Randomised clinical trial: efficacy of peginterferon alfa-2a in HBeAg positive chronic hepatitis B patients with lamivudine resistance

BACKGROUND

Previous studies suggested that a finite course of peginterferon alfa-2a may offer an alternative rescue therapy for patients with lamivudine resistance. However, because of the limitation of study design and small sample size, it is difficult to make definitive conclusion.

AIM

To explore the role of peginterferon alfa-2a, in the rescue treatment of HBeAg-positive chronic hepatitis B patients with lamivudine resistance.

METHODS

In this randomised study, chronic hepatitis B patients with lamivudine resistance were treated with peginterferon alfa-2a for 48 weeks (n=155) or adefovir for 72 weeks (n=80). All enrolled patients were treated with lamivudine for the first 12weeks.

RESULTS

At 6 months posttreatment, 14.6% (18/123) of peginterferon alfa-2a-treated patients achieved HBeAg seroconversion, in contrast to 3.8% (3/80) of adefovir-treated patients after 72 weeks continuous therapy (P=0.01). For peginterferon alfa-2a-treated patients, the rate of HBeAg seroconversion at week 72 was significantly higher in patients who had HBsAg decline >0.5 Log(10) IU/mL from baseline at week 24, compared with patients with HBsAg decline ≤0.5 Log(10) IU/mL from baseline at week 24 (25.5% vs. 7.7%, P=0.01). After 72 weeks continuous adefovir treatment, 22.5% of patients achieved HBV DNA <80 IU/mL, compared with 10.6% in peginterferon alfa-2a-treated patients at 6months off-treatment (P=0.02).

CONCLUSIONS

Overall, the response to peginterferon alfa-2a among patients with lamivudine resistance was suboptimal. HBeAg seroconversion rate at week 72 by 48 weeks peginterferon alfa-2a treatment was higher than continuous adefovir therapy. Monitoring HBsAg levels can help to predict response to peginterferon alfa-2a.

Detection of Laribacter hongkongensis using species-specific duplex PCR assays targeting the 16S rRNA gene and the 16S-23S rRNA intergenic spacer region (ISR)

AIMS

For the rapid detection of Laribacter hongkongensis, which is associated with human community-acquired gastroenteritis and traveller's diarrhoea, we developed a duplex species-specific PCR assay.

METHODS AND RESULTS

Full-length of the 16S-23S rRNA intergenic spacer region (ISR) sequences of 52 L. hongkongensis isolates were obtained by PCR-based sequencing. Two species-specific primer pairs targeting 16S rRNA gene and ISR were designed for duplex PCR detection of L. hongkongensis. The L. hongkongensis species-specific duplex PCR assay showed 100% specificity, and the minimum detectable level was 2.1 × 10(-2) ng μl(-1) genomic DNA which corresponds to 5000 CFU ml(-1).

CONCLUSIONS

The high specificity and sensitivity of the assay make it suitable for rapid detection of L. hongkongensis.

SIGNIFICANCE AND IMPACT OF THE STUDY

This species-specific duplex PCR method provides a rapid, simple, and reliable alternative to conventional methods to identify L. hongkongensis and may have applications in both clinical and environmental microbiology.

Survival time comparison between Hawley and clear overlay retainers: a randomized trial

The objectives of this study were to compare the survival time of the Hawley retainer (HR) and the clear overlay retainer (COR) over one-year follow-up and to analyze risk factors contributing to their breakage. In this randomized, controlled clinical trial, we assigned 120 adolescent patients to receive either the HR or the COR. All specific data on breakage dates, the reasons for breakage, and the broken parts of the retainers were recorded. A survival analysis was used to describe retainer survival over time. No significant differences were observed in survival times between the 2 groups for either the maxillary retainer (p = 0.254) or the mandibular retainer (p = 0.188). Both retainers tended to fracture, but the fracture locations were different. The findings indicate that clinicians should avoid increasing buccal root torque and reinforce the retainer base plates. Breakage rates may not influence the choice of retainer (Trial Registration number is ChiCTR-TRC-00000055).

