Proteomic characterization of hepatitis C eradication: enzyme switch in the healing liver.

Lipid pathway impairment, decrease in the antioxidant pool and downregulation in amino-acid metabolism are just some of the metabolic variations attributed to chronic HCV infection. All of them have been studied separately, mainly in animal models. Thanks to proteomic analysis we managed to describe (for the fist time to the best of our knowledge), in vivo and in humans, the metabolic alterations caused by HCV, and the recovery of the same alterations during HCV treatment. We performed proteomic analysis on liver specimens of a 28-year-old woman affected by hepatitis C genotype 1a, alcoholism and diabetes mellitus type 1, before and after antiviral treatment with pegylated interferon alpha 2b and ribavirin. The subject, thanks to a patient-tailored therapy, reached Sustained Virological Response. Throughout the treatment period the patient was monitored with subsequent biochemical, clinical and psychological examinations. The data obtained by the patient's close monitoring suggest a direct interaction between insulin resistance and an active HCV genotype 1 infection, with a leading role played by the infection, and not by insulin resistance, as demonstrated by the sharp fall of the insulin units needed per day during treatment. The proteomic analysis showed that after therapy, a downregulation of enzymes involved in amino acid metabolism, glycolysis/gluconeogenesis and alcohol catabolism takes place, the latter probably due to cessation of alcohol abuse. On the contrary, the metabolic pathways linked to metabolism of the reactive oxygen species were upregulated after therapy. Finally, a significant alteration in the pathway regulated by peroxisome proliferator-activated receptor alpha (PPARA), a major regulator of lipid metabolism in the liver, was reported. These "real time" data confirm in vivo, in humans, that during HCV infection, the pathways related to fatty acids, glucose metabolism and free radical scavenging are inhibited. The same enzyme deficit is completely recovered after HCV eradication.

Role of routine small intestinal biopsy in adult patient with irritable bowel syndrome-like symptoms.

AIM: The clinical evaluation of patients with chronic diarrhea and/or abdominal pain requires a complex work-up. The aim of the study was to evaluate whether routine duodenal biopsy sampling of macroscopically normal mucosa of patients with irritable bowel syndrome-like symptoms undergoing upper endoscopy assists in diagnosis and management. METHODS: Consecutive adults scheduled for upper endoscopy for evaluation of uninvestigated dyspepsia and abdominal pain and/or chronic diarrhea based upon the history, were enrolled. Gastric biopsies and 3 duodenal biopsies were taken for histological evaluation. RESULTS: A total of 786 sets of biopsies from 262 consecutive patients (200 females and 62 males, mean age 46 years; range: 15-82), were analyzed. Microscopic damage was observed in 212 of 262 patients (81%) with normal mucosa. Mild to moderate and severe duodenitis or villi atrophy was histologically confirmed in 65%, 26% and 8% of 212 patients respectively. The negative predictive value of a normal appearing duodenal mucosa was 19%. Additional tests confirmed celiac disease in 12 patients. Lactose malabsorption was present in 42%, bacterial overgrowth in 14%, and H. pylori infection in 28%. Colonoscopy performed in 92 patients revealed non specific colitis (25%), microscopic colitis (28%), Crohn's disease (1%), and diverticulosis (15%). CONCLUSION: Duodenal biopsies revealed abnormalities in the majority of adults with chronic diarrhea and/or abdominal pain despite macroscopically normal gross findings. These results suggest that duodenal biopsies could be helpful in patients with chronic diarrhea and/or abdominal pain for the following work up.

Sebaceous gland hyperplasia of the foreskin.

Two men, aged in their 20s, presented with multiple, soft, rounded papules on the prepuce. The lesions were centrally umbilicated, resembling molluscum contagiosum, but clearly distinct from Tyson's glands. Surface microscopy showed well-defined, milky-white, bag-shaped structures, which under histological examination were found to be sebaceous glands with various features of hyperplasia. A lymphocytic T-cell infiltrate, closely associated with progressive degeneration and destruction of the sebocytes, was visible around the glands. In the differential diagnosis of penile papular lesions, this unusual clinical presentation supported by dermatoscopy is consistent with preputial sebaceous gland hyperplasia. As both patients had a prominent T-cell infiltration, it is possible that under inflammatory stimulation, sebaceous glands undergo hypertrophy and gradual central involution.

