John Koskinas

Increased arterial stiffness and impaired endothelial function in nonalcoholic Fatty liver disease: a pilot study.

BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease both in the general and pediatric population and has been associated with increased cardiovascular risk. Arterial function and early atherosclerotic changes are markers of cardiovascular disease and independent predictors of the corresponding risk. Through a global approach, we investigated the relationships between NAFLD and functional arterial changes and early atherosclerosis. METHODS A total of 23 consecutive patients (mean age 55 ± 14 years, 11 males) with biopsy evidence of NAFLD and 28 control subjects matched for age, gender, body mass index, and other cardiovascular risk factors participated in the study. RESULTS Compared to controls, NAFLD subjects had significantly higher carotid-femoral pulse wave velocity (PWV; 8.2 ± 1.3 m/s vs. 6.9 ± 1.3 m/s, P = 0.001), higher carotid intima-media thickness (IMT; 0.79 ± 0.18 mm vs. 0.67 ± 0.13 mm, P = 0.01), and reduced flow-mediated dilatation (FMD; 1.92 ± 2.11% vs. 4.8 ± 2.43%, P < 0.001). In multivariable analysis, presence of NAFLD was an independent determinant of both PWV and FMD, whereas leptin was an independent determinant of PWV (B = 0.036, P < 0.05), and adiponectin was independently associated with FMD (B = 0.104, P < 0.05). In addition, histological activity of liver disease expressed by the global Brunt Grade was associated independently with FMD (B = -1.054, P < 0.05). CONCLUSIONS NAFLD is associated with arterial stiffness and endothelial dysfunction. Given the important independent prognostic role of these arterial indexes, these findings have important implications for increased cardiovascular risk in patients with NAFLD.

Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome.

Abstract Pylephlebitis is a condition with significant morbidity and mortality. We review herein 100 relevant case reports published since 1971. Eighty-one patients were reported with acute pylephlebitis, while the remaining patients had chronic pylephlebitis. The most common predisposing infections leading to pylephlebitis were diverticulitis and appendicitis. Cultures from blood or other tissues were positive in 77%. The infection was polymicrobial in half of the patients and the most common isolates were Bacteroides spp, Escherichia coli and Streptococcus spp. Thrombosis was extended to the superior mesenteric vein (SMV), splenic vein, and intrahepatic branches of the portal vein (PV) in 42%, 12%, and 39%, respectively. Antibiotics were administered in all and anticoagulation in 35 cases. Patients who received anticoagulation had a favourable outcome compared to those who received antibiotics alone (complete recanalization 25.7% vs 14.8% (p > 0.05), no recanalization 5.7% vs 22.2% (p < 0.05), and death 5.7% vs 22.2% (p < 0.01)). Cases with complete recanalization had prompt diagnosis and management and two-thirds were recently published. Nineteen patients died; the majority of these (73.7%) died over the period 1971–1990. In conclusion, pylephlebitis remains an entity with high morbidity and mortality, but modern imaging modalities have facilitated an earlier diagnosis and have improved the prognosis. Anticoagulation has a rather beneficial effect on patients with pylephlebitis.

Circulating and liver tissue levels of retinol‐binding protein‐4 in non‐alcoholic fatty liver disease

Aim:  Retinol‐binding protein‐4 (RBP4) has been proposed as a new adipokine that regulates insulin action in muscles and the liver, and contributes to the pathogenesis of insulin resistance. As non‐alcoholic fatty liver disease (NAFLD) is related to insulin resistance, we aimed to evaluate RBP4 levels in the serum and liver of patients with NAFLD.

Novel tumour-specific promoters for transcriptional targeting of hepatocellular carcinoma by herpes simplex virus vectors.

Hepatocellular carcinoma (HCC) is a cancer of poor prognosis, with limited success in patient treatment, which it makes an excellent target for gene therapy and viral oncolysis. Accordingly, herpes virus simplex type‐1 (HSV‐1) is one of the most promising viral platforms for transferring therapeutic genes and the development of oncolytic vectors that can target, multiply in, and eradicate hepatoma cells via their lytic cycle. Enhanced efficacy and specificity of HSV‐1‐based vectors towards HCC may be achieved by using HCC‐specific gene promoters to drive selective viral gene expression and accomplish conditional replication and/or to control the expression of therapeutic genes. However, careful verification of promoter function in the context of the replication‐competent HSV‐1 vectors is required. The present study aimed to identify novel HCC‐specific promoters that could efficiently direct transgene expression to HCC cells and maintain their activity during active viral replication.

