Prediction of long-term clinical outcome in a diverse chronic hepatitis B population: Role of the PAGE-B score.

An abundance of noninvasive scores have been associated with fibrosis and hepatocellular carcinoma (HCC) development. We aimed to compare the prognostic ability of these scores in relation to liver histology in chronic hepatitis B (CHB) patients. Liver biopsies from treatment-naïve CHB patients at one tertiary care centre were scored by a single hepato-pathologist. Laboratory values at liver biopsy were used to calculate the PAGE-B, REACH-B, GAG-HCC, CU-HCC and FIB-4 scores. Any clinical event was defined as HCC development, liver failure, transplantation and mortality. HCC and mortality data were obtained from national database registries. Of 557 patients, 40 developed a clinical event within a median follow-up of 10.1 (IQR 5.7-15.9) years. The PAGE-B score predicted any clinical event (C-statistic.86, 95% CI: 0.80-0.92), HCC development (C-statistic .91) and reduced transplant-free survival (C-statistic .83) with good accuracy, also when stratified by ethnicity, antiviral therapy after biopsy or advanced fibrosis. The C-statistics (95% CI) of the REACH-B, GAG-HCC, CU-HCC and FIB-4 scores for any event were .70 (0.59-0.81), .82 (0.75-0.89), .73 (0.63-0.84) and.79 (0.69-0.89), respectively. The PAGE-B event risk assessment improved modestly when combined with the Ishak fibrosis stage (C-statistic .87, 95% CI: 0.82-0.93). The PAGE-B score showed the best performance in assessing the likelihood of developing a clinical event among a diverse CHB population over 15 years of follow-up. Additional liver histological characteristics did not appear to provide a clinically significant improvement.

The number needed to treat to prevent mortality and cirrhosis-related complications among patients with cirrhosis and HCV genotype 1 infection.

Cirrhotic patients with chronic hepatitis C virus (HCV) infection remain at risk for complications following sustained virological response (SVR). Therefore, we aimed to evaluate treatment efficacy with the number needed to treat (NNT) to prevent clinical endpoints. Mortality and cirrhosis-related morbidity were assessed in an international multicentre cohort of consecutively treated patients with HCV genotype 1 infection and cirrhosis. The NNT to prevent death or clinical disease progression (any cirrhosis-related event or death) in one patient was determined with the adjusted (event-free) survival among patients without SVR and adjusted hazard ratio of SVR. Overall, 248 patients were followed for a median of 8.3 (IQR 6.2-11.1) years. Fifty-nine (24%) patients attained SVR. Among patients without SVR, the adjusted 5-year survival and event-free survival were 94.4% and 80.0%, respectively. SVR was associated with reduced all-cause mortality (HR 0.15, 95% CI 0.05-0.48, P = 0.002) and clinical disease progression (HR 0.16, 95% CI 0.07-0.36, P < 0.001). The NNT to prevent one death in 5 years declined from 1052 (95% CI 937-1755) at 2% SVR (interferon monotherapy) to 61 (95% CI 54-101) at 35% SVR (peginterferon and ribavirin). At 50% SVR, which might be expected with triple therapy, the estimated NNT was 43 (95% CI 38-71). The NNT to prevent clinical disease progression in one patient in 5 years was 302 (95% CI 271-407), 18 (95% CI 16-24) and 13 (95% CI 11-17) at 2%, 35% and 50% SVR, respectively. In conclusion, the NNT to prevent clinical endpoints among cirrhotic patients with HCV genotype 1 has declined enormously with the improvement of antiviral therapy.

Treatment in primary biliary cholangitis: Beyond ursodeoxycholic acid.

Primary biliary cholangitis (PBC) is a rare cholestatic immune-mediated liver disease. The clinical course varies from mild to severe, with a substantial group of patients developing cirrhosis within a decade. These patients are at risk of hepatocellular carcinoma, decompensation and liver failure. First line Ursodeoxycholic acid (UDCA) treatment improves the cholestatic surrogate markers, and was recently associated with a favorable survival free of liver transplantation, even in case of an incomplete biochemical response. However, despite adequate UDCA therapy, patients remain at risk of liver disease progression. Therefore, on-treatment multifactor-based risk stratification is necessary to identify patients in need of additional therapy. This requires a personalized approach; especially as recent studies suggest that complete biochemical normalization as most stringent response criterion might be preferred in selected patients to optimize their outcome. Today, stricter biochemical goals might actually be reachable with the addition of farnesoid X receptor or peroxisome proliferator-activated receptor agonists, or, in highly-selected cases, use of corticosteroids. Randomized controlled trials showed improvements in the key biochemical surrogate markers with the addition of these drugs, which have also been associated with improved clinical outcome. Considering this evolving PBC landscape, with more versatile treatment options and treatment goals, this review recapitulates the recent insight in UDCA therapy, the selection of patients with a residual risk of liver disease progression and the results of the currently available second line treatment options.