Different associations of C-reactive protein, fibrinogen and C3 with traditional risk factors in middle-aged men.

BACKGROUND: Some acute phase proteins are associated with both ischemic events and traditional risk factors. Since they are strongly interrelated, each of them partly reflects the characteristics of other proteins. This study was carried out to ascertain the specific preferential associations of some acute phase proteins with traditional risk factors for atherosclerotic disease. METHODS: High-sensitivity C-reactive protein, fibrinogen and C3-complement were assessed in 288 unselected men aged 55-64 years. Three multiple linear regression analyses were performed, in which each of the three acute phase proteins was considered the dependent variable of both traditional risk factors and the other two proteins. RESULTS: The three acute phase proteins strongly correlated with each other. Moreover, C-reactive protein was independently associated with triglycerides (P<0.0001), age (P=0.0130), body mass index (P=0.0179), and acute (P=0.0280) and chronic (P=0.0582) inflammations (R2=0.17). Fibrinogen was associated with alcohol consumption (inversely, P=0.0001) and smoking (P=0.0598) (R2=0.06). Finally, C3 was associated with insulin (P<0.0001), cholesterol (P=0.0001), sedentarity (P=0.0028), glucose (P=0.0077), and systolic blood pressure (P=0.0124) (R2=0.28). CONCLUSIONS: When simultaneously studied in multivariate analysis, acute phase proteins have different preferential associations with traditional risk factors, a probable consequence of their involvement in different cellular activations and metabolic processes.

Genomic instability in chronic viral hepatitis and hepatocellular carcinoma.

Chronic hepatitis may progress to cirrhosis and hepatocellular carcinoma (HCC). Progressive accumulation of mutations and genomic instability in chronic viral hepatitis might flag an increased risk of HCC development. Genomic instability at dinucleotide microsatellite loci in chromosomes 2, 13, and 17 and at 2 mononucleotide repeat loci was examined in liver tissues from 41 patients, including 30 without HCC (18 patients with chronic hepatitis and 12 with cirrhosis) and 11 with HCC. Genomic instability was detected in 51% of the 41 cases. Allelic imbalance at informative dinucleotide loci occurred in 37% of the cases. In 14 cases (34%), allelic imbalance was detected in chronic hepatitis or cirrhosis without HCC. Allelic imbalance at the chromosome 13 locus was detected in 50% of the cases of chronic hepatitis C. Allelic imbalance at the TP53 chromosome locus and/or at the chromosome 13 locus was significantly more frequent than alterations at the chromosome 2 locus (P =.026). Low-level microsatellite instability was found in 20% of all cases examined and high-level microsatellite instability in 3 patients (7.5%), including 2 cases of chronic hepatitis and 1 case of cirrhosis. Our results show that allelic imbalance occurs frequently in hepatitis-related HCC as well as in chronic hepatitis in patients without HCC. Allelic imbalance at the D13S170 chromosome 13 locus (13q31.2) occurs frequently in chronic hepatitis, suggesting that genomic alterations affecting the long arm of chromosome 13 might be used to monitor the natural progression of chronic hepatitis-associated liver carcinogenesis.

Rectal endometrial stromal sarcoma arising in endometriosis: report of a case.

PURPOSE: Endometriosis of the rectovaginal septum can harbor different types of secondary tumors that may involve the rectal wall and protrude into its lumen, thus making diagnosis difficult. Extrauterine low-grade endometrial stromal sarcoma may rarely arise in endometriosis. The purpose of this article was to present the third case of this association. METHOD: This was a clinicopathologic study. RESULTS: A 42-year-old female presented with abdominal pain and fever. Laparotomy revealed a large pelvic mass involving the rectovaginal septum and the colonic wall and which protruded into the lumen forming endoluminal polypoid masses. Concomitant peritoneal nodules and a metastatic paracolic lymph node were also found. Histopathologically, primary endometriotic foci were found in close relationship with an endometrial stromal sarcoma which invaded the rectal wall. The female genital tract had no endometriotic lesions. The patient was treated by surgery and subsequent chemotherapy and was alive and well 20 months later. CONCLUSIONS: Endometriosis and its possible malignant changes should be taken into account in the differential endoscopic diagnosis of rectal masses in females.

