SPINK2 Protein Expression Is an Independent Adverse Prognostic Marker in AML and Is Potentially Implicated in the Regulation of Ferroptosis and Immune Response

There is an urgent need for the identification as well as clinicopathological and functional characterization of potent prognostic biomarkers and therapeutic targets in acute myeloid leukemia (AML). Using immunohistochemistry and next-generation sequencing, we investigated the protein expression as well as clinicopathological and prognostic associations of serine protease inhibitor Kazal type 2 (SPINK2) in AML and examined its potential biological functions. High SPINK2 protein expression was an independent adverse biomarker for survival and an indicator of elevated therapy resistance and relapse risk. SPINK2 expression was associated with AML with an NPM1 mutation and an intermediate risk by cytogenetics and European LeukemiaNet (ELN) 2022 criteria. Furthermore, SPINK2 expression could refine the ELN2022prognostic stratification. Functionally, an RNA sequencing analysis uncovered a potential link of SPINK2 with ferroptosis and immune response. SPINK2 regulated the expression of certain P53 targets and ferroptosis-related genes, including SLC7A11 and STEAP3, and affected cystine uptake, intracellular iron levels and sensitivity to erastin, a specific ferroptosis inducer. Furthermore, SPINK2 inhibition consistently increased the expression of ALCAM, an immune response enhancer and promoter of T-cell activity. Additionally, we identified a potential small-molecule inhibitor of SPINK2, which requires further characterization. In summary, high SPINK2 protein expression was a potent adverse prognostic marker in AML and might represent a druggable target.

Deep genomic characterization highlights complexities and prognostic markers of pediatric acute myeloid leukemia

Pediatric acute myeloid leukemia (AML) is an uncommon but aggressive hematological malignancy. The poor outcome is attributed to inadequate prognostic classification and limited treatment options. A thorough understanding on the genetic basis of pediatric AML is important for the development of effective approaches to improve outcomes. Here, by comprehensively profiling fusion genes as well as mutations and copy number changes of 141 myeloid-related genes in 147 pediatric AML patients with subsequent variant functional characterization, we unveil complex mutational patterns of biological relevance and disease mechanisms including MYC deregulation. Also, our findings highlight TP53 alterations as strong adverse prognostic markers in pediatric AML and suggest the core spindle checkpoint kinase BUB1B as a selective dependency in this aggressive subgroup. Collectively, our present study provides detailed genomic characterization revealing not only complexities and mechanistic insights into pediatric AML but also significant risk stratification and therapeutic strategies to tackle the disease.

Mutational spectrum and prognosis in Chinese patients with prefibrotic primary myelofibrosis

Prefibrotic primary myelofibrosis (Pre‐PMF) has been classified as a separate entity of myeloproliferative neoplasms (MPNs). Pre‐PMF is clinically heterogeneous but a specific prognostic model is lacking. Gene mutations have emerged as useful tools for stratification of myelofibrosis patients. However, there have been limited studies comprehensively investigating the mutational spectrum and its clinicopathological significance in pre‐PMF subjects. In this study, we addressed these issues by profiling the mutation status of 141 genes in 172 Chinese MPN patients including 72 pre‐PMF cases. Our findings corroborated the clinical/molecular distinctiveness of pre‐PMF and suggested a refined risk classification strategy for this entity.

Association of HLA-B22 serotype with SARS-CoV-2 susceptibility in Hong Kong Chinese patients

The coronavirus disease 2019 (COVID‐19) is a highly infectious disease caused by SARS‐CoV‐2. Since its first report in December 2019, COVID‐19 has evolved into a global pandemic causing massive healthcare and socioeconomic challenges. HLA system is critical in mediating anti‐viral immunity and recent studies have suggested preferential involvement of HLA‐B in COVID‐19 susceptibility. Here, by investigating the HLA‐B genotypes in 190 unrelated Chinese patients with confirmed COVID‐19, we identified a significant positive association between the B22 serotype and SARS‐CoV‐2 infection (p = 0.002, Bonferroni‐corrected p = 0.032). Notably, the B22 serotype has been consistently linked to susceptibility to other viral infections. These data not only shed new insights into SARS‐CoV‐2 pathogenesis and vaccine development but also guide better infection prevention/control.

Venomous Fish Sting Cases Reported to Hong Kong Poison Information Centre: A Three-Year Retrospective Study on Epidemiology and Management

Objective

To study the epidemiology of venomous fish sting injuries, management and clinical outcomes of injured patients reported to the Hong Kong Poison Information Centre (HKPIC).

Methods

All venomous fish sting cases reported to HKPIC from July 2005 to June 2008 were retrieved from its database (DATOX) and the Hong Kong Hospital Authority (HA) Electronic Patient Record (ePR) computer system for analysis.

Results

There were a total of 33 fish sting cases in this study. The average age of the patients was 43 years (range 20 to 84) and 24 patients were males. Most cases were injured by catfish (n=12), followed by stonefish (n=7) and lionfish (n=4). Ten cases sustained fish sting injury whilst at work. Five patients developed fish sting complications including cellulitis, subacute tenosynovitis, abscess formation and foreign body retention. No mortality was recorded. Within 7 cases of stonefish injury, 3 cases were classified as moderate effect outcome. Two patients received stonefish antivenom and none developed anaphylaxis.

Conclusion

The majority of marine envenomations did not result in significant morbidity and required only supportive management. However, stonefish injuries might be associated with an increased risk of severe local symptoms which therefore required aggressive treatment including antivenom.

Late-Presenting Congenital Diaphragmatic Hernia: A Potentially Life Threatening Case

Congenital diaphragmatic hernia (CDH) generally presents with respiratory distress in the neonatal period. Late onset CDH is less common and is associated with a wide range of clinical symptoms. We report a case of a 4-year-old child presenting with sudden onset of dizziness, abdominal pain and vomiting after swimming. Radiological investigations showed a left CDH with mediastinal shift. She gradually developed respiratory distress after admission. Urgent operation showed that the contents of the hernia included stomach, spleen, small and large bowels. This case highlights the importance of suspicion of CDH, proper clinical examination and investigation of children with acute non-specific gastrointestinal complaints.

The Impact of Emergency Medicine Ward in Acute Intoxication Management

Background

The Emergency Medicine Ward (EMW) was established in Caritas Medical Centre (CMC) in November 2007 under the management of emergency physicians. With the support from the psychiatric team and medical social workers, it provided effective management for intoxicated patients as an alternative to traditional inpatient service.

Objective

The aim of this study was to evaluate the impact of the EMW in the management of acute intoxication.

Method

A retrospective comparative study with data retrieved from all admitted intoxicated and suspected intoxicated patients was carried out over two separate half-year periods in 2007 and 2008, before and after the establishment of the EMW. Data on patient demographics, reason of exposure, substance involved, treatment, psychiatric service offered, clinical outcome, hospital length of stay (LOS) and 28-day hospital re-admission were compared.

Results

A total of 316 intoxicated patients were admitted to CMC with 165 in the 2007 group and 151 in the 2008 group. Both groups shared similar basic epidemiological data. There was a marked reduction in hospital LOS from 80.1 hours to 45.9 hours (p<0.01), a markedly increased proportion of patients receiving psychiatric service from 47.9% to 71.5% (p<0.01) and a significant decline in the access time of psychiatric assessment from 27.4 hours to 10.6 hours (p<0.05). There were no statistically significant difference in treatment, patient clinical outcome and 28-day hospital re-admission.

Conclusions

The establishment of EMW achieved a significant reduction in hospital LOS of intoxicated patients without jeopardizing patient outcome. The results also illustrate that EMW can provide a good platform for the integration of psychiatric service for these patients.

Outcomes of Patients with Successfully Converted Paroxysmal Supraventricular Tachycardia after Four Hours of Observation in an Emergency Department of a District Hospital in Hong Kong

Objective

Paroxysmal supraventricular tachycardia (PSVT) is a common problem encountered in the accident & emergency department (AED). Most patients can be successfully converted to sinus rhythm by vagal manoeuvres or adenosine tri-phosphate (ATP) or may even convert spontaneously in the AED. The objective was to test the safety of a protocol in managing this group of patients. The outcomes and recurrence rate of PSVT patients who had been converted to sinus rhythm and discharged from the AED after a period of observation using a simple protocol were studied.

Methods

This was a prospective study on PSVT patients aged between 18–70 years from June 2003 to August 2005. The outcomes and recurrence rates of the PSVT patients within two periods, namely, 24 hours and 90 days after discharge from the AED, were assessed by the computerized system in public hospitals under the Hong Kong Hospital Authority.

Results

A total of 42 PSVT patients after successful conversion were discharged from the AED after four hours of observation. None had recurrence of PSVT within 24 hours. Four patients (9.5%) presented with recurrent PSVT within 90 days after discharge without negative outcomes. The timing of recurrence ranged from 2 to 22 days (mean 15 days). All the four patients had past history of PSVT and three of them had already been on long term anti-arrhythmic medication. One recurrent PSVT patient was arranged to undergo radiofrequency ablation.

Conclusion

PSVT patients successfully converted by vagal manoeuvre or ATP or converted spontaneously can be safely discharged from the emergency department after four hours of observation under the study protocol.

