Predictors of relapse in chronic hepatitis B after discontinuation of anti-viral therapy

BACKGROUND

Optimal duration of anti-viral therapy in chronic hepatitis B virus (HBV) infection remains unclear.

AIM

To investigate factors that could predict relapse after stopping anti-viral agents.

METHODS

Chronic hepatitis B patients who were treated with anti-viral agents (lamivudine, adefovir, entecavir) and have stopped the treatment were recruited. Anti-viral agents were stopped according to the recommendations of the Asian Pacific Association for the Study of the Liver. Virological relapse was defined as an increase in serum HBV DNA to >1000 copies/mL after discontinuation of treatment.

RESULTS

Eighty-four (69 treatment naïve and 15 lamivudine resistant) patients were eligible for this study. Thirty-seven patients developed virological relapse at 4.3 ± 2.9 (range 1-11) months after discontinuation of therapy. The 1-year cumulative probability of virological relapse was 42% and 47% in HBeAg (hepatitis B e antigen)-positive (n = 41) and HBeAg (hepatitis B e antigen)-negative (n = 43) patients, respectively. On multivariate analysis by Cox proportional hazard model, pre-existing lamivudine resistance, delayed suppression of HBV DNA to undetectable level during anti-viral therapy and to a higher HBsAg (hepatitis B surface antigen) level at the end of treatment were associated with virological relapse. Twelve of the 15 (80%) lamivudine resistant patients developed virological relapse. Among the 11 treatment naïve patients who had HBsAg ≤ 2 log IU/mL at the end of treatment, 1 (9%) of them had virological relapse.

CONCLUSIONS

Treatment cessation among lamivudine resistant patients is associated with high risk of virological relapse. Serum HBsAg level at the end of treatment and rate of HBV DNA suppression can provide supplementary information to guide the timing of stopping anti-viral drugs.

Establishment and evaluation of a model of a community health service in an underdeveloped area of China

OBJECTIVES

To develop and evaluate an applicable model for a community health service (CHS) in an underdeveloped area of China that ensures efficient, convenient and affordable primary healthcare access for all residents.

STUDY DESIGN

The current study was carried out in Puyang, a typical medium-sized city in central-eastern China. Based on the healthcare requirements of the residents in Puyang, a CHS network was set up and its operation was evaluated from 1999 to 2006. The system is characterized by its focus on community health education (CHE).

METHODS

Firstly, 8231 residents, selected at random, were surveyed to investigate the healthcare requirements of the local residents. Meanwhile, the operation of the pre-existing healthcare resources was investigated in Puyang. Based on the information gained, a network-based CHS system was proposed and established, with CHE as the major focus. This study compared CHS operation prior to and after establishment of the network. Finally, an analytic hierarchy process based evaluation model was applied to evaluate the operation of the CHS network.

RESULTS

There was a high prevalence (86.98 per thousand) of chronic diseases among the residents who participated in this investigation. The majority (84.39%) of the residents who had healthcare requirements resorted to professional health care; the other residents did not have access to health services. Among those residents who sought professional treatment, 71.3% visited primary healthcare institutions. This information reflects the enormous requirement for a CHS in primary health care but the lack of accessibility among the residents; this motivated the authors to establish a system to solve the problem. The improvement in CHS operation after the network was established suggests the importance of a network for optimizing the primary healthcare system. The improvement was indicated by better understanding of the residents regarding the CHS, and enhanced capability of self-monitoring for chronic diseases such as hypertension after the network was established. Moreover, the residents' knowledge of health care was significantly increased and, accordingly, the incidence of health risk behaviour was reduced after the network was established. Furthermore, the CHE index between 1999 and 2006 showed good correlation (r=0.988, p<0.005) with the CHS index, suggesting the important role of CHE in CHS development.

CONCLUSIONS

A network-characterized CHS system was established in Puyang, and improved the primary healthcare situation. This study provides a feasible model for the development of a CHS in medium and small cities in underdeveloped parts of China.