Short term effect of atorvastatin and vitamin E on serum levels of C3, a sensitive marker of the risk of myocardial infarction in men.

C3 complement is produced in response to macrophage activation and is a reliable marker of the risk of myocardial infarction in men. This study was designed to ascertain whether the treatment with atorvastatin, a powerful cholesterol lowering drug, and/or vitamin E, a natural antioxidant, may induce a short term decrease in serum C3 in subjects with persistently elevated levels. From an initial random sample of 1100 men aged 55-64 years, 140 subjects with 3 consecutive C3 measurements in the high tertile (>1.19 g/l) were selected. Those with total cholesterol <5.56 mmol/l were double blindly randomized in groups 1 (placebo, N = 28, G1) and 2 (vitamin E 600 IU/day, N= 30, G2). The subjects with total cholesterol values >5.56 mmol/l were randomized in groups 3 (placebo, N= 30, G3), 4 (atorvastatin 10 mg/day, N = 27, G4) and 5 (atorvastatin 10 mg/day + vitamin E 600 IU/day, N = 25, G5). After 3 months C3 levels were substantially unchanged in the first 4 groups, while in G5 a very significant decrement occurred: -0.070 g/l (5.2%); 95% CI 0.043-0.098; p <0.0001. "Normal" levels of C3 (< 1.19 g/l) were reached by 28% of G5 subjects. In G2 and G5 vitamin E levels increased by 60 and 36%, while in G4 they decreased by 23% (p < 0.0001), paralleling cholesterol and triglyceride fall. In all groups a progressive decrease in HDL cholesterol occurred (-17%, p < 0.0001). In conclusion, treatment with atorvastatin plus vitamin E for three months can lower persistently elevated C3 levels.

Microsatellite analysis at 10q25-q26 in Sardinian patients with sporadic endometrial carcinoma: identification of specification patterns of genetic alteration.

BACKGROUND: Loss of heterozygosity (LOH) at chromosome 10q25-q26 has been reported previously in endometrial carcinoma (EC), suggesting the presence of tumor suppressor gene(s). Nevertheless, frequency of genome-wide microsatellite instability (MSI) has been demonstrated higher in EC than in other common malignancy, mostly due to defective DNA mismatch repair. The authors further evaluated the role of the chromosome 10q25-q26 in endometrial tumorigenesis as well as the clinical significance of any observed genetic alteration in sporadic EC. METHODS: Paired normal and tumor samples from 94 Sardinian patients with sporadic EC at various stages of disease were screened by polymerase chain reaction (PCR)-based microsatellite analysis. Genomic DNA was isolated from paraffin embedded tissues and amplified by PCR using microsatellite markers spanning approximately 14 cM at 10q25-q26. Microsatellite instability was studied at four loci mapping to different chromosomal locations. RESULTS: Thirty-two (34%) EC patients were found negative for genetic alterations within the 10q25-q26 region. Among the remaining 62 (66%) EC cases, the authors identified 1) a minimum consensus region of LOH of approximately 1 cM, between D10S610 and D10S542 markers; and 2) a subset of tumors with prevalence of instability at 10q25-q26 (10qMI+), as expression of the presence of a MSI+ phenotype. CONCLUSIONS: The authors' data establish the existence of significant correlations between disease stages and 10qMI+ (with or without MSI+). However, longer follow-up and additional studies are required to define the clinical significance of these findings as prognostic factors. Moreover, the minimum region of LOH at 10q25-q26 will be further analyzed for identifying the putative tumor suppressor gene involved in EC pathogenesis.

Mortality rates and number of deaths from cardiovascular diseases in Italy from 1982 to 1993. A comparison with total and tumour data.

