Safety and on-treatment efficacy of telaprevir: the early access programme for patients with advanced hepatitis C

BACKGROUND AND AIM

Severe adverse events (AEs) compromise the outcome of direct antiviral agent-based treatment in patients with advanced liver fibrosis due to HCV infection. HEP3002 is an ongoing multinational programme to evaluate safety and efficacy of telaprevir (TVR) plus pegylated-interferon-α (PEG-IFNα) and ribavirin (RBV) in patients with advanced liver fibrosis caused by HCV genotype 1 (HCV-1).

METHODS

1782 patients with HCV-1 and bridging fibrosis or compensated cirrhosis were prospectively recruited from 16 countries worldwide, and treated with 12 weeks of TVR plus PEG-IFN/RBV, followed by 12 or 36 weeks of PEG-IFN and RBV (PR) alone dependent on virological response to treatment and previous response type.

RESULTS

1587 patients completed 12 weeks of triple therapy and 4 weeks of PR tail (53% cirrhosis, 22% HCV-1a). By week 12, HCV RNA was undetectable in 85% of naives, 88% of relapsers, 80% of partial responders and 72% of null responders. Overall, 931 patients (59%) developed grade 1-4 anaemia (grade 3/4 in 31%), 630 (40%) dose reduced RBV, 332 (21%) received erythropoietin and 157 (10%) were transfused. Age and female gender were the strongest predictors of anaemia. 64 patients (4%) developed a grade 3/4 rash. Discontinuation of TVR due to AEs was necessary in 193 patients (12%). Seven patients died (0.4%, six had cirrhosis).

CONCLUSIONS

In compensated patients with advanced fibrosis due to HCV-1, triple therapy with TVR led to satisfactory rates of safety, tolerability and on-treatment virological response with adequate managements of AEs.

The disease burden of hepatitis C in Belgium: development of a realistic disease control strategy

BACKGROUND

Novel direct antiviral agents (DAAs) will become available soon with higher sustained viral response (SVR), fewer side-effects and higher compliance. Our aim was to evaluate different realistic strategies to control the projected increase in HCV-related disease burden in Belgium.

METHODS

Based on literature review, expert opinions and historical assumptions, HCV-disease progression and mortality in Belgium was modeled to 2030. Strategies exploring the impact of increased treatment, treatment delay, and treatment restrictions were developed.

RESULTS

Although the overall HCV prevalence is decreasing in Belgium, the burden of advanced stage HCV, including cirrhosis and hepatocellular carcinoma (HCC), is expected to increase under current treatment and cure rates. By increasing SVR to 90% from 2016 onward and the number of treated cases (from 710 to 2,050), in 2030 the cases with cirrhosis, decompensated cirrhosis and HCC would be significantly lower than in 2013. This strategy was found most efficient when applied to F2-F4 cases. To obtain comparable outcomes with F0-F4 cases, 3,490 patients should be treated. A two year delayed access to the DAAs increased HCV related morbidity and mortality by 15% relative to our strategy.

CONCLUSIONS

Considering the evolving burden of HCV disease and the need for efficacious usage of healthcare resources, primary application of new DAAs in Belgium should focus on patients with significant and advanced fibrosis (F2-F4), providing these new drugs without delay upon availability and increasing access to therapy.

Hepatitis C epidemiology in Belgium

BACKGROUND

The burden of hepatitis C virus (HCV) infection is significant and is increasing with the aging population. The results of a modeling study that included Belgium, along with many other countries, was published in April 2014. An in depth discussion surrounding the epidemiology of HCV in Belgium will be presented here.

METHODS

A systematic literature review was conducted to assess the historical and current clinical burden of HCV in Belgium. Two expert panels were convened to discuss the strengths and limitations surrounding the available data and to generate consensus regarding the best estimates for total number of HCV cases, number of cases diagnosed, and the number of patients treated and cured, including potential HCV control strategies.

