In the Asia Pacific region Human Immunodeficiency virus (HIV) is often acquired in individuals already infected with hepatitis B virus (HBV). The immune suppression caused by HIV infection reduces cellular immune response against HBV and liver inflammation may improve, but the risk of developing cirrhosis is not. HBV infection does not affect the progression of HIV disease. Anti-retroviral agents may be directly hepatotoxic and cause ALT elevations in patients with chronic hepatitis. Highly active anti-retroviral therapy (HAART) improves immunity and as cytotoxic lymphocyte responses improve, hepatitis flares can occur, usually r within 3 months of initiation of HAART. These hepatitis flares may be followed by normalization of ALT and clearance of HBVDNA. If lamivudine is included in the HAART regime, hepatitis flares may not occur till late and these late flares signal the development of lamivudine resistant HBV strains (90% of HBV/HIV co-infection). Treatment options for chronic HBV infection include interferon (IFN), and nucleoside analogues. Lamivudine, adefovir dipivoxil, tenofovir disoproxil fumarate (DF) are nucleoside analogues with activity against both HBVDNA polymerase and HIV reverse transcriptase. The latter two compounds have added activity against lamivudine resistant HBVDNA. Lamivudine should be avoided in the initial treatment of both hepatitis B as well as HIV because of the high incidence of resistance. Interferon should be considered first for treatment of HBV in HIV co-infected individuals and is usually unsuccessful in the later stages of HIV infection when immune suppression is extreme. As new and improved agents in HAART continue to prolong survival, the use of liver transplantation for cirrhotic patients co-infected with HIV and HBV may increase.
Hepatitis B virus measurement ; HIV ; Lamivudine ; Antiretroviral Therapy, Highly Active ; Therapeutic procedure

Four to 6 months of conventional interferon alpha (IFN-alpha) (5MU daily or 10MU three times weekly) resulted in HBeAg loss in approximately 33% of HBeAg positive patients (controls: 12%). Longer treatment duration improved HBeAg seroconversion. Children with chronic HBV infection and high ALT respond to IFN-a at similar rates. Good end-of-treatment (ET) biochemical and virological response were also achieved with IFN-alpha in HBeAg negative, HBV-DNA positive hepatitis patients. Sustained response (SR) however, was disappointing, but improved with longer duration of treatment: (10-15% SR with 4/6 months treatment: 30% SR with 24 months treatment). Weekly pegylated IFN-alpha2a (PegIFN-alpha2a) for 24 weeks gave a significantly higher HBeAg conversion rate (33%) than conventional IFN-alpha2a (25%). Fifty-two weeks of PegIFN-alpha2b gave a sustained HBeAg loss in 35% patients and HBeAg seroconversion in 29% patients. Similar results were obtained with 48 weeks of weekly PegIFN-alpha2a. PegIFN-alpha2a monotherapy was found to be superior to lamivudine monotherapy in affecting a 6-month SR (normal ALTs and HBV DNA < 20,000 copies/mL) in HBeAg negative/anti-HBe positive chronic hepatitis B patients. There is a tendency for IFN-a and lamivudine combination to result in better sustained response than lamivudine monotherapy. This tendency is also observed with PegIFN-a and lamivudine combination although the combination did not appear to be better than PegIFN-alpha monotherapy. IFN induced HBeAg seroconversion is durable, could increase over time and resulted in better overall survival and survival free of hepatic decompensation or hepatocellular cancer. The main advantage of IFN-a therapy is that a course of finite duration may achieve sustained off-therapy response in a proportion of both HBeAg positive and HBeAg negative chronic hepatitis B patients. However, IFN treatment is usually associated with side-effects, especially flu-like symptoms, fatigue, neutropenia, thrombocytopenia and depression. These are usually tolerable but may require dose modification and premature cessation of treatment (5%). Interferon therapy induced hepatitis flares may lead to decompensation in patients with cirrhosis and can be dangerous in patients with decompensated liver function despite dose reduction.
Hepatitis B e Antigens ; therapeutic aspects ; Therapeutic procedure ; month ; Upper case Bee

INTRODUCTIONSeveral randomised controlled trials have demonstrated better outcomes with primary percutaneous coronary intervention (PCI) over fibrinolytic therapy in the treatment of patients with ST-segment elevation myocardial infarction (STEMI) and normal renal function. Whether this benefit extends to patients with impaired renal function is uncertain.

