COVID-19 severity is associated with the risk of gastrointestinal bleeding.

OBJECTIVE: The association between the severity of COVID-19 and gastrointestinal (GI) bleeding is unknown. This study aimed to determine whether the severity of COVID-19 is a risk factor for GI bleeding. DESIGN: A multicentre, retrospective cohort study was conducted on hospitalised patients with COVID-19 between January 2020 and December 2021. The severity of COVID-19 was classified according to the National Institute of Health severity classification. The primary outcome was the occurrence of GI bleeding during hospitalisation. The main analysis compared the relationship between the severity of COVID-19 and the occurrence of GI bleeding. Multivariable logistic regression analysis was performed to evaluate the association between the severity of COVID-19 and the occurrence of GI bleeding. RESULTS: 12 044 patients were included. 4165 (34.6%) and 1257 (10.4%) patients had severe and critical COVID-19, respectively, and 55 (0.5%) experienced GI bleeding. Multivariable analysis showed that patients with severe COVID-19 had a significantly higher risk of GI bleeding than patients with non-severe COVID-19 (OR: 3.013, 95% CI: 1.222 to 7.427). Patients with critical COVID-19 also had a significantly higher risk of GI bleeding (OR: 15.632, 95% CI: 6.581 to 37.130). Patients with severe COVID-19 had a significantly increased risk of lower GI bleeding (OR: 10.349, 95% CI: 1.253 to 85.463), but the risk of upper GI bleeding was unchanged (OR: 1.875, 95% CI: 0.658 to 5.342). CONCLUSION: The severity of COVID-19 is associated with GI bleeding, and especially lower GI bleeding was associated with the severity of COVID-19. Patients with severe or critical COVID-19 should be treated with caution as they are at higher risk for GI bleeding.

[A Case of Severe Hyperammonemic Encephalopathy in a Dialysis Patient Following mFOLFOX6 Therapy].

A 69-year-old man on hemodialysis for chronic renal failure was diagnosed with ascending colon cancer, and received surgical resection. Multiple liver metastases were detected after surgery. He was administered modified FOLFOX6 therapy (reducing the dose to 50%), and showed severe disturbance of consciousness due to hyperammonemia on treatment day 6. After treatment with daily hemodialysis, branched-chain amino acid solutions, lactulose and rifaximin, his conscious level improved on day 9. Intensive chemotherapy in dialysis patients should be carefully performed considering the serious adverse events including hyperammonemia.

Collaboration between Hepatologists and Primary Care Physicians in Treating Patients with Chronic Hepatitis C.

OBJECTIVE: The purpose of this study was to assess the treatment outcome in patients with chronic hepatitis C (CHC) using the current standard antiviral therapy when patient were treated in collaboration between hepatologists and primary care physicians (PCPs). PATIENTS AND METHODS: One hundred and ten patients with CHC were treated with a combination therapy of peginterferon-alpha 2b and ribavirin. Among them, 25 patients were treated by a collaboration between hepatologists and PCPs (collaboration group), whereas 85 patients were treated with exclusively by hepatologists (noncollaboration group). The duration of the therapy was 48 weeks for 58 'difficult- to-treat' patients (genotype 1 with a high load of HCV-RNA; 1H patients) and 24 weeks for the remaining 52 patients (non-1H patients). In the collaboration group, antiviral therapy was initiated and adjusted, if needed, by hepatologists (visits every four weeks), whereas the weekly administration of peginterferon-alpha 2b was performed by PCPs. Clinical characteristics and the treatment outcome were compared between these two groups. RESULTS: The two groups had similar baseline characteristics. By intention to treat, the two groups showed similar rates of treatment-related serious adverse effects (0% vs. 1%, respectively) and dropout rates for adverse effects (8% vs. 13%, respectively). Sustained virologic response rates were also similar between the two groups, being 42% vs. 39% in the 58 1H patients (NS) and 62% vs. 64% in the 52 non-1H patients (NS), respectively. CONCLUSIONS: Collaboration between hepatologists and PCPs may be a valid treatment alternative to treat patients with CHC using the current standard antiviral therapy.

[Biliary tract carcinoma in elderly patients in whom gemcitabine chemotherapy induced complete remission - a report of two cases].

