Development of an intervention to improve mental health for obstetric fistula patients in Tanzania.

Obstetric fistula is a debilitating childbirth injury that has been associated with high rates of psychological distress. Global efforts have helped to link women to surgical repair, but thus far no evidence-based interventions exist to address the psychological needs of these women during the hospital stay. In this paper, we describe the development of a psychological intervention for women in Tanzania who are receiving surgical care for an obstetric fistula. The intervention was developed based on theories of cognitive behavioral therapy and coping models. Content and delivery were informed by qualitative data collection with a range of stakeholders including women with fistula, and input from a study advisory board. The resulting intervention was six individual sessions, delivered by a trained community health nurse. The session topics were (1) recounting the fistula story; (2) creating a new story about the fistula; (3) loss, grief and shame; (4) specific strategies for coping; (5) social relationships; and (6) planning for the future. A trial run of the intervention revealed that the intervention could be delivered with fidelity and was acceptable to patients. A future randomized control trial will evaluate the efficacy of this intervention to address the mental health symptoms of this population.

Is there a role for immunotherapy in hepatocellular carcinoma?

Incidence of hepatocellular carcinoma has been rising in the last two decades because of the wide exposure to hepatitis C virus during 1960s and 1970s. Improvement in treatment has been achieved by local ablative therapies, however because of early recurrence and lack of effective chemotherapies, alternative treatments based on stimulation of the anti-tumour immune response could represent new strategies to control hepatocellular carcinoma spread and recurrence. Proof of principle of an effective immunotherapy has been achieved for other solid tumours such as melanoma and several results could be transferred to the immunotherapy of hepatocellular carcinoma. Specific tumour antigens have been identified in hepatocellular carcinoma, such as cancer testis antigens expressed in a large part of hepatocellular carcinomas and alpha-fetoprotein that has been already employed in clinical trials demonstrating immunogenicity without however significant clinical efficacy. Better results have been achieved by non-antigen-specific immunotherapies that demonstrated improvement in recurrence and recurrence-free survival in patients undergoing surgical resection for hepatocellular carcinoma. Passive immunotherapy and targeted therapies blocking tumour cell receptors or enzymatic pathways are already in the clinic for other malignancies and the near future will see these new treatments applied to hepatocellular carcinoma patients along with the development of efficacious active immunotherapies aimed at reducing disease recurrence and improving survival.

Lamivudine treatment can overcome cytotoxic T-cell hyporesponsiveness in chronic hepatitis B: new perspectives for immune therapy.

The hepatitis B virus (HBV) cytotoxic T lymphocyte (CTL) response in patients with chronic HBV infection is generally weak or totally undetectable. This inability to mount protective CTL responses is believed to be a crucial determinant of viral persistence, and its correction represents an important objective of immune therapies for chronic hepatitis B. However, amplification of CTL responses in vivo may be ineffective if HBV-specific CD8 cells are either absent or nonresponsive to exogenous stimulation. In this study, we asked whether antiviral treatments able to inhibit viral replication and to reduce viral and antigen load can successfully reconstitute CTL responses creating the appropriate conditions for their therapeutic stimulation. For this purpose, the HBV-specific CTL response before and during lamivudine therapy was studied longitudinally in 6 HLA-A2-positive patients with HBeAg+ chronic hepatitis B. Both HBV-specific cytotoxic T cell activity measured by chromium release assay on peptide stimulation in vitro and CD8+ T cell frequency measured ex vivo by HLA-A2/peptide tetramer staining were significantly augmented by lamivudine therapy. This enhancement followed the reconstitution of CD4 reactivity and the decline of viral load induced by therapy. Our study shows that lamivudine treatment in chronic hepatitis B can restore CTL reactivity, making CTL susceptible to exogenous stimulation. This effect may enhance the probability that T cell-based immune therapies delivered after lamivudine treatment can successfully reconstitute a protective CTL response able to cure chronic HBV infection.

Conserved hepatitis C virus sequences are highly immunogenic for CD4(+) T cells: implications for vaccine development.

