Randomized clinical trial: efficacy and safety of telbivudine and lamivudine in treatment-naïve patients with HBV-related decompensated cirrhosis

Patients with decompensated cirrhosis owing to chronic hepatitis B viral (HBV) infection have a high morbidity/mortality rate, and the treatment remains a challenge. We studied the safety and efficacy of telbivudine and lamivudine in such patients. This noninferiority, double-blind trial randomized 232 treatment-naive patients with decompensated HBV (1:1) in 80 academic hospitals to receive once-daily telbivudine 600 mg or lamivudine 100 mg for 104 weeks. Primary composite endpoint was proportion of patients with HBV DNA <10 000 copies/mL, normal alanine aminotransferase (ALT) and Child-Turcotte-Pugh score improvement/stabilization at week 52. Response rates using a post hoc modified endpoint (HBV DNA <300 copies/mL [57 IU/mL] and ALT normalization) in intent-to-treat analysis (missing = failure) were 56.3%vs 38.0% after 76 weeks (P = 0.018) and 45.6%vs 32.9% after 104 weeks (P = 0.093) for telbivudine vs lamivudine. Telbivudine treatment was an independent predictive factor for HBV DNA <300 copies/mL and ALT normalization (P = 0.037). Response rates with protocol-defined composite endpoint in intent-to-treat analysis (M = F) were 56.2 vs 54.0% (noninferiority not achieved) and 39.1%vs 36.4% (noninferiority achieved) in telbivudine and lamivudine groups at 52 and 104 weeks. Telbivudine treatment was associated with a significant improvement in glomerular filtration rate compared to lamivudine treatment and was also associated with a trend for improvement in survival (87%vs 79%). No cases of lactic acidosis were reported. Telbivudine compared to lamivudine was associated with a higher rate of patients with both viral suppression and ALT normalization, a trend towards a higher rate of survival and significant improvement in glomerular filtration.

Intravenous administration of adenoviruses targeting transforming growth factor beta signaling inhibits established bone metastases in 4T1 mouse mammary tumor model in an immunocompetent syngeneic host

We have examined the effect of adenoviruses expressing soluble transforming growth factor receptorII-Fc (sTGFβRIIFc) in a 4T1 mouse mammary tumor bone metastasis model using syngeneic BALB/c mice. Infection of 4T1 cells with a non-replicating adenovirus, Ad(E1-).sTβRFc, or with two oncolytic adenoviruses, Ad.sTβRFc and TAd.sTβRFc, expressing sTGFβRIIFc (the human TERT promoter drives viral replication in TAd.sTβRFc) produced sTGFβRIIFc protein. Oncolytic adenoviruses produced viral replication and induced cytotoxicity in 4T1 cells. 4T1 cells were resistant to the cytotoxic effects of TGFβ-1 (up to 10 ng ml(-1)). However, TGFβ-1 induced the phosphorylation of SMAD2 and SMAD3, which were inhibited by co-incubation with sTGFβRIIFc protein. TGFβ-1 also induced interleukin-11, a well-known osteolytic factor. Intracardiac injection of 4T1-luc2 cells produced bone metastases by day 4. Intravenous injection of Ad.sTβRFc (on days 5 and 7) followed by bioluminescence imaging (BLI) of mice on days 7, 11 and 14 in tumor-bearing mice indicated inhibition of bone metastasis progression (P<0.05). X-ray radiography of mice on day 14 showed a significant reduction of the lesion size by Ad.sTβRFc (P<0.01) and TAd.sTβRFc (P<0.05). Replication-deficient virus Ad(E1-).sTβRFc expressing sTGFβRIIFc showed some inhibition of bone metastasis, whereas Ad(E1-).Null was not effective in inhibiting bone metastases. Thus, systemic administration of Ad.sTβRFc and TAd.sTβRFc can inhibit bone metastasis in the 4T1 mouse mammary tumor model, and can be developed as potential anti-tumor agents for breast cancer.