A Case of Young Man with Stroke Caused by Internal Carotid Artery Dissection

Internal carotid artery dissection is one of the most frequent causes of stroke in young people. Seventy percents of cases are under 50 years old and there is a slight predominance of males. Trivial head injury or neck trauma may cause dissection. Magnetic resonance angiography is important in diagnosis and management planning. Early anti-thrombotic therapy is the main treatment modality. In this case report, a 27 years old male van driver who has played boxing for several years presented to us with acute confusion after a car accident. The patient was put on warfarin for several months and enjoyed good recovery at follow up.

Can Emergency Medicine Ward Shorten Hospital Length of Stay in Patients with Nasogastric Tube Related Coffee Ground Aspirate?

Introduction

The aim of this study was to determine whether elderly patients on nasogastric (NG) tube feeding who presented with coffee ground aspirate could be effectively and safely managed in a local setting of Emergency Medicine Ward (EMW).

Method

A retrospective study with data retrieved from all the cases admitted with a diagnosis of coffee ground aspirate or vomiting who were on NG tube feeding during three years before and after EMW was launched. Data including patient demographics, length of stay (LOS), types of pharmaceutical treatment received, need of upper endoscopy, in-hospital death and readmission rate within fourteen days were studied. Patients who were haemodynamically unstable, having melaena on per rectal examination, on warfarin or with underlying gastrointestinal malignancy were excluded.

Results

A total of 223 patients matching the studied criteria were included in the study, with 103 of them being admitted before the opening of EMW. For the 120 cases admitted after EMW was launched, 70 cases were admitted to EMW and 50 admitted to Medical Ward. The LOS for elderly patients on NG tube feeding presented with coffee ground aspirate was significantly shortened after EMW was launched (5.2 days vs. 4.2 days, p=0.046). In-hospital mortality and 14-day readmission rate were similar in the two studied period. Patients admitted to EMW and Medical Ward in the second study period were also analysed. Those admitted to EMW had a shorter LOS than those admitted to Medical ward during the same period (3.4 days vs. 5.3 days, p=0.001).

Conclusion

The establishment of EMW in local setting can achieve a significant reduction in hospital LOS without jeopardizing patient outcome for elderly patients who are on NG tube feeding presenting with coffee ground aspirate.

Concurrent fatty liver increases risk of hepatocellular carcinoma among patients with chronic hepatitis B

BACKGROUND AND AIMS

Concurrent fatty liver in hepatitis B virus (HBV)-infected patients without significant alcohol intake is a frequent and increasingly alarming problem because of the non-alcoholic fatty liver disease pandemic. The risk of HBV-related hepatocellular carcinoma (HCC) development was increased by concomitant obesity and diabetes. Direct evidence of the hepatocarcinogenic effect of fatty liver in chronic HBV remains elusive. We aimed to evaluate the risk of concurrent histologically proven fatty liver in HBV hepatocarcinogenesis.

METHODS

We conducted a retrospective cohort study on a liver biopsy cohort of HBV-infected patients without significant alcohol intake to evaluate the prevalence of concurrent histologically proven fatty liver and its association with subsequent HCC development. We also examined nine polymorphisms on six non-alcoholic fatty liver disease-related candidate genes (ADIPOQ, APOC3, GCKR, LEPR, PNPLA3, and PPARG).

RESULTS

Among 270 HBV-infected patients, concurrent fatty liver was found in 107 patients (39.6%) and was associated with metabolic risks, cirrhosis (P = 0.016) and PNPLA3 rs738409 CG/GG genotype (P = 0.002). At a median follow-up of 79.9 months, 11 patients (4.1%) developed HCC, and nine of them had concurrent fatty liver. By multivariable Cox analysis, concurrent fatty liver (HR 7.27, 95% confidence interval: 1.52-34.76; P = 0.013), age, cirrhosis, and APOC3 rs2854116 TC/CC genotype (HR 3.93, 95% confidence interval: 1.30-11.84; P = 0.013) were independent factors predicting HCC development.

CONCLUSIONS

Concurrent fatty liver is common in HBV-infected patients and an independent risk factor potentiating HBV-associated HCC development by 7.3-fold. The risk of HBV-related HCC is increased by APOC3 gene polymorphism, and further characterization is required by its role.

Adverse effects of vitamin D deficiency on outcomes of patients with chronic hepatitis B

BACKGROUND & AIMS

Vitamin D is an immunomodulator that might be involved in the pathogenesis of viral hepatitis. We investigated the effects of vitamin D deficiency on long-term outcomes of patients with chronic hepatitis B (CHB).

METHODS

We performed a prospective cohort study of 426 patients with CHB (65% male; mean age, 41 ± 13 years), who were enrolled from 1997 through 2000. Serum levels of 25-hydroxycholecalciferol (25(OH)D3) were measured on study enrollment (baseline). Patients were followed for 159 ± 46 months until last clinic visit or death; approximately 33% received antiviral therapy during the follow-up period. The primary outcome was a clinical event (hepatocellular carcinoma, complications of cirrhosis, or death).

RESULTS

At baseline, the patients' mean serum level of hepatitis B virus DNA was 5.0 ± 2.1 log10 IU/mL; their mean level of 25(OH)D3 was 24.3 ± 9.4 ng/mL, and 348 patients (82%) had vitamin D deficiency (<32 ng/mL). Serum levels of 25(OH)D3 did not correlate with cirrhosis or viral load. Ninety-seven patients (22.8%) developed clinical events by a mean time of 118 ± 60 months after study enrollment. Patients who developed clinical events had lower baseline serum levels of 25(OH)D3 (23.2 ± 10.4 ng/mL) than patients who did not (28.2 ± 9.3 ng/mL, P < .001). Low baseline serum 25(OH)D3 was an independent factor associated with clinical events after adjustment for sex, age, and cirrhosis. The adjusted hazard ratio of vitamin D deficiency for clinical events was 1.90 (95% confidence interval [CI], 1.06-2.43; P = .04). The 15-year cumulative incidence rate of clinical events among patients with vitamin D deficiency was 25.5% (95% CI, 23.1%-27.9%), compared with 11.1% (95% CI, 7.4%-14.8%) in patients with normal serum levels of 25(OH)D3.

CONCLUSIONS

Vitamin D deficiency is common among patients with CHB and is associated with adverse clinical outcomes.

Noninvasive assessments of liver fibrosis with transient elastography and Hui index predict survival in patients with chronic hepatitis B

BACKGROUND AND AIMS

The prognostic role of noninvasive assessments of liver fibrosis has been evolving. Our aim was to investigate the prognostic value of liver stiffness measurement (LSM) with transient elastography and serum-based Hui index to predict hepatic events and deaths in chronic hepatitis B (CHB) patients.

METHODS

The main prospective cohort included 1555 consecutive CHB patients referred for transient elastography examination; a subgroup of 980 patients underwent follow-up assessments at least 3 years later formed the serial cohort. Cox proportional hazard model was performed to determine the relationship of LSM, Hui index and other clinical variables with hepatic events and deaths.

RESULTS

During a mean follow-up of 69 ± 9 months, 119 patients (7.6%) developed hepatic events or deaths. Hepatic event-free survival was significantly decreased with increasing stages of LSM and Hui index. The 5-year cumulative probability of hepatic event-free survival of patients of Stage 1-7 of LSM were 99.3%, 98.8%, 95.7%, 90.9%, 89.6%, 74.6%, and 50.0%, respectively; that of Stage 1 to 3 of Hui index were 98.2%, 93.1%, and 77.5%, respectively. Independent predictors of hepatic event-free survival were age, baseline LSM, and follow-up Hui index. Serum ALT and body mass index affected the accuracy of prediction by LSM. Patients remained early stages of LSM or Hui index at follow-up visit had better survival compared to those remained at late stages.

CONCLUSION

Baseline and change in noninvasive parameters of liver fibrosis, LSM and Hui index, are accurate to predict hepatic event-free survival in CHB patients.

PNPLA3 gene polymorphism and response to lifestyle modification in patients with nonalcoholic fatty liver disease

BACKGROUND AND AIM

Lifestyle modification is the cornerstone for the management of nonalcoholic fatty liver disease (NAFLD), and patatin-like phospholipase 3 (PNPLA3) is one of the most important genetic determinants of NAFLD. We aimed to investigate the effect of PNPLA3 gene polymorphism on the response to lifestyle modification in NAFLD patients.

METHODS

This was a post-hoc analysis of a randomized controlled trial on a lifestyle modification program in community NAFLD patients. The PNPLA3 rs738409 gene polymorphism was correlated with changes in metabolic profile and intrahepatic triglyceride content (IHTG) as measured by proton magnetic resonance spectroscopy.

RESULTS

One hundred and fifty-four patients were equally randomized into the intervention and control groups. The presence of G allele was associated with greater reduction in IHTG (CC: 3.7 ± 5.2%, CG: 6.5 ± 3.6%), and GG: 11.3 ± 8.8% (Spearman's correlation, 0.34; P = 0.002), body weight (P = 0.030), waist-to-hip ratio (P = 0.024), total cholesterol (P = 0.031), and low-density lipoprotein cholesterol (P = 0.009) in the intervention group. In contrast, PNPLA3 polymorphism had no impact on IHTG changes in the control group. By multivariable analysis, PNPLA3 genotype and body mass index (BMI) change were independently associated with IHTG reduction in the intervention group. Only BMI change was associated with IHTG reduction in the control group.