Growth inhibition of Microcystis aeruginosa by white-rot fungus Lopharia spadicea

Harmful cyanobacterial blooms cause water deterioration and threaten human health. It is necessary to remove harmful cyanobacteria with useful methods. A bio-treatment may be one of the best ways to do this. A strain of specific white-rot fungus, Lopharia spadicea, with algicidal ability was isolated. Its algicidal ability on algae under various conditions was determined using three main influence factors: initial chlorophyll-a content, initial pH, and algal cell mixture. The result showed that the chlorophyll-a content of Microcystis aeruginosa FACHB-912, Oocystis borgei FACHB-1108, and Microcystis flos-aquae FACHB-1028 decreased from 798+/-13, 756+/-40, and 773+/-24 microg/L to 0 within 39 h. L. spadicea could also remove more than 95% chlorophyll-a when initial chlorophyll-a content increased from 397+/-13 to 2,132+/-4 microg/L. Moreover, the strain has great removal ability under a broad initial pH range of 5.5 to 9.5. The chlorophyll-a content of the three algal strain mixtures decreased from about 672+/-23 microg/L to 0 within 45 h. After superoxide dismutase (SOD) and malondialdehyde (MAD) were assessed in a co-culture of L. spadicea, it was observed that an increase in MAD content was correlated with the decrease in chlorophyll-a content of M. aeruginosa FACHB-912. This result suggested that the algae was not only greatly inhibited but also severely damaged by the fungus.

Reduction of Breast Density Following Tamoxifen Treatment Evaluated by 3-D MRI

Background: It has been reported that MRI-based density measurement is more sensitive than mammographic density to evaluate the small changes of breast density. This study analyzed the change of breast density in women receiving tamoxifen treatment using 3-D MRI.Material and Methods: Twenty-two breasts in 20 women were studied. Two MRI studies were performed at 1.5T, the baseline scan acquired after surgery and prior to receiving tamoxifen, and the follow-up scan at 10 months to 30 months after tamoxifen treatment. Non-fat-suppression T1-weighted images were used for the density measurement. The breast and the fibroglandular tissue were segmented using a computer-assisted algorithm recently published by our group. For each breast, the total fibroglandular tissue volume and the total breast volume were calculated, and then the ratio was calculated as the percent breast density (%BD). The changes in breast volume, fibroglandular tissue volume, and the percent density in the F/U scan compared to the B/L scan were evaluated. The reduction in the fibroglandular volume (ΔFV=FV2-FV1, ml), and in the percent breast density (Δ%BD= %BD2-%BD1) were analyzed.Results: The total breast volume did not show significant changes between F/U and B/L. For analysis of fibroglandular volume, 20 breasts showed volume reduction and 2 showed slight increase of volume. Overall, the mean ΔFV was 20.7ml, with 33% reduction. The ΔFV was correlated with the baseline FV (r=0.82) (Figure 1), indicating that when the fibroglandular tissue volume was higher, more reduction was found.For analysis of %BD, 19 breasts showed reduction, and 3 showed increased density, with a mean Δ%BD of 4.7%. The 22 breasts were further divided into three categories based on their B/L density as: fatty breast (%BD&lt; 8%, N=4), moderately dense breast (%BD 8-20%, N=9), and dense breast (%BD &gt;20%, N=9). The amount of density reduction was associated with the B/L density, showing 10.9, 17.2, and 28.6 ml for ΔFV; and 1.2%, 3.9%, and 7.2% for Δ%BD respectively in these 3 groups. Statistically, only Δ%BD between the fatty and the dense groups showed a significant difference (P=0.02).Discussion: MRI provides strong soft tissue contrast, thus it may have advantages for revealing detailed density distribution compared to mammography. The %BD can be measured by normalizing the FV to the total breast volume, analogous to the mammographic density. However, this will be subjective to the variations in the measurement of breast volume. The FV within the breast was a more robust parameter, which showed reduction in 20 of 22 breasts with a mean reduction of 33%, also a significant correlation with B/L FV. The reduction of density is expected to be through decreased hormonal level in the breast, and the reduction of fibroglandular tissue density should be correlated with the baseline density. Our results are consistent with this expectation, and demonstrate that MRI can be used to evaluate the density change induced by tamoxifen.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4021.

The utility of routine laboratory testing in hypoglycaemic emergency department patients

BACKGROUND

After treating a hypoglycaemic patient, how in-depth a work-up is required to prevent their next hypoglycaemic episode?

OBJECTIVE

To determine the utility of routine laboratory testing in the management of hypoglycaemia.