Rapid detection of poliovirus by reverse transcription and polymerase chain amplification: application for differentiation between poliovirus and nonpoliovirus enteroviruses

This report describes a rapid method of detection of poliovirus from viral isolates of clinical specimens using a single set of primers selected from the conserved 5' noncoding region of the poliovirus genome. Of the 144 clinical viral isolates examined, 81 were positive for polioviruses and 50 were positive for nonpoliovirus enteroviruses by tissue culture neutralization and infectivity. All 81 (100%) of the viral isolates identified as poliovirus by tissue culture infectivity were also positive by polymerase chain reaction. Of 50 nonpoliovirus enterovirus isolates found to be negative for poliovirus by tissue culture neutralization and infectivity, 48 were also negative by polymerase chain reaction. The high sensitivity (100%) and specificity (96%) of the primer set indicate that this assay has potential clinical applicability in the diagnosis of nonpoliovirus enterovirus infection.

Tuberculosis-diabetes mellitus bidirectional screening at a tertiary care centre, South India

SETTING

Tuberculosis (TB) and diabetes mellitus (DM) clinics at Bowring and Lady Curzon Hospital, a tertiary care centre in Bangalore, India.

OBEJCTIVE

To assess the feasibility and results of TB-DM bidirectional screening.

METHODS

A descriptive study conducted from 1 March to 30 September 2012, in which all TB patients were assessed for DM and vice versa. Fasting blood glucose values of ≥126 mg/dl and 110-125 mg/dl were considered as DM and pre-diabetes, respectively.

RESULTS

Of 510 TB patients, 32 (6.3%) had been previously diagnosed with DM. Screening among the remaining 478 patients yielded 15 (2.9%) with pre-diabetes and 15 (2.9%) newly diagnosed cases of DM. A higher prevalence of DM was found among patients aged ≥40 years, patients with pulmonary TB and smokers. Of the 47 TB-DM patients, 45 were enrolled in DM care. Of 1670 DM patients followed up in DM clinics, 45 already had TB. Among the remaining 1625 patients screened, 152 (9%) had symptoms suggestive of TB; two of these were found to have the disease.

CONCLUSION

Bidirectional screening for DM and TB is feasible and produces a high yield for DM among TB patients. The yield of TB among DM patients was low and needs future research using new, improved TB diagnostic tools.

Immunological failure despite virological suppression in HIV seropositive individuals on antiretroviral therapy

BACKGROUND

Some individuals experience a discordant response during antiretroviral therapy (ART), with a blunted CD4+ cell count response despite low HIV-1 RNA plasma levels.

MATERIALS AND METHODS

CD4 counts and viral load of 251 individuals on ART referred to the center were analysed for immunological failure. The viral load tests of 28 patients revealed a discordant response, characterized by low CD4 counts despite viral suppression (<47 copies in 23, <5000 in 4 patients and <10000 in one patient). Univariate and multiple regression analysis was done to determine factors associated with immunological failure in patients with viral suppression.

RESULTS

Twenty-eight patients developed immunological failure over a duration of 3.7±1.14 years despite viral suppression. In univariate analysis of discordant patients, low CD4 counts(<100cells/μl) at start of ART(P=0.0261), less than 50% gain in CD4 count (P=0.048) after one year of start of ART and duration on ART for more than 3 years (P=0.0436) were associated with immunological failure. In multiple regression, duration on ART, age and nadir CD4 count (lowest ever) on treatment were predictors of immunological failure in these patients. Overall females (n=8) demonstrated much higher CD4 counts of 136±72 than males (n=20) 79±38 cells/μl at the time of diagnosis of immunological failure.

CONCLUSIONS

Discordance was observed in 13.59% of patients. Detection of failure to first line therapy based on immunologic criteria, without viral load testing, can result in unnecessary switches to 2(nd) line therapy.

