity among different HDV clones from a single subject ranged from 0.29% to 1.15%. HDV sequences from the mother and her child (referred from southern Taiwan) were nearly identical (99.7%), both showed 92.2-93.4% homology with other genotype II isolates from north Taiwan and 76.3-77.1% homology with genotype I isolates.

CONCLUSIONS

Genotype II HDV is most prevalent in Taiwan. There are significant variations up to 8% in nucleotide sequence among different genotype II HDV clones isolated from patients in northern and southern Taiwan. Phylogenetic analysis revealed that HDV clones from the mother and her child form a monophyletic group, supporting a common source of infection. Susceptible children of HDV-infected mothers should be protected by hepatitis B virus vaccination and active education.

Prevalence and manifestations of hepatitis C seropositivity in children in an endemic area

BACKGROUND

According to our previous studies, Paisha Township in Penghu Islets is an endemic area for hepatitis B virus and hepatitis C virus (HCV) infection and for hepatocellular carcinoma. We conducted this study to understand the prevalence of anti-HCV seropositivity among children in this area and to observe clinical manifestations of anti-HCV-positive children.

METHODS

In March, 1994, 1164 (93.6%) of 1243 students from all 6 kindergartens, 9 primary schools and 3 middle schools in Paisha Township participated in the screening for anti-HCV by enzyme immunoassay with second generation commercial kits (Abbott EIA 2.0). Anti-HCV tests were duplicated for the positive sera in 2 laboratories. All anti-HCV-positive children were followed annually for 2 years.

RESULTS

The prevalences of children from kindergartens (ages 3 to 6 years), primary schools (ages 7 to 12 years) and middle schools (ages 13 to 15 years) were 0% (0 of 229), 0.8% (5 of 617) and 1.9% (6 of 318), respectively. Initially the optic density (OD) values of anti-HCV were > 2.0 in 4 cases (36%), between 1.0 and 2.0 in 2 cases, and < 1.0 in the other 5 cases. None had sonographic parenchymal changes in the liver. In the 2-year follow-up of the anti-HCV-positive subjects, type 2a HCV-RNA persisted in 3 of 4 children with an OD of anti-HCV more than 2.0; 2 of them had 2 elevations of alanine transaminase values. Four of 7 children with an OD of 2.0 or less had a decrease in OD values in the follow-up examinations, and 2 of them became anti-HCV-negative.

CONCLUSION

Only 36% (4 of 11) of anti-HCV-positive children had an OD of > 2.0. Subjects with sequentially low OD might recover from chronic HCV infection without detectable HCV RNA and with normal alanine aminotransferase values.

Incidence of hepatitis C infection in a hepatitis C endemic township in southern Taiwan

To realize the incidence of hepatitis C virus (HCV) infection in an HCV endemic township, Tzukuan, in Taiwan, we conducted a follow-up community-based survey. A total of 173 adults, 82 males and 91 females, with mean age of 55.5 +/- 9.9 years received initial and follow-up anti-HCV tests with one-year interval. One (1.2%, 95% CI: 0%-5.5%) of 84 anti-HCV-positive subjects was negative-seroconversion, and 4 (4.5%, 95% CI: 0.2%-8.8%) of 89 anti-HCV-negative subjects were positive-seroconversion. The results indicated that hepatitis C might be still spreading in the HCV-endemic area now.

Different viral aetiology of hepatocellular carcinoma between two hepatitis B and C endemic townships in Taiwan

In Taiwan, we found two hepatitis B virus (HBV)- and hepatitis C virus (HCV)-endemic townships, Paisha and Tzukuan, with an anti-HCV prevalence of 19 and 37% in men, and 26 and 38% in women, respectively. The hepatitis B surface antigen (HBsAg)-positive rates were 25 and 18%, for men and women in Paisha, and 25 and 22% in Tzukuan, respectively. According to the national death certification database (1982 to 1991), the annual age-adjusted mortality rates per 100,000 population for liver cancer among men and women were 83.0 and 13.8, respectively, in Paisha, and 55.9 and 17.0 in Tzukuan compared with 30.9 and 9.1 in Taiwan as a whole. The male-to-female ratios were 6.0 in Paisha and 3.3 in Tzukuan. Aetiology of 11 cases of hepatocellular carcinoma (HCC) from Paisha and 14 cases from Tzukuan were analysed. All HCC cases from Paisha were HBsAg positive, while 13/14 HCC cases from Tzukuan were anti-HCV positive. The endemic duration of HCV in Tzukuan seemed long enough to induce HCC, but the HCV appeared to be a newly introduced infection in Paisha.