METHODS

A cross-sectional study at two urban teaching hospitals from July 2006 to July 2007. The study included adult patients (> or = 18 years) with hypoglycaemia (fingerstick glucose < or = 60 mg/dl (3.33 mmol/l) in the emergency department or altered mental status resolved by glucose or glucagon). Predictor variables were age, gender, medical history, physical examination, hypoglycaemic agent (insulin vs oral hypoglycaemic). Outcome variables were electrolyte abnormality (serum sodium outside the range of 135-145 mmol/l; serum potassium outside the range of 3.5-5.0 mEq/dl), leucocytosis (white blood cell count >15,000/high power field) or urinary tract infection. Continuous data are presented as mean (SD). Categorical data are presented as percentages with 95% confidence intervals. Student's t and Fisher's exact tests were used to compare data when appropriate (alpha = 0.05, two-tailed).

RESULTS

291 patients were studied with a mean age of 64 years (SD 16) (range 22-95) 54 women. 200 patients (69%, 95% CI 63% to 74%) had at least one laboratory abnormality. These included newly diagnosed renal failure (23%), pre-existing renal failure (32%), hypokalaemia (8%), hyperkalaemia (11%), leucocytosis (4.2%) and pyuria (19%). No significant difference was found between the rates of abnormal laboratory results in patients on insulin versus those on oral hypoglycaemics. Higher admission rates (p = 0.001) were also observed in patients with abnormal (70%) compared with normal (53%) laboratory results.

CONCLUSION

The high rate of laboratory abnormalities in hypoglycaemic patients justifies routine testing.

Altered Mental Status from Olanzapine Overdose Treated with Physostigmine

BACKGROUND

Olanzapine is commonly prescribed to patients with schizophrenia. One retrospective study demonstrates the efficacy of physostigmine in reversing mental status changes induced by olanzapine. We report two patients with delirium due to confirmed olanzapine overdose treated with physostigmine. One patient's mental status transiently returned to normal. The other patient completely recovered. CASE 1: A 25-year-old man ingested 300 mg of olanzapine. On presentation, he was agitated, delirious, tachycardic, had dry skin and mucous membranes, and dilated pupils (6 mm) minimally reactive to light. Physostigmine, 0.5 mg, was given intravenously (IV) without effect. Additional physostigmine doses of 1.5 mg IV administered 5 minutes later and then 1 mg IV resulted in the patient having a clear sensorium and normal mentation. The patient's mental status continued to remain normal for the duration of his hospital stay. Olanzapine was identified in the urine by high performance liquid chromatography. CASE 2: A 20-year-old female ingested 600 mg of olanzapine. On presentation, she was tachycardic, obtunded, and minimally responsive to painful stimuli, with decreased bowel sounds, dry skin and dry mucous membranes. Physostigmine, 2 mg, was given IV. Shortly thereafter she regained full consciousness and began speaking coherently. She remained in this condition for approximately 30 minutes, and then became obtunded. Her serum olanzapine concentration was 1230 ng/mL. No further doses of physostigmine were administered. On day 3 of admission her mental status returned to normal.

CONCLUSION

We report two cases of olanzapine-induced mental status changes treated with physostigmine. The utility of physostigmine as a safe or necessary antidote in the setting of olanzapine overdose remains to be determined.

Characterization of one newly established esophageal cancer cell line CSEC from a high-incidence area in China

The Chaoshan littoral is located in a high-incidence area of esophageal cancer in the south of China. In this study, a new esophageal cancer cell line CSEC was established from a 47-year-old female Chinese patient in this district. The biological characters of the cultured cells were investigated, including morphology, ultrastructure, growth kinetic features, tumorigenicity, expression of tumor-associated antigen and cytogenetic features. CSEC cell line grew continuously with a doubling time of 39.5 h and had been passaged over 80 times. The CSEC cells possessed features of squamous epithelial cells with cytokeratin indicated by immunohistochemical staining and tonofilaments and desmosomes revealed by electron microscopy. Tumorigenicity to severe combined immunodeficient mice was confirmed and the tumors developed revealed well-differentiated squamous cell carcinoma, similar to the origin tumor from which the cell line derived. The cytogenetic analysis demonstrated hypertetraploid karyotypes. Chromosome structure aberrations were common and complicated. Immunohistochemical staining showed that CSEC cells were infected with HPV and over-expressed p53. In summary, the CSEC cell line is a well-differentiated esophageal squamous cell carcinoma cell line from a high-incidence area in southern China. It may provide a useful model for the pathogenesis and therapeutic research of esophageal squamous cell carcinoma.