Prognostic significance of genotyping Helicobacter pylori infection in patients in younger age groups with gastric cancer

BACKGROUND

Malignant tumours of the stomach are common, but the incidence of stomach cancer varies from country to country, probably a result of genetic, epigenetic and environmental factors. Stomach cancer often occurs in older people whose stomachs produce only small quantities of acid. Although infection with Helicobacter pylori has been proven beyond doubt in the aetiopathogenesis of various gastric disorders, not much is known about the genotypes of H pylori infection in early-onset gastric cancer.

AIM

To ascertain the genotypes of H pylori in gastric cancer.

METHODS

Ninety-two patients were separated into three groups on the basis of their endoscopic findings: group 1, gastric cancer; group 2, gastric ulcer; group 3, non-ulcer dyspepsia. Gastric biopsy specimens were obtained for culture and DNA isolation; additional specimens were taken from subjects with gastric cancer for histopathological analysis. Amplification was performed using specific oligonucleotide primers to obtain genotypic data. Four samples from each group were randomly selected for sequence analysis.

RESULTS

Genotypic analysis showed cagT+ve/hrgA+ve/cagA+ve/cagE+ve/vacAs1+ve to be highly prevalent in 79% of cases of H pylori infection. This genotype was found in 88% of subjects in group 1 and 78% in group 2. Intestinal-type adenocarcinoma was found in 35 subjects (83%), 32 (9%) of which harboured this genotype. Sequence analysis showed no significant strain-specific variations.

CONCLUSIONS

Certain genotypes of H pylori have higher predictive value for the development of intestinal-type carcinoma at an early age. Genotyping of H pylori may well be a useful tool for screening people at increased risk of developing malignancy.

OSTEOID OSTEOMA OF THE SKULL

1. A case of osteoid osteoma of the skull is reported, with characteristic clinical, radiological and pathological features.

2. Osteoid osteoma of the skull has not previously been reported.

Influence of matrix metalloproteinase-1 gene -1607 (1G/2G) (rs1799750) promoter polymorphism on circulating levels of MMP-1 in chronic pancreatitis

This study investigated the role of -1607 (1G/2G) (rs1799750) polymorphism of the MMP-1 gene in chronic pancreatitis. We genotyped 100 patients with chronic pancreatitis and 100 control subjects using tetra-primer ARMS-PCR followed by agarose gel electrophoresis. Serum levels of MMP-1 were determined by Elisa. Statistical analysis was applied to test the significance of the results. The genotypic and allelic distribution varied significantly between the disease group and the control subjects [OD = 1.981 (1.236-3.181), p = 0.004]. MMP-1 levels were higher in subjects homozygous for the 2G allele than in subjects with the 1G allele. The present study revealed a significant association of the MMP-1 -1607 1G/2G (rs1799750) gene promoter polymorphism with chronic pancreatitis, and it can be considered a biological marker in the etiology of chronic pancreatitis.

A single-nucleotide polymorphism in tumor necrosis factor-α (-308 G/A) as a biomarker in chronic pancreatitis

OBJECTIVE

Chronic pancreatitis is a gradual, long-term inflammation of the pancreas that results in alteration of its normal structure and function. The study aims to investigate the role of -308 (G/A) polymorphism of TNF-α gene in chronic pancreatitis.

MATERIAL AND METHODS

A total of 200 subjects were included in this case-control study. A total of 100 in patients admitted in the Gastroenterology Unit of Gandhi Hospital and Osmania General Hospital, Hyderabad were included in the present study. An equal number of healthy control subjects were randomly selected for the study. The genotyping of TNF-α gene was carried out by tetra-primer ARMS PCR followed by gel electrophoresis. The TNF-α levels were assayed by enzyme-linked immunosorbent assay.

RESULTS

A significant variation with respect to the genotypic and allelic distribution in the disease group when compared to control subjects [OR=2.001 (1.33-3.005), p<0.0001**] was observed. Subjects homozygous for the A allele had higher TNF-α levels compared to G allele.

