Liver fibrosis progression in a cohort of young HIV and HIV/ HBV co-infected patients: A longitudinal study using non-invasive APRI and Fib-4 scores.

Background: The risk of liver fibrosis increases over time in HIV and HIV-HBV individuals even under antiretroviral treatment (ART), warranting a rigorous and periodic monitorization. Given the lower availability of transient elastography, we aimed to assess the longitudinal variation of two non-invasive liver fibrosis scores, APRI and Fib-4, in cases with HIV monoinfection, HIV-HBV co-infection and individuals with HBsAg-seroclearance. Methods: We performed an observational retrospective study between 2013 and 2019 on 212 HIV patients including 111 individuals with HIV mono-infection, 62 individuals with HIV-HBV co-infection and positive HBsAg and 39 cases with HIV-HBV infection and HBsAg-loss. The groups were followed at 36, 48, and 60 months. Liver fibrosis was indicated by an APRI >0.5 or Fib-4≥1.45 score and advanced fibrosis by an APRI score >1.5 or Fib-4 >3.25. Logistic regression with generalized estimating equations (GEE) was used to assess the predictors for the presence of liver fibrosis over time. Results: During a median follow-up of 58.5 months the prevalence of liver fibrosis in all patients increased with 0.5% reaching 11.3% using an APRI score and with 0.9% reaching 10.8% using the Fib-4 score. At the visit corresponding to 60 months the prevalence of liver fibrosis was higher in all HIV-HBV patients compared with individuals with HIV mono-infection, namely: 16.1% on APRI and 12.9% on the Fib-4 score in HIV-HBV/HBsAg-positive individuals, 12.8% on both APRI and Fib-4 scores in HIV-HBV/HBsAg-negative individuals vs. 8.1 and 9%, respectively in HIV mono-infection. The presence of liver fibrosis over the study period was independently associated with plasma HIV RNA, CD4+T cell counts, HIV-HBV co-infection (for APRI >0.5) and ART non-adherence (for Fib-4 >1.45). At the final visit, non-adherence to ART and CD4+T cell counts remained associated with liver fibrosis. Conclusions: The study found a slow progression of APRI and Fib-4 scores over time in young PLWH with extensive ART. Liver fibrosis scores continued to increase in patients with HIV mono-infection yet remained lower than in HIV-HBV patients irrespective on the presence of HBsAg. The periodic follow-up using non-invasive scores on the long-term could help improve the surveillance in low-income settings and high scores should be followed by additional diagnostic methods.

Thresholds of Basal- and Calcium-Stimulated Calcitonin for Diagnosis of Thyroid Malignancy.

Since medullary thyroid carcinoma is an aggressive cancer, it is important to have an early detection based on stimulated calcitonin (CT), especially when basal-CT is slightly elevated. The objective of this work was to set specific thresholds for basal-CT- and calcium-stimulated calcitonin for prediction of thyroid malignancy in female population. The study included 2 groups: group A-women with elevated basal-CT (>9.82 pg/ml) and group B-women with normal basal-CT (control group). After calcium stimulation test precise protocol, histopathological reports of those that required surgery were correlated with both basal and stimulated calcitonin. The best basal and stimulated calcitonin cut-offs for distinguishing female patients with medullary thyroid carcinoma or C-Cell-hyperplasia from other pathologies or normal cases were: 12.9 pg/ml, respectively 285.25 pg/ml. For basal-CT above 30 pg/ml, malignancy was diagnosed in 9/9 patients (100%): 9 MTC. For stimulated calcitonin above 300 pg/ml, malignancy was diagnosed in 17/21 patients (80.95%): 12 MTC and 5 papillary thyroid carcinomas. The smallest nodule that proved to be medullary thyroid carcinoma had only 0.56/0.34/0.44 cm on ultrasound, with no other sonographic suspicious criteria. In conclusion, we have identified in Romanian female population basal and stimulated calcitonin thresholds to discriminate medullary thyroid carcinoma or C-Cell-hyperplasia from other cases. We recommend thyroid surgery in all women with stimulated calcitonin above 285 pg/ml. Further studies on larger groups are necessary to establish and confirm male and female cut-offs for early diagnosis of medullary thyroid carcinoma, and interestingly, maybe for macro-papillary thyroid carcinomas alike. The calcium administration has minimum side-effects, but continuous cardiac monitoring is required.

Safety of calcitonin stimulation tests with calcium.