Interleukin-21 is upregulated in hepatitis B-related acute-on-chronic liver failure and associated with severity of liver disease

The immune mechanism(s) that lead to hepatitis B-related acute-on-chronic liver failure (HB-ACLF) are poorly understood. Interleukin-21 is a newly discovered cytokine that is involved in autoimmune and inflammatory diseases. Its potential role in HB-ACLF remains unknown. The serum levels of 12 immune cytokines measured by cytometric bead arrays and the frequency of IL-21-secreting CD4+ T cells in peripheral blood mononuclear cells (PBMC) measured by intracellular cytokine staining were compared in moderate chronic hepatitis B (M-CHB, n = 20), severe chronic hepatitis B (S-CHB, n = 20), HB-ACLF (n = 39) and healthy controls (n = 10). PBMC from M-CHB patients or healthy subjects were stimulated with rhIL-21 in vitro, and cytokines in supernatants were measured by FlowCytomix. The frequencies of IL-21-secreting CD4+ T cells were higher in HB-ACLF (both P < 0.001) and S-CHB (P = 0.002 and 0.001) as compared to M-CHB patients and controls. Serum IL-21 levels were highest (P < 0.001) in HB-ACLF and positively associated with high MELD score (P = 0.001) and mortality (P = 0.038). Recovery from HB-ACLF was associated with reduced serum IL-21 levels (P = 0.003) and lower CD4+ IL-21(+) T-cell frequency (P = 0.006). The secretions of IL-1β (P < 0.001), IL-6 (P < 0.001), IL-10 (P < 0.001), IFN-γ (P = 0.001) and TNF-α (P = 0.042) from PBMC were significantly increased with rhIL-21 stimulation. In summary, IL-21 has a causal role in the development of severe liver inflammation, which is upregulated in HB-ACLF and associated with severity of liver disease.

Total auricular reconstruction without skin grafting

Successful ear reconstruction depends on two factors: an ear framework and the skin covering the framework. However, the relative deficiency of skin for coverage of the cartilage framework remains an issue. This new method for total auricular reconstruction is a three-stage operation and involves the use of two tissue expanders. First, two skin expanders are implanted, one underneath the scalp and the other sited behind the microtic ear. At the second stage, after lobule transposition, the two expanded skin flaps (upper and lower) and mastoid fascial flap are raised. At the same time, the autogenous rib cartilage is harvested and the framework constructed. The cartilage framework is then anchored between the upper expanded skin flap and the fascial flap with its inferior pole inserted into the rotated earlobe. The upper expanded skin flap covers the whole anterior surface of the framework and drapes over the margins of the fascial flap, which wrap the framework from beneath. The raw surface of fascial flap is covered with the lower expanded skin flap. The formation of a pseudomeatus and tragus is performed at the third stage. Deficiency of skin is the major problem encountered with the other conventional methods. Our innovations using two tissue expanders in combination with an autogenous rib cartilage framework eliminate this problem completely.

Phase III study of gemcitabine/oxaliplatin (GEMOX) with or without erlotinib in unresectable, metastatic biliary tract carcinoma

LBA4032

Background: Currently, there is no standard regimen for palliative chemotherapy in metastatic, unresectable biliary tract cancer (BTC). A phase II trial of erlotinib monotherapy showed a promising anti-tumor activity in BTC with tolerable toxicity. Additionally, gemcitabine + erlotinib demonstrated superior efficacy when compared to gemcitabine alone in pancreatic cancer. Hence, we conducted a phase III trial to compare between GEMOX vs GEMOX+erlotinib (Tarceva [T]) (GEMOX/T) as first-line chemotherapy in unresectable, metastatic BTC. Methods: Eligible patients were as follows: histologically confirmed adenocarcinoma of biliary tract (CCC), ampulla of vater (AOV) or gall bladder (GB); unresectable or metastatic; ECOG performance status of 0~2; adequate marrow, hepatic, renal and cardiac functions; no prior chemotherapy. The primary endpoint was progression free survival (PFS). The study regimen was gemcitabine 1,000mg/m2, oxaliplatin 100mg/m2, erlotinib 100mg qd daily q 2 weeks. Results: From February 2009 to August 2010, 268 pts were randomized, 133 patients to GEMOX arm and 135 patients to GEMOX/T arm. Patient characteristics: median age 61 yrs (range 30-82); male (63.4%); CCC (n=180, 67.2%), GB (n=82, 30.6%), and AOV (n=6, 2.2%). With a median follow-up of 13.9 months (range, 6.7 – 25.0), median PFS was 5.8 months (95% CI, 4.6 - 7.0) in GEMOX/T arm and 4.2 months (95% CI, 2.7 - 5.7) in GEMOX arm (P=0.080). In subgroup analysis (CCC, n=180), however, median PFS was significantly longer in GEMOX/T arm (5.9 months) when compared with GEMOX arm (3.0 months, P=0.049). The overall response rate was significantly higher in the GEMOX/T arm when compared with GEMOX arm. There was no significant difference in overall survival between the two arms (GEMOX/T: 9.5 months, 95% CI, 7.6 – 11.4; GEMOX: 9.5 months, 95% CI, 7.5 – 11.5; P=0.611). The EGFR mutation testing results in correlation to responsiveness to erlotinib will be presented at the meeting. Conclusions: This phase III represents the first multicenter, randomized trial to compare GEMOX vs GEMOX/T in unresectable, metastatic BTC. Although PFS was not prolonged in GEMOX/T, there was a significant benefit in terms of PFS in GEMOX/T arm for CCC patients.

