Selection of prognostic factors of acute hepatitis type non-A, non-B for patient listing for liver transplantation.

The aim of this study was to select prognostic factors from information available on admission in order to list patients for liver transplantation before the onset of hepatic encephalopathy in patients with fatal hepatitis type non-A, non-B. Information regarding patient profile and biochemical data obtained on admission was analyzed by multiple stepwise logistic regression, and independent prognostic factors related to death were selected. Four parameters were selected as independent prognostic factors. Patient age (over 50 years), serum total bilirubin level (over 10 mg/dl), peripheral leukocyte count, and prothrombin time were independently related to death. Positive predictive value, negative predictive value, and predictive accuracy were 0.86, 0.79, and 0.84, respectively. Our model is able to predict a patient's fatal outcome much earlier than other currently used models. It will be helpful for early referral to a transplant center.

Deficient superoxide-generating activity and its activation of blood monocytes in cancer patients.

Superoxide (O2-)-generating activity of blood monocytes, the precursors of macrophages, from patients with advanced cancer and/or infection was studied. Monocytes from normal subjects generated 0.288 +/- 0.022 nmol O2-/min/10(5) cells (mean +/- S.E.M., n = 36) after sequential stimulation with cytochalasin E and wheat germ agglutinin. Monocytes from 69 non-infected adult patients with advanced malignancy of the stomach, esophagus and liver, and 7 pediatric patients with neoplastic disease released significantly less O2- than those from normal subjects (0.176 +/- 0.015, P less than 0.005). Infection increased the activity about 4-fold in patients with malignancy compared to non-infected cancer patients. These results suggest that monocytes of cancer patients are defective in secreting O2-, though the activity may be stimulated by infection.

A new improved technique for placement of a pursestring suture on the edge of the distal part of the rectal stump using a skin stapler for low anterior resection.

Instead of a linear stapler or manual pursestring suture onto the lower part of the rectum, we placed a No. 2-0 Prolene suture on the edge of the rectal stump, using 12 to 16 clips and a disposable skin stapler. This technique is satisfactory for very low anterior resection.

Analysis of serum hepatitis A virus antibody response in different courses of hepatitis A virus infection.

Changes in the serum hepatitis A virus antibody (anti-HAV) response in patients with different clinical courses of HAV infection were examined using immune adherence hemagglutination (IAHA). Anti-HAV was detected 2-6 weeks after the onset of clinical symptoms in patients with the typical course of acute hepatitis A and 1-4 weeks after the onset in those with fulminant hepatitis A. Maximal anti-HAV titers were observed 8-20 weeks after the onset of clinical symptoms, and changes in anti-HAV were similar in the typical and the prolonged course of acute hepatitis A, but maximal antibody titers were higher in the prolonged course. Maximal anti-HAV titers in patients with subclinical HAV infection were significantly lower than titers in patients with the typical and prolonged courses of acute hepatitis A, and in those with fulminant hepatitis A. High titers of anti-HAV remained positive for at least 6 years after infection in patients with clinical infection and for at least 4 years in patients with subclinical infection on follow-up. These findings suggest that the maximum anti-HAV titer correlates with the clinical severity of HAV infection; knowledge of the antibody response should be useful for analyzing the pathogenesis of HAV infection.

Mechanisms of thrombocytopenia induced by interferon therapy for chronic hepatitis B.

To clarify the mechanisms of thrombocytopenia observed in patients with chronic hepatitis B treated with interferon. We studied six patients with chronic active hepatitis B who received intramuscular injections of natural interferon-alpha (3 or 5 million IU/ day) for 4 weeks. Peripheral blood platelet counts, bone marrow findings, and platelet kinetics, determined using 111In-labeled platelets, were analyzed. Platelets decreased significantly 1 week after the beginning of treatment and remained decreased until the completion of treatment. The number of nucleated cells and megakaryocytes in bone marrow decreased in three of five patients studied during treatment. The kinetic study showed platelet survival time to be 8.1 +/- 1.3 days (range, 5.8-10.0). One day after platelet injection, platelets accumulated predominantly in the splenic area in all patients, whereas hepatic accumulation was predominant 7 days after injection in three of the six patients. Thrombocytopenia during interferon treatment arises from the inhibition of stem cell proliferation and differentiation in the bone marrow and from the capture of platelets by the liver.