INTRODUCTION: Medullary thyroid carcinoma (MTC) is an aggressive form of thyroid cancer. Early detection is essential because only complete resection of the thyroid tumor and any local metastases can cure MTC. Calcitonin (CT) is a marker used for diagnosis of MTC. In controversial cases of slightly elevated CT levels, stimulation tests have shown their utility, but their safety should also be taken into account. OBJECTIVE: Our aim is to present our own experience regarding the safety of CT stimulating tests. MATERIALS AND METHODS: We applied a specific protocol of calcium stimulation test in 176 patients after informed consent (115 women with a median age of 46 years, range 21-79; 61 men with a median age of 54 years, range 22-78). We recorded the side effects and a further analysis was performed. RESULTS: The most frequent side effects noted were hot flashes in 159 out of 176 patients (90.34%), followed by dysgeusia (32/176) and bradycardia (10/176). Severe bradycardia was reported in only one patient (0.568%), which was rapidly reversible. There was no correlation between patients' age, weight, height, body mass index, basal CT or peak stimulated CT, and grade of severity, but men were more likely to develop cardiovascular side effects than women, namely, bradycardia, tachycardia, ventricular or atrial extrasystoles, hypertension, hypotension, or angina (p = 0.024), with an odds ratio of 2.94 (CI: 1.11-7.76). We recommend thyroid surgery in all women with sCT above 285 pg/ml. CONCLUSION: The calcium stimulation test is well tolerated, with few adverse reactions. The test should be performed with appropriate precautions (i.e., ECG monitoring during and after the test) to minimize the possibility of a serious event.

Calcitonin Stimulation Tests: Rationale, Technical Issues and Side Effects: A Review.

Calcitonin (CT) stimulation tests have great value and could help to: differentiate thyroid causes of elevated CT apart from non-thyroid sources, determine whether the patients with slightly elevated basal CT could/could not be candidates for surgery, and indicate the right moment for prophylactic thyroidectomy in children with MEN syndromes when with normal basal CT. This triggered the requests for development of CT stimulation tests, taking into consideration their safety and aimed us to write a systematic review of literature regarding the rationale, technical issues, and side effects of CT stimulating tests used for diagnosis of MTC. After a thorough review of the literature, we classified the reported side effects by severity, as defined by United States Food and Drug Administration. A statistical analysis was performed using IBM SPSS Statistics version 20. Various side effects were noticed during stimulation tests that differ by intensity, duration and severity, depending on types of substances and protocols used. The side effects after pentagastrin test were significantly more severe than those reported after calcium stimulation test (p=0.0396). There are also significant gender-specific differences in side effects induced by stimulation tests. In conclusion, we recommend performing Ca CT stimulation test when needed, considering preventive evaluation of some clinical, instrumental, and biochemical aspects of each patient. Precise instructions should be followed before a stimulation test and furthermore continuous cardiac monitoring is essential during and after the test to minimize the possibility of a serious event.

Lymphoproliferative disorder in a twin female teenager post kidney transplantation.

Post-transplant lymphoproliferative disorder (PTLD) is defined as a heterogeneous group of lymphoid and plasmocytic proliferations with variable malignant potential. They often arise in immunocompromised post solid organ transplant (SOT) patients linked with Epstein-Barr virus (EBV) infection. Clinical manifestations include fever, lymphadenopathy and organ involvement. Diagnosis of PTLD requires morphopathological tissue examination. Treatment of EBV-related PTLD in SOT patients includes immunosuppressive (IS) agents' reduction, use of antiviral medication, anti-B-lymphocyte antibodies and chemotherapy for high-risk patients. We report a case of late EBV-related PTLD occurring in a young female, coming from twins, nine years after renal transplant from deceased donor. Both sisters were diagnosed at the age of 10 with chronic kidney disease (CKD) based on nephronophthisis and underwent the first simultaneous renal transplant from deceased donor in Romania. PTLD Hodgkin's-like lymphoma and EBV-positive lesions were to be found in autopsy. Routine EBV viral load testing and immune condition in SOT patients could identify PTLD risk factors therefore early treatment can be applied. Monitoring EBV serology and immunological parameters are preferred as strategy for PTLD prevention.

Hepatic Osteodystrophy: A Global (Re)View of the Problem.