In this study the recent Italian trends in cardiovascular deaths and mortality are described and compared with the trends regarding total and tumour deaths and mortality. The data, collected from the National Institute of Statistics, are presented as total (T), tumour (TU), cardiovascular (CV), cerebrovascular (CVD), ischemic heart disease (IHD) standardized mortality (sm), non-standardized mortality (nsm) and absolute number of deaths (d), according to sex, age, and geographical area. Data on sm were available only for the age group <75 years old. In males, from 1982 to 1993, T-sm fell by 18%, TU-sm by 4%, CV-sm by 30%, CVD-sm by 38% and IHD-sm by 24%. In females, the decrements were generally greater: T-sm 20%, TU-sm 4%, CV-sm 35%, CVD-sm 39% and IHD-sm 28%. Since 1985/87, tumours have been the leading cause of mortality, in both sexes. By 1991/93, the highest rates of CV, CVD, IHD-sm were reported mostly in the South of Italy. Non-standardized mortality rates for tumours increased, and for cardiovascular diseases decreased, in both sexes and age groups (<75 and >/=75 years old). As for sm, in the group <75 years, old tumours have been the leading cause of mortality since 1985/87, but in the older age group CV-nsm has been more than twice TU-nsm. By 1991/93 in comparison with 1982/84, CV deaths have fallen by 6% (-28% in the age group <75 years, +3% in the age group >/=75 years), while TU deaths have grown by 17% (+3% in the age group <75 years, +45% in the age group >/=75 years). Considering all age groups, by 1991/93 the absolute number of CV-d (239.241) was much greater than the number of TU-d (151.908); overall, almost 70% of CV-d and 40% of TU-d took place in the older age group. For the near future, the rapid aging of the Italian population (from 1982/84 to 1991/93 there was a 40% increment in the population older than 75 years) is a relevant variable to take into account. Thus, despite the 'reassuring' fall in CV-sm and nsm, cardiovascular diseases are expected to remain the major cause of death and physical disability in adults.

Expression of the ALK protein by anaplastic large-cell lymphomas correlates with high proliferative activity.

A variable fraction of anaplastic large-cell lymphomas (ALCLs) exhibits a t(2;5)(p23;q35) translocation that results in expression of the chimeric hyperphosphorylated protein NPM-ALK (p80). Tumor cells expressing NPM-ALK exhibit markedly enhanced proliferative activity, but comparative cellular kinetic studies on ALK(+) (ALK lymphomas) and ALK(-) lymphomas are lacking. The present study showed that ALK(+) lymphomas, detected with the monoclonal antibody ALKc (n = 17), had significantly higher average values for the proliferation-associated parameters mitotic index, ana/telophase index, growth index (x x mitotic index - apoptotic index, assuming x = 3), percentages of Ki-67(+) cells and fraction of cells expressing cyclin A or B or the cell cycle-regulatory protein p34(cdc2) than did ALK(-) ALCLs (n = 15). Whether this intense proliferative activity contributes to the good response to chemotherapy and favorable outcome of ALK(+) ALCLs remains to be assessed in a larger series of patients. Our findings support the notion that ALK(+) and ALK(-) ALCLs are 2 distinct disease entities.

Relationship of serum C3 to fasting insulin, risk factors and previous ischaemic events in middle-aged men.

AIMS: Serum C3 is a powerful indicator of the risk of myocardial infarction, which correlates with body mass index, serum lipids and blood pressure. This study was performed to ascertain whether such correlations may be explained by an association of C3 with fasting insulin, and to assess comparatively the relationships of C3 and traditional risk factors to previous myocardial infarction. METHODS AND RESULTS: The fasting levels of C3, insulin, and the main risk factors were evaluated in 1090 unselected men aged 55-64 years, including 129 cases of previous ischaemic events (51 myocardial infarctions). In multivariate analysis C3 was associated with insulin (r=0.27, P<0.0001), cholesterol (r=0.18, P<0.0001), body mass index (r=0.13, P<0.0001), glucose (r=0.12, P=0.0001), systolic blood pressure (r=0.10, P<0.001), triglycerides (r=0.09, P<0.01) and HDL-cholesterol (r=-0.06, P<0.05). These variables explained 31% of the total C3 variance. Alcohol consumption and physical activity correlated inversely with C3, while no correlation was found with smoking and family history of myocardial infarction. C3 was associated with previous myocardial infarction and stroke, but not with angina pectoris and peripheral arterial disease. In logistic regression the variables associated with previous myocardial infarction were C3 (P=0.011), family history of myocardial infarction (P=0.018), ex-smoker status (P=0.020), age (P=0.025), glucose (P=0.028) and HDL-cholesterol (P=0.051, inverse relationship). CONCLUSIONS: The association of C3 with myocardial infarction persists retrospectively, and is more significant than any other association of traditional risk factors with previous myocardial infarction. Of the many variables associated with C3, fasting insulin is its main covariate, which suggests that C3 is a marker of a pro-atherogenic metabolic imbalance partly coinciding with insulin resistance.