Changes of hepatitis B markers among young adults in a hepatitis B virus endemic area: a follow up study on medical students

To elucidate the hepatitis B virus (HBV) infection status of teenagers, to observe changes of the status of these young adults after long-term follow up, to clarify the HBV replication activity of young HBsAg carriers, and to understand the anti-HBs titer of those immune to HBV-infection, a comparison between two health examinations at a 5-or 6-year interval was conducted among 132 medical students. Their ages were 19.1 +/- 0.9 (mean +/- SD). There were 19 (14.4%) HBsAg carriers, 57 (43.2%) immune to HBV infection, and 56 (42.4%) susceptible to HBV. All 19 HBsAg positive carriers were still in carrier status in the second examination. Twelve (63.1%) of the HBV carriers had already HBeAg negative seroconversion before the age of 25. And two carriers might be in the late e seroconversion phase. One susceptible student had a subclinical HBV infection during his university life, with an incidence of HBV infection of 0.47% (1/213) per person-year. Nine (11%) of 82 HBV-immune students had lower anti-HBs concentrations. Six of the 9 students were immunized by natural infection. Anamnestic response developed after booster vaccination. This study shows that these young adults have an HBsAg-carrier rate similar to the general adult population in Taiwan. However, HBeAg seroconversion occurs more often and earlier in this particular population than previous reports have indicated. Moreover, only 24 (40%) susceptible subjects received HBV vaccination after the first recommendation and it is necessary to be more forceful in recommending prompt vaccination.

Hepatic focal nodular hyperplasia: findings on color Doppler ultrasound

BACKGROUND

We assessed the color Doppler ultrasound (US) findings in focal nodular hyperplasia (FNH).

METHODS

Seven FNH lesions were imaged with color Doppler US and hepatic angiography.

RESULTS

In four lesions, color Doppler demonstrated a central stellate vascular appearance which correlated with central feeding artery with spoke-wheel sign angiographically. Except for one lesion, color Doppler US imaging correlated with angiographic findings.

CONCLUSIONS

Color Doppler US is capable of demonstrating the typical findings of a central feeding artery and stellate vascular pattern in many cases of FNH.

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.

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.

Aflatoxin exposure and risk of hepatocellular carcinoma in Taiwan

To investigate the carcinogenic effect of environmental aflatoxin exposure, 56 cases of hepatocellular carcinoma (HCC) diagnosed between 1991 and 1995 were identified and individually matched by age, sex, residence and date of recruitment to 220 healthy controls from the same large cohort in Taiwan. Blood samples were analyzed for hepatitis B and C viral markers and for aflatoxin-albumin adducts; urine was tested for aflatoxin metabolites. We obtained information about sociodemographic characteristics, habitual alcohol drinking, cigarette smoking and diet in a structured interview. Hepatitis B virus surface antigen (HBsAg) carriers had a significantly increased risk for HCC. After adjustment for HBsAg serostatus, the matched odds ratio (ORm) was significantly elevated for subjects with high levels of urinary aflatoxin metabolites. When stratified into tertiles, a dose-response relationship with HCC was observed. The ORm for detectable aflatoxin-albumin adducts was not significant after adjustment for HBsAg serostatus. HBsAg-seropositive subjects with high aflatoxin exposure had a higher risk than subjects with high aflatoxin exposure only or HBsAg seropositivity only. In male HBsAg-seropositive subjects, adjusted ORs were 2.8 (95% confidence interval [CI] = 0.9-9.1) for detectable compared with non-detectable aflatoxin-albumin adducts and 5.5 (CI = 1.3-23.4) for high compared with low urinary aflatoxin metabolite levels. Our results suggest that environmental aflatoxin exposure may enhance the hepatic carcinogenic potential of hepatitis B virus. A large-scale study will be needed to evaluate the effect of aflatoxin exposure on HBsAg non-carriers.