CONCLUSION

The present study revealed a significant association of the TNF-α gene promoter polymorphism with chronic pancreatitis. Thus, TNF-α genotype can be considered as one of the biological markers in the etiology of chronic pancreatitis.

HVS scheme for DICOM image compression: Design and comparative performance evaluation

Advanced digital imaging technology in medical domain demands efficient and effective DICOM image compression for progressive image transmission and picture archival. Here a compression system, which incorporates sensitivities of HVS coded with SPIHT quantization, is discussed. The weighting factors derived from luminance CSF are used to transform the wavelet subband coefficients to reflect characteristics of HVS in best possible manner. Mannos et al. and Daly HVS models have been used and results are compared. To evaluate the performance, Eskicioglu chart metric is considered. Experiment is done on both Monochrome and Color Dicom images of MRI, CT, OT, and CR, natural and benchmark images. Reconstructed image through our technique showed improvement in visual quality and Eskicioglu chart metric at same compression ratios. Also the Daly HVS model based compression shows better performance perceptually and quantitatively when compared to Mannos et el. model. Further "bior4.4" wavelet filter provides better results than "db9" filter for this compression system. Results give strong evidence that under common boundary conditions; our technique achieves competitive visual quality, compression ratio and coding/decoding time, when compared with jpeg2000 (kakadu).

Role of matrix metalloproteinase 3 gene promoter polymorphism in chronic pancreatitis

AIM

To study the role of 5A/6A polymorphism of matrix metalloproteinase (MMP-3) and their levels in the pathogenesis of chronic pancreatitis (CP).

METHODS

One hundred and twenty CP patients and an equal number of age and sex-matched healthy controls were included in the study. Genotypes were determined for 5A/6A allele of MMP-3 gene by allele specific PCR (AS-PCR). The serum MMP-3 levels were estimated using sandwich ELISA method.

RESULTS

The distribution of the genotypes of the 5A/6A polymorphism in both control and study patients was similar (p = 0.523). Within the disease group, patients with older age, early onset of the disease, and addictions such as smoking and alcohol consumption had higher levels as compared to those who did not have these features.

CONCLUSION

We conclude that functional polymorphism of MMP-3 (5A/6A) is not associated with CP. However, the higher levels within the disease group indicate its possible role in the disease process.

Cardiovascular disease risk assessment in diabetes and metabolic syndrome patients with and without non-alcoholic fatty liver disease

<p class="abstract"><strong><span lang="EN-US">Background:</span></strong><span lang="EN-US"> Recently non-alcoholic fatty liver disease (NAFLD) has been suggested as independent cardiovascular (CVD) risk factor and many studies have shown strong links between NAFLD and CVD but NAFLD has not been related to cardiovascular mortality independently on a long term follow up. Inflammation and oxidative stress is well recognized factors for NALFD which lead to many interrelated factors contributing to cardiovascular risk. Aim: To study the cardiovascular disease risk in diabetes and metabolic syndrome patients with and without NAFLD using different risk assessment calculators.</span></p><p class="abstract"><strong><span lang="EN-US">Methods: </span></strong>This was a single center, prospective cross sectional study. 62 patients with diabetes and metabolic syndrome attending the endocrinology &amp; gastroenterology clinics of Osmania General Hospital were enrolled in to the study with 31 patients in group A (NAFLD) and 31 patients in group B (Non-NAFLD). Patients were diagnosed with fatty liver by ultrasound examination.  </p><p class="abstract"><strong><span lang="EN-US">Results: </span></strong>The groups were individually evaluated for cardiovascular risk assessment by PROCAM risk score, atherosclerotic cardiovascular disease (ASCVD) score and atherosclerosis Index. The means ± standard(%) deviation of Procam risk score for NAFLD group was 6.00 ± 1.00 and for Non NAFLD group it was 10.00 ± 2.00 (p=0.039). ASCVD risk score shows 5.11 ± 1.12 for NAFLD and Non NAFLD group showed 8.25 ± 2.18 (p=0.235). The Atherosclerosis index for NAFLD group was 0.24 ± 0.03 and Non NAFLD 0.18 ± 0.04 (p=0.785). The QRsik2 score for NAFLD and Non-NAFLD patients was 13.16 ± 7.56 and 17.45 ± 10.36.</p><p class="abstract"><strong><span lang="EN-US">Conclusions: </span></strong>There was no difference in CVD risk assessment when assessed with different calculators in this population.</p>

