N-acetylcysteine for major mental disorders: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the efficacy and safety of adjunctive N-acetylcysteine (NAC), an antioxidant drug, in treating major depressive disorder (MDD), bipolar disorder, and schizophrenia.

METHODS

The PubMed, Cochrane Library, PsycINFO, CNKI, CBM, and WanFang databases were independently searched and screened by two researchers. Standardized mean differences (SMDs), risk ratios, and their 95% confidence intervals (CIs) were computed.

RESULTS

Six RCTs (n = 701) of NAC for schizophrenia (three RCTs, n = 307), bipolar disorder (two RCTs, n = 125), and MDD (one RCT, n = 269) were identified and analyzed as separate groups. Adjunctive NAC significantly improved total psychopathology (SMD = -0.74, 95% CI: -1.43, -0.06; I² = 84%, P = 0.03) in schizophrenia, but it had no significant effect on depressive and manic symptoms as assessed by the Young Mania Rating Scale in bipolar disorder and only a small effect on major depressive symptoms. Adverse drug reactions to NAC and discontinuation rates between the NAC and control groups were similar across the three disorders.

CONCLUSIONS

Adjunctive NAC appears to be a safe treatment that has efficacy for schizophrenia, but not for bipolar disorder or MDD. Further higher quality RCTs are warranted to determine the role of adjunctive NAC in the treatment of major psychiatric disorders.

Adjunctive memantine for schizophrenia: a meta-analysis of randomized, double-blind, placebo-controlled trials

BACKGROUND

Dysfunction of N-methyl-D-aspartate receptor (NMDAR) is involved in the pathophysiology of schizophrenia. A meta-analysis of randomized controlled trials (RCTs) was conducted to examine the efficacy and safety of memantine, a non-competitive NMDAR antagonist, in the treatment of schizophrenia.

METHODS

Standardized/weighted mean differences (SMDs/WMDs), risk ratio (RR), and their 95% confidence intervals (CIs) were calculated and analyzed.

RESULTS

Included in the meta-analysis were eight RCTs (n = 452) of 11.5 ± 2.6 weeks duration, with 229 patients on memantine (20 mg/day) and 223 patients on placebo. Adjunctive memantine outperformed placebo in the measures of Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale negative symptoms [SMD: -0.63 (95% CI -1.10 to -0.16), p = 0.009, I 2 = 77%], but not in the total, positive and general symptoms [SMD: -0.46 to -0.08 (95% CI -0.93 to 0.22), p = 0.06-0.60, I 2 = 0-74%] or the Clinical Global Impression Severity Scale [WMD: 0.04 (95% CI -0.24 to 0.32), p = 0.78]. The negative symptoms remained significant after excluding one outlying RCT [SMD: -0.41 (95% CI -0.72 to -0.11), p = 0.008, I 2 = 47%]. Compared with the placebo group, adjunctive memantine was associated with significant improvement in neurocognitive function using the Mini-Mental State Examination (MMSE) [WMD: 3.09, (95% CI 1.77-4.42), p < 0.00001, I 2 = 22%]. There was no significant difference in the discontinuation rate [RR: 1.34 (95% CI 0.76-2.37), p = 0.31, I 2 = 0%] and adverse drug reactions between the two groups.

CONCLUSIONS

This meta-analysis showed that adjunctive memantine appears to be an efficacious and safe treatment for improving negative symptoms and neurocognitive performance in schizophrenia. Higher quality RCTs with larger samples are warranted to confirm these findings.

The lymph node ratio does not provide additional prognostic information compared with the N1/N2 classification in Stage III colon cancer

AIM

The ratio of positive nodes to total nodes, the lymph node ratio (LNR), is a proposed alternative to the current N1/N2 classification of nodal disease. The true clinical benefit of adopting the LNR, however, has not been definitively demonstrated. This study compared the LNR with the current N1/N2 classification of Stage III colon cancer.

METHOD

Patients with Stage III colon cancer were identified from a prospectively maintained database (1996-2012). The specificity and sensitivity of the N1/N2 classification in the prediction of overall survival were determined using R. A cut-off point for the LNR was determined by setting the specificity the same as for the N1/N2 classification. The sensitivity of the two methods was then compared, and bootstrapping 1000-fold was performed. This was then repeated for disease-specific survival.

RESULTS

The specificity and sensitivity of the N1/N2 classification in predicting 3-year overall survival in this cohort (n = 402) was 62.2% and 52.1%, respectively. The cut-off point for the LNR was determined to be 0.27 for these data. On comparing LNR with the N1/N2 classification showed that for a given specificity, the LNR did not provide a statistically significant improvement in sensitivity (52.8% vs 52.1%, P = 0.31). For disease-specific death at 3 years, the specificity and sensitivity were 60.8% and 54.6%, respectively. The LNR did not provide a statistically significant improvement (55.4% vs 54.6%, P = 0.44).

CONCLUSION

Both the N1/N2 system and the LNR predict survival in colon cancer, but both have low specificity and sensitivity. The LNR does not provide additional prognostic value to current staging for overall or disease-specific survival for a given cut-off point.

