Prevalence of minimal hepatic encephalopathy and quality of life evaluations in hospitalized cirrhotic patients in China

AIM:To investigate the prevalence of minimal hepatic encephalopathy(MHE)and to assess corresponding health-related quality of life(HRQoL)in hospitalized cirrhotic patients in China.METHODS:This multi-center cross-sectional study included 16 teaching hospitals,which were members of "Hepatobiliary Cooperation Group,Society of Gastroenterology,Chinese Medical Association",from different areas of China carried out between June and October in 2011.All the eligible hospitalized cirrhotic patients(n = 538)were required to complete triplicate number connection tests combined with one digit symbol test for diagnosing MHE.Patients' clinical examination data were complemented by a modified questionnaire assessing HRQoL.Written informed consent was obtained from each patient.RESULTS:Male was predominant(68.6%)in 519 patients who met the criteria of the study,with a mean age of 49.17 ± 11.02 years.The most common cause of liver cirrhosis was chronic hepatitis B(55.9%).The prevalence of MHE was 39.9% and varied by ChildPugh-Classification score(CPC-A:24.8%,CPC-B:39.4% and CPC-C:56.1%,P < 0.01).MHE(P < 0.01)and higher CPC scores(P < 0.01)were associated with a high HRQoL scores(reflecting poorer quality of life).The prevalence of MHE was proportionate to CPC(P = 0.01)and high quality of life scores(P = 0.01).CONCLUSION:Hospitalized cirrhotic patients have a high prevalence of MHE that is proportionate to the degree of liver function and HRQoL impairment.

Preparation of chitosan-polyaspartic acid-5-fluorouracil nanoparticles and its anti-carcinoma effect on tumor growth in nude mice

AIM: To prepare chitosan-polyaspartic acid-5-fluorouracil (CTS-Pasp-5Fu) nanoparticles and investigate its anti-carcinoma effect and toxicity. METHODS: CTS-Pasp-5Fu nanoparticles were synthesized by ionic gelatification. Male BABL/c nude mice were injected with SGC-7901 gastric carcinoma cell line mass to establish a human gastric carcinoma model. They were randomly allocated into 4 groups: CTS-Pasp-5Fu (containing 5-Fu 1.25 mg/kg), 5-Fu (1.25 mg/kg), CTS-Pasp and normal saline groups. Tumor weight was measured and assay of colony forming unit-granulocyte and macrophage (CFU-GM) was performed. The structural change of cells and tissues was observed and the Bax and Bcl-2 genes were detected. RESULTS: Compared with normal saline, the inhibition rates of tumor growth for the CTS-Pasp, 5-Fu and CTS-Pasp-5Fu groups were 5.58%, 58.69% and 70.82%, respectively. The tumor inhibition rates for the CTS-Pasp, 5-Fu and CTS-Pasp-5Fu groups were 5.09%, 65.3% and 72.79%, respectively. There was a significant decrease in the number of CFU-GMformation and increase of total bilirubin, and alanine aminotransferase in the 5-Fu group, but no change in those of the other three groups. There was no change in white blood cell count and creatinine among the four groups. Pathological section of liver and nephridial tissues showed that the damage in the 5-Fu group was more severe than that in the CTS-Pasp-5Fu group. 5-Fu and CTS-Pasp-5Fu groups could both down-regulate the Bcl-2 expression and up-regulate the Bax expression to different extent, and the accommodate effect of CTS-Pasp-5Fu was more obvious than 5-Fu. CONCLUSION: The tumor inhibition rate of CTS-Pasp-5Fu nanoparticles is much higher than that of 5-Fu alone.