The authors experienced two patients with biliary tract carcinoma who could not be considered candidates for surgery. One was a 78-year-old female with cholangiocellular carcinoma who presented with acute cholangitis. Tumors had spread to both lobes of the liver, and chemotherapy with gemcitabine (GEM) alone was selected. After three months of treatment, the tumors disappeared radiographically. Disease-free survival has been maintained for 30 months. The second patient was a 79-year-old female with gallbladder carcinoma who presented with acute cholecystitis. Because of her poor cardiac function,GEM single-drug regimen was started. After four months, the tumor had completely disappeared on both computed tomography and ultrasonography. Currently, after 23 months of treatment period, the disease-free survival has persisted. Although GEM was originally applied to non-small cell lung cancer and pancreas cancer, recently, its anti-tumor effect on biliary tract carcinoma has been elucidated, and it is becoming the leader for the first-line regimen. However, the number of patients showing complete remission were still limited.

Extracorporeal elimination of TNF-alpha-producing CD14(dull)CD16(+) monocytes in leukocytapheresis therapy for ulcerative colitis.

BACKGROUND: In recent years leukocytapheresis using a leukocyte removal filter (known as lymphocytapheresis, LCAP) has been applied to the treatment of various autoimmune diseases including ulcerative colitis (UC). In the present study we aimed to clarify how LCAP therapy modifies inflammatory responses by modulating circulating TNF-alpha-producing monocytes. METHODS: Mononuclear cells were obtained from blood before and after the first treatment, and the expression profiles of various immune cells (naive versus. memory, regulatory CD4(+)CD25(bright) versus non-regulatory CD4(+)CD25(-) T cells, and CD14(+)CD16(-) versus CD14(dull)CD16(+) monocytes) were assessed. To evaluate immunological differences between CD14(+)CD16(-) and CD14(dull)CD16(+) monocytes, the expression of TNF-alpha, IL-6, IL-12, IL-10, IL-18, surface toll-like receptor 2 (TLR2), TLR4, and other activation markers including HLA-DR, CD80 and CD86, as well as cytokine profiles, were analyzed. RESULTS: LCAP treatment selectively removed CD14(dull)CD16(+) monocytes, which preferentially produce TNF-alpha and IL-12 and express HLA-DR, CD80, CD86, and TLR2, compared with the major fraction of CD14(+)CD16(-) monocytes, which conversely produce a higher amount of IL-10. In addition, the CD4(+)CD45RO(+)CD62L(-)/CD4(+)CD45RO(+)CD62L(+) ratio was significantly lower after LCAP therapy. However, the CD4(+)CD25(bright)/total CD4(+) ratio did not change. CONCLUSIONS: The present findings revealed the real target of proinflammatory CD14(dull)CD16(+) monocytes removed during LCAP treatment of UC and that LCAP might be used as an extracorporeal anti-TNF-alpha therapy, expanding the clinical applications of this procedure to include the treatment of Crohn's disease.

Enhancement of mitochondrial gene expression in the liver of primary biliary cirrhosis.

Primary biliary cirrhosis (PBC) is one of the most important autoimmune liver diseases but the etiology and pathogenesis remain unknown. In this study, we analyzed differential mRNA expression in the liver of a patient with PBC using suppression subtractive hybridization to identify overexpressed genes. Overexpression of mRNA transcripts from mitochondrial DNA was observed in the PBC liver, compared to normal liver. To explore the mechanism of increased mitochondrial transcription, we investigated the mRNA levels of nuclear DNA-encoded regulator molecules of mitochondrial gene expression in 60 liver biopsy samples from various diseases, including PBC, using competitive RT-PCR. Increased expression of mitochondrial transcriptional factor A (mtTFA) and mitochondrial nuclear respiratory factor 1 (NRF-1) mRNA was demonstrated in PBC liver compared to other liver diseases, while NRF-1 coactivator 1, PGC-1 was suppressed. Mitochondrial DNA-encoded mRNA molecules are overexpressed in the PBC liver, and this is associated with up-regulation of mitochondrial transcription factor mtTFA and its transactivator NRF-1. Further studies are needed to focus on the relevance of this perturbation of mitochondrial gene expression in the pathogenesis of PBC.

Quantitation of the level of hepatitis delta virus RNA in serum, by real-time polymerase chain reaction--and its possible correlation with the clinical stage of liver disease.

Some hepatitis B virus (HBV) carriers with chronic hepatitis delta virus (HDV) superinfection show progressive chronic hepatitis, whereas others show no apparent signs of liver disease. In the present study, we established a sensitive method for the quantitation of the level of HDV RNA in serum on the basis of real-time reverse-transcription polymerase chain reaction (RT-PCR), to clarify the role that the level of HDV RNA in serum plays in the diverse natural course of clinical manifestation. In 48 subjects who were positive for hepatitis B surface antigen and for anti-hepatitis delta antibody, the levels of HDV RNA in serum were quantitated by RT-PCR. The levels of HBV DNA in serum were determined by a transcription-mediated amplification assay. The levels of HDV RNA in serum of subjects with chronic hepatitis and of subjects with liver cirrhosis were significantly higher than those in asymptomatic carrier subjects. The levels of HBV DNA in serum did not differ significantly among these 3 groups. In conclusion, HDV RNA quantification by real-time RT-PCR is possibly a useful tool for understanding the pathophysiology of HDV infection.