Wide-field imaging of fluorescent deoxy-glucose in ex vivo malignant and normal breast tissue

Rapid in situ determination of surgical resection margins during breast cancer surgery would reduce patient time under anesthesia. We present preliminary data supporting the use of a fluorescent glucose analog (2-NBDG) as an optical contrast agent to differentiate freshly excised breast tissue containing cancerous cells from normal breast tissue. Multi-spectral images of 14 breast cancer specimens acquired before and after incubation with 2-NBDG demonstrated increased fluorescent signal in all of the malignant tissue due to increased 2-NBDG consumption. We demonstrate that 2-NBDG has potential as an optical contrast agent to differentiate cancerous from non-cancerous tissue.

Transgene-mediated expression of tumor necrosis factor soluble receptor attenuates morphine tolerance in rats

Opiate/narcotic analgesics are the most effective treatments for chronic severe pain, but their clinical utility is often hampered by the development of analgesic tolerance. Recent evidence suggests chronic morphine may activate glial cells to release proinflammatory cytokines. In this study, we used herpes simplex virus (HSV) vectors-based gene transfer to dorsal root ganglion to produce a local release of p55 TNF soluble receptor in the spinal cord in rats with morphine tolerance. Subcutaneous inoculation of HSV vectors expressing p55 TNF soluble receptor into the plantar surface of the hindpaws, enhanced the antinociceptive effect of acute morphine in rats. Subcutaneous inoculation of those vectors into hindpaws also delayed the development of chronic morphine tolerance in rats. TNF soluble receptor expressed by HSV vector reduced gene transcription of mRNA of spinal TNFα and IL-1β induced by repeated morphine. Furthermore, we found that TNF soluble receptor mediated by HSV, reversed the upregulation of TNFα, IL-1β and phosphorylation of p38 mitogen-activated protein kinase (MAPK) induced by repeated morphine. These results support the concept that proinflammatory cytokines may play an important role in the pathogenesis induced by morphine. This study provides a novel approach to treating morphine tolerance.

Minimum effective plasma concentration of efavirenz in treatment-naïve Chinese HIV-infected patients

To assess the relationship between mean efavirenz (EFV) plasma concentration and clinical effect during the first 48 weeks of combination antiretroviral therapy (cART), the baseline CD4 cell count was recorded and plasma EFV concentration and CD4 cell count were measured every 12 weeks. HIV-RNA viral load was determined in the 48th week of cART. In total, 42 subjects were recruited and grouped according to their mean concentration of EFV during the study period: groups A, B and C with EFV concentrations (mean) <2 mg/L (1.8 mg/L), 2-4 mg/L (2.9 mg/L) and >4 mg/L (5.5 mg/L), respectively. The CD4 cell counts in group C increased more quickly than in groups B and A, although this was not statistically significant (211 ± 176/μL versus 151 ± 145/μL and 172 ± 105/μL, respectively; P = 0.799). Groups B and C had higher rates of HIV viral load suppression than group A (P = 0.017). For treatment-naïve Chinese HIV-infected patients, EFV plasma concentrations above 2 mg/L appear to suppress HIV replication more effectively than concentrations below 2 mg/L.