Metformin synergizes 5-fluorouracil, epirubicin, and cyclophosphamide (FEC) combination therapy through impairing intracellular ATP production and DNA repair in breast cancer stem cells

Metformin, an AMPK activator, has been reported to improve pathological response to chemotherapy in diabetic breast cancer patients. To date, its mechanism of action in cancer, especially in cancer stem cells (CSCs) have not been fully elucidated. In this study, we demonstrated that metformin, but not other AMPK activators (e.g. AICAR and A-769662), synergizes 5-fluouracil, epirubicin, and cyclophosphamide (FEC) combination chemotherapy in non-stem breast cancer cells and breast cancer stem cells. We show that this occurs through an AMPK-dependent mechanism in parental breast cancer cell lines. In contrast, the synergistic effects of metformin and FEC occurred in an AMPK-independent mechanism in breast CSCs. Further analyses revealed that metformin accelerated glucose consumption and lactate production more severely in the breast CSCs but the production of intracellular ATP was severely hampered, leading to a severe energy crisis and impairs the ability of CSCs to repair FEC-induced DNA damage. Indeed, addition of extracellular ATP completely abrogated the synergistic effects of metformin on FEC sensitivity in breast CSCs. In conclusion, our results suggest that metformin synergizes FEC sensitivity through distinct mechanism in parental breast cancer cell lines and CSCs, thus providing further evidence for the clinical relevance of metformin for the treatment of cancers.

A Prospective Study of Serotonin and Norepinephrine Transporter Genes and the Response to Desvenlafaxine Over 8 Weeks in Major Depressive Disorder

No studies to date have evaluated SLC6A2 and SLC6A4 genetic polymorphisms influencing antidepressant response to desvenlafaxine. We conducted an 8-week, open-label, prospective pilot study in 35 patients with major depressive disorder to assess the effects of genetic variations in SLC6A2 and SLC6A4 on both efficacy and side effect profile of desvenlafaxine. Results revealed that homozygotes for the SLC6A4 HTTLPR S allele showed a 33% HDRS reduction compared to a 58% reduction for L allele carriers (p=0.037). No results survived adjustments for covariates or multiple comparisons. While these results need to be interpreted cautiously, they provide preliminary support for the SLC6A4 HTTLPR polymorphism as potential modifier of desvenlafaxine efficacy.

Extract of Ginkgo biloba for Tardive Dyskinesia: Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Free radicals may be involved in the pathogenesis of tardive dyskinesia (TD). We conducted this meta-analysis to systematically examine the efficacy of extract of Ginkgo biloba (EGb), a potent antioxidant possessing free radical-scavenging properties, as a treatment for TD in schizophrenia using randomized controlled trial (RCT) data.

METHOD

Drawn from English and Chinese databases, 3 RCTs of EGb augmentation of antipsychotics (APs) vs. AP plus placebo or AP monotherapy were identified. 2 evaluators extracted data. The primary outcome measure was the severity of TD symptoms assessed by the Abnormal Involuntary Movement Scale (AIMS). Weighted mean difference (WMD) and risk ratio (RR) ±95% confidence intervals (CI) were calculated. Statistical analyses were performed using Review Manager (version 5.1.7.0) and STATA (version 12.0).

RESULTS

The 3 RCTs (n=299) from China, of 12 weeks duration, involved schizophrenia patients with TD of 55.9±13.4 years old. EGb (240 mg/day) outperformed the control group in reducing the severity of TD and clinical symptoms as measured by the AIMS (trials=3, n=299, WMD: -2.30 (95%CI: - 3.04, -1.55), P<0.00001) and the adverse drug reactions as assessed by the Treatment Emergent Symptom Scale (TESS) (trials=2, n=142, WMD: -2.38 (95%CI: -4.01, -0.74), P=0.004). Both the Positive and Negative Syndrome Scale (PANSS) total score (trials=2, n=239, P=0.87) and all-cause discontinuation (trials=3, n=299, P=0.21) were similar between the EGb and control group.

CONCLUSION

This meta-analysis suggests that adjunctive EGb appeared to be an effective and safe option for improving TD in the treatment of schizophrenia patients. However, better RCTs are needed to demonstrate its efficacy and safety especially on cognitive function in TD.

TRIAL REGISTRATION

PROSPERO

CRD42015024930.

Clozapine prescription and quality of life in Chinese patients with schizophrenia treated in primary care

OBJECTIVE

Clozapine is frequently used to treat schizophrenia in China. Maintenance treatment for clinically stable patients with schizophrenia is usually provided by Chinese primary care physicians, but no study has investigated the frequency of its use prescribed by primary care physicians. This study described the frequency, demographic and clinical characteristics of clozapine treatment and its impact on insight and quality of life (QOL) of patients with schizophrenia treated in primary care in China.