Immunological failure despite virological suppression in HIV seropositive individuals on antiretroviral therapy

BACKGROUND

Some individuals experience a discordant response during antiretroviral therapy (ART), with a blunted CD4+ cell count response despite low HIV-1 RNA plasma levels.

MATERIALS AND METHODS

CD4 counts and viral load of 251 individuals on ART referred to the center were analysed for immunological failure. The viral load tests of 28 patients revealed a discordant response, characterized by low CD4 counts despite viral suppression (<47 copies in 23, <5000 in 4 patients and <10000 in one patient). Univariate and multiple regression analysis was done to determine factors associated with immunological failure in patients with viral suppression.

RESULTS

Twenty-eight patients developed immunological failure over a duration of 3.7±1.14 years despite viral suppression. In univariate analysis of discordant patients, low CD4 counts(<100cells/μl) at start of ART(P=0.0261), less than 50% gain in CD4 count (P=0.048) after one year of start of ART and duration on ART for more than 3 years (P=0.0436) were associated with immunological failure. In multiple regression, duration on ART, age and nadir CD4 count (lowest ever) on treatment were predictors of immunological failure in these patients. Overall females (n=8) demonstrated much higher CD4 counts of 136±72 than males (n=20) 79±38 cells/μl at the time of diagnosis of immunological failure.

CONCLUSIONS

Discordance was observed in 13.59% of patients. Detection of failure to first line therapy based on immunologic criteria, without viral load testing, can result in unnecessary switches to 2(nd) line therapy.

Gastric leiomyoma presenting as gastric volvulus

We report a 45-year-old lady who presented with recurrent vomiting, retching and epigastric pain, and was diagnosed to have gastric volvulus. After correction of the volvulus by endoscopic detorsion, a tumor was seen along the greater curvature. This was excised surgically. Histology showed leiomyoma.

Thirteen-week nose-only inhalation exposures of propylene glycol aerosols in Sprague Dawley rats with a lung systems toxicology analysis

The objectives of this study were to increase PG exposure above concentrations tested by Suber et al. and use systems toxicology analysis of lung tissue to understand molecular events. Sprague Dawley rats were exposed to filtered air (sham), propylene glycol/water (PG/W; 90:10) or a propylene glycol/vegetable glycerin/water (PG/VG/W; 50:40:10) reference. The reference group was added at the high dose to observe any changes that might be associated with a carrier more in line with e-vapor products. Macroscopic examinations and terminal organ weights revealed no observations associated with exposure to PG/W or reference. Food consumption and body weights were unaffected by PG/W or reference when compared to sham. No exposure related alterations were observed in serum chemistry, hematology, coagulation, urinalysis or BALF cytology and clinical chemistry. Although clinical observations of dried red material around the nose in the high dose PG/W group were reported, histopathology showed no nasal hemorrhaging which was previously reported by Suber et al. Non-adverse PG/W and reference related findings of minimal mucous cell hyperplasia were noted in nasal cavity section II. No other exposure-related findings were noted in the primary or recovery necropsies. A systems toxicology analysis on lung tissue showed no statistically significant differentially expressed transcripts or proteins compared to the sham group. The endpoints measured from the PG/W high dose group did not differ significantly from those in the more common carrier PG/VG/W. As anticipated, exposure to PG aerosols was slightly irritating but well tolerated. Accordingly, the highest PG exposure (5 mg/L, 6 hrs/day) was regarded as the NOAEC, corresponding to a PG delivered dose of 1,152 mg/kg/day in rats.