Primary Hepatic Actinomycosis

The clinical and imaging findings of primary hepatic actinomycosis are nonspecific and can mimic other diseases. This condition usually needs to be distinguished from other liver-occupying lesions, including malignancy. Review of the English language literature showed 67 cases of hepatic actinomycosis in immunocompetent, predominantly male patients. Infection was usually (75%) cryptogenic. The results of radiologic imaging showed that the lesion involved the right lobe in half of the cases, mimicked a liver tumor in 45%, and was single in two thirds of the cases. Hepatic actinomycosis coexisted with infections by common bacteria in 32% of cases reported. Diagnosis was usually achieved by microscopic examination of surgical or percutaneous specimens in 84.2% and 78.6%, respectively. Antibiotic therapy alone was used for treatment in approximately one half of cases and combined antibiotic treatment with surgical or percutaneous drainage procedure in the other half. The overall mortality rate was 7.6%. In conclusion, primary hepatic actinomycosis is a rare and usually cryptogenic infection. It is more common in men and immunocompetent subjects. It is well responsive to medical or combined medical and interventional treatment.

E2F-1 is overexpressed and pro-apoptotic in human hepatocellular carcinoma

E2F-1 is a transcription factor involved in DNA synthesis and repair, cell proliferation, and apoptosis. Hyposphorylated pRb represses E2F-1 action in early G1 phase, while in late G1, pRb hyperphosphorylation leads to E2F-1 release and activation. In vitro studies have shown that E2F-1 may act either as oncogene or as tumor suppressor gene. We evaluated immunohistochemical expression of E2F-1 protein in chronic viral liver disease and hepatocellular carcinoma (HCC) and correlated this with clinicopathological parameters, cell proliferation, apoptosis, and the expression of E2F-1-regulators, pRb, and phospho-pRb (Ser795). In liver biopsies from 30 patients with chronic viral hepatitis, including 22 with cirrhosis without HCC, and 57 with cirrhosis with HCC, E2F-1 expression was assessed by immunohistochemistry. In chronic hepatitis and cirrhosis, hepatocytes and cholangiocytes demonstrated mild cytoplasmic and/or nuclear membrane E2F-1 immunostaining. In contrast, all HCC (100 %) showed strong nuclear E2F-1 immunostaining, with or without membrane accentuation, while a minority demonstrated additional moderate cytoplasmic immunostaining. Abnormally low pRb and phospho-pRb expression was seen in 70 % and 67.9 % of HCC, respectively. In HCC, nuclear E2F-1 expression was inversely correlated with phospho-pRb expression (p = 0.001) and positively related to tumor apoptotic index (p = 0.025). No significant correlation was found between E2F-1 expression and patient demographics, HCC etiology, tumor grade, pRb, p53 expression, or cell proliferation. In conclusion, we show that the increased expression of E2F-1 protein in human HCC is correlated with enhanced tumor cell apoptosis supporting a pro-apoptotic role of E2F-1 in human HCC.

Analysis of serum α-fetoprotein-L3% and des-γ carboxyprothrombin markers in cases with misleading hepatocellular carcinoma total α-fetoprotein levels

Serum fraction of α-fetoprotein L3 (AFP-L3%) and des-γ carboxyprothrombin (DCP) are proposed serum markers for the diagnosis of hepatocellular carcinoma (HCC). We evaluated their performance in two patient populations with total AFP levels non-diagnostic for HCC. From a cohort of 150 consecutive patients with HCC, 60 patients with total AFP <200 ng/ml were identified. Additionally, 50 patients with elevated AFP and no radiological evidence of HCC, for at least one year of follow-up, were included. AFP-L3% and DCP were measured by the Liquid Phase Binding Assay System (LiBASys). In cases where AFP-L3% was undetectable, a more sensitive method based on-chip electrokinetic reaction was applied. AFP-L3% was found to be positive in 22 (36.7%) of patients with HCC and 6 (12%) of non-HCC patients. DCP was found to be positive in 26 patients with HCC (43%) and in none of the non-HCC patients. Thirty-six out of sixty (60%) patients with HCC were positive for either AFP-L3% or DCP. With the on-chip technology, AFP-L3% was found to be positive in 10 patients with HCC and in 5 patients without HCC, who tested negative by LiBASys. The final sensitivity of combined AFP, AFP-L3% and DCP testing, in the entire cohort of patients with HCC, was 84%. The specificity of AFP-L3% and DCP in the studied population was 78.5 and 100%, respectively. The addition of AFP-L3% and DCP increased the sensitivity and specificity of total serum AFP for the diagnosis of HCC. The on chip AFP-L3% assay was more sensitive but less specific compared to LiBASys.