RESULTS

Although no national studies exist, there were an estimated 70,000 (10,000-91,000) viremic HCV infections in 1994. By 2010 there were an estimated 22,900 individuals diagnosed with viremic HCV, and in 2011 approximately 710 patients were treated annually. An estimated 13% of liver transplants were attributable to HCV in 2011. Genotype 1 predominated (59%), followed by genotypes 3 (19%) and 4 (14%).

CONCLUSIONS

Estimates of HCV prevalence, diagnosed cases and liver transplants due to HCV were available through published studies. However these publications were subject to bias and were occasionally outdated. Improved estimates of HCV prevalence would be useful for informing treatment, prevention and policy efforts in Belgium.

Current and future health and economic impact of hepatitis C in Belgium

BACKGROUND AND STUDY AIMS

Chronic hepatitis C virus (HCV) infection is a serious global health problem affecting 150 million individuals worldwide. Although infection rates are decreasing, an aging population with progressing disease is expected to result in increased burden of advanced stage disease with high associated costs. This analysis describes the current and projected future economic impact of HCV sequelae in Belgium.

METHODS

A previously described and validated model was populated with Belgian inputs and calibrated to project the current and future health and economic burden of HCV. Monte Carlo and sensitivity analyses were run to quantify uncertainty. All estimates exclude the cost of antiviral therapy.

RESULTS

Costs associated with HCV were projected to peak in 2026 at Euro126M (Euro30M-Euro257M), while decompensated cirrhosis and hepatocellular carcinoma costs were projected to increase until 2031 and 2034. The projected 2014-2030 cumulative cost of HCV under current conditions was Euro1,850M. Scenarios to reduce the burden of HCV could result in Euro70M-Euro400M in cumulative cost savings. Starting treatment (1,000 patients) in 2015 could result in Euro150M cost savings. The lifetime cost of HCV increases with life expectancy, with highest future costs projected among young females with early stage disease.

CONCLUSIONS

The economic burden of HCV and advanced stage disease were projected to further increase. Cost reductions are possible with timely interventions aimed at minimizing the health burden of advanced stage disease.

Historical epidemiology of hepatitis C virus (HCV) in selected countries

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.

The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm

The disease burden of hepatitis C virus (HCV) is expected to increase as the infected population ages. A modelling approach was used to estimate the total number of viremic infections, diagnosed, treated and new infections in 2013. In addition, the model was used to estimate the change in the total number of HCV infections, the disease progression and mortality in 2013-2030. Finally, expert panel consensus was used to capture current treatment practices in each country. Using today's treatment paradigm, the total number of HCV infections is projected to decline or remain flat in all countries studied. However, in the same time period, the number of individuals with late-stage liver disease is projected to increase. This study concluded that the current treatment rate and efficacy are not sufficient to manage the disease burden of HCV. Thus, alternative strategies are required to keep the number of HCV individuals with advanced liver disease and liver-related deaths from increasing.

Strategies to manage hepatitis C virus (HCV) disease burden

The number of hepatitis C virus (HCV) infections is projected to decline while those with advanced liver disease will increase. A modeling approach was used to forecast two treatment scenarios: (i) the impact of increased treatment efficacy while keeping the number of treated patients constant and (ii) increasing efficacy and treatment rate. This analysis suggests that successful diagnosis and treatment of a small proportion of patients can contribute significantly to the reduction of disease burden in the countries studied. The largest reduction in HCV-related morbidity and mortality occurs when increased treatment is combined with higher efficacy therapies, generally in combination with increased diagnosis. With a treatment rate of approximately 10%, this analysis suggests it is possible to achieve elimination of HCV (defined as a >90% decline in total infections by 2030). However, for most countries presented, this will require a 3-5 fold increase in diagnosis and/or treatment. Thus, building the public health and clinical provider capacity for improved diagnosis and treatment will be critical.