METHOD

A total of 623 patients with schizophrenia treated in 22 primary care services in Guangzhou, China in 2013 formed the study sample. Patients' socio-demographic and clinical characteristics including psychopathology, medication side effects and QOL were recorded using a standardized protocol and data collection.

RESULTS

The frequency of clozapine prescription was 35.6% with a mean daily dose of 127.7±88.2 mg. There were no significant differences between the patients with and without clozapine in either of the QOL domains after controlling the confounding factors. Multiple logistic regression analyses revealed that patients on clozapine had younger age of onset, more hospitalizations, more severe extrapyramidal side effects, but better insight and fewer prescriptions of first generation antipsychotics.

CONCLUSIONS

Clozapine use was found to be common and associated with better insight in patients with schizophrenia treated in primary care in China. Further examination of the rationale and appropriateness of clozapine in primary care in China is warranted.

Do clinical features and survival of single hormone receptor positive breast cancers differ from double hormone receptor positive breast cancers?

The significance of the single hormone receptor positive phenotype of breast cancer is still poorly understood. The use of hormone therapy has been found to be less effective for this type, which has a survival outcome midway between double positive and double negative phenotypes. The aim of this study was to investigate differences in patient and tumor characteristics and survival between double-receptor positive (ER+PR+), double receptor negative (ER-PR-) and single receptor positive (ER+PR- and ER-PR+) breast cancer in an Asian setting. A total of 1,992 patients with newly diagnosed stage I to IV breast cancer between 2003 and 2008, and where information on ER and PR were available, were included in this study. The majority of patients had ER+PR+ tumors (n=903: 45.3%), followed by 741 (37.2%) ER-PR-, 247 (12.4%) ER+PR-, and 101 (5.1%) ER-PR+ tumors. Using multivariate analysis, ER+PR- tumors were 2.4 times more likely to be grade 3 compared to ER+PR+ tumors. ER+PR- and ER-PR+ tumors were 82% and 86% respectively less likely to be grade 3 compared with ER-PR- tumors. ER-PR+ tumours were associated with younger age. There were no survival differences between patients with ER+PR+ and ER-PR+ tumors. However, ER+PR- tumors have poorer survival compared with ER+PR+ tumours. ER-PR- tumours had the worst survival. Adjuvant hormonal therapy with tamoxifen was found to have identical survival advantage in patients with ER+PR+ and ER-PR+ tumors whereas impact was slightly lower in patients with ER+PR- tumors. In conclusion, we found ER+PR- tumors to be more aggressive and have poorer survival when compared to ER+PR+ tumors, while patients with ER-PR+ tumours were younger, but had a similar survival to their counterparts with ER+PR+ tumours.

Is S-Adenosyl Methionine (SAMe) for Depression Only Effective in Males? A Re-Analysis of Data from a Randomized Clinical Trial

OBJECTIVE

The aim of this study was to examine whether gender differences may have affected treatment response to S-adenosyl methionine (SAMe) in a recent failed randomized clinical trial (RCT) for adults with major depressive disorder.

METHODS

Data from a 2-site, 12-week, double-blind RCT (n=189) assessing the efficacy of SAMe vs. placebo and a comparator selective serotonin reuptake inhibitor (escitalopram) were subjected to post-hoc analyses to evaluate effects of patient gender on treatment response.

RESULTS

When assessing the efficacy outcomes within each gender separately, SAMe was superior to placebo among males (n=51), but not among females (n=62). Males showed a significant reduction of depression severity from baseline to study endpoint on the 17-item Hamilton Depression Rating Scale (4.3 point difference; p=0.034; d=0.95), while females did not show significant change. This finding emerged despite equivalence on baseline measures of depression severity between the gender groups.

CONCLUSION

RESULTS of this secondary data analysis suggest that gender might impact the antidepressant efficacy of SAMe, with greater therapeutic effect found in males. The underlying mechanism is still relatively unknown. Further work is needed to replicate this observation in independent samples.Clinicaltrials.gov identifier: NCT00101452.

The predictive accuracy of PREDICT: a personalized decision-making tool for Southeast Asian women with breast cancer

Web-based prognostication tools may provide a simple and economically feasible option to aid prognostication and selection of chemotherapy in early breast cancers. We validated PREDICT, a free online breast cancer prognostication and treatment benefit tool, in a resource-limited setting. All 1480 patients who underwent complete surgical treatment for stages I to III breast cancer from 1998 to 2006 were identified from the prospective breast cancer registry of University Malaya Medical Centre, Kuala Lumpur, Malaysia. Calibration was evaluated by comparing the model-predicted overall survival (OS) with patients' actual OS. Model discrimination was tested using receiver-operating characteristic (ROC) analysis. Median age at diagnosis was 50 years. The median tumor size at presentation was 3 cm and 54% of patients had lymph node-negative disease. About 55% of women had estrogen receptor-positive breast cancer. Overall, the model-predicted 5 and 10-year OS was 86.3% and 77.5%, respectively, whereas the observed 5 and 10-year OS was 87.6% (difference: -1.3%) and 74.2% (difference: 3.3%), respectively; P values for goodness-of-fit test were 0.18 and 0.12, respectively. The program was accurate in most subgroups of patients, but significantly overestimated survival in patients aged <40 years, and in those receiving neoadjuvant chemotherapy. PREDICT performed well in terms of discrimination; areas under ROC curve were 0.78 (95% confidence interval [CI]: 0.74-0.81) and 0.73 (95% CI: 0.68-0.78) for 5 and 10-year OS, respectively. Based on its accurate performance in this study, PREDICT may be clinically useful in prognosticating women with breast cancer and personalizing breast cancer treatment in resource-limited settings.