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.

Decreased bone mineral density in premenopausal patients with systemic lupus erythematosus

To study bone mineral density (BMD) in premenopausal adult female patients with systemic lupus erythematosus (SLE) and its relation with clinical parameters, 56 SLE patients (mean age 31 years, mean disease duration 6.3 years) and 15 normal controls were studied. BMD at the lumbar vertebrae (L2-L4) was measured by dual energy X-ray absorptiometry (DEXA). Classification of BMD was made according to the WHO criteria in 1994. Correlation between BMD and clinical parameters was calculated. It was found BMD in the SLE patients (0.942 +/- 0.136 g/cm2) was lower than in the control group (1.055 +/- 0.080 g/cm2) (P < 0.01). According to the WHO criteria, 17 patients (30%) had normal BMD, 22 patients (40%) had osteopenia and 17 patients (30%) had osteoporosis. BMD was inversely correlated with disease duration in SLE patients (p < 0.005). The minimal disease duration for a female SLE patient to develop osteopenia was 3.5 years. In conclusion, SLE patients have lower lumbar BMD than normal controls. SLE patients with longer disease duration have lower BMD. In order to achieve early prevention of osteoporosis, we suggest that female SLE patients with disease duration for more than 3.5 years should take a BMD examination.

Elevated aflatoxin exposure and increased risk of hepatocellular carcinoma

To elucidate the importance of aflatoxin in the etiology of hepatocellular carcinoma (HCC), a community-based cohort study combined with molecular dosimetry of aflatoxin exposure was performed in the Penghu Islets where the HCC mortality rate is highest in Taiwan. A total of 6,487 residents aged 30 to 65 years were recruited in the two-stage screening survey and underwent regular follow-up examination. Among 33 newly diagnosed HCC cases, 31 (94%) were chronic hepatitis B surface antigen (HBsAg) carriers and 3 (9%) were positive for antibodies against hepatitis C virus (HCV). Among 20 HCC patients and 86 matched healthy controls whose serum samples were tested for aflatoxin B1 (AFB1)-albumin adducts by competitive enzyme-linked immunosorbant assay (ELISA), 13 (65%) HCC patients and 32 (37%) matched controls were seropositive, showing a statistically significant multivariate-adjusted odds ratio of 5.5 with a 95% confidence interval of 1.2 to 24.5. The results imply the elevated risk of HCC among Penghu residents may be attributable to their heavy exposure to aflatoxins and high HBsAg carrier rate.

Aflatoxin exposure and risk of hepatocellular carcinoma in Taiwan

To investigate the carcinogenic effect of environmental aflatoxin exposure, 56 cases of hepatocellular carcinoma (HCC) diagnosed between 1991 and 1995 were identified and individually matched by age, sex, residence and date of recruitment to 220 healthy controls from the same large cohort in Taiwan. Blood samples were analyzed for hepatitis B and C viral markers and for aflatoxin-albumin adducts; urine was tested for aflatoxin metabolites. We obtained information about sociodemographic characteristics, habitual alcohol drinking, cigarette smoking and diet in a structured interview. Hepatitis B virus surface antigen (HBsAg) carriers had a significantly increased risk for HCC. After adjustment for HBsAg serostatus, the matched odds ratio (ORm) was significantly elevated for subjects with high levels of urinary aflatoxin metabolites. When stratified into tertiles, a dose-response relationship with HCC was observed. The ORm for detectable aflatoxin-albumin adducts was not significant after adjustment for HBsAg serostatus. HBsAg-seropositive subjects with high aflatoxin exposure had a higher risk than subjects with high aflatoxin exposure only or HBsAg seropositivity only. In male HBsAg-seropositive subjects, adjusted ORs were 2.8 (95% confidence interval [CI] = 0.9-9.1) for detectable compared with non-detectable aflatoxin-albumin adducts and 5.5 (CI = 1.3-23.4) for high compared with low urinary aflatoxin metabolite levels. Our results suggest that environmental aflatoxin exposure may enhance the hepatic carcinogenic potential of hepatitis B virus. A large-scale study will be needed to evaluate the effect of aflatoxin exposure on HBsAg non-carriers.