The HLA class II-restricted T-cell response to hepatitis C virus (HCV) antigens is believed to influence the final outcome of hepatitis C, because it is vigorous in patients who recover from acute hepatitis C, but it is weak in those who develop a chronic infection. For this reason, exogenous stimulation of T-cell responses in chronic HCV infection may represent a strategy to cure patients with chronic hepatitis C by approximating the vigor of their T-cell reactivity to that of patients who succeed in recovering from hepatitis. It may also be a preventive approach to avoid spread of the virus by facilitating the development of a vigorous protective response at the very early stages of infection. T-cell-based vaccines composed of immunodominant, promiscuous, and conserved T-cell epitopes may represent a powerful tool to achieve optimal stimulation of the T-cell reactivity. To identify HLA class II-restricted T-cell epitopes useful for this purpose, 22 subjects with acute HCV infection were studied and followed for an average time of 29 months. Eight of them recovered from hepatitis, and 14 developed a chronic infection. Overlapping 20-mer peptides covering the entire core and NS4 antigens and a panel of peptides representing highly conserved regions of core, NS3, NS4, and NS5 were used. By direct peripheral blood T-cell stimulation and by fine-specificity analysis of HCV-specific T-cell lines and clones, highly immunogenic T-cell epitopes were identified within core, NS3, and NS4. All these epitopes are immunodominant and highly conserved among the known HCV isolates. Moreover, they are promiscuous, because they can be presented to T cells by different HLA class II molecules. Immunodominance, sequence conservation, and promiscuity make these epitopes ideal components of preventive or therapeutic T-cell-based vaccines against HCV.

Lamivudine treatment can restore T cell responsiveness in chronic hepatitis B.

High viral and/or antigen load may be an important cause of the T cell hyporesponsiveness to hepatitis B virus (HBV) antigens that is often observed in patients with chronic HBV infection. Reduction of viral and antigen load by lamivudine treatment represents an ideal model for investigating this hypothesis. HLA class II restricted T cell responses and serum levels of HBV-DNA, HBsAg, and HBeAg were studied before and during lamivudine treatment in 12 patients with hepatitis B e antigen positive chronic active hepatitis B to assess possible correlations between viral and/or antigen load and vigor of the T cell response. Cell proliferation to HBV nucleocapsid antigens and peptides and frequency of circulating HBV nucleocapsid-specific T cells were assessed to characterize CD4-mediated responses. A highly significant enhancement of the CD4-mediated response to HBV nucleocapsid antigens was already detectable in most patients 7-14 d after the start of lamivudine treatment. This effect was dramatic and persistent in 10 patients but undetectable in 2. It occurred concomitant with a rapid and marked reduction of viremia. Interestingly, lamivudine also enhanced the responses to mitogens and recall antigens, showing that its effect was not limited to HBV-specific T cells. In conclusion, an efficient antiviral T cell response can be restored by lamivudine treatment in patients with chronic hepatitis B concurrently with reduction of viremia, indicating the importance of viral load in the pathogenesis of T cell hyporesponsiveness in these patients. Since lamivudine treatment can overcome T cell hyporeactivity, combining lamivudine with treatments directed to stimulate the T cell response may represent an effective strategy to induce eradication of chronic HBV infection.

Predominant T-helper 1 cytokine profile of hepatitis B virus nucleocapsid-specific T cells in acute self-limited hepatitis B.