Determinants of choice of surgery in Asian patients with early breast cancer in a middle income country

BACKGROUND

Breast-conserving surgery (BCS) plus radiotherapy is equivalent to modified radical mastectomy (MRM) in terms of outcome. However there is wide variation in mastectomy rates dependent both on tumour and patient characteristics.

OBJECTIVE

This study aimed to assess the determinants of surgery choice in Asian patients with early breast cancer in a middle-income country.

MATERIALS AND METHODS

184 patients with early breast cancer treated between Jan 2008 and Dec 2010 were recruited to complete a questionnaire. Chi-square test was used to analyze the association between surgery choice and demographic and tumour factors, surgeon recommendation, family member and partner opinions, fear of recurrence, avoidance of second surgery, fear of disfigurement, interference with sex life, fear of radiation and loss of femininity.

RESULTS

85 (46%) had BCS while 99 (54%) had mastectomy. Age >60, Chinese ethnicity, lower education level, and larger tumour size were significantly associated with mastectomy. Surgeon recommendation was important in surgery choice. Although both groups did not place much importance on interference with sex life, 14.1% of the BCS group felt it was very important compared to 5.1% in the mastectomy group and this was statistically significant. There was no statistical difference between the two groups in terms of the other factors. When analyzed by ethnicity, significantly more Malay and Indian women considered partner and family member opinions very important and were more concerned about loss of femininity compared to Chinese women. There were no statistical differences between the three ethnic groups in terms of the other factors.

CONCLUSIONS

When counseling on surgical options, the surgeon has to take into account the ethnicity, social background and education level, age and reliance on partner and family members. Decision-making is usually a collective effort rather than just between the patient and surgeon, and involving the whole family into the process early is important.

Abstract P6-06-11: The Will Rogers phenomenon in breast cancer - How does the change from AJCC 5th edition to AJCC 6th edition affect cancer survival?

Introduction: Staging of cancers are important to select appropriate treatment and to estimate prognosis. The most extensive and significant revisions that have ever been made in the breast cancer staging system occurred when the 5th Edition (AJCC5) was updated to the 6th Edition (AJCC6) in Jan 2003. The principal changes were related to the size, number, and location of metastases to the lymph nodes. AJCC6 takes into account the number of lymph nodes involved, and if 4 or more lymph nodes are involved, a Stage 2 breast cancer under AJCC5 is upstaged to Stage 3 under AJCC6. The presence of a supraclavicular lymph node in the absence of other metastases was considered a Stage 4 under AJCC5, but under AJCC6, patients with a supraclavicular lymph node is downstaged to Stage 3. The Will Rogers phenomenon to describe the effect of the “stage migration” has been described as one of the most important biases limiting the use of historical cohorts when comparing survival or treatment. In breast cancer, when we move the “poor prognosis” Stage 2’s, with 4 or more nodes involved, to Stage 3, the Stage 2's remaining will be a “better prognosis” Stage 2, and hence survival should improve. These “poor prognosis” Stage 2's will then be the “better prognosis” Stage 3's and hence the survival of Stage 3 should improve. The aim of this study is to investigate how the change from AJCC5 to AJCC6 affected stage-specific survival in a group of Asian breast cancer patients.

Patients and Methods: 3127 new cases of breast cancer cases presenting to the University Malaya Medical Centre between Jan 1993 and Dec 2007 were prospectively registered into the UMMC Breast Cancer Database. Non-epithelial cancers and ductal carcinoma in situ were excluded. All patients were restaged into AJCC5 and AJCC6

Results:

Comparison of Staging by AJCC5 and AJCC6StageAJCC5AJCC61706 (22.6%)706 (22.6%)21553 (49.7%)1230 (39.3%)3511 (16.3%)854 (27.3%)4357 (11.4%)337 (10.8%)Total31273127

Discussion: It is important to compare stage-specific survival in different time periods to determine whether survival has improved, usually due to timely and optimal treatment. Out of 1553 women classified into Stage 2 breast cancer, 323 or 20.8%, were moved to Stage 3 under AJCC6. The shift from Stage 4 to 3 is less significant because only 20 out of 357 women (5.6%) had supraclavicular lymph node metastases only. The survival of AJCC 5 Stage 2 breast cancer had a 5 year survival rate of 82.9% compared to a 86.1% with AJCC6 Stage 2. Similarly, the 5 year survival of AJCC5 Stage 3 was 50.6% compared to 59% with AJCC6 Stage 3.