CONCLUSION

Although the PNPLA3 rs738409 GG genotype confers a higher risk of NAFLD, these patients are more sensitive to the beneficial effects of lifestyle modification and should be encouraged to do so.

Serum hepatitis B surface antigen kinetics in severe reactivation of hepatitis B e antigen negative chronic hepatitis B patients receiving nucleoside/nucleotide analogues

BACKGROUND

Kinetics of serum hepatitis B surface antigen (HBsAg) level in hepatitis B e antigen (HBeAg)-negative chronic hepatitis B patients presented with severe reactivation and received oral antiviral therapy is unknown. We aimed to investigate the kinetics of HBsAg level among these patients.

METHODS

HBeAg-negative patients on antiviral therapy with follow-up for 2 years were studied. Those presented with severe reactivation (alanine aminotransferase [ALT] ≥5 times of normal) were compared to those with mild hepatitis. Serum HBsAg level was measured by Elecsys HBsAg II Quant assay (Roche) at baseline and 6-monthly.

RESULTS

A total of 192 (74 severe reactivation) patients were studied. Eighty-one (42%), 74 (39%) and 37 (19%) patients were on lamivudine, entecavir and telbivudine, respectively. Forty-four (23%) patients had early HBsAg decline, that is, ≥0.5 log10 reduction, at month 6. Patients with severe reactivation had higher serum baseline ALT (1,415 ±897 versus 73 ±39 IU/l), HBV DNA (6.4 ±1.6 versus 5.2 ±1.2 log10 IU/ml) and HBsAg (3.3 ±1.0 versus 2.9 ±0.6 log10 IU/ml), as well as an earlier HBsAg decline (50% versus 6%; all P<0.001) than those without. The HBsAg change of patients with severe reactivation was higher at months 0-6 (-0.58 ±-1.26 versus -0.01 ±-0.26 log10 IU/ml; P<0.001) but then became comparable from months 6-24 (-0.19 ±-0.60 versus -0.13 ±-0.19 log10 IU/ml; P=0.85), compared to those presented with mild hepatitis.

CONCLUSIONS

Patients who presented with severe reactivation of HBeAg-negative hepatitis were more likely to develop early HBsAg decline during antiviral therapy. It may indicate a transient strong immune clearance with rapid initial reduction in serum HBsAg, which cannot be sustained due to a faster clearance of serum HBsAg.

On-treatment alpha-fetoprotein is a specific tumor marker for hepatocellular carcinoma in patients with chronic hepatitis B receiving entecavir

Alpha-fetoprotein (AFP) is the most widely used biomarker for hepatocellular carcinoma (HCC) surveillance, which is criticized as neither sensitive nor specific in active hepatitis and liver cirrhosis. The aim of this study was to determine the performance of AFP as a tumor marker for HCC in entecavir-treated patients with chronic hepatitis B (CHB). This was a retrospective-prospective cohort study of 1,531 entecavir-treated patients under regular HCC surveillance with AFP and ultrasonography. Mean age was 52 ± 12 years; 1,099 (72%) patients were male and 332 (21.7%) had clinical evidence of cirrhosis. At a mean follow-up of 51 ± 13 months, 57 (2.9%) patients developed HCC (median size: 3.3 cm). AFP fluctuated with alanine aminotransferase (ALT) and peaked at the time of starting entecavir, then gradually decreased after. AFP started to increase 6 months before the diagnosis of HCC. The receiver operator characteristic curve (AUROC) of AFP was highest at the time of HCC diagnosis (0.85; 95% confidence interval [CI]: 0.73-0.98) and remained satisfactory at 3 (0.82; 95% CI: 0.73-0.91) and 6 months (0.79; 95% CI: 0.69-0.89) before the diagnosis. Using the conventional AFP cut-off (20 μg/L) at month 0, the sensitivity and specificity to diagnose HCC were 38.6% and 98.9%, respectively. Adopting the lower cut-off value (6 μg/L) of AFP level at month 0, sensitivity was increased to 80.7%, whereas specificity was decreased to 80.4%.

CONCLUSION

On-treatment AFP is a specific tumor marker for HCC in CHB patients receiving entecavir therapy. Adopting a lower cut-off value of AFP level at 6 μg/L would significantly increase the sensitivity for HCC detection.

Tumour bed clip localisation for targeted breast radiotherapy: compliance is proportional to trial-related research activity: tumour bed clip localisation in breast radiotherapy

BACKGROUND

In breast cancer, with the increasing use of intensity-modulated radiotherapy (IMRT), the need for accurate tumour bed localisation is paramount. We determined current practice of clip usage in patients referred to a regional centre for radiotherapy following breast conserving surgery. We also investigated whether participation of surgical units in IMRT trials, where tumour bed clip use is emphasised, was associated with clip insertion.

METHODS

A retrospective cohort study of consecutive CT planning images (n = 205), of breast cancer patients treated with radiotherapy following breast conserving surgery. Presence and number of clips; referring hospital and referring surgeon of the patient was recorded. This was correlated to previous participation of referring hospital to IMRT trials.

RESULTS

Of 196 eligible patients, 126 (64%) had clips sited, of which 15 (12%) had two or fewer clips. Five referring hospitals were high recruiters (≥14 patients), and five hospitals were low/non-recruiters (≤1 patient) to IMRT trials. Of patients from low/non-recruiting centres, 29 of 43 (67%) had clips omitted, compared to 41 of 153 (27%) from high-recruiting centres (p < 0.001). Median number of clips used in centres recruiting high numbers of patients was four, compared to zero in low recruiting centres. Ten of 31 referring surgeons routinely omitted clips.

CONCLUSION

Despite inclusion in national guidelines, clip insertion has not become routine in the UK in patients undergoing breast conserving surgery. However, hospitals involved in breast radiotherapy randomised controlled trials are more compliant with clip usage recommendations. Auditing of clip insertion should be considered as a quality control marker in breast surgery.

Liver fibrosis progression is uncommon in patients with inactive chronic hepatitis B: a prospective cohort study with paired transient elastography examination

BACKGROUND AND AIMS

The European Association for the Study of the Liver (EASL) defines the inactive hepatitis B virus (HBV) carrier state based on HBV DNA and alanine aminotransferase (ALT) levels. This study aimed to evaluate the risk of disease progression in such patients.

METHODS

Three hundred sixty-one patients negative for hepatitis B e antigen (HBeAg) with HBV DNA levels < 20,000 IU/mL and normal ALT and without advanced fibrosis at baseline underwent liver stiffness measurement (LSM) by transient elastography between 2006 and 2008 and again between 2010 and 2012. Liver fibrosis progression was defined as an increase in LSM by 30% or more at the second assessment to levels suggestive of advanced fibrosis.

RESULTS

At baseline, the mean age was 48 ± 11 years and 51% were males; ALT level was 28 ± 11 IU/L, HBV DNA level was 2.7 ± 1.0 log10  IU/mL, and LSM was 5.4 ± 1.5 kPa. After an interval of 44 ± 7 months, liver fibrosis progression was observed in 10 (2.8%) patients, and 49 (13.6%) started antiviral therapy. Gender, age, and levels of ALT, HBV DNA, and HBsAg were shown not to be associated with liver fibrosis progression. Among 244 patients with baseline HBV DNA < 2000 IU/mL, 2.9% had liver fibrosis progression, 8.2% started antiviral therapy, and 4.1% had HBV DNA ≥ 20,000 IU/mL during follow-up. Corresponding figures in 117 patients with baseline HBV DNA levels of 2000-20,000 IU/mL were 2.6%, 24.8%, and 7.7%, respectively (P = 1.0, < 0.001 and = 0.21 respectively).

CONCLUSIONS

Liver fibrosis progression within 3-4 years is rare in HBeAg-negative patients with HBV DNA <20,000 IU/mL and normal ALT, but a significant proportion of patients develop treatment indications during follow-up. The study supports the EASL's definition of inactive carriers and its recommendation of regular monitoring.

Liver fibrosis progression is uncommon in patients with inactive chronic hepatitis B: a prospective cohort study with paired transient elastography examination

BACKGROUND AND AIMS

The European Association for the Study of the Liver (EASL) defines the inactive hepatitis B virus (HBV) carrier state based on HBV DNA and alanine aminotransferase (ALT) levels. This study aimed to evaluate the risk of disease progression in such patients.

METHODS

Three hundred sixty-one patients negative for hepatitis B e antigen (HBeAg) with HBV DNA levels < 20,000 IU/mL and normal ALT and without advanced fibrosis at baseline underwent liver stiffness measurement (LSM) by transient elastography between 2006 and 2008 and again between 2010 and 2012. Liver fibrosis progression was defined as an increase in LSM by 30% or more at the second assessment to levels suggestive of advanced fibrosis.

RESULTS

At baseline, the mean age was 48 ± 11 years and 51% were males; ALT level was 28 ± 11 IU/L, HBV DNA level was 2.7 ± 1.0 log10  IU/mL, and LSM was 5.4 ± 1.5 kPa. After an interval of 44 ± 7 months, liver fibrosis progression was observed in 10 (2.8%) patients, and 49 (13.6%) started antiviral therapy. Gender, age, and levels of ALT, HBV DNA, and HBsAg were shown not to be associated with liver fibrosis progression. Among 244 patients with baseline HBV DNA < 2000 IU/mL, 2.9% had liver fibrosis progression, 8.2% started antiviral therapy, and 4.1% had HBV DNA ≥ 20,000 IU/mL during follow-up. Corresponding figures in 117 patients with baseline HBV DNA levels of 2000-20,000 IU/mL were 2.6%, 24.8%, and 7.7%, respectively (P = 1.0, < 0.001 and = 0.21 respectively).