Neonatal viability evaluation by Apgar score in puppies delivered by cesarean section in two brachycephalic breeds (English and French bulldog)

This study tried to define neonatal viability after cesarean section in brachycephalic breeds and the efficacy of an adapted Apgar test to assess newborn survival. Data from 44 cesarean sections and 302 puppies were included. Before surgery (59-61 days after ovulation), an ultrasound evaluation defined the fetal biparietal diameter (BPD). Immediately after the uterine delivery, the pups were evaluated to detect birth defects and then, a modified Apgar score (range: 0-10) was used to define neonatal health at 5min (Apgar 1) and 60min (Apgar 2) after neonatal delivery; puppies were classified into three categories: critical neonates (score: 0-3), moderate viability neonates (score: 4-6) and normal viability neonates (score: 7-10). Mean (±SEM) value of BPD was 30.8±0.1mm and 28.9±0.1mm in English and French Bull-Dog fetus, respectively. The incidence of spontaneous neonatal mortality (4.98%, 14/281) and birth defects (6.95%) were not influenced by the sex; however, congenital anomalies and neonatal mortality were higher (p<0.01) in those litters with a greater number of neonates. In Apgar 1, the percentage of critical neonates, moderate viability neonates and normal viability neonates were 20.5%, 46.3% and 33.1% respectively; sixty minutes after birth, the critical neonates only represented 10.3% of the total puppies. Almost all neonates (238/239) showing moderate or normal viability at Apgar 1, survived for the first 24h after birth. The results of the study showed a direct relationship (p<0.01) between the Apgar score and neonatal viability. Therefore, the routine performance of the Apgar score would appear to be essential in the assessment of the status of brachycephalic breed puppies.

A multicentre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery

AIM

The introduction of multimodal or fast track (FT) rehabilitation and laparoscopy in colorectal surgery has improved patient recovery and shortened hospital stay (HS). This study aimed to determine the influence of laparoscopic or open surgery on the postoperative recovery of colorectal cancer patients having a conventional care (CC) or FT protocol in the postoperative period.

METHOD

A multicentre prospective study was controlled with a retrospective group. The prospective group included 300 patients having elective colorectal resection for cancer. The retrospective control group included 201 patients with the same characteristics who were treated before the introduction of the programme. The patients were divided into four groups including laparoscopy + FT, open surgery + FT, laparoscopy + CC, and open surgery + CC. The primary end-points were HS and morbidity. Secondary end-points included mortality and reoperation rates.

RESULTS

The overall median HS was 7 days. The median HS for laparoscopy + FT was 5 days, open + FT 6 days, laparoscopy + CC 9 days and open + CC 10 days (P < 0.001). In the regression model the laparoscopy + FT group had the greatest reduction in HS (P < 0.001). A significant reduction in HS was observed in the laparoscopy + FT group compared with laparoscopy + CC (P < 0.001). The overall patient morbidity was 30.6%. The logistic regression model adjusted for propensity score showed no statistically significant differences between the study groups regarding all other end-points.

CONCLUSION

Colorectal cancer patients who underwent laparoscopic surgery within a multimodal rehabilitation protocol experienced the shortest HS and the lowest morbidity.

Attitude and risk of substance use in adolescents diagnosed with Asperger syndrome

BACKGROUND

Adolescence is a stage of development with increased risk of drug use. Individual personality traits are among those factors that influence the onset of substance use in adolescence and its psychiatric comorbidity. Little research has been done on the comorbidity between substance abuse risk and Asperger syndrome, and none specifically in adolescence. The objective of this study is to assess the risk of drug use by adolescents with Asperger syndrome and compare it with that risk in control subjects. A secondary objective was to analyze the personality factors that may be associated with substance use in the same two groups.

METHODS

We used three self-administered questionnaires, one for drug risk assessment (FRIDA) and the other two for personality trait assessment (MACI and SSS-V).

RESULTS

Adolescents diagnosed with Asperger syndrome are at less risk for drug use derived from family and access to drugs factors. Subjects with Asperger syndrome did score higher on introversive, inhibited, doleful, and borderline tendency prototypes than healthy controls, and scored lower on all sensation-seeking traits. Being male, a diagnosis of Asperger syndrome, and unruly, introversive, and sensation-seeking traits were all independently associated with the risk of drug abuse.