Conclusion: Similar to other studies, the stage specific survival in women with Stage 2 and 3 breast cancer improves significantly when AJCC6 is used for staging in the same cohort of patients, again underlying the importance of standardizing the stage when comparing survival from two time periods.

Comparison of 5-year relative survival by AJCC5 and AJCC6StageAJCC5AJCC6196.996.9282.986.1350.659414.412.6

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-11.

Functional variants at the 11q13 risk locus for breast cancer regulate cyclin D1 expression through long-range enhancers

Analysis of 4,405 variants in 89,050 European subjects from 41 case-control studies identified three independent association signals for estrogen-receptor-positive tumors at 11q13. The strongest signal maps to a transcriptional enhancer element in which the G allele of the best candidate causative variant rs554219 increases risk of breast cancer, reduces both binding of ELK4 transcription factor and luciferase activity in reporter assays, and may be associated with low cyclin D1 protein levels in tumors. Another candidate variant, rs78540526, lies in the same enhancer element. Risk association signal 2, rs75915166, creates a GATA3 binding site within a silencer element. Chromatin conformation studies demonstrate that these enhancer and silencer elements interact with each other and with their likely target gene, CCND1.

ABCB1 polymorphism predicts escitalopram dose needed for remission in major depression

The ATP-binding cassette family of transporter proteins, subfamily B (MDR/TAP), member 1 (ABCB1) (P-glycoprotein) transporter is a key component of the blood-brain barrier. Many antidepressants are subject to ABCB1 efflux. Functional polymorphisms of ABCB1 may influence central nervous system bioavailability of antidepressants subject to efflux. Single-nucleotide polymorphisms (SNPs) at rs1045642 (C3435T) of ABCB1 have been associated with efflux pump efficiency. This may explain part of the interindividual variation in antidepressant dose needed to remit. Individuals (N=113) with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) major depressive disorder (MDD) were treated with escitalopram (ESC) or venlafaxine (VEN) over 8 weeks. The17-item Hamilton Depression Rating Scale was assessed serially, blind to genotype. SNP rs1045642 of ABCB1 along with two SNPs previously reported to be in linkage disequilibrium with it (rs2032582 and rs1128503) were genotyped. Demographic features, clinical features, P450 metabolizer status and 5-HTTLPR (serotonin-transporter-linked promoter region) genotype were controlled for. Carriers of rs1045642 TT needed on average 11 mg of ESC to remit, whereas TC and CC carriers required 24 and 19 mg, respectively (P=0.0001). This equates to a 2.0- (95% confidence interval=1.5-3.4; P<0.001) fold greater ESC dose needed to remit for C carriers compared with TT carriers at rs1045642. Of VEN-treated subjects carrying TT genotype at rs1045642, 73.3% remitted compared with 12.5% for CC genotype (odds ratio=6.69; 95% confidence interval=1.72-25.9, P=0.006). These data suggest that antidepressant dose needed to remit can be predicted by an ABCB1 SNP. This has the potential clinical translation implications for dose selection and remission from MDD.

Relative contribution of individual oxidized components in ox-LDL to inhibition on endothelium-dependent relaxation in rat aorta

BACKGROUND AND AIM

Oxidized low-density lipoprotein (ox-LDL) causes atherosclerosis and endothelial dysfunction. No study up to the present date has examined the relative contribution of all the oxidized components in ox-LDL to inhibition on vascular function. Our aim was to investigate the effects of individual oxidized components at concentrations similar to those in ox-LDL on the impairment of endothelium-dependent relaxation in rat aorta.

METHODS AND RESULTS

Rat thoracic aorta was pre-treated with lysophosphatidylcholine (LPC), cholesterol oxidized products (COPs), oxidized linoleic acid (ox-18:2) and oxidized linolenic acid (ox-18:3) at concentrations similar to those in human ox-LDL. Ox-LDL as a whole caused 61% inhibition while LPC, COPs and ox-18:2 at concentrations similar to those in ox-LDL caused 12%, 24% and 19% inhibition, respectively, on endothelium-dependent relaxation, suggesting that COPs produced the most adverse effect followed by ox-18:2 and LPC in an additional way. Three COPs including 7-ketocholesterol, 7α-hydroxycholesterol and 7β-hydroxycholesterol showed inhibition on endothelium-dependent relaxation with E(max) being reduced to 79-87% compared with the control E(max) (95%). At Western blot analysis phosphorylation of eNOS at Ser1177 site and total eNOS were not altered by ox-LDL treatment, indicating that ox-LDL did not affect nitric oxide (NO) synthesis capacity. Ox-LDL might react directly with NO and lower NO bioavailability.

CONCLUSION

The present study demonstrated the relative contribution of individual oxidized components in ox-LDL in the inhibition of endothelium-dependent relaxation in rat aorta. This inhibitory effect could be caused by the reduction of NO bioactivity.