CONCLUSIONS

Liver fibrosis progression within 3-4 years is rare in HBeAg-negative patients with HBV DNA <20,000 IU/mL and normal ALT, but a significant proportion of patients develop treatment indications during follow-up. The study supports the EASL's definition of inactive carriers and its recommendation of regular monitoring.

Entecavir treatment reduces hepatic events and deaths in chronic hepatitis B patients with liver cirrhosis

Entecavir is a potent antiviral agent with high genetic barrier to resistance, hence it is currently recommended as first-line antiviral therapy for chronic hepatitis B (CHB). The aim of this study was to investigate the efficacy of entecavir on clinical outcomes and deaths. It was a retrospective-prospective cohort study based on two cohorts of patients. The entecavir cohort included consecutive CHB patients who had received entecavir 0.5 mg/day for at least 12 months. The historical control cohort included untreated patients recruited since 1997 who underwent routine clinical care. The primary outcome was the 5-year cumulative probability of hepatic events, defined as any cirrhotic complications, hepatocellular carcinoma (HCC), and/or liver-related mortality. A total of 1,446 entecavir-treated patients (72% men; age, 51 ± 12 years; follow-up, 36 ± 13 months) and 424 treatment-naïve patients (65% men; age, 41 ± 13 years; follow-up, 114 ± 31 months) were studied. Overall, there was no difference in hepatic events between the entecavir and control cohorts. Among patients with liver cirrhosis (482 entecavir-treated, 69 treatment-naïve), entecavir-treated patients had reduced risks of all clinical outcomes when compared with treatment-naïve patients with cirrhosis after adjusted for model for end-stage liver disease score: hepatic events (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.34-0.78; P = 0.002), HCC (HR, 0.55; 95% CI, 0.31-0.99; P = 0.049), liver-related mortality (HR, 0.26; 95% CI, 0.13-0.55; P < 0.001), and all-cause mortality (HR, 0.34; 95% CI, 0.18-0.62; P < 0.001). Entecavir-treated patients with cirrhosis who failed to achieve undetectable hepatitis B virus DNA (105/482 [22%]) had comparable risk of hepatic events as the untreated patients.

CONCLUSION

Entecavir therapy reduces the risks of hepatic events, HCC, liver-related and all-cause mortality of CHB patients with liver cirrhosis in 5 years, particularly among those who had maintained viral suppression.

Liver fibrosis progression in chronic hepatitis B patients positive for hepatitis B e antigen: a prospective cohort study with paired transient elastography examination

BACKGROUND AND AIM

Chronic hepatitis B patients in immune-reactive hepatitis B e antigen (HBeAg)-positive phase may have more rapid progression than those in immune-tolerant phase. We aimed to evaluate the risk of liver fibrosis progression in HBeAg-positive patients at different phases.

METHODS

Two hundred forty-seven HBeAg-positive patients without advanced fibrosis at baseline underwent liver stiffness measurement (LSM) by transient elastography in 2006-2008 and again in 2010-2012. Liver fibrosis progression was defined as increase in LSM by 30% or more to levels suggestive of advanced fibrosis at the second assessment.

RESULTS

At baseline, the mean age was 38 ± 11 years, 58% were males, alanine aminotransferase (ALT) was 65 ± 52 IU/L, hepatitis B virus DNA was 4.2 ± 1.2 log IU/mL, and LSM was 6.3 ± 2.1 kPa. At an interval of 42 ± 6 months, 13 patients (5.2%) developed liver fibrosis progression, and 106 patients (42.9%) required antiviral therapy. None of the clinical parameters (e.g., gender, age, ALT, hepatitis B virus DNA, hepatitis B surface antigen level, etc.) was associated with liver fibrosis progression. Among 74 and 137 patients in immune-tolerant and immune-reactive phase, 4.1% and 6.6% had liver fibrosis progression, and 12.2% and 67.2% received antiviral therapy respectively (P = 0.45 and P < 0.001). Immune-tolerant patients with low-normal (< 0.5× upper limit of normal) or high-normal ALT (0.5-1× upper limit of normal) also had similar risk of liver fibrosis progression (5.7% vs. 2.6%; P = 0.49).

CONCLUSIONS

Liver fibrosis progression is uncommon in HBeAg-positive patients. Patients in immune-reactive phase treated with antiviral therapy did not have increased risk of liver fibrosis progression.

Accuracy of risk scores for patients with chronic hepatitis B receiving entecavir treatment

BACKGROUND & AIMS

Little is known about the validity of hepatocellular carcinoma (HCC) risk scores derived from treatment-naïve patients with chronic hepatitis B for patients treated with entecavir.

METHODS

We performed a retrospective-prospective cohort study of 1531 patients with chronic hepatitis B (age, 51 ± 12 years; 1099 male; 332 with clinical cirrhosis) who were treated with entecavir 0.5 mg daily for at least 12 months at Prince of Wales Hospital in Hong Kong from December 2005 to August 2012. The patients were assessed once every 3 to 6 months for symptoms, drug history, and adherence; blood samples were collected for biochemical analyses. We validated 3 HCC risk scores (CU-HCC, GAG-HCC, and REACH-B scores) based on data collected when patients began treatment with entecavir and 2 years later.

RESULTS

After 42 ± 13 months of follow-up, 47 patients (2.9%) developed HCC. The 5-year cumulative incidence of HCC was 4.3% (95% confidence interval [CI], 3.6%-5.0%). Older age, presence of cirrhosis, and virologic remission after 24 months or more of therapy were independently associated with HCC in the entire cohort; advanced age and hypoalbuminemia were associated with HCC in patients without cirrhosis. The area under the receiver operating characteristic curves (AUCs) for baseline CU-HCC, GAG-HCC, and REACH-B scores for HCC were 0.80 (95% CI, 0.75-0.86), 0.76 (95% CI, 0.70-0.82), and 0.71 (95% CI, 0.62-0.81), respectively; the time-dependent AUCs 1 to 4 years after patients started treatment were comparable to those at baseline. The cutoff value of the baseline CU-HCC score identified patients who would develop HCC with 93.6% sensitivity and 47.8% specificity, the baseline GAG-HCC score with 55.3% sensitivity and 78.9% specificity, and the baseline REACH-B score with 95.2% sensitivity and 16.5% specificity. Compared with patients with CU-HCC scores <5 at baseline, those with CU-HCC scores that either decreased from ≥5 to <5 or remained ≥5 had a higher risk of HCC (5-year cumulative incidences, 0% vs 3.9% and 7.3%; P = .002 and P < .001, respectively).

CONCLUSIONS

The CU-HCC, GAG-HCC, and REACH-B HCC risk scores accurately predict which patients with chronic hepatitis B treated with entecavir will develop HCC.

Efficacy of entecavir switch therapy in chronic hepatitis B patients with incomplete virological response to telbivudine

BACKGROUND

The roadmap concept suggests the use of on-treatment HBV DNA to guide treatment strategy of chronic hepatitis B patients treated by telbivudine. Our aim was to validate the roadmap approach of entecavir switch therapy in patients with incomplete response to telbivudine.

METHODS

Consecutive chronic hepatitis B patients on telbivudine monotherapy were studied. Incomplete virological response was defined as detectable HBV DNA after 6-12 months of treatment. Maintained virological response was defined as undetectable HBV DNA until the last follow-up.

RESULTS

Among the 79 patients on telbivudine, 39 (49%) had undetectable HBV DNA after 6-12 months of telbivudine treatment and 40 (51%) had incomplete virological response. In total, 33 incomplete responders switched to entecavir at 11 months (6-23), and 26 (79%) achieved maintained virological response after 25 months (4-46). Low HBV DNA level before switch therapy was the independent factor associated with maintained virological response to entecavir (P=0.01). A total of 24 of 25 (96%) patients with HBV DNA<2,000 IU/ml, versus 2 of 8 (25%) patients with HBV DNA≥2,000 IU/ml, had maintained virological response after switching to entecavir. Although rtM204I and/or rtL180M was detected in 3 of 7 patients with incomplete virological response to entecavir, none of the patients with HBV DNA<2,000 IU/ml during telbivudine treatment harboured these amino acid substitutions.

CONCLUSIONS

Roadmap approach using entecavir switch at month 6-12 among incomplete responders to telbivudine is recommended if the HBV DNA is <2,000 IU/ml at the time of switching.

Abstract P5-11-01: Extending breast conservation choices for women with breast cancer

Introduction: Long term outcomes for women treated with breast conserving surgery are similar to women having mastectomy. The adoption of modern oncoplastic techniques (e.g. volume displacement) has increased the proportion of women having breast conserving surgery compared with mastectomy. The widespread use of therapeutic reduction mammoplasty (TRM) can further reduce the need for mastectomy in a modern oncoplastic breast unit. We analyse if the introduction of TRM has led to an increase in breast conservation and more choice for women treated at our unit.

Methods: Operative logbooks were reviewed. The two-year period April 2007 - April 2009 (before widespread adoption of TRM) was compared to April 2010 - April 2012. Length of stay, re-admission rates, additional operative procedures and cancer recurrences were analysed.