CONCLUSIONS

Both identified personality factors and other variables associated with the Asperger syndrome contribute to the low risk of drug abuse observed in this population. Exploring protective factors for drug use in these subjects may prove useful for interventions with adolescents at risk for consumption.

The neurobiology of autism spectrum disorders

Data is progressively and robustly accumulating regarding the biological basis of autism. Autism spectrum disorders (ASD) are currently considered a group of neurodevelopmental disorders with onset very early in life and a complex, heterogeneous, multifactorial aetiology. A comprehensive search of the last five years of the Medline database was conducted in order to summarize recent evidence on the neurobiological bases of autism. The main findings on genetic influence, neuropathology, neurostructure and brain networks are summarized. In addition, findings from peripheral samples of subjects with autism and animal models, which show immune, oxidative, mitochondrial dysregulations, are reported. Then, other biomarkers from very different systems associated with autism are reported. Finally, an attempt is made to try and integrate the available evidence, which points to a oligogenetic, multifactorial aetiology that converges in an aberrant micro-organization of the cortex, with abnormal functioning of the synapses and abnormalities in very general physiological pathways (such as inflammatory, immune and redox systems).

[Detection of tumors in the central zone of the prostate with 11C-Choline PET/CT]

Prostate tumors originate 68% in the peripheral region and 24% in the transitional region where tumors originating in the central zone are rare (8%). However, diagnosis of the tumors in the central zone is important since they exhibit greater aggressiveness conditioned by their location and different biological behavior. Magnetic resonance imaging shows problems in identifying lesions in the central prostate zone, since this region has a heterogeneous signal, mainly after the primary treatment. Ultrasound guided sextant biopsy shows a negative result in 28% of prostate tumors. Therefore, it is advisable to repeat or even to perform saturation biopsies. We present two patients, one of them with suspected biochemical prostate cancer and one with biochemical recurrence after radical treatment. In both, (11)C-Choline PET/CT allowed detection of the tumor focus in the central zone of the prostate, with negative complementary diagnostic test and biopsies.

Computed tomography-assessed right ventricular dysfunction and risk stratification of patients with acute non-massive pulmonary embolism: systematic review and meta-analysis

BACKGROUND

The ability of computed tomography (CT)-assessed right ventricular dysfunction (RVD) to identify normotensive patients with acute pulmonary embolism (PE) at high risk of mortality or adverse outcome lacks clarity.

METHODS AND RESULTS

We performed a systematic review and a meta-analysis of studies in normotensive patients with acute PE to assess the prognostic value of CT-assessed RVD for death and a predefined composite outcome of PE-related complications. We conducted unrestricted searches of MEDLINE and EMBASE from 1980 to March 2013, and used the terms 'computed tomography', 'pulmonary embolism', and 'prognos*'. We used a random-effects model to pool study results, funnel-plot inspection to evaluate for publication bias, and I(2) testing to assess for heterogeneity. The analysis included data from 10 studies (2288 patients). Overall, 99 of 1268 patients with RVD assessed by CT died (7.8%; 95% confidence interval [CI] 6.3-9.3) as compared with 52 of 1020 without RVD (5.1%; 95% CI 3.7-6.4). CT-assessed RVD had significant associations with mortality (odds ratio [OR] 1.8; 95% CI 1.3-2.6), with death resulting from PE (OR 7.4; 95% CI 1.4-39.5), and with PE-related complications (OR 2.4; 95% CI 1.2-4.7). Pooled likelihood ratios (LRs) were not extreme (negative LR 0.71; 95% CI 0.57-0.89; and positive LR 1.27; 95% CI 1.12-1.43).

CONCLUSIONS

Although RVD assessed by CT showed an association with an increased risk of mortality in patients with hemodynamically stable PE, it resulted in only small increases in the ability to classify risk.

Physical activity and self-reported health status among adolescents: a cross-sectional population-based study

OBJECTIVES

Little is known about the dose-response relationship between physical activity and health benefits among young people. Our objective was to analyse the association between the frequency of undertaking moderate-to-vigorous physical activity (MVPA) and the self-reported health status of the adolescent population.

