Mutsuo Shigemoto

Bezafibrate in the treatment of primary biliary cirrhosis: comparison with ursodeoxycholic acid

tive and well tolerated (3). In this study, although the majority of the patients cleared or significantly decreased HBV DNA, only 7.4% cleared HBeAg and 5.6% seroconverted to anti-HBe. Similar to interferona treatment, high baseline ALT values were the only predictive parameter for response. Efficacy and tolerability of treatment beyond 1 yr needs to be investigated and our patients are continuing to take lamivudine. Although we could not examine mutation in the YMDD motif, development of resistance to lamivudine might be a possible explanation in our nonresponder patients. A combination anti-HBV regimen using lamivudine and other agents with different mechanisms of action should be investigated to maximize the elimination of the viral infection while minimizing or preventing damage to the liver cells and tissues and the development of viral resistance (6). In conclusion, although lamivudine alone reduces HBV DNA levels significantly, it is ineffective on HBeAg to anti-HBe seroconversion during 1 yr of treatment.

Investigation into the efficacy of bezafibrate against primary biliary cirrhosis, with histological references from cases receiving long term monotherapy

yps smaller than 2 cm (5). Our case also showed a change in shape from semipedunculated to pedunculated with a long stalk from the first to the second endoscopic examinations and displayed rapid growth to more than 2 cm between the second and the third endoscopic examinations. We used p53, Ki-67, and PCNA as indices of cell proliferation and malignant transformation markers because they are simple and easy to use. Because the major pool of proliferating cells resides in the superficial area of gastric carcinoma (6), the investigation of tumor-proliferating activity from biopsy specimens could be a very useful indicator to diagnose malignancy. Abnormal accumulation of p53 protein occurs only in cancerous lesions, and p53 overexpression is also detected in cases of hyperplastic polyps harboring carcinoma (2, 7). The rate of p53 mutation in gastric carcinoma, however, is about 60% (8). PCNA-positive cells also tend to localize within cancer tissues (9). Our case showed that PCNA-positive cells existed only in dysplastic or cancer cells. In early gastric cancer, the mean Ki-67–labeling index is about 30% (6, 10). The mean Ki-67 index at second endoscopic examination in our case was 36.3%, which indicated the possibility of malignant transformation. Thus, a combination of several proliferative markers may be necessary to detect malignant transformation. The results of these immunohistochemical findings showed malignant transformation at least at the second endoscopic examination, when, in retrospect, malignant transformation could have been recognized from the slight macroscopic change; this consideration may be useful in deciding the course of treatment. To detect malignant transformation of hyperplastic polyps, an immunohistochemical examination could avoid unnecessary follow-up and lead to economical treatment because of early carcinoma diagnosis.

Roles of angiogenic factors and endothelin-1 in gastric ulcer healing

Endothelins (ETs) participate directly and indirectly in angiogenesis via ET receptors. During early fetal angiogenesis, vascular endothelial growth factor (VEGF) and its receptors kinase insert domain-containing receptor (KDR) and fms-like tyrosine kinase-1 (Flt-1) are required for the development of the systemic vasculature. In late angiogenesis, stromal-cell-derived factor (SDF-1) and its receptor CXC chemokine receptor 4 (CXCR4) act in an organ-specific manner to promote the formation and development of large blood vessels supplying the gastrointestinal tract. We studied the roles of these ligand receptors in angiogenesis during healing of gastric ulcers. We studied the following five groups, each consisting of ten cases of endoscopically confirmed gastric ulcer: active stage (GA), healing stage (GH) and scar stage (GS) of gastric ulcers located in the angulus; Helicobacter pylori (Hp)-positive gastritis (gast+); and Hp-negative gastritis (gast-). All cases in the ulcer groups were Hp-positive. The study materials consisted of frozen biopsy specimens of lesions arising in the angulus. ET-1 was measured by enzyme immunoassay. The other factors were assayed by reverse-transcription-PCR. The distributions of ET-1, ETA receptor (ETAR), SDF-1 and CXCR4 in the gastric mucosa were evaluated by enzyme immunoassay. ET-1 and ETAR reached peak levels during the GH (ET: P<0.05, ETAR: P<0.01). VEGF mRNA increased slightly during the GA, but did not differ significantly among the groups. KDR and Flt-1 levels were high during the GA, the level being significantly higher than those during the GH and GS (P<0.05). SDF-1 levels significantly decreased during the GH and GS compared with levels during the GA, and CXCR4 significantly increased during the GH and GS (P<0.01). On immunostaining, ET-1-positive cells and ETAR-positive cells were found in the endothelium, vascular smooth muscle and gastric epithelium, and CXCR4-positive cells were found in the endothelium and gastric epithelium during the GH and GS. Our results suggest that VEGF receptors are mainly expressed early in ulcer development and participate in the initial stage of angiogenesis. SDF-1 receptors and ETAR are primarily expressed during the GH and GS and are involved in vascular maturation and gastric mucosal regeneration during late angiogenesis.