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.

High seroprevalence of IgG against Helicobacter pylori among endoscopists in Taiwan

A prospective survey to investigate the seroprevalence of IgG against Helicobacter pylori among endoscopists in Taiwan was conducted by analyzing blood samples of 70 study subjects and 64 nonendoscopist physicians with quantitative ELISA. Personal information and the practices of infection control related to gastroscopy examination were obtained by a self-administered questionnaire. Significant differences were detected in the IgG prevalence between study and control subjects (80.0% vs 51.6%; P < 0.05). The serum level of antibody in endoscopists (385.2 +/- 36.1 unit/ml) was significantly higher than that of nonedoscopists (211.8 +/- 33.0 unit/ml; P = 0.018). Endoscopists performing 30 or more sessions of gastroscopy per week had higher seroprevalence than those performing less than 30 sessions (90.9% vs 70.3%; P = 0.0126). In conclusion, endoscopists in Taiwan had a high prevalence of H. pylori infection. The cause might be related to the frequency of gastroscopies performed.

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.

Elevated aflatoxin exposure and increased risk of hepatocellular carcinoma

To elucidate the importance of aflatoxin in the etiology of hepatocellular carcinoma (HCC), a community-based cohort study combined with molecular dosimetry of aflatoxin exposure was performed in the Penghu Islets where the HCC mortality rate is highest in Taiwan. A total of 6,487 residents aged 30 to 65 years were recruited in the two-stage screening survey and underwent regular follow-up examination. Among 33 newly diagnosed HCC cases, 31 (94%) were chronic hepatitis B surface antigen (HBsAg) carriers and 3 (9%) were positive for antibodies against hepatitis C virus (HCV). Among 20 HCC patients and 86 matched healthy controls whose serum samples were tested for aflatoxin B1 (AFB1)-albumin adducts by competitive enzyme-linked immunosorbant assay (ELISA), 13 (65%) HCC patients and 32 (37%) matched controls were seropositive, showing a statistically significant multivariate-adjusted odds ratio of 5.5 with a 95% confidence interval of 1.2 to 24.5. The results imply the elevated risk of HCC among Penghu residents may be attributable to their heavy exposure to aflatoxins and high HBsAg carrier rate.

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.

Mutual confounding and interactive effects between hepatitis C and hepatitis B viral infections in hepatocellular carcinogenesis: a population-based case-control study in Taiwan

A population-based case-control study was conducted in Taiwan to determine the hepatitis C virus (HCV)-associated risk of hepatocellular carcinoma (HCC) in a hyperendemic area for hepatitis B virus (HBV) infection. A total of 58 recently diagnosed HCC patients and 225 matched community controls, who participated in a community-based liver cancer screening program, were recruited between March 1991 and March 1994. Control subjects were matched to HCC patients by age (+/- 5 years), sex, residence, and date of serum sample collection (+/- 3 months). Serum samples from all study subjects were tested for hepatitis B surface antigen (HBsAg) and antibodies to HCV (anti-HCVs) by enzyme immunoassays, as well as HCV RNA by reverse transcription-PCR assays. Accordingly, patients with HCC were more likely than were controls to be positive for HBsAg (82.8% versus 12.9%, with an odds ratio (OR) of 22.9), anti-HCVs (13.8% versus 4.4%, with an OR of 3.9), and HCV RNA (13.8% versus 5.8%, with an OR of 2.7). After adjustment for anti-HCVs and HCV RNA positivities, the matched ORs associated with HBsAg increased to 27.6 and 28.1, respectively, whereas the corresponding adjusted ORs for anti-HCVs and HCV RNA after controlling for HBsAg status were increased to 8.8 and 6.2, respectively. In the meantime, interactive effects between HCV and HBV on risk were also observed. Compared with those who were negative for both anti-HCVs and HBsAg, the matched ORs associated with the sole positivity of anti-HCVs and HBsAg were 4.0 (95% confidence interval = 0.7-24.0) and 24.6 (95% confidence interval = 9.5-64.1), respectively, whereas 6 HCC cases but none of control subjects were positive for both anti-HCVs and HBsAg. These results indicate that there are mutual confounding and interactive effects between HCV and HBV with respect to their links to HCC in this endemic area of chronic HBV infections.