DESIGN

Cross-sectional study.

SETTING

All regions of Spain.

PARTICIPANTS

Students aged 11-18 years participating in the Spanish Health Behaviour in School-aged Children survey 2006. A total of 375 schools and 21 188 students were selected.

MAIN OUTCOMES

The frequency of undertaking MVPA was measured by a questionnaire, with the following four health indicators: self-rated health, health complaints, satisfaction with life and health-related quality of life. Linear and logistic regression models were used to analyse the association, adjusting for potential confounding variables and the modelling of the dose-response relationship.

RESULTS

As the frequency of MVPA increased, the association with health benefits was stronger. A linear trend (p<0.05) was found for self-rated health and health complaints in males and females and for satisfaction with life among females; for health-related quality of life this relationship was quadratic for both sexes (p<0.05). For self-reported health and health complaints, the effect was found to be of greater magnitude in males than in females and, in all scales, the benefits were observed from the lowest frequencies of MVPA, especially in males.

CONCLUSIONS

A protective effect of MVPA was found in both sexes for the four health indicators studied, and this activity had a gradient effect. Among males, health benefits were detected from very low levels of physical activity and the magnitude of the relationship was greater than that for females.

Postoperative nausea and vomiting: incidence, characteristics and risk factors--a prospective cohort study

BACKGROUND

Postoperative nausea and vomiting are a common complication after surgery. The objective of the study was to identify risk factors, and to determine the incidence of postoperative nausea and vomiting in a cohort of patients in a tertiary university hospital.

METHODS

Prospective cohort study was conducted in a Post Anesthetic Care Unit during a period of 3 weeks. One hundred and fifty-seven adult patients subjected to scheduled non-cardiac and non-intracranial surgery were eligible for the study. Patient perioperative characteristics data were analyzed. The postoperative nausea and vomiting intensity scale and nausea visual analog scale were applied to measure postoperative nausea and vomiting at 6h and 24h after surgery. Descriptive analysis was performed and the Mann-Whitney U, Fisher's exact, or Chi-square tests were applied. A univariate and multivariate logistic binary regressions with calculation of odds ratio (OR) and its 95% confidence interval (95% CI) were performed.

RESULTS

Thirty-nine (25%) patients and 54 (34%) patients had postoperative nausea and vomiting at 6h and 24h, respectively. Of the patients who experienced postoperative nausea and vomiting, 6 (15%) had clinically significant postoperative nausea and vomiting (postoperative nausea and vomiting intensity scale>50) at 6h and 9 (23%) at 24h. The majority of patients classified nausea as mild at 6h (57%) and 24h (56%). At 6h, 3 (10%) patients classified nausea as severe, and at 24h 5 (9%) patients reported the same. The median and interquartile ranges for nausea visual analog scale were 40 (20-60) at 6h and 50 (20-60) at 24h. Six patients (14%) at 6h, and 7 (18%) at 24h had a nausea visual analog scale score>75. Patients with postoperative nausea and vomiting intensity scale>50 had higher scores in the nausea visual analog scale at 6h (75 versus 30, P<.05) and 24h (70 versus 40, P<.05). The univariate analysis identified risk factors for postoperative nausea and vomiting: Apfel score>2 (OR 3.2, 95% CI 1.6-6.4, P=.001), previous history of postoperative nausea and vomiting (OR 2.9 95% CI 1.3-6.5, P=.009) and female patients (OR 2.7, 95% CI 1.4-5.4, P=.005). In the multivariate analysis previous history of postoperative nausea and vomiting (adjusted OR 2.5, 95% CI 1.1-5.7, P=.030) and female gender (adjusted OR 2.4, 95% CI 1.2-4.9, P=.015) were considered as independent risk factors for postoperative nausea and vomiting.

CONCLUSION

Most of the patients do not have clinically significant postoperative nausea and vomiting. The patients who presented with postoperative nausea and vomiting intensity scale>50 had higher scores in the nausea visual analog scale. Independent risk factors for postoperative nausea and vomiting were previous history of postoperative nausea and vomiting and being female.