Sensitive detection of hepatocellular injury in chronic hepatitis C patients with circulating hepatocyte-derived microRNA-122.

As chronic hepatitis C patients with progressive disease can present themselves with normal ALT levels, more sensitive biomarkers are needed. MicroRNAs are newly discovered small noncoding RNAs that are stable and detectable in the circulation. We aimed to investigate the association between hepatocyte-derived microRNAs in serum and liver injury in patients with chronic hepatitis C. The hepatocyte-derived miR-122 and miR-192 were analysed in sera of 102 chronic HCV-infected patients and 24 healthy controls. Serum levels of miR-122 and miR-192 correlated strongly with ALT (R = 0.67 and R = 0.65, respectively, P < 0.001 for both). Median levels of miR-122 and miR-192 in HCV-infected patients were 23 times and 8 times higher as in healthy controls (P < 0.001 for both). Even within the HCV-infected patients with a normal ALT (n = 38), the levels of miR-122 and miR-192 were 12 times and 4 times higher compared with healthy controls (P < 0.001 for both). Multivariate logistic regression analyses showed that only miR-122 was a significant predictor of the presence of chronic HCV infection (P = 0.026). Importantly, miR-122 was also superior in discriminating chronic HCV-infected patients with a normal ALT from healthy controls compared with the ALT level (AUC = 0.97 vs AUC = 0.78, P = 0.007). In conclusion, our study confirmed that liver injury is associated with high levels of hepatocyte-derived microRNAs in circulation and demonstrated that in particular miR-122 is a sensitive marker to distinguish chronic hepatitis C patients from healthy controls. More sensitive blood markers would benefit especially those patients with minor levels of hepatocellular injury, who are not identified by current screening with ALT testing.

Time-trends in disease characteristics and comorbidities in patients with chronic hepatitis B in the period 1980-2020.

BACKGROUND & AIMS: The incidence of chronic hepatitis B (CHB) is declining due to successful implementation of vaccination programs and widespread use of antiviral therapy. We aimed to study time-trends in disease characteristics and comorbidities in newly referred CHB patients. METHODS: We collected information on hepatitis B virus (HBV) related disease characteristics (including hepatitis B e-antigen (HBeAg) status, viremia, stage of liver fibrosis and indication for treatment and/or hepatocellular carcinoma (HCC) surveillance) and presence of comorbidities in all CHB patients referred to our center from 1980 through 2020. Patient characteristics were compared according to referral date (before 2000, between 2000 and 2010 and after 2010). RESULTS: We identified 1515 eligible patients. Patients referred after 2010 were older (36 versus 34 years, p < 0.001), more often non-Caucasian (82.3% versus 55.0%, p < 0.001) and more frequently HBeAg negative (81.5% versus 49.8%, p < 0.001) when compared to patients referred before 2000. Adjusted for ethnicity, sex and age, patients referred after 2010 were less likely to have significant fibrosis (adjusted odds ratio [aOR]:0.178, p < 0.001) or indication for antiviral therapy (aOR:0.342, p < 0.001) but were more likely to be affected by the metabolic syndrome (aOR:1.985, p = 0.013), hepatic steatosis (aOR:1.727, p < 0.001) and metabolic dysfunction associated fatty liver disease (MAFLD) (aOR:1.438, p = 0.013). CONCLUSIONS: The characteristics of the CHB populations are changing. Newly referred patients are older, have less active HBV related liver disease but are more likely to be co-affected by MAFLD. These findings provide guidance for adequate allocation of resources to cope with the changing characteristics of the CHB population. FUNDING: Foundation for Liver and Gastrointestinal Research Rotterdam, the Netherlands and Gilead Sciences.

The therapeutic potential of polymersomes loaded with 225Ac evaluated in 2D and 3D in vitro glioma models.

Alpha emitters have great potential in targeted tumour therapy, especially in destroying micrometastases, due to their high linear energy transfer (LET). To prevent toxicity caused by recoiled daughter atoms in healthy tissue, alpha emitters like 225Ac can be encapsulated in polymeric nanocarriers (polymersomes), which are capable of retaining the daughter atoms to a large degree. In the translation to a (pre-)clinical setting, it is essential to evaluate their therapeutic potential. As multicellular tumour spheroids mimic a tumour microenvironment more closely than a two-dimensional cellular monolayer, this study has focussed on the interaction of the polymersomes with U87 human glioma spheroids. We have found that polymersomes distribute themselves throughout the spheroid after 4 days which, considering the long half-life of 225Ac (9.9 d) (Vaidyanathan and Zalutsky, 1996), allows for irradiation of the entire spheroid. A decrease in spheroidal growth has been observed upon the addition of only 0.1 kBq 225Ac, an effect which was more pronounced for the 225Ac in polymersomes than when only coupled to DTPA. At higher activities (5 kBq), the spheroids have been found to be destroyed completely after two days. We have thus demonstrated that 225Ac containing polymersomes effectively inhibit tumour spheroid growth, making them very promising candidates for future in vivo testing.