Chronic hepatitis delta virus infection with genotype IIb variant is correlated with progressive liver disease.

We determined the sequence of the hepatitis delta virus (HDV) genome in 40 Japanese patients, most of whom were from the Miyako Islands, Okinawa, Japan. Consensus sequences from 33 HDV full genomes out of a total of 40 patients were determined by directly sequencing four partially overlapping PCR products. Phylogenetic tree analysis classified these 33 complete HDV genomes as HDV genotype I (two patients), genotype IIa (one patient) and genotype IIb (30 patients). Among the 30 genotype IIb patients, there were two clusters of genetic variants. One group consisted of six isolates showing significant homology with genotype IIb, previously reported from Taiwan. The other group consisted of 24 isolates, whose sequences formed a new genetic subgroup (genotype IIb-Miyako; IIb-M). When the genetic structures were compared in detail between IIb and IIb-M, characteristic variations were found in the C-terminal sequence of the large delta antigen-conferring packaging signal as well as the RNA editing site. Determination of subclasses of genotype IIb in a total of 37 patients, including seven HDV patients whose partial HDV sequence was determined, revealed eight patients with IIb and 29 patients with IIb-M. Although there was no significant difference in the clinical background or virological state of hepatitis B virus between these two groups, patients with genotype IIb-M showed greater progression of chronic hepatitis and cirrhosis than those with genotype IIb (P=0.0009). These data indicate the existence of a genetic subgroup of HDV genotype IIb, which is associated with different clinical characteristics and which could be related to genetic variations in functionally important parts of the HDV genome.

Amino acid substitutions in PKR-eIF2 phosphorylation homology domain (PePHD) of hepatitis C virus E2 protein in genotype 2a/2b and 1b in Japan and interferon efficacy.

Recently, the envelope protein 2 (E2) of hepatitis C virus (HCV) was reported to interact with double stranded RNA-dependent protein kinase (PKR) through an element homologous to the phosphorylation site of PKR and its target, eukaryotic translation initiation factor (eIF) 2alpha (PKR-eIF2alpha phosphorylation homology domain: PePHD). Inhibition of the kinase activity of PKR by this interaction was postulated as a mechanism for the resistance to interferon (IFN) therapy. The aim of this study was to clarify whether the variation of PePHD amino acid sequences affects IFN efficacy in Japanese population. Amino acid sequences of PePHD (aa. 659-670 in genotype1b, aa. 663-674 in genotype 2a and 2b) were determined in randomly selected 112 patients with chronic hepatitis C (genotype 1b; 83 patients, 2a; 14 patients, 2b; 15 patients) prior to IFN monotheray. In 21 out of the 23 genotype 1b sustained responders (SR) (91%) and 55 out of the 60 non-SR (92%), PePHD sequences were identical to that of the HCV-1b consensus sequence. Only two SR showed one amino acid substitution in PePHD, and five non-SR showed amino acid substitutions in PePHD. Among 14 genotype 2a patients, only two SR had one amino acid substitution comparing to the consensus HCV-2a sequence. Likely, only one SR had an amino acid substitution in PePHD among 15 genotype 2b patients. In conclusion, our study revealed no clinical relationship between the amino acid sequence of PePHD and the outcome of IFN therapy. PePHD polymorphism was not suggested to play a role in predicting IFN efficacy.

Sequence elements correlating with circulating viral load in genotype 1b hepatitis C virus infection.

The correlation between hepatitis C virus (HCV) genomic sequences and circulating HCV RNA levels was assessed to investigate the genetic elements affecting viral load. The interferon sensitivity-determining region (ISDR) sequence and the serum viral load were strongly correlated in 226 patients examined. Analysis of the entire HCV genome from six patients (three with a high and the others with a low viral load) with similar ISDR sequences identified several candidate residues associated with viral load. The amino acid (aa) sequences of these candidate residues and flanking regions in 67 additional patients revealed that only the residue at aa 962 varied significantly between the HCV patients with low and high serum loads (P=0.042). At this position, alanine was observed more frequently in the patients with a high viral load. In conclusion, our results strongly suggest that serum HCV RNA loads are inversely correlated with amino acid substitutions in the ISDR, and aa 962 was identified as a possible second determinant of serum HCV RNA load.