A randomized,double-blind,placebo-controlled trial assessing the efficacy and safety of tegaserod in patients from China with chronic constipation

AIM： To evaluate the efficacy and safety of tegaserod, 6 mg twice daily （b.i.d.）, in men and women with chronic constipation （CC） from China. METHODS： This was a multicenter, double-blind, placebo-controlled study. Following a 2-wk treatmentfree baseline period, patients were randomized to receive either tegaserod （6 mg b.i.d.） or placebo （b.i.d.） for 4 wk. An analysis of covariance with repeated measures was used to determine the overall effect of treatment for the primary efficacy variable; the change from baseline in the number of complete spontaneous bowel movements （CSBMs） during the 4-wk treatment period. Secondary efficacy endpoints included other measures of response in terms of CSBMs, and patients＇ daily and weekly assessment of bowel habits. Safety was also assessed, based on the incidence and severity of adverse events （AEs）. RESULTS： A total of 607 patients were randomized to receive either tegaserod （n = 304） or placebo （n = 303）. Tegaserod treatment resulted in a rapid and significant increase from baseline in the adjusted mean number of CSBMs per week over wk 1-4 compared with placebo （1.39 vs 0.91, P = 0.0002）. A statistically significant difference in favor of tegaserod was also observed for a mean increase ≥ 1 CSBM/wk over wk 1-4 （47.7% vs 35.0%, tegaserod vs placebo, respectively, P = 0.0018） and for the absolute number of≥ 3 CSBMs/wk over wk 1-4 （25.0% vs 14.5%, tegaserod vs placebo, respectively, P = 0.0021）. Improvements in other symptoms of CC were also seen in the tegaserod group, including improved stool form and reduced straining. In addition, more patients in the tegaserod group reported satisfactory relief from their constipation symptoms. The frequency and severity of AEs was comparable between tegaserod and placebo groups, with the exception of a greater incidence of diarrhea in patients receiving tegaserod （3.6%） compared with placebo （1.7%）. CONCLUSION： Tecjaserod treatment improved multiple symptoms of CC and was associated with a favorable safety profile.

Auphen and dibutyryl cAMP suppress growth of hepatocellular carcinoma by regulating expression of aquaporins 3 and 9 in vivo

AIM: To investigate whether the regulation of aquaporin 3 (AQP3) and AQP9 induced by Auphen and dibutyryl cAMP (dbcAMP) inhibits hepatic tumorigenesis.METHODS: Expression of AQP3 and AQP9 was detected by Western blot, immunohistochemistry (IHC), and RT-PCR in HCC samples and paired non-cancerous liver tissue samples from 30 hepatocellular carcinoma (HCC) patients. A xenograft tumor model was used in vivo. Nine nude mice were divided into control, Auphen-treated, and dbcAMP-treated groups (n = 3 for each group). AQP3 and AQP9 protein expression after induction of xenograft tumors was detected by IHC and mRNA by RT-PCR analysis. The terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling assay and histological evaluation were used to detect apoptosis of tumor cells, and the concentration of serum &#x003b1;-fetoprotein (AFP) was measured using RT-PCR and an ELISA kit.RESULTS: The volumes and weights of tumors decreased significantly in the Auphen- and dbcAMP-treated mice compared with the control mice (P &#x0003c; 0.01). The levels of AQP3 were significantly lower in the Auphen treatment group, and levels of AQP9 were significantly higher in thedbcAMP treatment mice than in the control mice (P &#x0003c; 0.01). The reduction of AQP3 by Auphen and increase of AQP9 by dbcAMP in nude mice suppressed tumor growth of HCC, which resulted in reduced AFP levels in serum and tissues, and apoptosis of tumor cells in the Auphen- and dbcAMP-treated mice, when compared with control mice (P &#x0003c; 0.01). Compared with para-carcinoma tissues, AQP3 expression increased in tumor tissues whereas the expression of AQP9 decreased. By correlating clinicopathological and expression levels, we demonstrated that the expression of AQP3 and AQP9 was correlated with clinical progression of HCC and disease outcomes.CONCLUSION: AQP3 increases in HCC while AQP9 decreases. Regulation of AQP3 and AQP9 expression by Auphen and dbcAMP inhibits the development and growth of HCC.