MATERIALS AND METHODSWe studied 1672 patients with STEMI within 12 hours of symptom onset who were admitted to 2 major public hospitals in Singapore from 2000 to 2002. All patients received either upfront fibrinolytic or PCI as determined by the attending cardiologist. Serum creatinine was measured on admission and the glomerular filtration rate (GFR) was determined using the Modification of Diet in Renal Disease equation. The impact of reperfusion strategy on 30-ay mortality was then determined for patients with GFR > or =60 mL min-(1) 1.73 m-(2) and GFR <60 mL min-(1) 1.73 m-(2).

RESULTSThe mean age was 56 +/- 12 years (85% male) and mean GFR was 81 +/- 30 mL min-(1) 1.73 m-(2). Unadjusted 30-day mortality rates for fibrinolytic-treated vs primary PCI-treated patients were 29.4% vs 17.9%, P <0.05, in the impaired renal function group and 5.4% vs 3.1%, P <0.05, in the normal renal function group. After adjusting for covariates, primary PCI was associated with a significantly lower mortality in the normal renal function group [odds ratio (OR), 0.41; 95% confidence interval (CI), 0.19-0.89] but not in the impaired renal function group [OR, 0.70; 95% CI, 0.31-1.60].

CONCLUSIONSPrimary PCI was associated with improved 30-day survival among patients with normal renal function but not among those with impaired renal function. Randomised trials are needed to study the relative efficacy of both reperfusion strategies in patients with impaired renal function.

Adult ; Angioplasty, Balloon, Coronary ; Antifibrinolytic Agents ; therapeutic use ; Electrocardiography ; Female ; Glomerular Filtration Rate ; Humans ; Male ; Middle Aged ; Myocardial Infarction ; complications ; drug therapy ; surgery ; Registries ; Renal Insufficiency, Chronic ; complications ; Retrospective Studies ; Survival Analysis

INTRODUCTIONThis study reports the outcomes of patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation followed by surgery in a local population of Singapore.

MATERIALS AND METHODSThe records of 85 patients who underwent neoadjuvant chemoradiation for locally advanced rectal cancer followed by surgery at the Tan Tock Seng Hospital (TTSH) between November 2002 and January 2012 were reviewed. The treatment protocol comprised radiotherapy to a total dose of 50.4 Gy concurrent with 5-fluorouracil-based chemotherapy. Patients underwent total mesorectal excision surgery following the completion of neoadjuvant chemoradiation. Local control, disease-free survival and overall survival were analysed using Kaplan-Meier methods.

RESULTSMedian age of the patients was 61 years. All of them completed radiotherapy. One patient did not complete neoadjuvant chemotherapy. The median time to surgery was 52 days. Fifty-five percent (47 of 85) of patients achieved pathological downstaging and 13% (11 of 85) of patients had a pathologic complete response to preoperative treatment. The neoadjuvant chemoradiation was well tolerated. Four percent of patients had grade 3 diarrhoea and 4% of them had grade 3 dermatitis. There were no grade 4 toxicities. With a median follow-up of 41 months, the 5-year actuarial local recurrence, disease-free survival and overall survival rates were 7%, 71.9%, and 83.2% respectively. Univariate analysis showed that patients with positive surgical margins had significantly worse disease-free survival and overall survival (P=0.012 and P<0.001 respectively) and a trend towards a higher rate of local recurrence (P=0.08).

CONCLUSIONOur study provides evidence that neoadjuvant chemoradiation is an effective treatment for locally advanced rectal cancer. Our outcomes are comparable with internationally published data and demonstrate the reproducibility of the neoadjuvant approach in an Asian population.