Effects of selenium and iodine deficiency on bone, cartilage growth plate and chondrocyte differentiation in two generations of rats

OBJECTIVE

The purpose of the current study was to investigate the roles of combined selenium and iodine deficiency in bone development as a possible experimental model of Kashin-Beck osteoarthropathy.

METHODS

Sprague-Dawley rats (n=48) were randomly divided into selenium deficiency (-Se+I), iodine deficiency (+Se-I), combined selenium and iodine deficiency (-Se-I), and selenium and iodine sufficient (+Se+I) groups. Growth of bone and cartilage, and the expression of type X collagen (ColX) and parathyroid hormone-related peptide (PTHrP) were measured in two generations of rats (F(0) and F(1)).

RESULTS

The tibial length in -Se-I rats was significantly shorter in F(1) generation. In +Se-I of F(1) rats, the thickness of the growth plate cartilage, and the proliferative zone was smaller, while in -Se-I rats the growth plate, and the proliferative and hypertrophic zones were also thinner in F(1) generation. In articular cartilage, ColX expression was increased in the deep zone in -Se-I rats of F(0) generation, and in -Se+I, +Se-I and -Se-I rats of F(1) generation. PTHrP expression was increased in the middle zone of -Se+I, +Se-I and -Se-I rats of both F(0) and F(1) generations. In the growth plate cartilage, ColX and PTHrP were expressed in the hypertrophic zone. ColX expression was significantly weaker in -Se+I and -Se-I rats in both F(0) and F(1) generations, while PTHrP expression was stronger in -Se+I, +Se-I and -Se-I rats in both F(0) and F(1) animals.

CONCLUSIONS

Combined selenium and iodine deficiency impaired the growth of bone and cartilage. The changes in the expression of ColX and PTHrP induced by combined selenium and iodine deficiency were compatible to measurements of ColX and PTHrP in Kashin-Beck osteoarthropathy.

Plasticity of ovarian cancer cell SKOV3ip and vasculogenic mimicry in vivo

The aim of this study is to investigate the plasticity of human epithelial ovarian cancer cell SKOV3ip and formation of vasculogenic mimicry (VM) in vivo. SKOV3ip was transfected with lentiviral vector carrying green fluorescence protein (GFP). Female nude mice were implanted intraperitoneally with GFP-labled SKOV3ip. When the transplanted tumor reached a volume of approximately 1 cm(3), paraffin-embedded, formaldehyde-fixed tissue was prepared and stained with hematoxylin and eosin (H & E). Tumor tissues were also studied by electron microscopy and fluorescence microscopy. The results of H & E staining, electron microscopy, and fluorescence microscopy indicated SKOV3ip formed patterned networks with erythrocytes in them, in the absence of vascular epithelial cells, which was a sign that SKOV3ip engaged in VM in vivo. Expression of vascular epithelium marker CD31 was investigated by immunohistochemical staining, immunofluorescence assay, semiquantitative reverse transcriptase-polymerase chain reaction (RT-PCR), and flow cytometric analysis (FACS). Factor VIII and vascular endothelial growth factor (VEGF) were also analyzed by FACS. Weak and focal CD31 immunohistochemical staining was found along the channels of tumor cells. Immunofluorescence assay and RT-PCR demonstrated that CD31 was expressed in primary-cultured SKOV3ip. CD31 and Factor VIII, but not VEGF were detected in primary-cultured SKOV3ip by FACS. The present study has shown that human ovarian cancer cell line SKOV3ip may be able to express some specific markers of vascular epithelial cells and has plasticity to form VM in vivo. In the following study, we indicated that hypoxia-inducible factor (HIF)-1alpha inhibitor, rapamycin, could possibly prevent VM and phenotype transformation of SKOV3ip, reflected by down-regulating expression of CD31 and Factor VIII. HIF-1alpha protein expression correlated with CD31 and Factor VIII protein expression in SKOV3ip. These results indicated that VM might be associated with HIF-1alpha.