Liver disease in adult transfusion‐dependent beta‐thalassaemic patients: investigating the role of iron overload and chronic HCV infection

Iron overload and hepatitis‐C virus (HCV) infection, have been implicated in the evolution of liver disease, in patients with transfusion‐dependent beta‐thalassaemia major (BTM). However, the impact of these factors in late stages of liver disease in adults with BTM, has not been extensively studied.

Hepatitis C Virus (HCV)-Related Cryoglobulinemia: Cryoglobulin Type and Anti-HCV Profile

ABSTRACT Cryoglobulin characteristics in chronic hepatitis C (CHC) might be of importance for knowing more about the pathogenesis and treatment of the disease. We aimed to investigate the relationship between cryoglobulin types and their specificity against hepatitis C virus (HCV) antigenic epitopes in CHC patients. We analyzed samples from 43 patients with HCV-associated cryoglobulinemia, of whom 4 had concomitant lymphoma. Cryoglobulins were measured, purified, typed by immunofixation electrophoresis, and tested for IgG and IgM anti-HCV antibodies by immunoblot analysis and an enzyme-linked immunosorbent assay (ELISA). Clinical and other laboratory data were recorded. The median cryocrit level of the tested samples was 6%. Type I cryoglobulins were detected in 9.3% (4/43) of the cryoprecipitates, and type II cryoglobulins were detected in 48.8% (21/43) of the cryoprecipitates. IgM monoclonal protein, mainly IgM(κ), was found in 92% (23/25) of type I and II cryoprecipitates. Type III cryoglobulins were identified in 41.9% (18/43) of the patients and were associated with high blood serum IgG levels. In 81.3% (13/16) of type II and 92.3% (12/13) of type III cryoglobulins, there was IgG reactivity against the viral core region. Ninety-two percent and 32% of IgG anti-HCV core-positive cryoprecipitates had additional specificities against the NS3 and NS4 regions, respectively. Also, IgM anti-HCV antibodies were detected in 31% of the cryoprecipitates. In conclusion, all types of cryoglobulins were found in patients with HCV-associated cryoglobulinemia, with type II being the most frequently identified. Type III cryoglobulins were common and were associated with high serum IgG levels. HCV-related cryoglobulins demonstrated IgM, and particularly IgG, anti-HCV specificities, mainly against the core and NS3 epitopes.

Post embolization syndrome in doxorubicin eluting chemoembolization with DC bead.

BACKGROUND/AIMS The investigation of post embolization syndrome (PES) in patients with hepatocellular carcinoma (HCC) after treatment with doxorubicin loaded DC Bead (DEB-DOX). METHODOLOGY The study included 237 patients treated with sequential DEB-TACE performed at set time intervals every two months until 3 sessions/6 month f-u. Patients were ECOG 0-1, Child-Stage-A (n=116, 48.9%) and B (n=121, 51%). Embolizations were as selective as possible with DC Bead of 100-300µm in diameter followed by 300-500µm loaded with doxorubicin at 37.5mg/mL of hydrated bead (max:150mg). RESULTS PES regardless of severity was observed in up to 86.5%. However grade 2 PES ranged between 25% and 42.19% across treatments. Temperatures above 38°C were seen in 22.7% to 38.3% across treatments. No statistically significant increase of PES was seen in beads of 100-300µm in diameter; incidence of fever and pain presented correlation with the extent of embolization (p=0.0001-0.006 across treatments). Baseline tumor diameter was associated with incidence of fever (p=0.0001-0.001). Duration of fever correlated with the extent of embolization (p=0.008). PES was not associated with elevation of liver enzymes and was correlated with degree of necrosis (p<0.001). CONCLUSIONS PES after DEB-DOX represents tumor response to treatment and does not represent collateral healthy liver damage.