The cytokine pattern secreted by T cells on viral antigen recognition is believed to exert a profound influence on both the type of disease caused by the infecting agent and the final outcome of the viral infection. To characterize the cytokine pattern associated with spontaneous resolution of acute hepatitis B, we analyzed interferon gamma (IFN-gamma), interleukin (IL)-4, and IL-5 production by a wide series of hepatitis B virus (HBV) nucleocapsid-specific T-cell lines (34 lines) and T-cell clones (71 clones) derived from the peripheral blood of 13 patients during the acute or recovery phase of hepatitis B (2 and 7 of them were studied only in the recovery or the acute phase, respectively, and 4 during both). Most T-cell lines (67%) and clones (77%) isolated during the acute phase of infection expressed a T-helper (Th) 1 cytokine profile dominated by the production of IFN-gamma. A larger proportion (74%) of T-cell lines produced several years after resolution of hepatitis was able to secrete not only IFN-gamma, but also IL-4 and IL-5 (Th0-like cells). Results indicate that the antigen-specific fraction of peripheral blood T cells in acute self-limited hepatitis B selectively secrete Th1-type eytokines, suggesting that Th1-mediated effects may contribute not only to liver cell injury, but probably also to recovery from disease and successful control of infection.

Long-lasting memory T cell responses following self-limited acute hepatitis B.

The molecular and cellular basis of long-term T cell memory against viral antigens is still largely undefined. To characterize anti-viral protection by memory T cells against non-cytopathic viruses able to cause acute self-limited and chronic infections, such as the hepatitis B virus (HBV), we studied HLA class II restricted responses against HBV structural antigens in 17 patients with acute hepatitis B, during the acute stage of infection and 2.2 to 13 yr after clinical resolution of disease. Results indicate that: (a) significant T cell proliferative responses to HBV nucleocapsid antigens were detectable in all patients during the acute phase of infection and in 14/17 also 2-13 yr after clinical resolution of disease; b) long-lasting T cell responses were sustained by CD45RO+T cells, predominantly expressing the phenotype of recently activated cells; c) limiting dilution analysis showed that in some patients the frequency of HBV-specific T cells was comparable to that observed in the acute stage of infection and, usually, higher than in patients with chronic HBV infection; d) the same amino acid sequences were recognized by T cells in the acute and recovery phases of infection; and e) HBV-DNA was detectable by nested-PCR in approximately half of the subjects. to conclusion, our results show that vigorous anti-viral T cell responses are detectable in vitro several years after clinical recovery from acute hepatitis B. Detection of minute amounts of virus in some recovered subjects suggests that long-term maintenance of an active anti-viral T cell response could be important not only for protection against reinfection but also for keeping the persisting virus under tight control.

Fine specificity of the human T-cell response to the hepatitis B virus preS1 antigen.

The T-cell response to hepatitis B virus envelope antigens was studied in 11 hepatitis B vaccine recipients; 7 were selected to analyze the fine specificity of the T-cell response to the preS1 antigen. Four distinct T-cell epitopes were identified by peripheral blood lymphomononuclear cell stimulation with a panel of short synthetic peptides covering the preS1 sequence. The immunodominance of the preS1 epitopes included within peptides 21-30 and 29-48 was shown by their capacity to restimulate an HLA class II restricted proliferative response of T cells primed with the whole preS1 antigen. Conversely, peptide-specific T cells selected by peripheral blood lymphomononuclear cell stimulation with peptides 21-30 and 29-48 were able to recognize the native preS1 molecule, confirming that these epitopes are actually generated by the intracellular processing of preS1. Finally, amino acid residues essential for T-cell activation by peptide 21-30 were identified using 10 analogues of the stimulatory peptide containing single alanine substitutions. These results may be relevant to the design of efficient synthetic vaccines against hepatitis B virus infection.

Autopresentation of hepatitis B virus envelope antigens by T cells.

Processing and presentation by T cells appear to be limited to antigens that can directly interact with the T-cell surface, thereby overcoming the T-cell inefficiency in antigen capture and internalization. Our study provides evidence that the hepatitis B virus (HBV) envelope proteins can also be efficiently processed and presented by CD4+ and CD8+ T cells to other T cells in a human leukocyte antigen class II-restricted fashion. This phenomenon suggests a receptor-mediated interaction between T cells and the HBV envelope and defines a system that can, we hope, be exploited for the identification of the receptor binding site within the HBV envelope and for the characterization of the putative cellular HBV receptor.

Fine specificity of the human T cell response to hepatitis B virus core antigen.