Miravirsen dosing in chronic hepatitis C patients results in decreased microRNA-122 levels without affecting other microRNAs in plasma.

BACKGROUND: MicroRNA-122 (miR-122) is an important host factor for hepatitis C virus replication. Administration of miravirsen, an anti-miR-122 oligonucleotide, resulted in a dose dependent and prolonged decrease in HCV RNA levels in chronic hepatitis C patients. AIM: To assess the plasma level of various miRNAs in patients dosed with miravirsen. METHODS: We included 16 of 36 chronic hepatitis C patients who received five injections of either 3 mg/kg (n = 4), 5 mg/kg (n = 4), 7 mg/kg (n = 4) miravirsen or placebo (n = 4) over a 4-week period in a double-blind, randomised phase 2a study. Plasma levels of 179 miRNAs were determined by qPCR and compared between patients dosed with miravirsen or placebo. RESULTS: Median plasma miR-122 level at baseline in patients receiving miravirsen was 3.9 × 10(3) compared to 1.3 × 10(4) copies/4 µL in placebo-dosed patients (P = 0.68). At week 1, 4, 6 and 10/12, patients dosed with miravirsen had respectively a median 72-fold, 174-fold, 1109-fold and 552-fold lower expression of miR-122 than at baseline (P = 0.001, as compared to patients receiving placebo). At week 4 of dosing, miRNA-profiling demonstrated a significant lower expression of miR-210 and miR-532-5p compared to baseline (3.0 and 4.7-fold lower respectively). However, subsequent longitudinal analysis showed no significant differences in miR-210 and miR-532-5p plasma levels throughout the study period. CONCLUSIONS: We demonstrated a substantial and prolonged decrease in plasma miR-122 levels in patients dosed with miravirsen. Plasma levels of other miRNAs were not significantly affected by antagonising miR-122.

The estimated future disease burden of hepatitis C virus in the Netherlands with different treatment paradigms.

BACKGROUND & AIMS: Prevalence of hepatitis C virus (HCV) infection in the Netherlands is low (anti-HCV prevalence 0.22%). All-oral treatment with direct-acting antivirals (DAAs) is tolerable and effective but expensive. Our analysis projected the future HCV-related disease burden in the Netherlands by applying different treatment scenarios. METHODS: Using a modelling approach, the size of the HCV-viraemic population in the Netherlands in 2014 was estimated using available data and expert consensus. The base scenario (based on the current Dutch situation) and different treatment scenarios (with increased efficacy, treatment uptake, and diagnoses) were modelled and the future HCV disease burden was predicted for each scenario. RESULTS: The estimated number of individuals with viraemic HCV infection in the Netherlands in 2014 was 19,200 (prevalence 0.12%). By 2030, this number is projected to decrease by 4 5% in the base scenario and by 85% if the number of treated patients increases. Furthermore, the number of individuals with hepatocellular carcinoma and liver-related deaths is estimated to decrease by 19% and 27%, respectively, in the base scenario, but may both be further decreased by 68% when focusing on treatment of HCV patients with a fibrosis stage of ≥ F2. CONCLUSIONS: A substantial reduction in HCV-related disease burden is possible with increases in treatment uptake as the efficacy of current therapies is high. Further reduction of HCV-related disease burden may be achieved through increases in diagnosis and preventative measures. These results might inform the further development of effective disease management strategies in the Netherlands.

A contribution to the improvement of accuracy in the quantitation of THC.

The accuracy of a quantitative analysis is highly dependent on the quality of the reference standard. Although reference standards are more and more supplied with a certificate, laboratories may feel the need for additional acceptance testing. In general, confirmation of the purity of many solid reference substances can be obtained by a number of simple tests. However, verification of the true content of reference solutions may be complicated. A number of problems with the THC quantitation caused our interest for a verification method for the THC reference solution. The quantitation of THC is performed by gas chromatography with flame ionisation detector. The effective carbon number concept was used to predict GC/FID response factors. Equations and data are presented to calculate theoretical response ratios of cannabinoids. The experimental data for CBD and CBN were in excellent agreement with the theoretical ones. The paper shows that the response factors of CBD and/or CBN can be used for the calculation of the THC content of either reference solutions or cannabis samples.

1-phenylethylamines: a new series of illicit drugs?