Results: During the 2007–2009 time period, a single surgeon undertook 209 primary operations for breast cancer. 64 women underwent mastectomy (30.6%). Of these, 26 (40.6%)had an immediate reconstruction with latissimus dorsi flap (+/− an implant). 4 women in this period had a TRM as their primary surgery for breast cancer (1.9%).

During the 2010–2012 period, the same surgeon undertook 201 primary operations for breast cancer. 55 women underwent mastectomy (27.4%): 27 had immediate latissimus dorsi reconstruction; 13 had implant based reconstruction (overall reconstruction rate 72%). 32 patients underwent TRM as their primary breast cancer operation (15.9%), all with simultaneous contralateral breast reduction.

Of the immediate reconstruction group in 2007–09, 11 women (42%) have undergone another operative procedure – nipple reconstruction, contralateral breast operations, capsulectomy or “tidying-up” procedures. One patient has had a recurrence of her breast cancer and one patient has died of breast cancer in the 5 year follow-up period. One patient has developed contralateral breast cancer.

In the 2010–12 TRM group, 6 patients (18.8%) underwent a second operation – 3 re-excisions of positive margins and 3 axillary clearances (positive sentinel lymph node biopsy at first operation).

The median length of stay for women treated with TRM was 1 day compared to a median stay of 6 days for patients undergoing latissimus dorsi reconstruction.

Conclusions: Our unit already had high breast conserving surgery rates and a high reconstruction:mastectomy ratio. Introduction of TRM became widespread approximately 2 years ago. Using a TRM technique 25–50% of the breast volume can be removed. This enables some patients who would have been advised mastectomy to be offered a choice of breast conserving surgery; hence the further modest reduction in mastectomy rate seen.

TRM enables breast (and nipple) conservation and a quicker recovery period. TRM may appeal to women thinking about breast reduction before a breast cancer diagnosis. It is useful after neoadjuvant treatment, for multifocal tumours and in women where a high tumour volume:breast volume ratio would make good cosmetic results difficult to achieve with traditional breast conservation techniques. A further advantage of TRM is the simultaneous contralateral breast reduction; thus reducing re-operation rates.

In conclusion, most importantly, TRM extends breast conserving surgery choices for women with breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-11-01.

Hypertriglyceridaemia-induced pancreatitis: a contributory role of capecitabine?

Capecitabine is an orally administered pro-drug of 5-fluorouracil that confers superior disease-free survival and presumably has a more favourable side-effect profile. Here we report on a patient who developed acute necrotising pancreatitis and very high triglyceride levels as well as hand-foot syndrome after receiving capecitabine for colonic cancer. Increased awareness of this potential side-effect and close monitoring of lipid levels may be warranted, especially in patients who have other conditions predisposing them to severe secondary hyperlipidaemia when using this drug.

Prediction of off-treatment response to lamivudine by serum hepatitis B surface antigen quantification in hepatitis B e antigen-negative patients

BACKGROUND

The timing of antiviral therapy cessation in hepatitis B e antigen (HBeAg)-negative patients is controversial. Here, we aimed to investigate the role of HBV DNA and hepatitis B surface antigen (HBsAg) monitoring to predict off-treatment sustained response.

METHODS

A total of 53 HBeAg-negative chronic hepatitis B patients who received lamivudine for 34 ±23 (range 12-76) months and had lamivudine stopped for 47 ±35 months were studied. Primary outcome was sustained response, defined as HBV DNA≤200 IU/ml, at 12 months post-treatment (SR-12).

RESULTS

A total of 9 (17%) patients achieved SR-12. HBV DNA at baseline, month 6 and end of treatment had no association with SR-12. HBsAg levels tended to decrease more significantly during treatment among SR-12 responders. At the end of treatment, both HBsAg ≤2 log IU/ml and reduction by >1 log from baseline had sensitivity, specificity, positive and negative predictive values for SR-12 of 78%, 96%, 78% and 96%, respectively. All 5 patients with HBsAg≤2 log IU/ml and reduction >1 log at the end of treatment achieved SR-12 and all 40 patients with HBsAg>2 log IU/ml and reduction ≤1 log did not have SR-12. The cumulative probability of sustained response and HBsAg clearance at 5 years among patients with HBsAg≤2 log IU/ml were 88% and 72%, respectively, that among patients with HBsAg reduction >1 log were 74% and 61%, respectively.

CONCLUSIONS

Monitoring of HBsAg level can guide the timing of stopping lamivudine in HBeAg-negative chronic hepatitis B.

Hepatitis B virus infection and fatty liver in the general population

BACKGROUND & AIMS

In animal studies, expression of hepatitis B virus (HBV) proteins causes hepatic steatosis. We aimed to study the prevalence of fatty liver in people with and without HBV infection in the general population.

METHODS

We performed a cross-sectional population study in Hong Kong Chinese. Intrahepatic triglyceride content (IHTG) was measured by proton-magnetic resonance spectroscopy.

RESULTS

One thousand and thirteen subjects (91 HBV patients and 922 controls) were recruited. The median IHTG was 1.3% (0.2-33.3) in HBV patients and 2.1% (0-44.2) in controls (p <0.001). Excluding subjects with significant alcohol consumption, the prevalence of nonalcoholic fatty liver disease was 13.5% (95% confidence interval [CI] 6.4%, 20.6%) in HBV patients and 28.3% (95% CI 25.3%, 31.2%) in controls (p=0.003). The fatty liver prevalence differed in HBV patients and controls aged 40-59 years but was similar in those aged 60 years or above. After adjusting for demographic and metabolic factors, HBV infection remained an independent factor associated with lower risk of fatty liver (adjusted odds ratio 0.42; 95% CI 0.20, 0.88; p=0.022). HBV patients also had a lower prevalence of metabolic syndrome (11.0% vs. 20.2%; p=0.034), but the difference was mainly attributed to lower triglyceride levels. Among HBV patients, viral genotypes, HBV DNA level and hepatitis B e antigen status were not associated with fatty liver.

CONCLUSIONS

HBV infection is associated with a lower prevalence of fatty liver, hypertriglyceridemia and metabolic syndrome. Viral replication may affect lipid metabolism and this warrants further studies.

Viral determinants of hepatitis B surface antigen seroclearance in hepatitis B e antigen-negative chronic hepatitis B patients

BACKGROUND

We studied whether quantification of serum HBsAg and HBV DNA levels could predict spontaneous HBsAg clearance in patients with negative hepatitis B e antigen (HBeAg).

METHODS

Serum HBsAg and HBV DNA levels were measured at baseline among a longitudinal cohort of 103 HBeAg-negative patients recruited since 1997.

RESULTS

Twelve (12%) patients developed HBsAg seroclearance after 88 ± 26 months (range, 21-139) of follow-up. At baseline, the serum HBsAg level among patients who cleared HBsAg (1.30 ± 1.27 log IU/mL) was significantly lower than those who did not clear HBsAg (2.96 ± 0.84 log IU/mL; P < .001). The area under receiver operating characteristics (ROC) curve for serum HBsAg to predict HBsAg seroclearance was 0.90 (95% confidence interval [CI], 0.83-0.97; P < .001). Nine (75%) of 12 patients who had HBsAg seroclearance versus 8 (9%) of 91 who remained HBsAg-positive had serum HBsAg ≤100 IU/mL at the baseline (P < .001). An HBsAg cutoff of ≤100 IU/mL had 75% sensitivity and 91% specificity to predict HBsAg seroclearance. Baseline serum HBV DNA could not predict HBsAg seroclearance; the area under ROC curve was 0.64 (95% CI, 0.46-0.81; P = .13).

CONCLUSIONS

Single-point serum HBsAg level can predict the chance of HBsAg seroclearance in chronic hepatitis B patients with negative HBeAg.

Relationship between serum hepatitis B virus DNA and surface antigen with covalently closed circular DNA in HBeAg-negative patients

Hepatitis B virus (HBV) covalently closed circular DNA (cccDNA) is responsible for viral persistence. This study aimed to investigate the serum surrogate markers for cccDNA and to evaluate the intrahepatic viral events associated with disease activity in HBeAg-negative chronic hepatitis B patients. Thirty-three treatment-naïve patients with a negative HBeAg who had a liver biopsy were studied. Active disease was defined as a serum alanine aminotransferase >40 IU/L and a serum HBV DNA >10,000 copies/ml. This study showed significant correlation between serum HBV DNA and both log cccDNA (r = 0.41, P = 0.018) and log total intrahepatic HBV DNA (r = 0.71, P < 0.0001). No significant correlation was observed between serum HBsAg and log cccDNA (P = 0.15) or log total intrahepatic HBV DNA (P = 0.97). Fourteen and 19 patients had inactive and active disease, respectively. The median log cccDNA and log total intrahepatic HBV DNA (copies/10(6) cells) were significantly higher in patients with active disease compared with those with inactive disease (4.11 vs. 3.53, P = 0.03 and 5.46 vs. 4.64, P < 0.001, respectively). The HBV replicative efficiency, defined as the ratio of serum HBV DNA to cccDNA, was approximately 20% higher in patients with active disease. No significant difference was observed in the HBsAg levels and the ratio of serum HBsAg to cccDNA between the two groups. In conclusion, serum HBV DNA, but not HBsAg, reflects the amount of cccDNA and the replication efficiency of HBV in patients with HBeAg-negative chronic hepatitis B.