Erythropoietic protoporphyria with fatal liver failure.

A 33-year-old woman with a history of photosensitivity, persistent abdominal pain, and liver dysfunction was admitted to our department because of abdominal pain and progression of liver dysfunction. On admission, levels of protoporphyrin and coproporphyrin within erythrocytes were markedly increased. Autofluorescent erythrocytes were also detected, leading to a diagnosis of erythropoietic protoporphyria. A liver biopsy specimen revealed cirrhosis with dark brown granules filling hepatocytes, bile canaliculi, and bile ductules. Transfusion of washed erythrocytes, hemodialysis, and administration of cholestyramine and beta-carotene transiently improved levels of porphyrins and liver function. The patient died of rupture of esophageal varices followed by multiple organ failure. However, the treatments were believed to have extended survival.

The incidence of hepatocellular carcinoma in patients with chronic hepatitis C after interferon treatment.

To determine whether serum hepatitis C virus (HCV) RNA disappearance after interferon (IFN) treatment prevents development of hepatocellular carcinoma (HCC), we evaluated retrospectively the incidence of HCC in patients with chronic hepatitis C. A total of 213 patients were monitored for more than 6 months after completion of IFN treatment. Sixty-three of the 213 patients (29.6%) achieved a complete response (CR) to treatment and 150 (70.4%) had no response (NR). HCC developed in 12 (5.6%), all of whom were NR. Logistic analysis showed age, alpha -fetoprotein, and staging of histological finding before IFN treatment were independent factors to development of HCC. The fact that there was no HCC development from CR provides a basis for IFN treatment in chronic HCV infection.

Bright loop appearance; a characteristic ultrasonography sign of early hepatocellular carcinoma.

Ultrasonography (US) and computed tomography (CT) are the most effective screening methodologies for hepatocellular carcinoma (HCC). In our US screening, 20% of small HCC nodules less than 20 mm in diameter were detected as hyperechoic tumors. Among these hyperechoic HCC nodules, we have often observed (BL) which is defined as hypoechoic nodules in the hyperechoic tumor. In this study, we report that the BL is a sign of dedifferentiation of early stage of HCC with fatty change by US. From 1994 to 1998, we performed tumor targeting needle biopsy in 938 hepatic nodular lesions. Among them, 284 nodules <20 mm in diameter, histologically diagnosed as HCC, were studied. BL is defined as a hyperechoic tumor containing a hypoechoic nodule >4 mm in diameter by US. Among 284 nodules, well, moderately and poorly differentiated HCC were 183 (64.4%), 100 (35.2%) and 1 (0.4%), respectively. On US, hypoechoic, isoechoic, and hyperechoic nodules were 188 (66.2%), 32 (11.3%) and 64 (22.5%), respectively. Forty-seven nodules of 64 hyperechoic HCC nodules <20 mm in diameter, 47 nodules (73.4%) showed fatty changes. Of 64 hyperechoic HCC nodules, we recognized 22 nodules (34.4%) as BL. The proportion of BL type hyperechoic nodules increased with the tumor size. Two hyperechoic nodules followed by US changed to BL with tumor enlargement. Histologic examination of a resected HCC with BL showed that hyperechoic HCC nodule represented well-differentiated HCC with fatty change and inner hypoechoic lesion represented moderately differentiated HCC without fatty change. In US screening for HCC, BL was often observed in HCC nodules from 11 to 20 mm in diameter. Histologic examination revealed that BL of HCC on US was associated with tumor progression and indicated dedifferentiation showing moderately differentiated HCC in well-differentiated HCC with fatty change.

A cohort study of chronic liver disease in an HCV hyperendemic area of Japan: a prospective analysis for 12 years.

