[Hepatitis B virus transmission patterns in the Netherlands, 2004]

OBJECTIVE

To gain insight into hepatitis B virus (HBV) transmission in the Netherlands.

DESIGN

Descriptive.

METHOD

During 2004, epidemiological data and blood samples (if available) were collected for all reported cases of acute HBV infections in the Netherlands. Following DNA isolation and amplification a 648 base pairs fragment of the HBV S gene was sequenced and subjected to phylogenetic analysis. The sequencing details were also linked to epidemiological information.

RESULTS

In 2004, 291 cases ofacute HBV infections were reported. Blood samples were received from 171 patients (59%), and the genotype could be determined for 158 patients (54%). 6 genotypes were identified: A (64%), B (3%), C (3%), D (21%), E (5%) and F (4%). Of all patients with genotype A, 52% had been infected via homosexual or bisexual contact and 16% via heterosexual contact. Of all patients with genotype D, 42% had been infected via heterosexual contact and 15% via homosexual or bisexual contact. The genotype A cluster was extremely homogeneous with many identical sequences, while genotype B-E clusters were more heterogeneous. 4 identical sequences were found within genotype F, but the patients could not be epidemiologically linked.

CONCLUSION

Sexual transmission, particularly via homosexual or bisexual contact in men, formed the most important risk factor for acquiring an acute HBV infection. Genotype A was predominant in the Netherlands, especially among homosexual or bisexual men. Most infections within genotype D occurred as a result of heterosexual contact. The results show that there was ongoing transmission of HBV in homosexual or bisexual men, while in heterosexuals more cases of new introduction were seen, possibly via chronic carriers from areas where HBV is endemic.

[Chronic hepatitis B virus (HBV) infection: usefulness of the combination of HBeAg and ALT determination to predict a high HBV-DNA level and therefore the necessity of referral to a specialist for possible antiviral treatment]

OBJECTIVE

To assess the usefulness of a simple practical guideline based on hepatitis B e-antigen (HBeAg) status and a single alanine aminotransferase (ALT) determination to predict hepatitis B virus (HBV) load in chronic HBV patients as a criterion for referral to a specialist for possible antiviral therapy.

DESIGN

Prospective observational study.

METHOD

420 patients with chronic HBV infection were seen at the Municipal Health Service (MHS) in Rotterdam between 2002 and 2005. The usefulness ofa guideline based on HBeAg positivity and/or elevated ALT levels to predict high HBV DNA levels (defined as more than 10(5) copies/ml) was determined. Patients with HBeAg or an elevated ALT level were referred to a specialist according to the practical guideline. Positive and negative predictive value, sensitivity, and specificity of the referral guideline for a high HBV-DNA level were calculated.

RESULTS

Less than half, 43% (181/420) of the patients, were eligible for referral to specialist care. The positive predictive value of the referral guideline was 45% (82/181, 95% CI: 38-53). The negative predictive value, i.e. the proportion of patients with low viral loads who were (rightly) not selected for referral, was 95% (227/239; 95% CI: 71-97). The sensitivity was 87% (95% CI: 80-93): the patients selected included 82 of 94 patients with a high HBV DNA level. Of the 12 patients with high viral loads not referred according to the guideline, 11 had a viral load of between 10(5)-10(6) copies/ml.

CONCLUSION

A referral guideline based on HBeAg status and a single ALT determination can successfully predict viral load in chronic HBV patients and can be used in primary care to select patients for referral to specialist care. This guideline may limit the number of unnecessarily referred patients, enhancing the efficiency of the care for patients with chronic HBV infection.

Transmission routes of hepatitis B virus infection in chronic hepatitis B patients in The Netherlands

The Netherlands is a low endemic country for hepatitis B virus (HBV). Rotterdam, a city in The Netherlands harbors a large group of chronic hepatitis B (CHB) patients of which most are born abroad. The study included 464 consecutive CHB patients who were reported to the Municipal Public Health Service in Rotterdam from January 1, 2002 to September 15, 2005. The HBV genotypes, possible transmission routes of infection and travel history of CHB patients born in The Netherlands, were compared with those CHB patients living in The Netherlands but who were foreign-born, taking into account the ethnicity of the mother. Of the 464 patients with CHB infection, 14% were Dutch-born and 86% were foreign-born. The CHB patients in the Dutch-born group had genotypes A (35%), B (15%), C (11%), D (37%), and G (2%). In the foreign-born group, the distribution of genotypes was A (20%), B (15%), C (11%), D (40%), and E (15%). In the Dutch-born group, sexual transmission accounted for a larger proportion of infections (P < 0.0001) compared to the foreign-born group, whereas perinatal transmission is reported to be higher in the foreign-born group and in the Dutch-born group with a foreign mother. The genotypes of the chronic HBV strains determined corresponded well with the HBV genotypes expected from the countries of origin of the patients or their mothers. Genotypes A and D are predominant in CHB patients in The Netherlands.