Changes of nitric oxide and growth factors during gastric ulcer healing.

We measured the concentrations of vascular endothelial growth factor (VEGF), nitric oxide and endothelin-1 (ET-1) in the gastric mucosa and examined the relationships between these factors. VEGF, nitric oxide and ET participate in angiogenesis and vascular remodeling, important elements of gastric ulcer healing. We studied cases of gastric ulcer as confirmed by endoscopic examination. All 61 cases in the angulus were positive for Helicobacter pylori (Hp). Fifteen cases were active stage (GA), 23 were healing stage (GH), and 23 were scarring stage (GS). As control, 17 cases of Hp-positive gastritis (gast+) and 14 cases of Hp-negative gastritis (gast-) were studied. Biopsy samples taken from the angulus during endoscopic examination were frozen and sliced into thin sections. ET was measured by enzyme immunoassay, VEGF was measured by enzyme-linked immunosorbent assay (ELISA) and nitric oxide was measured in terms of metabolite oxides of nitrogen (NOx) as described by Griess. ET, VEGF and inducible nitric oxide synthase (iNOS) were immunostained. The GA group had the highest concentration of NOx, suggesting that nitric oxide participates in the early stage of mucosal repair. In the GH group, all three factors showed high concentrations, suggesting that all may be involved in increased production. In the GS group, all three factors were significantly lower than in the GA and GH groups. Immunohistochemical studies showed that the distribution of ET- and iNOS-positive cells differed according to the ulcer stage. In particular, ET- and iNOS-positive cells in the vascular wall were primarily endothelial cells during GA and GH and vascular smooth muscle cells (VSMCs) during GS. These findings suggest that endothelial cells produce increased amounts of ET, nitric oxide and VEGF early in ulcer healing, a period of active endothelial cell repair and angiogenesis. During the scarring stage, vascular remodeling may result from the effects of ET and nitric oxide in regulating the proliferation of VSMCs. Our results suggest that VEGF. nitric oxide and ET participate in angiogenesis, vascular remodeling and mucosal regeneration during ulcer healing.

Study of effectiveness of bezafibrate in the treatment of chronic hepatitis C

1. Wong VS, Hughes V, Trull A, et al. Serum hyaluronic is a useful marker of liver fibrosis in chronic hepatitis C virus infection. J Viral Hepat 1998;5:187–92. 2. Murawaki Y, Ikuta Y, Koda M, et al. Comparison of serum 7S fragment of type IV collagen and serum central triple-helix of type IV collagen for assessment of liver fibrosis in patients with chronic viral liver disease. J Hepatol 1996;24:148–54. 3. Poynard T, Bedossa P, METAVIR and CLINIVIR Cooperative Study Groups. Age and platelet count: A simple index for predicting the presence of histological lesions in patients with antibodies to hepatitis C virus. J Viral Hepat 1997;4:199–208. 4. The METAVIR Cooperative Group. Interand intra-observer variation in the assessment of liver biopsy of chronic hepatitis C. Hepatology 1994;20:15–20. 5. Hu KQ, Tong MJ. The long-term outcomes of patients with compensated hepatitis C virus-related cirrhosis and history of parenteral exposure in the United States. Hepatology 1999;29: 1311–6. 6. Fattovich G, Giustina G, Degos F, et al. Morbidity and mortality in compensated cirrhosis type C: A retrospective follow-up study of 384 patients. Gastroenterology 1997;112:463– 72. 7. Roudot-Thoraval F, Bastie A, Pawlotsky JM, et al. Epidemiological factors affecting the severity of hepatitis C virus-related liver disease: A french survey of 6,664 patients. Hepatology 1997;26:485–90. 8. Gordon SC, Bayati N, Silverman AL. Clinical outcome of hepatitis C as a function of mode of transmission. Hepatology 1998;28:562–7.

Potential roles of large mafs in cell lineages and developing pancreas.