A mass screening in 1990 of H town in Japan demonstrated a high prevalence of hepatitis C virus (HCV) infection in our previous studies. The purpose of the present study was to evaluate the prognosis and natural history of liver disease among the same residents after 12 years. Of 509 residents, 69 people had died, and 55 people had moved to other regions. In all, 139 persons of the remaining 385 residing in H town were examined for liver function tests, antibodies to HCV (anti-HCV), serum HCV RNA, and hepatitis B virus surface antigen (HBsAg). The data of 14 of these 385 people were collected from medical records. The cause of death of the 69 individuals was investigated. The prognosis of liver disease could be clarified after 12 years in 222 of the 509 residents. Most of the residents with liver disease had an advanced stage of disease. Of the 69 persons who died, the mortality rate caused by liver cirrhosis or hepatocellular carcinoma (HCC) was 44 and 53%, respectively, among 25 persons with positive anti-HCV, and 19 with positive HCV RNA. One person with positive HBsAg died of HCC. Persons with chronic HCV or HBV infection had significantly higher mortality rates from liver cirrhosis and HCC than those without infection (P<0.00001). The present study suggests that early detection and treatment for HCC should be carried out as HCV carriers age. Furthermore, persistent HCV carriers should receive therapy for suppression of the development of HCC. The eradication of HCC should be considered a national goal.

High prevalence of anticardiolipin antibodies in patients with HCV-associated oral lichen planus.

Hepatitis C virus (HCV) has been linked to extrahepatic manifestations such as oral lichen planus (OLP). In addition, anticardiolipin antibodies (aCL) and cryoglobulin have been demonstrated in chronic hepatitis C. The aim of this study was to investigate these prevalences in patients with HCV-associated OLP. The prospective study investigated the role of these factors in 133 subjects: 28 with OLP-HCV(+) (group 1), 22 with OLP-HCV(-) (group 2), 33 without OLP-HCV(+) (group 3), and 50 healthy volunteers matched for age and sex served as control group (group 4). Levels of immunoglobulin G (IgG) and IgM aCL antibodies, and cryoglobulin in serum were evaluated by enzyme-linked immunosorbent assay. The prevalence of aCL in groups 1, 2, 3, and 4 were 32.1, 18, 36.3, and 8%, respectively. The positive rate of aCL was significantly higher in groups 1 and 3 than that in the control group (group 1; p=0.02 vs. the control group, group 3; p<0.01 vs. the control group). There were no significant differences in cryoglobulin among the groups. The findings of the present study showed a high prevalence of IgG and IgM aCL in the serum of patients with HCV infectious diseases. A positive factor for aCL was determined by age, sex, the presence of OLP, and HCV infection.

Dipyridamole potentiates adriamycin cytotoxicity by a mechanism other than inhibiting nucleoside uptake.

Nitrobenzylthioinosine (NBTI) and dipyridamole (DP) are competitive inhibitors of cellular nucleoside uptake. Although combined treatment of HeLa cells with adriamycin (ADM) and DP enhanced ADM cytotoxicity in cell growth and clonogenic assays, the combination of ADM and noncytostatic levels (less than 1 microM) of NBTI did not change the cytotoxic potential of ADM in vitro. DP enhanced the inhibition of clonogenicity by ADM, even in nucleoside-enriched mediums. These results suggest that the synergy between ADM and DP was hardly due to the inhibition of nucleoside uptake by DP, but was due to the enhancement of intracellular ADM accumulation by DP.

Modulation of cytotoxic effect of anticancer drugs by dipyridamole in HeLa cells in vitro.

Exponentially growing HeLa cells were treated with various antitumor drugs and dipyridamole (DP), and the cell growth inhibition ratio was determined. Enhanced growth inhibition was found in combined treatment with DP and 5-fluorouracil, 1-hexylcarbamoyl-5-fluorouracil, methotrexate, adriamycin, daunomycin, 4'-0-tetrahydropyranyl-adriamycin, actinomycin D and vincristine. In contrast, reduction of the cytotoxic effect of cytosine arabinoside and enocitabine was found when these were combined with DP.