Molecular epidemiology of acute hepatitis B in the Netherlands in 2004: nationwide survey

To gain insight into hepatitis B virus (HBV) transmission in the Netherlands, epidemiological data and sera were collected from reported cases of acute HBV infections in the Netherlands in 2004. Cases were classified according to mode of transmission. A fragment of the S-gene of HBV (648 bp) was amplified, sequenced, and subjected to phylogenetic analysis. Of the 291 acute HBV cases reported in 2004, 158 (54%) were available for genotyping. Phylogenetic analysis identified 6 genotypes: A (64%), B (3%), C (3%), D (21%), E (5%) and F (5%). Of HBV infected men having sex with men, 86% were infected with genotype A, accounting for 43% of all patients infected with this genotype. There were only three reported cases of injecting drug use of which one was available for sequencing (genotype A). Unlike the genotype A cluster, sequences within the genotype B-E clusters were heterogenic. Within genotype F, several isolates had identical sequences, but patients could not be epidemiologically linked. Sexual transmission, particularly by men having sex with men was the most important transmission route for HBV. Injecting drug use plays a minor role. Genotype A is predominant in the Netherlands, especially among men having sex with men. In addition to imported strains, there seems to be a pool of related but non-identical strains circulating among chronic carriers in the migrant population, from which occasionally new patients are infected, primarily by heterosexual transmission.

[Evaluation of the Rotterdam guideline for referral in case of chronic hepatitis B: improvement possible via a shortening of the referral chain and better distribution of information]

OBJECTIVE

Evaluation of the Rotterdam guideline for referring patients with chronic hepatitis B virus (HBV) infections from primary to specialist care for diagnosis and treatment.

DESIGN

Retrospective.

METHOD

Whether or not the guideline was followed correctly was determined in patients with chronic hepatitis B who were reported to the Municipal Health Service (GGD) in Rotterdam in 1998 and 1999. This was done by a study of their files and by questioning their general practitioners by phone.

RESULTS

During the study period, 376 cases of chronic hepatitis B were seen at the GGD; 32% of the patients dropped out during the referral trajectory. Drop-out took place at three different times: 13% during the process of deciding whether the patient should be referred according to the guideline, 12% during the consultation period at the GGD, and 7% after consultation at the GGD and before first contact with a specialist (via referral from the general practitioner). The reasons for dropping out were either procedural factors, such as missing information in the patient file and unclear management by the GGD, and personal factors such as failure of the general practitioner or the patient to comply with the recommendations.

CONCLUSION

The guideline for the referral of chronic hepatitis B patients functioned well but implementation can be improved, since some patients did not reach the specialist. Improvement would be made possible by shortening the referral chain and by giving more information to patients and general practitioners about hepatitis B and its potential consequences.

Restricted 12p amplification and RAS mutation in human germ cell tumors of the adult testis

Human testicular germ-cell tumors of young adults (TGCTs), both seminomas and nonseminomas, are characterized by 12p overrepresentation, mostly as isochromosomes, of which the biological and clinical significance is still unclear. A limited number of TGCTs has been identified with an additional high-level amplification of a restricted region of 12p including the K-RAS proto-oncogene. Here we show that the incidence of these restricted 12p amplifications is approximately 8% in primary TGCTs. Within a single cell formation of i(12p) and restricted 12p amplification is mutually exclusive. The borders of the amplicons cluster in short regions, and the amplicon was never found in the adjacent carcinoma in situ cells. Seminomas with the restricted 12p amplification virtually lacked apoptosis and the tumor cells showed prolonged in vitro survival like seminoma cells with a mutated RAS gene. However, no differences in proliferation index between these different groups of seminomas were found. Although patients with a seminoma containing a homogeneous restricted 12p amplification presented at a significantly younger age than those lacking it, the presence of a restricted 12p amplification/RAS mutation did not predict the stage of the disease at clinical presentation and the treatment response of primary seminomas. In 55 primary and metastatic tumors from 44 different patients who failed cisplatinum-based chemotherapy, the restricted 12p amplification and RAS mutations had the same incidence as in the consecutive series of responding patients. These data support the model that gain of 12p in TGCTs is related to invasive growth. It allows tumor cells, in particular those showing characteristics of early germ cells (ie, the seminoma cells), to survive outside their specific microenvironment. Overexpression of certain genes on 12p probably inhibits apoptosis in these tumor cells. However, the copy numbers of the restricted amplification of 12p and K-RAS mutations do not predict response to therapy and survival of the patients.

Chromosomal constitution of human spermatocytic seminomas: comparative genomic hybridization supported by conventional and interphase cytogenetics

No data on the chromosomal constitution of spermatocytic seminomas are available thus far because of their rarity. Ploidy analysis performed on paraffin-embedded cases showed varying results from (near-) diploid to aneuploid. We applied comparative genomic hybridization on four snap-frozen primary spermatocytic seminomas of three different patients. Conventional cytogenetic analysis was successful in one, and "interphase cytogenetics" with centromeric region-specific probes was applied to another. The results from comparative genomic hybridization showed almost exclusively numerical chromosomal aberrations, in agreement with the data from karyotyping. Despite the limited number of cases studied, a nonrandom pattern of chromosome imbalances was detected: chromosome 9 was gained in all spermatocytic seminomas. This suggests that that this aberration plays a role in the development of this cancer. Interphase cytogenetics shows that the copy number of most chromosomes ranges from two to four, with an average of near trisomic. This constitutes the first report on the chromosomal constitution of spermatocytic seminomas.