Adult ; Aged ; Aged, 80 and over ; Chemoradiotherapy, Adjuvant ; Female ; Humans ; Male ; Middle Aged ; Neoadjuvant Therapy ; Neoplasm Staging ; Rectal Neoplasms ; pathology ; therapy ; Treatment Outcome

The establishment of a polarized cellular morphology is essential for a variety of processes including neural tube morphogenesis and the development of the brain. Cdc42 is a Ras-related GTPase that plays an essential role in controlling cell polarity through the regulation of the actin and microtubule cytoskeleton architecture. Previous studies have shown that Cdc42 plays an indispensable role in telencephalon development in earlier embryo developmental stage (before E12.5). However, the functions of Cdc42 in other parts of brain in later embryo developmental stage or in adult brain remain unclear. Thus, in order to address the role of Cdc42 in the whole brain in later embryo developmental stage or in adulthood, we used Cre/loxP technology to generate two lines of tissue-specific Cdc42-knock-out mice. Inactivation of Cdc42 was achieved in neuroepithelial cells by crossing Cdc42/ flox mice with Nestin-Cre mice and resulted in hydrocephalus, causing death to occur within the postnatal stage. Histological analyses of the brains from these mice showed that ependymal cell differentiation was disrupted, resulting in aqueductal stenosis. Deletion of Cdc42 in the cerebral cortex also induced obvious defects in interkinetic nuclear migration and hypoplasia. To further explore the role of Cdc42 in adult mice brain, we examined the effects of knocking-out Cdc42 in radial glial cells by crossing Cdc42/flox mice with human glial fibrillary acidic protein (GFAP)-Cre mice. Inactivation of Cdc42 in radial glial cells resulted in hydrocephalus and ependymal cell denudation. Taken together, these results highlight the importance of Cdc42 for ependymal cell differentiation and maintaining, and suggest that these functions likely contribute to the essential roles played by Cdc42 in the development of the brain.
Animals ; Brain ; metabolism ; pathology ; Cell Differentiation ; Cell Polarity ; Cerebral Cortex ; cytology ; metabolism ; Constriction, Pathologic ; Embryo, Mammalian ; metabolism ; Embryonic Development ; Ependyma ; cytology ; metabolism ; Glial Fibrillary Acidic Protein ; genetics ; metabolism ; Humans ; Hydrocephalus ; metabolism ; pathology ; Integrases ; genetics ; metabolism ; Mice ; Mice, Knockout ; cdc42 GTP-Binding Protein ; genetics ; metabolism

Sex hormone estrogen is one of the most active intrinsic angiogenesis regulators; its therapeutic use has been limited due to its carcinogenic potential. Plant-derived phytoestrogens are attractive alternatives, but reports on their angiogenic activities often lack in-depth analysis and sometimes are controversial. Herein, we report a data-mining study with the existing literature, using IPA system to classify and characterize phytoestrogens based on their angiogenic properties and pharmacological consequences. We found that pro-angiogenic phytoestrogens functioned predominantly as cardiovascular protectors whereas anti-angiogenic phytoestrogens played a role in cancer prevention and therapy. This bidirectional regulation were shown to be target-selective and, for the most part, estrogen-receptor-dependent. The transactivation properties of ERα and ERβ by phytoestrogens were examined in the context of angiogenesis-related gene transcription. ERα and ERβ were shown to signal in opposite ways when complexed with the phytoestrogen for bidirectional regulation of angiogenesis. With ERα, phytoestrogen activated or inhibited transcription of some angiogenesis-related genes, resulting in the promotion of angiogenesis, whereas, with ERβ, phytoestrogen regulated transcription of angiogenesis-related genes, resulting in inhibition of angiogenesis. Therefore, the selectivity of phytoestrogen to ERα and ERβ may be critical in the balance of pro- or anti-angiogenesis process.
Angiogenesis Inducing Agents ; metabolism ; Angiogenesis Inhibitors ; metabolism ; Animals ; Gene Expression Regulation ; Humans ; Phytoestrogens ; metabolism ; Receptors, Estrogen ; genetics ; metabolism ; Signal Transduction