Polymorphisms of AZIN1 rs2679757 and TRPM5 rs886277 are Associated with Cirrhosis Risk in Chinese Patients with Chronic Hepatitis B

Objective Genome-wide association studies(GWAS)have linked many single nucleotide polymorphisms(SNPs)to the outcomes of a variety of liver diseases.The aim of the present study was to evaluate the association of several candidate SNPs with the risk and severity of cirrhosis due to chronic hepatitis B in a Chinese population.Methods A total of 714 Chinese participants with persistent HBV infection were studied.Patients were divided into cirrhotic(n=429)and non-cirrhotic(n=285)groups based on clinical and pathological evidence.The progression rate and severity of liver cirrhosis were evaluated with an arbitrary t-score system.Genotypes of six SNPs in five candidate genes were detected with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry(MALDI-TOF MS).The genotypic distributions of the SNPs were compared between the age-matched cirrhotic and non-cirrhotic subjects.The association between the risk of SNPs and the severity and progression rate of cirrhosis was further analyzed.Results Rs2679757 polymorphism of the antizyme inhibitor 1(AZIN1)gene and Rs886277 in the transient receptor potential cation channel subfamily M,member 5 gene(TRPM5)were found to be associated with cirrhosis risk in CHB.They were also correlated with the overall severity and progression rate of cirrhosis.Genotype frequencies of other SNPs were not different between the cirrhosis and non-cirrhosis groups.Conclusions AZIN1 rs2679757 and TRPM5 rs886277 are associated with the risk and the progression rate of HBV-related liver fibrosis in Chinese patients.The emerging SNPs associated with cirrhosis prognosis warrant further clinical validation in other CHB cohorts or ethnic groups,and merit mechanistic studies to reveal their roles in fibrosis progression.

The use of melittin to enhance transgene expression mediated by recombinant adeno-associated virus serotype 2 vectors both in vitro and in vivo

Objective: Melittin, a cell-penetrating peptide, improves the efficiency of many non-viral gene delivery vectors, yet its application in viral vectors has not been well studied. The non-pathogenic recombinant adeno-associated virus(rAAV) vector is an ideal in vivo gene delivery vector. However, its full potential will only be achieved after improvement of its transduction efficiency. To improve the transduction efficiency of rAAV2 vectors, we attempted to develop a melittin-based r AAV2 vector delivery strategy.Methods: The melittin peptide was inserted into the rAAV2 capsid either in the loop Ⅷ of all viral proteins(VPs) or at the N terminus of VP2. Various r AAV2-gfp or-fluc vectors were subjected to quantitative real-time polymerase chain reaction and Western blot assays to determine their titers and integrity of capsid proteins, respectively. Alternatively, the vectors based on wild-type capsid were pre-incubated with melittin, followed by transduction of cultured cells or tail vein administration of the mixture to C57BL/6 and BALB/c nude mice. In vivo bioluminescence imaging was performed to evaluate the transgene expression.Results: rAAV2 vectors with melittin peptide inserted in the loop Ⅷ of VPs had low transduction efficiency, probably due to dramatically reduced ability to bind to the target cells. Fusing the melittin peptide at the N-terminus of VP2 produced vectors without the VP2 subunit. Interestingly, among the commonly used rAAV vectors, pre-incubation of r AAV2 and rAAV6 vectors with melittin significantly enhanced their transduction efficiency in HEK293 and Huh7 cells in vitro. Melittin also had the ability to increase the rAAV2-mediated transgene expression in mouse liver in vivo. Mechanistically, melittin did not change the vector-receptor interaction. Moreover, cell counting kit-8 assays of cultured cells and serum transaminase levels indicated melittin had little cytotoxicity.Conclusion: Pre-incubation with melittin, but not insertion of melittin into the rAAV2 capsid, significantly enhanced rAAV2-mediated transgene expression. Although further in vivo evaluations are required, this research not only expands the pharmacological potential of melittin, but also provides a new strategy to improve gene therapy mediated by rAAV vectors.