Fluorescence diagnosis and photodynamic therapy for Bowen's disease treatment

INTRODUCTION

It has already been demonstrated the high efficacy of photodynamic therapy (PDT) for Bowen's disease (BD) treatment. Fluorescence diagnosis consists on registration of the fluorescence emitted by tissue after application of a photosensitizer, indicating presence of tumoral cells. It has been described as a useful tool for actinic keratosis. Different results have been published about fluorescence diagnosis for basal cell carcinomas. Very few reports about the role of fluorescence diagnosis for this entity exist and this is the first one which correlates the fluorescence image after PDT with the histopathological response.

OBJECTIVES

To assess the role of fluorescence diagnosis during BD follow-up.

METHODS

We carried out an observational, retrospective and descriptive study. A total of 29 BD biopsy proven lesions were included. All the lesions had been treated with the standard protocol (Topical methyl- aminolaevulinic acid under occlusion for 3 hours and followed by illumination with red-light (630 nm, 38 J/cm(2), 7.5 minutes. Two sessions one week apart). Clinical and fluorescence photographs were taken before treatment and one month after the 2(nd) one. At that moment a post-treatment biopsy was performed. Clinical response was classified as partial, complete or no response. Fluorescence response was classified as negative, intermediate or intense. The follow-up period and the adverse events observed including pain were also collected.

RESULTS

We found statistical association between fluorescence and the clinical and histopathological evaluations performed after treatment. Fluorescence diagnosis obtained a 100% sensitivity (higher than clinical evaluation alone) and a specificity of 85.7% (CI: 70.8-100).

CONCLUSIONS

Fluorescence diagnosis seems a valid diagnostic tool, useful during the follow up of Bowen disease lesions with the advantage of avoiding unnecessary post-treatment biopsies.

Hepatic expression of CCL2 in alcoholic liver disease is associated with disease severity and neutrophil infiltrates

Serum levels and liver expression of CCL2 are increased in patients with alcoholic hepatitis (AH). In an experimental model of alcoholic liver disease (ALD), CCL2 was implicated in proinflammatory cytokines activation and hepatic lipid metabolism, but its role in human disease is currently unknown. In a large cohort of ALD patients, we analysed plasma levels and liver expression of CCL2 and their association with liver disease severity and histological lesions. We also studied the relationship between -2518 A > G CCL2 and CCR2 190 A/G polymorphisms and severity of ALD. We show that CCL2 plasma levels are increased in ALD patients compared with healthy subjects. AH patients had significantly higher plasma levels and hepatic expression of CCL2 than patients without AH. Plasma levels and hepatic expression of CCL2 were associated with disease severity. CCL2 liver expression was correlated with neutrophil infiltrate and interleukin (IL)-8 expression, but not with steatosis. Moreover, there were more G-allele carriers of -2518 A > G CCL2 polymorphism in severe AH patients than in other ALD patients. Our results demonstrate that CCL2 is increased in ALD, particularly in severe forms, and suggest a role for CCL2 in the pathogenesis of ALD via neutrophil recruitment.

[Management of chronic hepatitis C in 2012 in Belgium]

Chronic hepatitis C virus infection is a major public health problem. It is estimated that 15 to 35% of infected patients will develop cirrhosis after a period of 30 years. Fibrosis stage must be evaluated in all hepatitis-C-infected patients. Noninvasive methods for the evaluation of liver fibrosis have been developed, mainly serum markers and transient elastography or Fibroscan. The goal of therapy is to achieve a sustained virological response, defined by hepatitis C RNA undetectable in serum 6 months after the end of therapy. This indicates viral eradication. Treatment of chronic hepatitis C has considerably improved. The association of pegylated interferon with ribavirin remains the standard of care for non-genotype-1-infected patients. Genotype-1-infected patients (who represent the majority of cases) are preferentially treated by triple therapy pegylated interferon plus ribavirin plus a first generation protease inhibitor (telaprevir or boceprevir). While triple therapy represents a major advance, by increasing the possibility of viral eradication, such therapy also presents new challenges, including the need for strict compliance, risk of additional side effects and development of resistant variants, drug-drug interactions, etc., which call for first-rate expertise in management of chronic hepatitis C therapy. Several new antiviral compounds are currently in clinical development and might lead to viral eradication in the vast majority of infected patients in the near future.