A patient with commotio cordis successfully resuscitated by bystander cardiopulmonary resuscitation and automated external defibrillator

Sudden deaths of children and adolescents during competitive sports are usually due to congenital heart diseases. Ventricular fibrillation, however, may also occur in individuals with no underlying cardiac disease who have sustained a low-impact chest wall blow. This phenomenon is described as commotio cordis, and the overall survival rate is poor. Successful resuscitation can be achieved by prompt cardiopulmonary resuscitation and early defibrillation. We report a teenager who sustained a chest wall blow that resulted in a cardiac arrest during a rugby competition. Cardiopulmonary resuscitation was given by bystanders. The ambulance crew arrived with an automated external defibrillator. Ventricular fibrillation was detected and responded to defibrillation. Subsequent investigations including imaging and electrophysiological studies did not reveal any cardiac or brain abnormality, and the patient recovered well neurologically. Accessible cardiopulmonary resuscitation-trained personnel and automated external defibrillators should be present at all organised sporting events.

A longitudinal study on the natural history of serum hepatitis B surface antigen changes in chronic hepatitis B

Serum hepatitis B surface antigen (HBsAg) quantification has been suggested to reflect the concentration of covalently closed circular DNA in the liver. We aimed to investigate the HBsAg levels at different stages of chronic hepatitis B and the changes in HBsAg level during the natural progression of disease. One hundred seventeen untreated patients with chronic hepatitis B were studied with longitudinal follow-up for 99 ± 16 months. HBsAg quantification was performed at the first visit, the last visit, and three visits at each quartile during the follow-up. At the first visit, HBsAg level was higher among patients who were hepatitis B e antigen (HBeAg)-positive (N = 49) than those who were HBeAg-negative (N = 68) (4.01 ± 0.91 log IU/mL versus 2.73 ± 1.25 log IU/mL, P < 0.001). HBsAg level was persistently high at approximately 5 log IU/mL among patients in the immune tolerance phase (N = 7). The HBsAg levels among patients with HBeAg-positive active disease (N = 25) or sustained HBeAg seroconversion (N = 17) were comparable at approximately 3-4 log IU/mL. The HBsAg levels among patients who were HBeAg-negative tended to be higher among patients with active (N = 46) than those with inactive disease (N = 22). The median HBsAg levels decreased in HBeAg-negative patients with active and inactive disease by 0.041 log IU/mL/year and 0.043 log IU/mL/year, respectively. Twenty-two (17%) patients had HBsAg reduction >1 log IU/mL at the last visit; most of them showed reduced hepatitis B virus DNA, and eight had HBsAg loss.

CONCLUSION

HBsAg remained stable in HBeAg-positive patients and tended to reduce slowly in HBeAg-negative patients. Reduction of HBsAg for >1 log IU/mL could reflect improved immune control.

Comparison of inter- and intraobserver agreement and reliability between three different types of placental volume measurement technique (XI VOCAL, VOCAL and multiplanar) and validity in the in-vitro setting

OBJECTIVES

To compare XI VOCAL (eXtended Imaging Virtual Organ Computer-aided AnaLysis) for three-dimensional (3D) ultrasound volumetry of the placenta and of phantom objects with a rotational method using VOCAL and with the multiplanar method.

METHODS

We acquired 3D volume datasets from 32 fetuses at 11-14 weeks' gestation. Placental volume was calculated twice by each of two observers using XI VOCAL (with 5, 10, 15 and 20 slices), multiplanar (1-mm interval) and VOCAL (with 12 degrees, 18 degrees and 30 degrees rotation) methods. In addition, validity was assessed using the in-vitro setting with three phantom objects of known volume.

RESULTS

Both inter- and intraobserver reliabilities were very high for all three methods. There was no systematic bias between any two methods except between XI VOCAL (10 slices) and the multiplanar (1-mm interval) method, with a smaller volume using the former method. The limits of agreement were wide between any two of the three methods. In the in-vitro setting, there was a trend towards less valid measurements with the XI VOCAL technique and fewer slices. With the same number of steps, measurements made with VOCAL (12 degrees and 18 degrees) were more valid than were those made with XI VOCAL (15 and 10 slices, respectively).

CONCLUSION

XI VOCAL cannot be used interchangeably with VOCAL or multiplanar techniques in measuring placental volume at 11-14 weeks' gestation.

Disease progression of non-alcoholic fatty liver disease: a prospective study with paired liver biopsies at 3 years

BACKGROUND

Patients with non-alcoholic steatohepatitis (NASH) have increased mortality and liver-related complications. In contrast, simple steatosis is considered benign and non-progressive.

OBJECTIVE

To investigate disease progression in patients with different degrees of non-alcoholic fatty liver disease (NAFLD) activity.

DESIGN

Prospective longitudinal hospital-based cohort study.

PATIENTS

Fifty-two patients (age 44+/-9 years) with biopsy-proven NAFLD had liver biopsies repeated at month 36.

RESULTS

Among 13 patients with simple steatosis at baseline, 2 (15%) had a normal liver at month 36, 3 (23%) continued to have simple steatosis, 5 (39%) developed borderline NASH and 3 (23%) developed NASH. Among 22 patients with borderline NASH at baseline, 4 (18%) had simple steatosis and 13 (59%) had borderline NASH at month 36, while 5 (23%) developed NASH. Among 17 patients with NASH at baseline, 10 (59%) continued to have NASH and 6 (35%) had borderline NASH at month 36. Only 1 (6%) patient regressed to simple steatosis. Overall, 14 (27%) patients had fibrosis progression, 25 (48%) had static disease, and 13 (25%) had fibrosis regression. Reduction in body mass index and waist circumference was independently associated with non-progressive disease activity and fibrosis. The baseline serum levels and month 36 changes in adiponectin, tumour necrosis factor alpha, interleukin 6 and leptin were not associated with disease progression. Serum cytokeratin-18 fragment level reflected disease activity and its change correlated with the change in NAFLD activity score (R=0.51, p<0.001).

CONCLUSIONS

Patients with simple steatosis may still develop NASH and fibrosis progression. Weight reduction is associated with non-progressive disease. All patients with NAFLD should undergo periodic assessment and lifestyle modification.

Durability of peginterferon alfa-2b treatment at 5 years in patients with hepatitis B e antigen-positive chronic hepatitis B

Approximately 30%-40% of patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B treated with peginterferon and/or lamivudine achieve HBeAg seroconversion 6 months after the end of treatment. The durability and long-term effect of treatment are unknown. In this study, 85 HBeAg-positive patients who received peginterferon alfa-2b 1.5 microg/kg/week for 32 weeks and lamivudine 100 mg/day for 52 or 104 weeks were prospectively followed for 6.1 +/- 1.7 years posttreatment. Twenty-five (29%) patients had virologic response (HBeAg seroconversion and HBV DNA <10,000 copies/mL) at 5 years. The rate of HBeAg seroconversion rose progressively from 37% at the end of treatment to 60% at 5 years. Twenty-seven (32%) and 11 (13%) patients had undetectable HBV DNA (<100 copies/mL) at the end of peginterferon treatment and at 5 years, respectively. Two (2.4%) patients achieved hepatitis B surface antigen (HBsAg) seroclearance at 2.6 and 84 months posttreatment. Among virologic responders at the end of treatment, 82% and 57% and sustained HBeAg seroconversion and virologic response at 5 years. End-of-treatment serum quantitative HBsAg was significantly lower in patients with sustained virologic response at 5 years (median 1,431 IU/mL versus 2,689 IU/mL [P = 0.041]). At the last follow-up, the liver stiffness measurement by transient elastography was 5.8 +/- 2.7 kPa. Only two patients had liver stiffness suggestive of advanced fibrosis. Week 16 HBV DNA, end-of-treatment HBeAg seroconversion, and undetectable HBV DNA were independent factors associated with virologic response at 5 years. The duration of concomitant lamivudine treatment had no impact on any long-term response.

CONCLUSION

Peginterferon has high durability in HBeAg-positive chronic hepatitis B patients with end-of-treatment virologic response.

Fetal biometry by an inexperienced operator using two- and three-dimensional ultrasound

OBJECTIVE

To compare the reproducibility, accuracy and time required for fetal biometric measurements using two-dimensional (2D) and three-dimensional (3D) ultrasonography by an inexperienced operator.

METHODS

Fifty consecutive fetuses were evaluated at a gestational age of 17-34 weeks. For every fetus measurements-including biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL)-were made by an inexperienced operator using 2D ultrasound and then saved 3D volumes. As a control, measurements were also made by an experienced operator using 2D ultrasonography alone. Each fetal biometric parameter was measured twice by each operator. All images were assessed by two experienced reviewers, blinded to the operator's identity, using a scoring system based on objective evaluation criteria.

RESULTS

The interobserver, intraobserver and inter- method variability for 2D ultrasonography by the experienced operator (2D-exp), and 2D and 3D ultrasonography by the inexperienced operator (2D-inexp and 3D-inexp) was small (all intraclass correlation coefficients > or = 0.991). A non-significantly higher proportion of fetal biometric measurements by 3D-inexp than 2D-inexp were within 1 mm of the measurements by 2D-exp. There were no differences in the mean image quality scores of fetal biometry between 2D-exp and 2D-inexp, 2D-exp and 3D-inexp. However, the quality score of AC images obtained by 3D-inexp was greater than that obtained by 2D-inexp (5.5 vs. 5.3, P = 0.018). The mean time required to measure BPD, HC, AC and FL was less for 3D-inexp than for 2D-inexp (67.2 vs. 97.0 s, 64.6 vs. 97.0 s, 60.1 vs. 81.5 s and 65.5 vs. 95.1 s, respectively; all P < 0.001), but was significantly greater than for 2D-exp, with corresponding figures of 24.3, 24.3, 27.9 and 27.2 s.