Objectives: Maf is a family of transcription factor proteins characterized by a typical bZip structure, and mafA, a member of the large-maf family, is a strong transactivator of insulin in cell lines. The present study investigated the expression profiles of the large-maf family proteins in porcine pancreatic tissue and in primary culture cells. Methods: Immunohistochemical staining was performed to localize each maf protein. Messenger RNA expression was quantitated by real-time polymerase chain reaction, and protein expression was assessed by Western blotting. Results: Islet formation was not as clear in newborn pancreatic tissue as in adult pancreatic tissue. MafA- and c-maf-positive cells were more diffusely localized in pancreatic tissue with fewer mafB-positive cell clusters scattered throughout. By contrast, islet formation was clearer, and positive staining for mafA and c-maf tended to be more prominent in the islets of adult pancreatic tissue. Messenger RNA and protein expressions were consistent with the immunohistochemical findings. MafA, mafB, and c-maf coexpressed with insulin-positive cells, and c-maf coexpressed with glucagon-positive cells in adult porcine pancreas based on the results of a double-staining study. Conclusions: Large mafs were identified in normal porcine and human pancreas, and the expression levels and localizations of the large mafs in newborn and adult pancreatic tissues differed. Mafs may play important roles in establishing endocrine function during pancreatic cell differentiation.

Relationship between recurrence of gastric ulcer and the microcirculation

We investigated the relationship between microcirculatory disturbance and the host response to Helicobacter pylori infections in gastric ulcer scars to determine the role of endothelin-1 (ET) in ulcer recurrence. The subjects were divided into three groups. The GuS group consisted of patients who had red scarring (S1 stage) at the gastric angle with H. pylori, the gast+ group who had gastritis with H. pylori, and the gast- group who had gastritis without H. pylori. During endoscopic examination, biopsies were taken from the gastric angle. Mucosal ET, nitric oxide (NO), interleukin-8 (IL-8), and RANTES were measured. ET, inducible NO synthase (iNOS), and endothelial constitutive NOS (ecNOS) were immunostained. Mucosal ET and oxides of nitrogen (NOx) were significantly higher in the GuS group than in the other groups. IL-8 was elevated in the GuS and gast+ groups, and RANTES was elevated in the gast+ group (p < 0.01). There was prominent inflammatory cell infiltration in the GuS group. ET-positive cells were found in vascular smooth muscle, gastric epithelium, and gastric smooth muscle. iNOS-positive cells were found in vascular smooth muscle, gastric epithelium, gastric smooth muscle, and inflammatory cells. In conclusion, local inflammation and microcirculatory disturbance persist at the center of the ulcer scar (S1). Decreased cytokine levels and increased ET and NO (mainly synthesized by iNOS) levels suggested that microcirculatory disturbance is a more important factor than immune response in ulcer recurrence.

Increase in hepatic tissue blood flow by teprenone

Abstract  The major objective of the present study was to evaluate mechanisms by which teprenone, a gastric mucosal protecting agent, increases hepatic mucosal blood flow using male Sprague‐Dawley rats. Hepatic and gastric blood flow was measured using a laser blood flow meter after administration of teprenone, dissolved in Tween 80, into the inferior vena cava. Teprenone itself increased hepatic and gastric blood flow. It also increased hepatic and gastric blood flow in rats with acute hepatic disorders due to carbon tetrachloride (CCL4) and improved histological changes, such as inflammatory cell infiltration and fatty changes in the liver. The fact that blood endothelin (ET) concentrations increased after administration of teprenone suggest that teprenone has great affinity for ETB receptors and shows ETB ‐receptor antagonist‐like effects. Hepatic blood flow decreased after administration of N‐nitro‐L‐arginine methyl ester, a nitric oxide (NO) synthetase inhibitor, suggesting that teprenone increases NO activity. Teprenone was thought to increase hepatic and gastric blood flow by different mechanisms, because it increased gastric mucosal prostaglandin E2 concentrations.