[Multidisciplinary management of hepatocellular carcinoma in cirrhotic patients]

The treatment of hepatocellular carcinoma (HCC) in cirrhotic patients is challenging: the incidence is increasing, the cirrhosis dramatically limits the tolerance to treatment possibilities, there are many therapeutic modalities but resources are limited, namely in the context of organ shortage for transplantation. Liver transplantation (LT) is the optimal treatment as it combines the largest tumor resection possible and the correction of the underlying liver disease. Due to organ shortage however, LT is reserved for early-stages HCC. Surgical resection and radiofrequency destruction represent potentially curative options in highly selected patients. Arterial embolizations, chemo- or radio-embolizations, allow local tumor control but are not curative. These techniques could be performed before surgical resection or LT, to downstage the tumor and/or to control tumor progression while waiting for a graft. Finally, sorafenib is the only systemic treatment which has shown a survival benefit in advanced HCC. The benefit of combination of sorafenib and surgical treatments remains undetermined. The challenge in the management of HCC in cirrhotic patients is to integrate both individual (age, comorbidities, cirrhosis stage, tumor stage, specific contraindications to LT, etc.) and collective variables (expected waiting time before LT) to determine the best therapeutic option for each patient. In this process, multidisciplinarity is a key for success.

[Management of alcoholic hepatitis]

Alcoholic hepatitis is a severe form of alcoholic liver disease. Diagnosis is based on the association of new onset of jaundice and a compatible liver biopsy. Alcoholic hepatitis is severe when the Maddrey is up to 32 and, in this case, is associated with a mortality of 40-50% at 2 months. Corticosteroids improve survival of patients suffering from severe alcoholic hepatitis. The decrease of total bilirubin at day 7 of treatment and the Lille score are markers of response to corticosteroids. The absence of response is associated with a dramatic outcome (mortality rate of 75% at 6 months). Liver transplantation could be an alternative in a strictly selected group of non-responders.

Meta-analysis: the impact of IL28B polymorphisms on rapid and sustained virological response in HCV-2 and -3 patients

BACKGROUND

Recent studies suggested that IL28B polymorphisms may affect rapid and sustained virological response rates in HCV patients infected with genotype 2 or 3.

AIM

To assess the role of IL28B polymorphisms on the virological response in HCV-2 and -3 patients.

METHODS

We performed meta-analysis of studies evaluating the impact of rs12979860 and rs8099917 polymorphisms on rapid and sustained virological response in HCV-2 or -3 patients.

RESULTS

Twenty-three studies involving 3042 patients were included. The first meta-analysis evaluated the impact of rs12979860 polymorphism and included 1963 patients. When compared with rs12979860 CT/TT patients, CC patients had a higher rapid virological response rate (mean difference: 12.9%, 95% CI: 6.5-19.4%, P < 0.001) and a higher sustained virological response rate (mean difference: 4.9%, 95% CI: 0.1-9.8%, P = 0.046). The second meta-analysis evaluated the impact of rs8099917 polymorphism and included 2246 patients. When compared with rs8099917 TG/GG patients, TT patients had a higher rapid virological response rate (mean difference: 14.8%, 95% CI: 7.2-22.4%, P < 0.001) and a higher sustained virological response rate (mean difference: 5.5%, 95% CI: 0.4-10.6%, P = 0.033). When considering only patients treated for 24 weeks, results were unchanged. No potential sources of between-study heterogeneity were identified.

CONCLUSIONS

Favourable IL28B polymorphisms are associated with higher rapid and sustained virological response rates in HCV-2 and -3 patients. However, as the impact on a sustained response is very limited, it is unlikely that IL28B polymorphisms provide additional predictive value when considering other predictors of a sustained response.