CONCLUSION

Fetal biometric measurements obtained by an inexperienced operator using both 2D and 3D ultrasound were reproducible and showed good agreement with those obtained by an experienced operator. The use of 3D ultrasound by an inexperienced operator allows faster measurements to be made than by 2D ultrasound and also seems to facilitate the acquisition of higher-quality images for measurement of AC.

Interaction of adipokines and hepatitis B virus on histological liver injury in the Chinese

OBJECTIVES

Chronic hepatitis B patients with diabetes and metabolic syndrome are at increased risk of cirrhosis and hepatocellular carcinoma, but the underlying mechanism is unclear. Our objective was to test whether dysregulation of adipokines contributes to liver injury. We also studied whether viral factors affected adipokines, insulin resistance, and hepatic steatosis.

METHODS

A prospective cohort of 266 chronic hepatitis B patients undergoing liver biopsy was studied. Fasting blood was taken for the analysis of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), adiponectin, leptin, and resistin. Insulin resistance was assessed by the homeostasis model assessment of insulin resistance (HOMA-IR). Factors associated with significant necroinflammation and cirrhosis were identified.

RESULTS

Histological activity index was correlated with serum TNF-alpha (R=0.40, P<0.0001) and IL-6 (R=0.32, P<0.0001) but not with adiponectin, leptin, or resistin. By multivariate analysis, TNF-alpha was associated with significant necroinflammation after adjusting for age and viral factors (odds ratio (OR) 1.041, 95% confidence interval (CI) 1.002-1.082, P=0.04). Serum adiponectin had positive correlation with hepatitis B virus DNA (R=0.17, P=0.007) and was decreased in patients with insulin resistance and hepatic steatosis. On the other hand, viral load, hepatitis B e-antigen status, and genotypes had no association with insulin resistance, hepatic steatosis, and the levels of TNF-alpha and IL-6. A total of 68 (25.6%) patients had cirrhosis. HOMA-IR, but not adipokine dysregulation, was independently associated with cirrhosis (OR 1.09, 95% CI 1.02-1.15, P=0.006).

CONCLUSIONS

TNF-alpha and/or IL-6 contribute to hepatic necroinflammation in chronic hepatitis B patients. Adiponectin protects against insulin resistance and hepatic steatosis but does not affect liver injury. Adipokines and viral factors contribute to liver injury independently.

Hepatitis B virus genotype C is associated with more severe liver fibrosis than genotype B

BACKGROUND & AIMS

Histologic analyses of liver fibrosis have been limited by small sample sizes and the predominance of samples from patients with active hepatitis.

METHODS

We performed a prospective study of transient elastography in treatment-naive patients with chronic hepatitis B, to investigate the relationship between hepatitis B virus (HBV) genotype and liver fibrosis. A validated liver stiffness measurement algorithm was used to define insignificant fibrosis and advanced fibrosis.

RESULTS

Of 1106 patients, 711 (64%) were older than age 40, 370 (34%) had positive test results for hepatitis B e antigen (HBeAg), and 386 (35%) had increased serum levels of alanine aminotransferase. Of the patients, 524 (49%) had genotype B and 582 (51%) had genotype C HBV infection. Patients with genotype C infection had insignificant fibrosis less often (42% vs 55%; P < .0001) and advanced fibrosis more often (25% vs 19%; P = .015) than those infected with genotype B HBV. The difference in the severity of liver fibrosis between the 2 HBV genotypes was most marked among patients older than age 40 and those who tested negative for HBeAg. The mean age of patients infected by genotype C was greater than that of patients infected by genotype B HBV (41 vs 36 y). Among patients who were older than age 40 and tested negative for HBeAg, those with genotype C infection had higher levels of HBV DNA and alanine aminotransferase than those with genotype B HBV.

CONCLUSIONS

Genotype C HBV was associated with more severe liver fibrosis than genotype B HBV, probably because of delayed HBeAg seroconversion and prolonged active disease.

Surrogate end points and long-term outcome in patients with chronic hepatitis B

BACKGROUND & AIMS

It is unclear whether surrogate end points reported in clinical trials correlate with long-term outcome of patients with chronic hepatitis B.

METHODS

Patients with chronic hepatitis B who participated in any of 4 randomized controlled trials were followed prospectively for liver-related events (hepatocellular carcinoma, ascites, spontaneous bacterial peritonitis, variceal bleeding, liver transplantation, and death). Biochemical (normal ALT levels), virologic (levels of hepatitis B virus DNA below 10,000 copies/mL), and histologic (reduction of necroinflammation grading by 2 points or more with no increase in fibrosis staging) responses were evaluated at the end of each trial.

RESULTS

One hundred ninety-five patients with adequate pretreatment and post-treatment liver biopsies (15 mm long and 6 portal tracts) were followed for 86 months (interquartile range, 77-98). Liver-related events occurred in 12 patients (6%). The risk of liver-related events was lower in patients with biochemical (hazard ratio, 0.21; 95% confidence interval, 0.068-0.68) and histologic (hazard ratio, 0.095; 95% confidence interval, 0.012-0.74) responses. Only 1 patient with a histologic response and 1 patient with an ALT level below Prati's cutoffs (30 IU/L in men and 19 IU/L in women) developed liver-related events. Fifteen of 25 patients (60%) with cirrhosis at baseline had regression of cirrhosis, and none of these patients died or developed liver-related events. In contrast, 3 of these patients still developed liver-related events, despite an initial virologic response, and 2 had virologic breakthrough.

CONCLUSIONS

Biochemical and histologic responses, particularly regression of cirrhosis, in patients with chronic hepatitis B are associated with decreased liver-related complications.

High serum interleukin-6 level predicts future hepatocellular carcinoma development in patients with chronic hepatitis B

Increased interleukin-6 (IL-6) production is implicated in the pathogenesis of hepatocellular carcinoma (HCC) in animal models. Although previous studies showed that HCC patients had higher serum IL-6 level at the time of diagnosis, it is unclear if the cytokine contributes to the development of HCC or is just a reaction to cancer. To address this question, we performed a nested case-control study. Consecutive chronic hepatitis B patients were recruited from 1997 to 2000 and followed till 2008. Profiling of 27 cytokines, chemokines and growth factors was performed at baseline, date of peak alanine aminotransferase (ALT) level and the last visit. Thirty-seven patients developed HCC at a median follow-up of 62 months (interquartile range: 41-110). Serum IL-6 was higher in patients with HCC than controls both during peak ALT and at the last visit (both p = 0.02). Patients with IL-6 above 7 pg/ml during peak ALT had increased risk of HCC or death (adjusted hazard ratio 3.0; 95% confidence interval 1.2, 7.8; p = 0.02). The sensitivity, specificity, positive and negative predictive values of this cutoff to predict future HCC development were 70%, 73%, 72% and 71%, respectively. Combination of IL-6 and AFP improved the sensitivity in diagnosing HCC or predicting future HCC development. In conclusion, high serum IL-6 level predates the development of HCC in chronic hepatitis B patients, and has moderate accuracy in predicting future cancer. This may assist clinicians in selecting high-risk patients for HCC surveillance program.

Lamivudine monoprophylaxis and adefovir salvage for liver transplantation in chronic hepatitis B: a seven-year follow-up study

In Asia Pacific countries, lamivudine is used frequently as the sole prophylaxis for hepatitis B virus (HBV) recurrence after liver transplantation due to financial consideration. The aim was to evaluate the long-term outcome of lamivudine monoprophylaxis with adefovir salvage for liver transplantation in chronic hepatitis B. Consecutive chronic hepatitis B patients who received liver transplantation from 1999 to 2003 and with at least 12 months follow up were studied. Lamivudine monotherapy was used for antiviral prophylaxis and adefovir was added as salvage treatment for recurrence of HBV. Twenty-four patients were followed up for 272 (76-372) weeks post-liver transplantation. HBV recurrence developed in seven patients with cumulative probabilities of 8%, 13%, 28%, 35%, 35%, and 49% in 1, 2, 3, 4, 5, and 6 years. At the time of recurrence of HBV, the HBV DNA level was 910,244 (363 to 9 x 10(8)) copies/ml. On direct sequencing, four patients had rtM204I mutation and three patients HBV DNA levels were too low for sequencing. Six patients had elevated ALT (two patients had ALT >1,000 IU/L and jaundice) but none had hepatic encephalopathy. After adefovir treatment for 150 (91-193) weeks, six (86%) patients had normal ALT. HBV DNA was undetectable in two (29%) patients, 100-1,000 copies/ml in two (29%) patients and 10,000-100,000 copies/ml in three (43%) patients on last visit. No genotypic resistance to adefovir was detected. Lamivudine followed by adefovir salvage is effective for prophylaxis of recurrence of HBV after liver transplantation up to 7 years.