Relapse of amoebic infection 10 years after the infection

A 52-year-old man with schizophrenia, who had a history of amoebic liver abscess treated with combination antimicrobial agents, presented 10 years later with severe rectal bleeding. Diagnosis of amoebic colitis was confirmed by histological examination of endoscopic biopsy. Doctors treating patients with amoebic infection should be aware of the risk of eradication failure. Post-treatment stool testing, preferably by antigen testing or polymerase chain reaction, should be performed after antimicrobial treatment.

Hepatocarcinogenesis of regenerative and dysplastic nodules in Chinese patients

OBJECTIVES

To determine the development rate of hepatocellular carcinoma and survival of patients diagnosed to have regenerative, and low-grade and high-grade dysplastic liver nodules.

DESIGN

Retrospective descriptive study.

SETTING

Acute public hospital, Hong Kong.

PATIENTS

Patients with non-malignant liver nodules confirmed by imaging-guided liver biopsy between January 1997 and December 2008.

MAIN OUTCOME MEASURES

Rates of hepatocellular carcinoma development and survival.

RESULTS

A total of 147 patients with non-malignant liver nodules were followed up over a median duration of 29 months. The initial histological diagnosis included regenerative nodules (n=74), low-grade dysplastic nodules (n=34), and high-grade dysplastic nodules (n=39). The respective cumulative hepatocellular carcinoma development rate during the first, second, third, and fourth year were 3%, 5%, 9% and 12% for simple regenerative nodules, 29%, 35%, 38% and 44% for low-grade dysplastic nodules, and 38%, 41%, 51% and 51% for high-grade dysplastic nodules. The hepatocellular carcinoma development rate was highest in those with high-grade dysplastic nodules. Multivariate analysis showed that histological dysplastic changes were associated with increased alpha-fetoprotein levels and advanced age, which were both independent predictors of hepatocellular carcinoma development. Histological dysplastic changes, male sex, advanced age, prolonged prothrombin time, and ultrasound appearances were independent predictors of mortality.

CONCLUSION

The presence of dysplastic change in liver nodules increased the risk of hepatocellular carcinoma development and death.

Comparison of breast cancer in Indonesia and Malaysia--a clinico-pathological study between Dharmais Cancer Centre Jakarta and University Malaya Medical Centre, Kuala Lumpur

INTRODUCTION

The age standardised incidence rate (ASR) of breast cancer in Malaysia which is a high middle- income country is similar to Indonesia, a low middle-income country. (Globocan 2008) It is however unknown whether the presentation of breast cancer differs between these two countries.

OBJECTIVE

We compared the stage, age at presentation, and pathological characteristics of breast cancer between two tertiary hospitals in Indonesia and Malaysia; Dharmais Cancer Centre (DCC), which is the national cancer referral centre in Indonesia, and University Malaya Medical Centre (UMMC), which is an academic hospital with established breast oncology services in Kuala Lumpur. One thousand, one hundred and fourteen consecutive women (477 in UMMC: 637 in DCC) who were newly diagnosed with breast cancer between January and December, 2010 were included. Patient's age, TNM stage at presentation, and pathological characteristics were compared. Estrogen receptor (ER) and progesterone receptor (PR) were considered positive if 10% or greater of invasive cell nuclei were stained while HER2 was considered positive with an immunohistochemistry staining intensity of 3+ . Logistic regression analyses were performed to identify differences.

RESULTS

Median age at diagnosis was 52 years in UMMC and 47 years in DCC, whereby patients in DCC were more likely to be very young at diagnosis (aged < 35 years) compared to their counterparts in UMMC (Odds ratio (OR): 2.09; 95%CI: 1.32-3.31). Approximately one third of patients in UMMC presented with TNM stage III or IV, compared to 63% in DCC. Patients in DCC were three times more likely to present with metastatic breast cancer compared to patients in UMMC (OR: 3.01; 95% CI: 2.02-4.48). The percentage of low grade tumours in DCC was higher than in UMMC (28% vs 11% respectively), and the difference persisted even after multivariate adjustment. Although the frequency of ER and PR positivity appeared to be higher in UMMC (65% and 55% respectively) compared to DCC (48% and 40% respectively), these differences were not statistically significant following adjustment for age, stage, HER2 status and grade. The frequency of HER2 positivity was 45% in DCC compared to 26% in UMMC, and remained significantly higher even after multivariate adjustment (multivariate OR:1.76; 95%CI:1.25-2.47, in DCC compared to UMMC). The proportion of triple negative breast cancer was however similar in the two centres (19% in UMMC vs 21% in DCC).

CONCLUSION

Indonesian women with breast cancer seem to present at a younger age and at later stages compared to Malaysian women. Their tumors were more likely to be of low grade and HER2 positive, even after adjustment for other factors, while hormone receptor positivity proved similar in the two groups. The higher HER2 positivity rate in Indonesian patients warrants further study.

Ten-year review of epidemiology, clinical features, and treatment outcome of achalasia in a regional hospital in Hong Kong

OBJECTIVE

To describe the epidemiology, clinical features, and treatment outcome of achalasia in Chinese patients.