The fine specificity of the human T cell response to the hepatitis B virus core antigen (HBcAg) was investigated in 23 patients with acute hepatitis B virus (HBV) infection using a panel of short synthetic peptides covering the entire core region. An immunodominant T cell epitope which was recognized by all except one patient, was identified within the core sequence 50-69. Two further important T cell recognition sites were represented by the amino acid sequences 1-20 and 117-131, which were stimulatory for the T cells of 69% and 73% of the patients, respectively. T cell recognition of the synthetic peptides was HLA class II restricted because the peptide-induced T cell proliferation was inhibited by anti-HLA class II but not by anti-HLA class I monoclonal antibodies. These findings may be relevant to the development of future preventive and therapeutic strategies against HBV infection.

Immune pathogenesis of hepatitis B.

Available information about the immune pathogenesis of HBV infection in man is very limited. However, the present availability of recombinant sources of the different HBV antigens expressed in the appropriate forms to induce activation of either HLA class I or HLA class II-restricted T cells, provides the necessary tools to investigate directly the mechanisms of liver damage, the role of the different cellular components of the immune system in HBV clearance and the specific nature of the immune defects potentially responsible for the chronic evolution of HBV infection. In addition, improved knowledge of HBV biology suggests a dynamic interpretation of the HBV-immune system interactions, based on which viral mutations as well as direct interferences of HBV with specific immune functions are believed to play a relevant role with respect to the outcome of HBV infection.

Identification of immunodominant T cell epitopes of the hepatitis B virus nucleocapsid antigen.

Several lines of experimental evidence suggest that inclusion of core sequences in the hepatitis B vaccine may represent a feasible strategy to increase the efficacy of the vaccination. In order to identify immunodominant core epitopes, peripheral blood T cells purified from 23 patients with acute hepatitis B and different HLA haplotypes were tested with a panel of 18 short synthetic peptides (15 to 20 amino acids [AA]) covering the entire core region. All patients except one showed a strong T cell proliferative response to a single immunodominant 20 amino acid sequence located within the aminoterminal half of the core molecule. Two additional important sequences were also identified at the aminoterminal end and within the carboxyterminal half of the core molecule. These sequences were able to induce significant levels of T cell proliferation in 69 and 73% of the patients studied, respectively. T cell response to these epitopes was HLA class II restricted. The observations that (a) polyclonal T cell lines produced by PBMC stimulation with native HBcAg were specifically reactive with the relevant peptides and that (b) polyclonal T cell lines produced with synthetic peptides could be restimulated with native HBcAg, provide evidence that AA sequences contained within the synthetic peptides represent real products of the intracellular processing of the native core molecule. In conclusion, the identification of immunodominant T cell epitopes within the core molecule provides the molecular basis for the design of alternative and hopefully more immunogenic vaccines.

[Pseudoaneurysm of the peroneal artery caused by a non-penetrating injury]. / Pseudo aneurisma dell'arteria peronea da trauma non penetrante.

The rareness of false arterial aneurysm, a consequence of a non-penetrating injury of a limb, induced the Authors, on the basis of the most recent literature, to review its physiopathologic, clinical and therapeutical aspects, with the purpose to hasten its diagnosis and prevent its complications through the adoption of the most suitable surgical treatment.

[Importance of combined surgical and heparin treatment of peripheral embolism]. / Importanza del trattamento chirurgico ed eparinico combinato nell'embolia periferica.

The authors dwell upon the physiopathologic and diagnostical aspects of the peripheral embolism, and emphasize the effectiveness of the surgical treatment if associated to the anticoagulative one: the valid results obtained should be ascribed to a prompt diagnosis, a stronger surgical aggressiveness and a constant combination of heparinic and surgical therapy.

[Biliary peritonitis]. / Le peritoniti biliari.

The Authors contribute to the definition of the diagnosis and treatment of biliary peritonitis (PB) by showing 12 cases of it. They appraise the etiopathogenetic aspects of this pathology, point out the peculiarities of its precocious radiological and echographic picture, and emphasize its high mortality in patients not subjected to adequate emergency therapy.