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.

[Community-based hepatocellular carcinoma screening in seven townships in Taiwan]

The early detection and prompt treatment of hepatocellular carcinoma (HCC) may prolong life and improve the quality of life of affected patients. In order to compare sensitivity and specificity of various screening biomarkers, identify subjects with a high risk of developing HCC, and estimate prevalence and incidence of HCC among subjects, a community-based HCC screening program was implemented in Sanchi, Chutung, Potzu, and Kaohsu, Taiwan Island as well as Makung, Huhsi and Paihsa in Penghu Islets. First stage screening of HCC was based on serological markers including hepatitis B surface antigen (HBsAg), antibody against hepatitis C virus (anti-HCV), alpha-fetoprotein (AFP > or = 20 ng/mL), alanine transaminase (> or = 40 IU/L), and aspartate transaminase (> or = 45 IU/L); as well as history of liver cirrhosis or HCC among first-degree relatives. Subjects who were positive for at least one of above six first-stage criteria were referred for second-stage screening by abdominal ultrasonography. Confirmatory diagnosis of HCC was made in suspicious cases according to aspiration cytology surgical pathology, digital substracted angiogram and/or computed tomography. A total of 12,026 men in seven study townships and 1,800 women in two townships in Penghu were recruited for first-stage screening (response rate: men, 25.5%; women, 46.8%). The positive rates for first-stage screening were 30.9% men and 34.6% women. The response rates for second-stage screening were 91% men and 90.5% women. Age-standardized prevalence of HCC per 1,000 subjects was 5.2 for men and 0.8 for women in Penghu Islets and 1.2 for men on Taiwan island. Among five serological biomarkers, HBsAg carrier status had the highest sensitivity (88.2%) and AFP had the second highest sensitivity (43.1%). The specificity of these markers was highest for AFP (99.0%) and lowest for HBsAg carrier status (80.3%). There were 16 new HCC cases identified after an intensive follow-up of 137 cases affected with liver cirrhos is giving an annual HCC incidence rate of 5.3%, while the rate for non-cirrhotic subjects who were positive on first-stage screening was only 0.15%. The combination of HBsAg and AFP for the first-stage screening and abdominal ultrasonography for the second-state screening seems valid for the early detection of HCC, but its cost-effectiveness remains to be elucidated by a longer follow-up study.

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.

The role of hepatitis C virus in chronic hepatitis B virus infection

To investigate the influence of hepatitis C virus (HCV) infection on patients with chronic hepatitis B virus (HBV), the presence of antibody against C100-3 antigen of HCV (anti-HCV) was examined in 420 patients with chronic HBV infection and 275 healthy subjects. It was found that the prevalence of HCV infection increased in parallel with the severity of liver damage. The positive rates of anti-HCV were as follows: healthy subjects, 2.9% (8/275); asymptomatic carriers, 2.6% (5/193); chronic hepatitis, 5.2% (3/58); liver cirrhosis, 11.4% (8/70); hepatocellular carcinoma (HCC), 12.1% (12/99). To elucidate the interaction of these two viruses in hepatocellular carcinoma, 128 HCC patients and 384 age-matched and sex-matched subjects were further analyzed. Eighty-seven of 128 HCC patients (68.0%) were only positive for HBsAg, 13 patients (10.1%) were only anti-HCV positive, and 12 (9.4%) were positive for both markers. The presence of HBsAg and anti-HCV was associated strongly with HCC. Moreover, the risk of HCC was significantly higher when both HBsAg and anti-HCV were present simultaneously. These results suggested that concurrent HCV infection might accelerate the progression of chronic HBV infection and may contribute to the pathogenesis of HCC in patients with chronic HBV infection.