Thrombolytic therapy of synthetic graft occlusions before vascular reconstructive procedures.

The objective of this study was to evaluate the impact of thrombolysis of synthetic grafts before urgent vascular reconstruction. In 29 patients, 41 thrombosed synthetic grafts that underwent intraarterial thrombolysis were studied. The cases were divided into three groups: group I--complete thrombolysis followed by reconstruction; group II--complete thrombolysis alone; and group III--incomplete lysis requiring reconstruction or sympathectomy. Follow-up ranged from 1 to 556 days (mean: 149 days). Kaplan-Meier analysis was used to determine patency and limb salvage rates. One-year patency and limb salvage rates were 53% and 95%, 34% and 67%, and 38% and 48%, respectively, for groups I, II, and III. Eighteen complications occurred in 16 of the 41 (39%) episodes. One patient died of intracranial hemorrhage. The best results were achieved when complete lysis was followed by appropriate reconstruction. Patency was equally poor in complete thrombolysis alone and reconstructions required by incomplete thrombolysis. Limb salvage was better after complete thrombolysis, regardless of the appropriate reconstruction.

Transcription-mediated amplification is more useful in the follow-up of patients with chronic hepatitis B treated with lamivudine.

Changes in the HBV DNA level during the treatment of patients with chronic hepatitis B with lamivudine were investigated by the transcription-mediated amplification (TMA) assay. Twenty-four patients treated with lamivudine (males:female= 20:4, age: 44.0+/-9.0 years, chronic hepatitis: 14, cirrhosis: 7, cirrhosis with hepatocellular carcinoma: 3) were investigated. The dosage of lamivudine was 75 mg/day in 3, 100 mg/day in 8, and 150 mg/day in 13 patients, and the administration period was 48+/-16 weeks (24-79 weeks). Sixteen patients were HBe antigen-positive before treatment, and the HBV DNA level was 7.4+/-1.2 (4.0- more than 8.7) LGE/ml. The HBV DNA level was measured every 1-6 months by the TMA assay and the branched DNA signal amplification technology (b-DNA assay). Serum HBV DNA disappeared in all patients by the b-DNA during the treatment period, while six patients had persistent HBV DNA by the TMA. The time of HBV DNA disappearance by the TMA in 18 patients was 2-5 months after initiation of treatment. The disappearance rate of HBV DNA was 3/8 (38%) in patients whose HBV DNA level before treatment was 8.0 LGE/ml or higher, 7/8 (88%) in those with 7-7.9 LGE/ml, and 8/8 (100%) in those with 6.9 LGE/ml or lower, showing that disappearance of HBV DNA became difficult when the HBV DNA level before treatment was high (P<0.01). In six patients, the HBV DNA level disappeared once, then increased thereafter. The present findings suggested that these increases in the HBV DNA level were due to an increase of YMDD mutant in three of these six patients, and due to a decrease in the dosage in two patients. In treatment with lamivudine, the TMA assay is more useful for understanding the changes in the HBV DNA level than b-DNA assay.

Two-year follow-up study after treatment with lamivudine for chronic hepatitis B: seven cases reported.

2 times baseline) and returned to seropositive for HBV DNA and HBeAg after lamivudine cessation. One of these five patients died of liver failure 3 months after treatment. However, in two of five patients whose alanine aminotransferase (ALT) had rebounded, HBV DNA became undetectable, and the ALT levels markedly decreased 2 years after the end of therapy. Since the disappearance of HBV DNA and stabilization of the ALT level were observed within two patients by 2 years after cessation of treatment, the patients whose ALT had rebounded should be followed up for a long-term period. To confirm the effect of lamivudine, long-term follow-up in many patients is necessary.

Second generation amplicor-HCV monitor assay: clinical features and predictors of the response to interferon.