Hepatic osteodystrophy is a common and frequently untreated complication, manifested as osteoporosis or osteopenia, encountered in the evolution of chronic liver diseases. This article provides a narrative review of hepatic osteodystrophy. The aim is to revise the prevalence, pathophysiology, diagnosis and management of hepatic osteodystrophy. We searched medical literature via PubMed, Google Scholar, Wiley, Science Direct, and Springer Link using respective keywords to obtain data on low bone mineral density connected to chronic liver diseases. Many studies have reported an increased prevalence of osteoporosis/osteopenia in patients with chronic liver diseases. The pathogenesis is multifactorial, involving genetic factors, vitamin deficiencies, proinflammatory cytokines, hypogonadism, hyperbilirubinemia, antiviral therapy, corticosteroid drugs, and lifestyle factors. The management of patients should include individualized assessment for fracture risk factors and bone mineral density. Vitamin D and calcium supplementation should be recommended in all patients with chronic liver diseases and osteoporosis. Bisphosphonates are the most efficient drugs used in the treatment of hepatic osteodystrophy. In the future, it is necessary to define better the management and specific treatment of hepatic osteodystrophy for prevention of fragility fractures and to improve the patient quality of life.

Body Composition Changes in Patients with Chronic Hepatitis C.

AIMS: We aimed to quantify global and regional body composition changes in chronic hepatitis C (CHC) patients, compare them to healthy controls and identify possible association between body composition changes and CHC. To our knowledge, this study is the first one comparing CHC patients to controls with regard to soft tissue body composition changes. METHODS: We assessed 60 CHC patients and 60 healthy controls by Dual Energy X-Ray Absorptiometry. Soft tissue and bone body composition parameters were compared between the groups (using the Mann-Whitney test). These parameters were correlated (using Spearman's rank correlation coefficient - rho) with independent variables (age, gender, body mass index - BMI, cigarette smoking, time since CHC diagnosis, viral load, fibrosis grade, type of treatment, time of treatment) for the entire CHC group and also for subgroups according to gender. RESULTS: Total fat mass, trunk fat mass and percent body fat were lower in CHC patients as compared to controls. Several risk factors were associated with the reduced fat mass: low BMI, cigarette smoking and peginterferon alpha 2a plus ribavirin treatment. Peginterferon alpha 2a and ribavirin treatment negatively correlated with lean body parameters, especially in CHC males group. Bone mineral density (BMD) was lower as compared to controls and was correlated with low BMI, cigarette smoking and peginterferon alpha 2a and ribavirin treatment. CONCLUSIONS: Patients with CHC have an acquired type of lipodystrophy (particularly in the trunk region), and also a reduced BMD as compared with controls. A low BMI, cigarette smoking and peginterferon alpha 2a and ribavirin therapy were associated with a low fat mass and low BMD.

Upregulation of Key Molecules for Targeted Imaging and Therapy.

Targeted diagnosis and therapy enable precise tumor detection and treatment. Successful examples for precise tumor targeting are diagnostic and therapeutic radioligands. However, patients with tumors expressing low levels of the relevant molecular targets are deemed ineligible for such targeted approaches. METHODS: We performed a screen for drugs that upregulate the somatostatin receptor subtype 2 (sstr2). Then, we characterized the effects of these drugs on transcriptional, translational, and functional levels in vitro and in vivo. RESULTS: We identified 9 drugs that act as epigenetic modifiers, including the inhibitor of DNA methyltransferase decitabine as well as the inhibitors of histone deacetylase tacedinaline and romidepsin. In vitro, these drugs upregulated sstr2 on transcriptional, translational, and functional levels in a time- and dose-dependent manner. Thereby, their combinations revealed synergistic effects. In vivo, drug-based sstr2 upregulation improved the tumor-to-background and tumor-to-kidney ratios, which are the key determinants of successful sstr2-targeted imaging and radiopeptide therapy. CONCLUSION: We present an approach that uses epigenetic modifiers to improve sstr2 targeting in vitro and in vivo. Translation of this method into the clinic may potentially convert patients ineligible for targeted imaging and therapy to eligible candidates.

Indium-111 labeled gold nanoparticles for in-vivo molecular targeting.

The present report describes the synthesis and biological evaluation of a molecular imaging platform based on gold nanoparticles directly labeled with indium-111. The direct labeling approach facilitated radiolabeling with high activities while maintaining excellent stability within the biological environment. The resulting imaging platform exhibited low interference of the radiolabel with targeting molecules, which is highly desirable for in-vivo probe tracking and molecular targeted tumor imaging. The indium-111 labeled gold nanoparticles were synthesized using a simple procedure that allowed stable labeling of the nanoparticle core with various indium-111 activities. Subsequent surface modification of the particle cores with RGD-based ligands at various densities allowed for molecular targeting of the αvß3 integrin in-vitro and for molecular targeted imaging in human melanoma and glioblastoma models in-vivo. The results demonstrate the vast potential of direct labeling with radioisotopes for tracking gold nanoparticles within biological systems.