DESIGN

Retrospective study.

SETTING

Major regional hospital, Hong Kong.

PATIENTS

Clinical records of patients with the diagnosis of achalasia from July 1997 to June 2007 were reviewed.

RESULTS

Thirty-two patients were diagnosed with achalasia during the study period. The mean age at diagnosis was 50 years (standard deviation, 20 years). The female-to-male ratio was 1.3:1. The main presenting symptoms were dysphagia (78%) and vomiting (50%). Nine laparoscopic and two open Heller's operations had been performed and 16 patients had undergone endoscopic dilatations. Four patients had botulinum toxin injection and four were taking calcium channel blocker (nifedipine) medications. Botulinum toxin injection and medical therapy had poor short- and long-term responses. Laparoscopic myotomy and pneumatic dilatation had comparable good short- and long-term responses.

CONCLUSION

Achalasia affected all age-groups but there was a peak at middle age. Pneumatic dilatation and Heller's myotomy (open or laparoscopic approach) appeared able to maintain longer symptom responses than medical therapy and botulinum toxin injection.

Experience with hookwire localisation excision biopsy at a medical centre in Malaysia

INTRODUCTION

With an increasing number of women undergoing breast screening, an effective method of removing non-palpable lumps detected by mammography or sonography is by hookwire localisation excision biopsy (HWLB). The aim of this paper was to audit the practice of HWLB at the University Malaya Medical Centre.

METHODS

Patients with benign or suspicious preoperative diagnoses of a non-palpable lump and who underwent HWLB were included in this study. Pathological examination of the surgical specimens was conducted and a correlation with preoperative assessment modalities was reported.

RESULTS

A total of 59 HWLBs were carried out in 57 female patients. The mean age of the patients was 51.5 years. The overall malignancy rate was 32.3 percent (19 out of 59 cases) with a benign to malignant ratio of 3.1 to 1. Ten of these cases were ductal carcinoma-in-situ. Out of 25 patients who were suspicious on preoperative assessment, 16 malignancies were found, while in the 33 patients thought to be benign on preoperative assessment, there were three malignancies, giving a sensitivity of 84.2 percent and a specificity of 76.9 percent (p is less than 0.05). The mean tissue volume excised in 53 available records was 50.0 cm(3), with pathological tissue comprising only 15.4 percent of the total excised volume. Clear margins were obtained in 42.1 percent of the patients. The overall operative complication rate was 10.2 percent.

CONCLUSION

Malignancy was reported in one third of women undergoing HWLB, of which 16 had suspicious features on radiological assessment and/or fine needle aspiration cytology/core needle biopsy preoperatively. Non-palpable lumps should be excised by HWLB for a definitive diagnosis in case of any suspicion on preoperative assessment, as the prognosis is excellent.

Is it Necessary to Excise All Breast Lesions? Experience from a University-Based Breast Unit

BACKGROUND

Breast cancer is becoming more important in Asia since it affect the younger age group. Question arises whether it is safe for breast lesions to be left in-situ if all the elements in triple assessment are benign. The aim of this study is to audit all the excision biopsies of breast lumps done in the University Malaya Medical Centre (UMMC), to review the association of age with the type of pathological finding and to evaluate the rate of carcinoma in these biopsies.

METHODS

We conducted a retrospective study of all women who had excision biopsy of a breast lump in the University Malaya Medical Centre from January 2005 to December 2006. All patients with malignant preoperative biopsies were excluded.

RESULTS

Of 717 lesions in 664 patients, 459 (64%) were fibroadenoma, 114 (15.9%) were fibrocystic disease, 20 (2.8%) were phylloides tumour, 27 (3.8%) were papilloma, 59 (8.2%) were malignant and 38 (5.3%) were of other pathology. Of the 717 open biopsies, 449 (62.6%) had fine-needle aspiration cytology (FNAC), 31 (4.3%) had core needle biopsy (CNB), while 14 (2.0%) had both FNAC and CNB done prior to excision biopsy. 251 (35%) had neither FNAC nor CNB. The incidence of fibroadenoma decreased with increasing age and the incidence of fibrocystic changes and papilloma increased with increasing age. There was no association of age with phylloides tumour. The incidence of unexpected malignancy increased with increasing age. The incidence rates were 0.3%, 4.5%, 19.4%, 29.7% and 29.6% for the age group below 30, 30-39, 40-49, 50-59 and above 60 years of age respectively. Of the 59 malignant lesions, FNAC was performed on 47 (79.7%) and CNB on 16 (27.1%). 9 had both FNAC and CNB and 3 had neither FNAC nor CNB. Out of the 56 lesions where FNAC/CNB were done, 23 (41.1%) were reported as benign, 20 (35.7%) as suspicious, 4 (7.1%) as atypical, 5 (8.9%) as inadequate, 2 (3.6%) as equivocal and 2 (3.6%) as lymphoid lesions. Out of the 23 prior biopsies reported as benign, 22 were in the age group above 40.