Identification of a founder BRCA2 mutation in Sardinia.

Sardinian population can be instrumental in defining the molecular basis of cancer, using the identity-by-descent method. We selected seven Sardinian breast cancer families originating from the northern-central part of the island with multiple affected members in different generations. We genotyped 106 members of the seven families and 20 control nuclear families with markers flanking BRCA2 locus at 13q12-q13. The detection of a common haplotype shared by four out of seven families (60%) suggests the presence of a founder BRCA2 mutation. Direct sequencing of BRCA2 coding exons of patients carrying the shared haplotype, allowed the identification of a 'frame-shift' mutation at codon 2867 (8765delAG), causing a premature termination-codon. This mutation was found in breast cancer patients as well as one prostate and one bladder cancer patient with shared haplotype. We then investigated the frequency of 8765delAG in the Sardinian breast cancer population by analysing 270 paraffin-embedded normal tissue samples from breast cancer patients. Five patients (1.7%) were found to be positive for the 8765delAG mutation. Discovery of a founder mutation in Sardinia through the identity-by-descent method demonstrates that this approach can be applied successfully to find mutations either for breast cancer or for other types of tumours.

High prevalence of Helicobacter pylori infection in shepherds.

It has been suggested that Helicobacter pylori infection may, in some instances, be a zoonosis. The aim of this study was to evaluate the prevalence of H. pylori infection in Sardinian shepherds and their families in relation to exposure to sheep and sheep dogs. Sardinian shepherds and a control group of blood donors completed detailed questionnaires regarding demographics, childhood and current economic status, and the presence of symptoms related to the upper gastrointestinal tract. H. pylori status was determined by a sensitive ELISA for anti-H. pylori IgG and by western blot for anti-CagA IgG. A subgroup of shepherds had upper gastrointestinal endoscopy with biopsy to assess the severity of the gastritis. H. pylori infection in Sardinian shepherds approached 100% and was positively related to animal contact (98% of shepherds, 73% of family members without regular direct animal contact compared to 43% of blood donors) (P < 0.001). Importantly, the family members shared the same childhood with the shepherds but choose different careers (e.g., teachers, nurses, business) and did not have regular contact with sheep. In conclusion, the prevalence of H. pylori infection in Sardinian shepherds is among the highest in the world and is associated with direct contact with sheep and sheep dogs. These results suggest that the cycle of H. pylori infection might, in certain circumstances, include phases in the environment, animals (sheep or dogs) and human beings.

Pretreatment antibiotic resistance in Helicobacter pylori infection: results of three randomized controlled studies.