Since 1993 many seizures of 1-phenylethylamine have been made in several European countries. It was originally thought that 1-phenylethylamine had been made in error, but later information suggested that it had been prepared deliberately. The related compounds, 1-amino-1-(4-methylphenyl)ethane and 1-methylamino-1-phenylethane and the 1-propanamine isomer of 3,4-methylenedioxyamphetamine, have also occurred in isolated cases. Analytical data are presented on these amines as well as a number of Leuckart impurities in 1-phenylethylamine. The pharmacological effects of these substances are largely unknown.

On the variability of plant bio-concentration factors (BCF) of environmental radionuclides: a case study on the effects of surface film and free space on the interpretation of 99mTcO4- sorption in duckweed.

The present paper addresses plant bioaccumulation factor (BCF) variability, and specifically focuses attention upon the handling of duckweed (Lemna gibba) material, sampled from experimental media, especially considering accumulation/kinetic studies with 99mTcO4-. In these short-term studies, relatively small BCF-values may be encountered, with related interferences in its assessment due to the presence of 99mTcO4- in the surface film medium (SF) and in the cellular water free spaces (FS). The sample handling methods used to remove the SF + FS component of the accumulated 99mTcO4- consisted of blotting, centrifugation and rinsing. The three methods were investigated using D-[1-(14)C]mannitol, 42K+, 82Br- and 99mTcO4- radioisotopes, which were measured by beta- and gamma-spectrometry, in both solution and solid samples. Centrifugation seems the most promising method to remove SF + FS 99mTcO4-. Results based on both mass analysis and radioactivity determinations in centrifugated fluids are independent of applied concentrations (10(-11) to 10(-13) mol m(-3) 99mTcO4-), and are invariably compatible with the conceptual idea of the FS as a free-entrance phase for solutes. Blotting results in an overestimation of BCF values (up to factor 3 for the 99mTcO4- experiments performed), probably due to the incomplete removal of the SF + FS, and is suggested to yield irregular results, leading to high variances in BCF values obtained. The application of an efflux/rinsing period is indicated to result in an underestimation of BCF values (up to factor 10 for the 99mTcO4- experiments performed), probably due to excess removal of (non-SF + FS) components of accumulated solutes. Here we advocate centrifugation as a routine sample handling method to avoid SF + FS interferences in short-term (kinetic) 99mTcO4- uptake studies in duckweed. Moreover, the results suggest a more general applicability of centrifugation as a sample handling method to avoid SF + FS interferences in short-term element accumulation studies; centrifugation approaches should, however, be adjusted to plant cell characteristics.

Transport rate of arsenic, cadmium, copper and zinc in Potamogeton pectinatus L.: radiotracer experiments with 76As,109,115Cd,64Cu and 65,69mZn.

The present study was aimed at obtaining an insight into possible experimental approaches for providing numerical data on both the accumulation of sediment As, Cd, Cu and Zn in the submerged water plant Potamogeton pectinatus L., and the possible corresponding metal flows into the water phase. A hydroculture two-compartment system was used as the experimental set-up, and the selected metals were followed by measurements of their radioisotopes 76As, 109Cd, 115Cd, 64Cu, 65Zn and 69mZn. All experiments were performed in single plant mode. The results stress the extreme importance of leakage tests, which were performed using 99mTcO4-, and which resulted in approximately 30% of all experiments being discarded. Metal flows were shown as very near the metal limits of detection or obscured by and/or numerically very near the occurring leakage phenomena. Bio-concentration factors BCF (fresh wt. fine root basis) were calculated as 100, 10, 10 and 100-500 l/kg for Cu, Zn, Cd and As, respectively. The mobility, expressed as the shoot/root concentration ratio, CR, was obtained as < 10(-4), < 10(-5), 10(-3) and 10(-3) - 10(-2) for Cu, As, Cd and Zn, respectively. Double-labeling experiments showed that the CR values were due to the exclusive root-mediated transport in radiotracer experiments: results for simultaneous applications of 109Cd and 115Cd or 65Zn and 69mZn showed field-simulated CR values of approximately 0.04 and 14, respectively. Single-tracer experiments, using liquid scintillation counting (LSC) with 109Cd and 65Zn, were shown to strongly improve the sensitivities of flow determinations. Under the applied conditions, metal flows could be determined as <5 x 10(-8), <5 X 10(-8), 3.5+/-1.8 x 10(-10) and <8 x 10(-9) mol/h per kg root fresh wt. for Cu, As, Cd and Zn, respectively. Upscaling calculations, assuming plant steady state behavior, indicate that the metal accumulation in the plants may comprise up to 1% of the sediment metal occurrence, that the major part of an accumulated metal is retained in the plant roots, and that plant-mediated metal flow into the water phase (< 0.01% for Cd, Cu and Zn, < 0.1% for As within a growing season) may be regarded as not significantly contributing to the overall process of metal mobilization. It should be noted, however, that the above conclusions should be drawn with care, due to the pilot nature and the short-term duration of the presented experiments.