Comparison of inter- and intraobserver agreement between three types of fetal volume measurement technique (XI VOCAL, VOCAL and multiplanar)

OBJECTIVES

To compare the new XI VOCAL (eXtended Imaging Virtual Organ Computer-aided Analysis) for three-dimensional (3D) ultrasound measurement of fetal volume with the conventional multiplanar technique and a rotational method using VOCAL.

METHODS

We acquired 3D volume datasets from 30 fetuses at 11-14 weeks of gestation using a commercially available ultrasound system. Fetal volume was calculated using XI VOCAL (with 5, 10, 15 and 20 slices), multiplanar (1-mm interval) and VOCAL (with 12 degrees, 18 degrees and 30 degrees rotation) techniques. The level of agreement for interobserver and intraobserver variability was determined and evaluated for all methods and reliability was assessed.

RESULTS

Fetal volume measurements obtained using XI VOCAL (10 slices) showed good correlation with those obtained using VOCAL (18 degrees) (r = 0.940, P = 0.076; intraclass correlation coefficient (ICC), 0.962 (95% CI, 0.920-0.982), P = 0.182), and XI VOCAL (15 slices) showed good correlation with VOCAL (12 degrees ) (r = 0.961, P = 0.092; ICC, 0.979 (95% CI, 0.957-0.990), P = 0.190). The mean difference between paired measurements by the XI VOCAL (10 slices) and VOCAL (18 degrees ) methods was 1.00 mL, while that by the XI VOCAL (15 slices) and VOCAL (12 degrees) methods was 0.90 mL. 95% limits of agreement were - 2.80 to 4.80 between XI VOCAL (10 slices) and VOCAL (18 degrees) and - 1.90 to 3.70 between XI VOCAL (15 slices) and VOCAL (12 degrees). There was a small difference in the time required to complete the fetal volume measurement between XI VOCAL and VOCAL when a similar number of slices or rotational steps was used (P < 0.05), XI VOCAL taking less time.

CONCLUSION

XI VOCAL (with 10, 15 and 20 slices) can be used interchangeably with the multiplanar technique (1-mm interval) for the measurement of fetal volume. XI VOCAL (10 slices) and VOCAL (18 degrees) can be used interchangeably, as can XI VOCAL (15 slices) and VOCAL (12 degrees), for the measurement of fetal volume.

Clinical factors associated with liver stiffness in hepatitis B e antigen-positive chronic hepatitis B patients

BACKGROUND & AIMS

We analyzed the clinical factors associated with advanced liver fibrosis in hepatitis B e antigen (HBeAg)-positive chronic hepatitis B patients.

METHODS

We prospectively recruited treatment-naive HBeAg-positive patients for liver stiffness measurement (LSM) by transient elastography. Insignificant and advanced fibrosis was defined as an LSM of 6.0 kPa or less, and greater than 9.0 kPa for patients with alanine aminotransferase (ALT) levels less than or equal to the f upper limit of normal (ULN), and 7.5 kPa or less and greater than 9.0 kPa for those with ALT levels between 1 and 5 x ULN, respectively, based on a previous study with histologic validation.

RESULTS

A total of 453 patients were studied. Among 74 patients who also had a liver biopsy, the cut-off levels for advanced fibrosis had 95% specificity. Age and ALT level, but not hepatitis B virus DNA level, were associated independently with LSM. Based on receiver operating characteristics curve analysis, patients older than 35 years had the highest specificity for advanced fibrosis. The risk of advanced fibrosis increased in patients with an ALT level greater than 0.5 x ULN. Among the 47 patients who were older than 35 years with an ALT level of 0.5 x ULN or less, 39 (83%) had an LSM suggestive of insignificant fibrosis, and 1 (2%) had advanced fibrosis. Among the 217 patients who were older than 35 years with an ALT level greater than 0.5 x ULN, 61 (28%) had LSM indicating insignificant fibrosis, and 80 (37%) had advanced fibrosis.

CONCLUSIONS

Risk of advanced liver fibrosis increased in HBeAg-positive patients older than 35 years of age with an ALT level greater than 0.5 x ULN.

Evaluation of alanine transaminase and hepatitis B virus DNA to predict liver cirrhosis in hepatitis B e antigen-negative chronic hepatitis B using transient elastography

BACKGROUND AND AIMS

We aimed to investigate the relationship between serum hepatitis B virus (HBV) DNA and alanine transaminase (ALT) levels and the risk of cirrhosis in a large cohort of hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB) patients based on transient elastography.

METHODS

We prospectively studied treatment-naive HBeAg-negative patients recruited based on territory-wide referrals. We defined possible cirrhosis and probable cirrhosis with two different cutoffs according to the results from a subgroup of patients with histologic proof.

RESULTS

One thousand one hundred ninety-seven patients with successful liver stiffness measurement (LSM) were studied. In the subgroup of 100 patients with liver biopsy, LSM of > or =8.4 kiloPascal (kPa) had a sensitivity of 90% and LSM of > or =13.4 kPa had a specificity of 94% for liver cirrhosis. Possible and probable cirrhosis were defined as a LSM value > or =8.4 kPa and > or =13.4 kPa, and were present in 31% and 11% of the patients, respectively. The risk of cirrhosis was significantly increased when ALT level was >0.5x upper limit of normal (ULN) or serum HBV DNA >4 log(10) copies/mL. Among patients who have ALT < or =0.5 x ULN and HBV DNA < or =4 log(10) copies/mL, 10% (26/264) and 3% (7/264) had possible and probable cirrhosis respectively, which were significantly lower when compared with 34% (329/887, P < 0.001) and 14% (125/887, P < 0.001) of those who had higher ALT and HBV DNA levels.

CONCLUSIONS

Liver cirrhosis was common among HBeAg-negative CHB patients. Patients with ALT levels >0.5 x ULN and/or serum HBV DNA >4 log(10) copies/mL have higher risk of cirrhosis and need further assessment for antiviral therapy.

Activated Stat3 expression in gestational trophoblastic disease: correlation with clinicopathological parameters and apoptotic indices

AIMS

To assess the expression profile of the activated form of signal transducer and activator of transcription (Stat)3 in gestational trophoblastic disease (GTD) and correlate the findings with clinicopathological parameters.

METHODS AND RESULTS

By immunohistochemistry, both cytoplasmic and nuclear expression of p-Stat3-Ser(727) was demonstrated in 88 trophoblastic tissues, including placentas and GTD. Nuclear immunoreactivity of p-Stat3-Ser(727) was significantly higher in hydatidiform mole (HM) (P < 0.001) and choriocarcinoma (P = 0.009) when compared with normal placentas. Placental site trophoblastic tumours (PSTT) and epithelioid trophoblastic tumours (ETT) also demonstrated higher nuclear p-Stat3-Ser(727) expression than their normal trophoblast counterparts. Higher p-Stat3-Ser(727) expression was confirmed in choriocarcinoma cell lines, JEG-3 and JAR, than in a normal trophoblast cell line, with both nuclear and cytoplasmic fractions demonstrated by immunoblotting. Spontaneously regressed HM showed significantly increased nuclear and cytoplasmic p-Stat3-Ser(727) immunoreactivity over those that developed gestational trophoblastic neoplasia (GTN) (P = 0.013, P = 0.039). There was a significant positive and inverse correlation between nuclear p-Stat3-Ser(727) immunoreactivity and apoptotic indices [terminal deoxynucleotidyl transferase (TdT)-mediated deoxyuridine triphosphate (dUTP) nick end labelling and M30 CytoDeath antibody] (P = 0.001, P < 0.001, Spearman's rho test) and Bcl-2 expression (P = 0.034), respectively.

CONCLUSIONS

p-Stat3-Ser(727) plays a role in the pathogenesis of GTD, probably through the regulation of apoptosis. p-Stat3-Ser(727) immunoreactivity is a potential marker in predicting GTN in HM.

Early hepatitis B virus DNA suppression can predict virologic response to peginterferon and lamivudine treatment

BACKGROUND & AIMS

We aimed to investigate the early on-treatment HBV DNA response to predict sustained virologic response for peginterferon and lamivudine combination therapy.

METHODS

Patients recruited in previous clinical trials receiving 32-week peginterferon alfa-2b and 52- to 104-week lamivudine combination treatment were studied. The areas under the receiver operating characteristic curve (ROC) of HBV DNA at different time intervals were analyzed to predict sustained virologic response, which was defined as HBeAg seroconversion and HBV DNA <10,000 copies/mL at 1 year after treatment.

RESULTS

Fifty-seven patients had peginterferon started 8 weeks before lamivudine, and 9 patients had the 2 drugs commenced simultaneously. Eighteen (27%) patients developed sustained virologic response. The area under ROC for log HBV DNA to predict sustained virologic response reached 0.80 (95% confidence interval, 0.69-0.91; P < .001) at week 8 and plateaued off at subsequent time intervals. Among the 57 patients started with peginterferon monotherapy during the first 8 weeks, the area under ROC was 0.83 (95% confidence interval, 0.73-0.94; P < .001). Compared with other time intervals, the likelihood ratio for sustained virologic response was highest for HBV DNA <10,000 copies/mL at week 8 (10.35), with a high sensitivity (0.89) and negative predictive value (0.92). Two of 33 (6%) patients who had HBV DNA >or=10,000 copies/mL at week 8 developed sustained virologic response.

CONCLUSIONS

HBV DNA >or=10,000 copies/mL at week 8 of peginterferon treatment had a low chance of sustained virologic response.