BACKGROUND: Although combinations of antibiotics and antisecretory drugs are useful for treatment of Helicobacter pylori infection, treatment failure is common. The aim of this study was to evaluate the relation between pretreatment antibiotic resistance and outcome by using six different treatment regimens for H. pylori infection. PATIENTS AND METHODS: Three hundred sixty-nine consecutive H. pylori-infected patients with dyspeptic symptoms were enrolled in three consecutive randomized, controlled, single-center clinical trials: trial A, 128 patients; trial B, 125 patients; trial C, 116 patients. Treatments consisted of (A) a 15-day course of dual therapy (omeprazole, 20 mg bid, and amoxicillin, 1 gm bid, or clarithromycin, 500 mg tid) (OA vs OC); (B) a 7-day triple therapy of omeprazole, 20 mg bid, plus metronidazole, 500 mg bid, and amoxicillin, 1,000 mg bid, or clarithromycin, 500 mg tid (OMA vs OMC); or (C) omeprazole, 20 mg bid, plus metronidazole, 500 mg bid, plus tetracycline, 500 mg qid, or doxycycline, 100 mg tid (OMT vs OMD). Diagnostic endoscopy was made in all patients before and 5 to 6 weeks after therapy. Six biopsies were taken from each patient for histology, rapid urease test, and H. pylori culture; antibiotic susceptibility testing was performed using the E-test method. RESULTS: Overall cure rates were poor for both dual therapies OA and OC (38% and 37%, respectively) and for triple therapies OMA, OMC, and OMD (57%, 55%, and 58%, respectively). The OMT combination was successful in 91% (95% confidence interval [CI], 80.4%-97%). Metronidazole resistance was present in 29.7% (95% CI, 24%-35%), amoxicillin resistance was present in 26% (95% CI, 21%-32%), clarithromycin resistance was present in 23.1% (95% CI, 18%-29%), tetracycline resistance was present in 14% (95% CI, 10%-20%), and doxycycline resistance was present in 33.3% (95% CI, 21%-47%). Antibiotic resistance markedly reduced the cure rates and accounted for most of the poor results with the triple therapies: 89% versus 23%; 77% versus 26%; 100% versus 60%; and 67% versus 23% for OMC, OMA, OMT, and OMD, respectively. OMT appeared to be the best because of the high success rate with metronidazole-resistant H. pylori (71%) and in low-level tetracycline resistance. CONCLUSIONS: Pretreatment antibiotic-resistant H. pylori can, in part, explain the low cure rate of the infection and the variability in outcome in reported trials.

Telecardiology community: a new approach to take care of cardiac patients. "Boario Home-Care" Investigators.

BACKGROUND: Cardiovascular diseases are the leading cause of morbidity and mortality in Western countries and represent, in terms of diagnostic and treatment measures, a large amount of health care expenses. A telecardiology service may offer to general practitioners, in real time, a useful diagnostic tool and the possibility of an accurate screening of patients with suspected ischemic heart disease. METHODS: From February to July 1998, in the provinces of Bergamo and Brescia (Italy), 178 general practitioners received a portable Card Guard 7100 electrocardiographer transferring, by a mobile or fixed telephone, a 12 lead ECG to a receiving station, where a cardiologist was available for the reporting and interactive teleconsultation. RESULTS: During the first 6 months a total 2800 calls took place. Due to incompleteness of requested data only 2254 traces, corresponding to 2254 subjects (mean age 63 +/- 18 years) were entered in the study. In 27% of patients (n = 609) there was a history of systemic hypertension, in 12.5% (n = 283) there was a history of coronary artery disease, and in 38% (n = 834) there was no history of cardiovascular diseases. At the time of ECG recording, 42% of patients (n = 949) were symptomatic: more common symptoms were chest pain (39%), dyspnea (23%), palpitation (19%), dizziness or faint (10%), and asthenia (9%). No action was suggested by cardiologists in 74% of cases. Of the remaining patients, 16% (n = 92) were referred to the Emergency Department, 27% (n = 158) were offered further diagnostic tests as an out patient, and 56% (n = 328) were started on medication or had their treatment changed. CONCLUSIONS: A telecardiology system provides a useful support to general practitioners in the management, in real time, of patients with cardiovascular conditions, and possibly contributes to optimization of health care costs in terms of appropriateness of hospital admissions and diagnostic tests.

Aggressive congenital fibromatosis of the small intestine in the newborn. Report of a case and review of the literature.

A case of so-called congenital fibro(leio)myosarcoma of the small intestine in a 18-day-old female baby, treated only with surgical resection, was studied by immunohistochemistry and electron microscopy in order to investigate the proliferating cell type. The tumour cells showed positivity only for vimentin and CD 34 and were negative for smooth muscle actin, desmin, alpha-sarcomeric actin, factor VIIIR: Ag and S-100 protein. Ultrastructural findings showed oval nuclei with prominent nucleoli, rare intracytoplasmic mitochondria and well developed rough endoplasmic reticulum. According to histoimmunological and electron microscopy findings the proliferating cells were likely to be of fibroblastic origin. A 7-year follow-up showed a favourable clinical evolution thus confirming that surgical resection can be a sufficient therapeutic approach. The morphological findings and clinical behaviour suggest that more appropriate terminology for this tumour would be "aggressive congenital fibromatosis" which better highlights its local progressive invasion without metastases.