Early diagnosis and therapeutic choice of Klebsiella pneumoniae liver abscess

Nowadays,pyogenic liver abscess(PLA)is still a common and severe intra-abdominal infection,and Klebsiella pneumoniae had emerged as the most common pathogenic bacteria worldwide in the past ten years.Our study aims to achieve an early pathogenic diagnosis and rational therapy modality for Klebsiella pneumoniae liver abscess(KLA)through clinical data analysis.A total of 197 inpatients in Zhongshan Hospital,Shanghai,diagnosed as having liver abscess between March 2001 and September 2009 were enrolled.Patients with monomicrobial infection were divided into two groups:patients with K.pneumoniae liver abscess(KLA group,n=106)and those with non-Klebsiella pneumoniae liver abscess(NKLA group,n=56).A retrospective analysis was made between these two groups on the aspects of underlying diseases,clinical characteristics,laboratory data,culture results,and imaging findings.To evaluate the effects of different medical interventions,monomicrobial KLA patients were further divided into four subgroups(percutaneous liver aspiration,aspiration plus antibiotics flushing,aspiration plus retained catheter,and aspiration plus antibiotics flushing and retained catheter),and corresponding therapeutic effects were analyzed.KLA was more likely to occur in patients with coexisting diseases such as diabetes mellitus(53.77%vs 25.00%,P=0.001)and hepatic adipose infiltration(16.04%vs 5.36%,P=0.029).Compared to NKLA group,clinical characteristics including abdominal pain(40.57%vs 57.14%,P=0.044),hypodynamia(19.81%vs 46.43%,P=0.001),and hepatomegaly(4.72%vs 14.29%,P=0.033)were much milder,but with a higher fasting blood glucose level(7.84±0.36 vs 5.76±0.30,P=0.001)on admission in KLA group.In addition,KLA abscess often appeared singly in the right lobe of the liver with gas forming nature(32.88%vs 13.51%,P=0.039),unsmooth rim(71.23%vs 40.54%,P=0.002),and dynamic septum enhancement(41.10%vs 16.22%,P=0.009).Compared to mono aspiration subgroup,additional antibiotic flushing could not further improve clinical outcomes of KLA patients(P>0.05);however,the retained catheter showed obvious advantage in reducing abscess diameter(34.38±3.25 mm vs 22.67±2.37 mm,P=0.017).It can be concluded that the strong association with diabetes,milder clinical symptoms,and gas-forming nature in CT images makes early pathogenic diagnosis of KLA possible.Comparatively,ultrasonography-guided percutaneous liver aspiration with retained catheter may be the most rational intervention modality of KLA.

Development and preliminary verification of the evaluation system for clinical practice guidelines in China

Objective:Clinical practice guidelines can improve healthcare processes and patient outcomes;however,the quality of these guidelines varies greatly in China.The aim of this study was to construct a comprehensive instrument for the appraisal of clinical practice guidelines in China(AGREE-CHINA),and to validate its reliability as a tool for helping potential guideline users in assessing guideline quality.Methods:First,an interdisciplinary working group was established for developing the methods.They also created a checklist as a tool according to the Appraisal of Guidelines,Research and EvaluationⅡ(AGREEⅡ)standards,considering the particularity of Chinese clinical practice.Next,the first draft of AGREE-China was developed by vote,modification,preliminary trial,and crossverification.To ensure the objectivity,credibility,and reproducibility of the draft assessment,all of the checklists and standards were cross-reviewed fairly widely.Fin ally,AGREE-CHINA and AGREEⅡwere used to assess the Chinese guideli nes published in the past five years,and the results were compared.Results:The presented AGREE-CHINA covered five main checkpoints(science and rigor,effectiveness and safety,economy,usability and feasibility,and conflicts of interest)with each point divided into several more specific checkpoints.Definitions and rationales for each main checkpoint appear in the Appendix.The quality ratings based on the total scores of AGREE-China and AGREEⅡwere consistent(r=0.508,P=0.020).Compared with AGREEⅡ,the study showed a higher level of interraterreliability for AGREE-CHINA overall(ICC=0.957,P<0.001).The mean time required for AGREE-CHINA was less than that for AGREEⅡ:this was approximately 30 minutes for every assessment.User satisfaction was generally high.Conclusions:This paper has presented the first edition of the AGREE-CHINA appraisal tool for clinical guidelines.It is quick and easy to use;it assesses and performs well in comparison to AGREEⅡ.This first version of AGREE-CHINA will require further development and validation.