The aims of this study were to compare the amplicor-HCV monitor assay versions 1.0 and 2.0, and to investigate the clinical usefulness of this assay in patients with chronic hepatitis C. We retrospectively analyzed 154 patients, and 133 of these patients received interferon therapy. Sixty-nine patients were complete responders (CR), and 64 were non-responders. Serum HCV RNA levels of version 1.0 and version 2.0 and HCV genotypes were determined in all patients. There was a good correlation between versions 1.0 and 2.0 in both genotype 1b and 2a, 2b (r=0.907 and 0.726, respectively). In genotype 1b, the mean HCV RNA level obtained by version 1.0 was 384+/-547 kcopies/ml and that obtained by version 2.0 was 488+/-825 kI.U./ml. In genotype 2a/2b, the mean level obtained by version 1.0 was 170+/-369 kcopies/ml and that obtained by version 2.0 was 340+/-402 kI.U./ml. Discriminant analysis revealed that the discriminating points of IFN response were 168 kcopies/ml (genotype 1b, version 1.0), 106 kcopies/ml (genotype 2a and 2b, version 1.0), 102 kI.U./ml (genotype 1b, version 2.0), and 277 kI.U./ml (genotype 2a and 2b, version 2.0). When the patients were stratified according to the discriminating points, the CR rate below the discriminating points were 73.8 and 86.2% in versions 1.0 and 2.0, respectively, in genotype 1b, and the rates were 73.2 and 82.3% in genotype 2a/2b. In addition, receiver-operating characteristic analysis revealed that version 2.0 had significantly better discriminative ability in patients with genotype 1b. We conclude that the second version of the amplicor-HCV monitor assay measures HCV RNA levels with the same precision as version 1.0 and is more useful for the prediction of interferon response than version 1.0.

The effect of heparin on stress ulcer formation in rats.

The effect of heparin on acute gastric hemorrhagic lesions in rats induced by cold restraint stress was examined in relation to dose responsiveness. Prestress heparin with intravenous injection of either 50 or 500 U/Kg significantly reduced gastric bleeding (P less than 0.01). Treatment with the former dose inhibited the formation of gastric ulceration (P less than 0.01). Heparin poststress with both doses did not significantly affect either gastric bleeding or ulceration. In contrast, both heparin prestress and poststress at 5000 U/Kg intravenously markedly enhanced gastric bleeding (P less than 0.05 and P less than 0.01, respectively). The results encourage the use of low-heparin prophylaxis for stress ulcers in patients at high risk, and support the concept of a thrombotic etiology for this disease.

Inhibition of stress ulcer formation by aminophylline in rats.

The preventive effect of aminophylline in the development of stress ulcer by cold restraint was examined in Sprague-Dawley rats. Aminophylline, in a dose of 0.5 mg/kg, significantly inhibited stress ulcer formation in comparison to the control group. The preventative effect of aminophylline appeared to result from the inhibition of thrombus formation produced by the inhibition of platelet aggregation.

The effect of dipyridamole on experimentally induced stress ulcers.

Several doses of dipyridamomle were tested to assess a reduction in gastric bleeding and ulcer formation in rats exposed to cold stress restraint. When saline was compared to 12.5 mg/kg dipyridamole and 50 units/kg heparin, dipyridamole was significantly better than saline controls (P less than 0.05) in the reduction of both gastric bleeding and gastric ulceration, while the effects of heparin were not significant in either case. Finally, mean hematocrit, platelet count, and gastric acid secretion were not significantly affected by the dose of dipyridamole used (12.5 mg/kg). The results of this study show dipyridamole to be useful in the reduction of both stress ulceration and gastric bleeding induced in rats by cold stress restraint.

Thrombotic etiology of stress ulcers. 1. The effect of anticoagulant and antiplatelet aggregators in the development of stress ulcers in rats.

The preventative effect of anticoagulant (heparin) and antiplatelet aggregators (dipyridamole, low-dose aspirin, and ticlopidine), which are well known as antithrombotic agents, were recognized in this study of the development of stress ulcers in rats under cold restraint stress. On the basis of these findings, we suggest that the development of stress ulceration has a thrombotic etiology and that antiplatelet aggregators may be useful in the treatment of critically ill patients with stress ulcers.