Identification of the critical region of 12p over-representation in testicular germ cell tumors of adolescents and adults

Cytogenetically, testicular germ cell tumors of adolescents and adults (TGCTs) are characterized by gain of 12p-sequences, most often through isochromosome formation (i(12p)). Fluorescence in situ hybridization (FISH) has shown that i(12p))-negative TGCTs also cryptically contain extra 12p-sequences. The consistency of 12p-over-representation in all histological subtypes of TGCTs, including their preinvasive stage, suggests that gain of one or more genes on 12p is crucial in the development of this cancer. So far, studies aimed at the identification of the relevant gene(s) were based on the 'candidate-gene approach'. No convincing evidence in favor of or against a particular gene has been reported. We combined conventional karyotyping, comparative genomic hybridization, and FISH to identify TGCTs with amplifications of restricted regions of 12p. Out of 49 primary TGCTs (23 without i(12p), 13 with and 13 unknown), eight tumors (six without i(12p) and two unknown) showed amplifications corresponding to 12p11.1-p12.1. Using bicolour-FISH, physical mapping, and semi-quantitative polymerase chain reactions, the size of the shortest region of overlap of amplification (SROA) was estimated to be between 1750-3000 kb. In addition, we mapped a number of genes in and around this region. While fourteen known genes could be excluded as candidates based on their location outside this region, we demonstrate that KRAS2, JAW1 and SOX5 genes are localized within the SROA. While KRAS2 and JAW1 map to the proximal border of the SROA, SOX5 maps centrally in the SROA. KRAS2 and JAW1 are expressed in all TGCTs, whereas one 12p amplicon-positive TGCT lacks expression of SOX5. The critical region of 12p over-represented in TGCTs is less than 8% of the total length of the short arm of chromosome 12. It will be helpful in the identification of the gene(s) involved in TGCT-development.

Comparative genomic hybridization in hypotriploid/hyperdiploid tumors

Hypotriploidy/hyperdiploidy ("intermediate ploidy") often occurs in testicular germ cell tumors of adolescents and adults. Disomic and trisomic chromosomes represent significant parts of the tumor genome and a few chromosomes fall outside the two- to three-copy number range. We performed comparative genomic hybridization (CGH) with DNA isolated from a cell line from a case of testicular germ cell tumor of adolescents and adults and found most of the ratio values to be dislocated from the baseline 1.0 and placed adjacent of the diagnostic thresholds of 0.8 and 1.2. We attributed that to the fact that, in current software packages for analysis of CGH, the fluorescence ratio baseline is assumed to correspond to the copy number of most loci of the genome. We then evaluated, instead of the commonly used fluorescent ratio value from the whole metaphase, the use of the fluorescence ratios of single chromosomes. The results permitted a clear distinction between the chromosomes with two and three copies and, in particular, of the regions deleted or amplified outside the two- to three-copy range. We concluded that the evaluation of unbalances of DNA copy number in intermediate ploidy cases is best carried out using multiple normalization.

Cloning and expression of interleukin-3 genes of chimpanzee and New World monkeys

Interleukin-3 (IL-3) genes were cloned from chimpanzee (Pan troglodytes), tamarin (Saguinus oedipus) and marmoset (Callithrix jacchus) and expressed in COS cells. Although the IL-3 gene structure is well conserved in these primate species, sequence analysis revealed extensive base substitutions. The chimpanzee IL-3 protein, which is highly homologous (98.5% identity) to human IL-3, stimulated proliferation of human cells dependent on IL-3. In contrast, due to the numerous amino acid substitutions in the New World monkey IL-3 species, no stimulation of human cells was observed, illustrating the extensive evolutionary divergence of IL-3.

Receptor and antibody interactions of human interleukin-3 characterized by mutational analysis

Human interleukin-3 (hIL-3) is a regulator of proliferation and differentiation of multipotent hemopoietic progenitor cells. Mutants of hIL-3 have been constructed by oligonucleotide-directed mutagenesis and expressed in Escherichia coli and Bacillus licheniformis. Purified muteins were assayed for induction of DNA synthesis in IL-3-dependent human cells and for binding to the IL-3 receptor. Residues at the NH2 and COOH termini together comprising one-quarter of the molecule could be removed without loss of biological function. Deletions of 6-15 residues within the central part of the molecule caused a large reduction (up to 5 logs) but no complete loss of activity. Substitution of evolutionary conserved residues resulted in a strong decrease of biological activity and demonstrated that the S-S bridge is an essential structural element in hIL-3. Interestingly, four muteins displayed a significantly higher potency of binding to the IL-3 receptor than in stimulating DNA synthesis. These results demonstrate that receptor binding may be (partly) disconnected from activation of DNA synthesis. Analysis of hIL-3 muteins demonstrated that the majority of monoclonal antibodies are directed against a small portion of the IL-3 molecule. The neutralizing potential of individual monoclonal antibodies could be increased by a combination of antibodies directed against nonoverlapping epitopes.