CONCLUSIONS

In conclusion, the rate of unexpected malignancy in open biopsies increases with age. It is recommended that all women above the age of 40 presenting with a palpable breast lump or a suspicious non-palpable abnormality on screening mammogram to have their lump excised even though the lump is benign on FNAC or CNB. However, women age of 30 to 39 should also have the lump excised in the presence of other risk factors such as family history of breast cancer.

The epidemiology and clinical characteristics of Crohn's disease in the Hong Kong Chinese population: experiences from a regional hospital

OBJECTIVE

To study the descriptive epidemiology and clinical profile of patients with Crohn's disease.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Patients with Crohn's disease diagnosed between January 1991 and December 2006 inclusive.

RESULTS

Over the period studied, 27 Chinese patients were diagnosed with Crohn's disease in our hospital. Our hospital-based incidence and prevalence rate had increased more than 2- and 5-fold, respectively over that period. The mean age at diagnosis was 26 years and median duration of disease was 81 months. Most patients had ileocolonic disease (67%) followed by Crohn's colitis (22%) and ileal disease (11%); more patients had non-stricturing and non-penetrating disease (63%) than stricturing (15%) or penetrating disease (22%). Peri-anal disease occurred in 37% of our patients. At diagnosis, many of the patients (41%) had mild-moderate disease, but 30% each had moderate-severe and severe-fulminant disease. At the time of this study, 85% of the patients were in disease remission with medical treatment. However, 48% had undergone surgery for diagnosis or complications. No patient had developed colorectal cancer or died.

CONCLUSIONS

The incidence and prevalence of Crohn's disease are increasing in the Chinese population. It usually affects young persons with a substantial proportion of patients presented with severe-fulminant disease. More epidemiological and clinical studies are needed for this emerging disease in Asian regions.

Elevated plasma glutathione peroxidase concentration in acute severe asthma: comparison with plasma glutathione peroxidase activity, selenium and malondialdehyde

OBJECTIVE

To investigate plasma glutathione peroxidase concentration, glutathione peroxidase activity, plasma selenium and oxidative stress in acute severe asthma.

MATERIAL AND METHODS

The study was case-control in design, with cases presenting to the emergency department with acute severe asthma and controls randomly selected from a larger cross-sectional study. Plasma malondialdehyde (MDA) was used as a measure of oxidative stress and plasma selenium was measured using ICP-MS. Glutathione peroxidase (GPx) activity was analysed using a colorimetric GPx assay and plasma GPx level was measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Fifteen cases [mean (range) predicted peak expiratory flow rate (PEFR) of 43% (20-69)] and 15 matched controls were recruited. MDA levels (mean+/-SD) were higher in acute asthma subjects (1.30+/-0.56 micromol/L) than in controls (0.86+/-0.53 micromol/L; p<0.05). There were no differences between cases and controls for selenium (99+/-34 microg/L versus 109+/-17 microg/L) or for GPx activity (39+/-25 nmol min(-1) mL(-1) versus 38+/-24 nmol min(-1) mL(-1)), however, GPx plasma levels measured by ELISA were higher in cases than controls (22.5+/-10.8 mg/L versus 13.8+/-7.3 mg/L; p<0.05).

CONCLUSIONS

Patients with acute severe asthma demonstrated increased MDA levels but no differences in plasma selenium levels or GPx activity. GPx levels measured by ELISA were elevated in severe asthma. These results are consistent with an adaptive up-regulation of GPx to protect against oxidative stress.

A survey on the preference for continuing professional dental education amongst general dental practitioners who attended the 26th Asia Pacific Dental Congress

AIMS

To identify the subjects of interest and to examine the modes as well as means of study for continuing professional dental education amongst general dental practitioners who attended the 26th Asia Pacific Dental Congress, 28 May-1 June 2004, Hong Kong.

METHODS

A total of 381 general dental practitioners as the registered conference delegates from Hong Kong, Mainland China and other Asia-Pacific regions were randomly selected for the present survey. The survey was conducted through face-to-face interviews by a group of practising dentists in Hong Kong.

RESULTS

Overall, orthodontics and prosthodontics were the most popular subjects for clinical degree programmes, whilst oral implantology and cosmetic dentistry were the highly preferred subjects for continuing education courses. Concerning the preferred mode of study for degree programmes, the part-time study mode was chosen by 68.3% of the participating dentists. A didactic teaching approach was preferred by most of the participants (81.7%) for postgraduate study. The majority of the interviewees (76.5%) were interested in a proposed clinical degree programme to be offered jointly by The University of Hong Kong and a leading university in the Mainland. Overall, there was no marked difference in the preference for continuing dental education amongst the respondents from Hong Kong, Mainland China and other Asia-Pacific regions.

CONCLUSIONS

The present survey shows the currently preferred specialty areas and subjects for continuing professional dental education amongst the general dental practitioners who attended the 26th Asia Pacific Dental Congress, with didactic teaching as the most preferred mode of study on a part-time basis.