Fe3O4-PEI-RITC magnetic nanoparticles with imaging and gene transfer capability: development of a tool for neural cell transplantation therapies.

PURPOSE: To develop Fe(3)O(4)-PEI-RITC magnetic nanoparticles with multimodal MRI-fluorescence imaging and transfection capability, for use in neural cell replacement therapies. METHODS: The Fe(3)O(4)-PEI-RITC MNPs were synthesised through a multi-step chemical grafting procedure: (i) Silanisation of MNPs with 3-iodopropyltrimethoxysilane; (ii) PEI coupling with iodopropyl groups on the MNP surface; and (iii) RITC binding onto the PEI coating. The cell labelling and transfection capabilities of these particles were evaluated in astrocytes derived from primary cultures. RESULTS: Fe(3)O(4)-PEI-RITC MNPs did not exert acute toxic effects in astrocytes (at ≤ 6 days). Cells showed rapid and extensive particle uptake with up to 100% cellular labelling observed by 24 h. MRI and microscopy studies demonstrate that the particles have potential for use in bimodal MR-fluorescence imaging. Additionally, the particles were capable of delivering plasmids encoding reporter protein (approximately 4 kb) to astrocytes, albeit with low efficiencies. CONCLUSIONS: Multifunctional Fe(3)O(4)-PEI-RITC MNPs were successfully prepared using a multi-step synthetic pathway, with the PEI and RITC chemically bound onto the MNP surface. Their combined MR-fluorescence imaging capabilities with additional potential for transfection applications can provide a powerful tool, after further development, for non-invasive cell tracking and gene transfer to neural transplant populations.

Novel magnetite-silica nanocomposite (Fe3O4-SBA-15) particles for DNA binding and gene delivery aided by a magnet array.

Novel magnetite-silica nanocomposite particles were prepared using SBA-15 nanoporous silica as template. Magnetite nanoparticles were impregnated into the nanopore array of the silica template through thermal decomposition of iron(III) acetylacetonate, Fe(AcAc)3 at 200 degrees C. These composite particles were characterized using TEM, XRD and SQUID magnetometry. The TEM images showed that the size of composite particles was around 500 nm and the particles retained the nanoporous array of SBA-15. The formation of magnetite nanoparticles was confirmed by the powder XRD study. These composite particles also exhibited ferrimagnetic properties. By coating with short chain polyethyleneimine (PEI), these particles are capable of binding DNA molecules for gene delivery and transfection. With an external magnetic field, the transfection efficiency was shown to have an increase of around 15%. The results indicated that these composite nanoparticles may be further developed as a new tool for nanomagnetic gene transfection.

Thrombocytopenia in chronic hepatitis C.

BACKGROUND AND AIMS: Thrombocytopenia in patients with chronic hepatitis C may be the result of several factors: bone marrow inhibition, the decrease of liver thrombopoietin production and an autoimmune mechanism. Clinical variables such as age, gender, severity of liver disease and degree of viremia could influence the severity of platelet reduction. The goal of this study is to determine the prevalent mechanism of thrombocytopenia in patients with chronic hepatitis C and the clinical predictors of its severity. METHODS: Eighty-one patients with chronic hepatitis C and thrombocytopenia were included. The viral inhibition on the bone marrow (central mechanism) was studied by performing bone marrow biopsy from the iliac crest. The presence of antiplatelet antibodies by ELISA assessed the peripheral mechanism. The clinical predictors included in the analysis were: age, gender, ALT level, liver fibrosis stage and HCV RNA. RESULTS: Coexistence of a central and peripheral mechanism was found in the vast majority (93.3%) of patients with severe thrombocytopenia (< 100,000/microL) and in most patients (61.53%) with moderate thrombocytopenia (100,000- 125,000/microL). In patients with less severe thrombocytopenia (126,000-149,000/microL), autoimmune destruction was the sole mechanism (85%). Thrombocytopenia was significantly associated with ALT values, viral load and stage of fibrosis. CONCLUSIONS: Our data demonstrates that chronic hepatitis C is associated with a variable degree of thrombocytopenia. As the disease advances, the platelet count decreases and, in most cases, both mechanisms are involved. The stage of fibrosis is one of the major determinants of thrombocytopenia.