Effects of antisecretory agents on angiogenesis during healing of gastric ulcers

BackgroundWe studied the effects of a proton pump inhibitor (PPI) and an H2-receptor antagonist (H2-blocker) on angiogenesis during gastric ulcer healing, by examining stromal cell-derived factor (SDF-1) and CXC chemokine receptor 4 (CXCR4) expression in the gastric mucosa.MethodsPatients with gastric ulcers were allocated to an untreated control group, consisting of patients with active ulcers (GA), healing ulcers (GH), and ulcer scars (GS) or a PPI group (P; given rabeprazole at 20 mg/day), or an H2-blocker group (H; given nizatidine at 800 mg/day). Frozen sections of biopsy specimens were examined by reverse transcription-polymerase chain reaction (RT-PCR) to analyze SDF-1 and CXCR4 mRNA.ResultsCXCR4 mRNA levels were elevated in the control (GH and GS patients) group and the H2-blocker group. CXCR4 was significantly elevated in the P-GA subgroup of the PPI group (P < 0.01), but its level decreased with time.ConclusionsIn the PPI group, CXCR4 levels were increased in the early phase of ulcer healing and returned to a level similar to that in the control group during the scar phase. These results suggest that PPIs increase the expression of CXCR4 mRNA and thus promote vessel regeneration and maturation, facilitating ulcer healing.

Efficacy of bezafibrate in a patient with primary sclerosing cholangitis

on these observations, we diagnosed typical localized PSC of the intrahepatic bile ducts. We additionally diagnosed idiopathic hypereosinophilic syndrome, based on the increased eosinophilic leukocyte count (2035/mm3). A daily dose of 30mg prednisolone was administered to treat this condition, and the eosinophilic leukocyte count normalized within approximately 2 weeks. The dose was subsequently decreased to 10mg/day as maintenance therapy. An initial dose of 900mg/day of UDCA was used to treat the PSC; however, unsatisfactory results necessitated an increase to 1200mg/day from May 2000. Further elevations in biliary enzyme levels were recorded in the months following January 2001, as well as an elevated total bilirubin level of 2.8mg/dl. The patient was hospitalized in June 2001 for further investigation, and liver transplantation was considered. At this time, the level of ALT was 165IU/l, and levels of biliary enzymes were particularly high, with ALP at 1711IU/l, LAP at 865U/ml, and γ-GTP at 466IU/l (Fig. 1). ERCP revealed further evident stricturing and obstruction of the intrahepatic bile ducts. Liver biopsy revealed an “onion-skin” appearance, formed by concentric circles surrounding the intrahepatic bile ducts in the region of the portal vein. Based on the deterioration in the disease state over 6 years, we began administration of bezafibrate, at 40 mg/ day. After 2 months of treatment, ALT, ALP, LAP, and γ-GTP levels had decreased to 73IU/l, 407 IU/l, 441U/ml, and 199 IU/l, respectively. The level of total bilirubin had normalized at 1.2mg/dl, and reached a plateau. After 10 months of treatment, levels of hepatobiliary enzymes had stabilized at slightly or moderately elevated levels, with ALT, ALP, LAP, and γ-GTP at 79 IU/l, 412 IU/l, 429U/ml, and 192 IU/l, respectively. The peroxisome proliferator-activated receptor (PPAR) is deeply involved in the inflammatory response, in addition to being involved in lipid metaPrimary sclerosing cholangitis (PSC) is a progressive chronic inflammatory disease. An autoimmune disorder is thought to play a role in the mechanism of its development; however, no satisfactory drug therapy has been established for patients with PSC. Many cases are resistant to the ursodeoxycholic acid (UDCA) therapy currently used, and there are no reports demonstrating improvement of the longterm prognosis. We recently reported the efficacy of bezafibrate in improving both the biochemical and the histological status of patients with primary biliary cirrhosis (PBC).1–3 In common with PSC, PBC is a chronic liver disease, causing marked impairment of the biliary system, and an autoimmune disorder plays a role in its development. Here we describe marked improvement in the biochemical status of a patient with PSC on the administration of bezafibrate. To our knowledge, this is the first demonstration of the efficacy of bezafibrate against PSC, and indicates its potential as a new therapeutic drug for this disease. The patient (male, now aged 21 years) was first hospitalized in 1995 (aged 15 years) to investigate the cause of elevated hepatobiliary enzyme levels and eosinophilic leukocyte count. Biochemical test results showed a moderately elevated serum level of alanine aminotransferase (ALT), at 120IU/l (normal range, 5–45IU/l), and marked elevations in serum levels of biliary enzymes, with alkaline phosphatase (ALP) at 1445IU/l (normal range, 100–325 IU/l), leucine aminopeptidase (LAP) at 664U/ml (normal range, 100–200U/ml), and gamma-glutamyl transpeptidase (γ-GTP) at 258IU/l (normal range, 80IU/l). Endoscopic retrograde cholangiopancreatography (ERCP) revealed multifocal stricturing and a beaded, “prunedtree” appearance of the intrahepatic bile ducts. Based