[Cardiovascular and respiratory changes during laparoscopy in neonates and infants]

The pneumoperitoneum induced during laparoscopy has cardiovascular and respiratory effects that have to be taken into account to perform laparoscopic procedures in neonates and small infants. The aim of this paper is to describe the hemodynamic and ventilatory changes that occur in a group of these patients undergoing standard laparoscopic procedure. We performed a retrospective review of patients undergoing laparoscopic pyloromyotomy in our institution. We collected demographic data, data from the intervention, outcome and complications and hemodynamic parameters (heart rate--HR--and blood pressure--BP--) and respiratory (O2 saturation--SO2--and exhaled CO2--ECO2--) at different times during surgery. We performed statistical analysis of these data. We reviewed a total of 55 charts. Mean age was 34 days and average weight 3,785 g. All patients were ventilated with pressure control mode and received maintenance fluid therapy. BP, HR and SO2 were stable throughout the surgery not showing significant differences. The ECO2 increased significantly after inflation, however it was controlled by increasig respiratory rate. In conclusion, the hemodynamic and ventilatory response in these patients is controllable with anesthetic and surgical measures but it is important to consider the possible consequences of pneumoperitoneum in this group of patients.

Preclinical activity of LBH589 alone or in combination with chemotherapy in a xenogeneic mouse model of human acute lymphoblastic leukemia

Histone deacetylases (HDACs) have been identified as therapeutic targets due to their regulatory function in chromatin structure and organization. Here, we analyzed the therapeutic effect of LBH589, a class I-II HDAC inhibitor, in acute lymphoblastic leukemia (ALL). In vitro, LBH589 induced dose-dependent antiproliferative and apoptotic effects, which were associated with increased H3 and H4 histone acetylation. Intravenous administration of LBH589 in immunodeficient BALB/c-RAG2(-/-)γc(-/-) mice in which human-derived T and B-ALL cell lines were injected induced a significant reduction in tumor growth. Using primary ALL cells, a xenograft model of human leukemia in BALB/c-RAG2(-/-)γc(-/-) mice was established, allowing continuous passages of transplanted cells to several mouse generations. Treatment of mice engrafted with T or B-ALL cells with LBH589 induced an in vivo increase in the acetylation of H3 and H4, which was accompanied with prolonged survival of LBH589-treated mice in comparison with those receiving vincristine and dexamethasone. Notably, the therapeutic efficacy of LBH589 was significantly enhanced in combination with vincristine and dexamethasone. Our results show the therapeutic activity of LBH589 in combination with standard chemotherapy in pre-clinical models of ALL and suggest that this combination may be of clinical value in the treatment of patients with ALL.

European Academy of Allergy and Clinical Immunology task force report on 'dose-response relationship in allergen-specific immunotherapy'

BACKGROUND

For a century, allergen-specific immunotherapy (SIT) has proven to be an effective treatment for allergic rhinitis, asthma, and insect sting allergy. However, as allergen doses are frequently adapted to the individual patient, there are few data on dose-response relationship in SIT. Allergen products for SIT are being increasingly required to conform to regulatory requirements for human medicines, which include the need to demonstrate dose-dependent effects.

METHODS

This report, produced by a Task Force of the EAACI Immunotherapy Interest Group, evaluates the currently available data on dose-response relationships in SIT and aims to provide recommendations for the design of future studies.

RESULTS

Fifteen dose-ranging studies fulfilled the inclusion criteria and twelve reported a dose-response relationship for clinical efficacy. Several studies also reported a dose-response relationship for immunological and safety endpoints. Due to the use of different reference materials and methodologies for the determination of allergen content, variations in study design, and choice of endpoints, no comparisons could be made between studies and, as a consequence, no general dosing recommendations can be made.

CONCLUSION

Despite recently introduced guidelines on the standardization of allergen preparations and study design, the Task Force identified a need for universally accepted standards for the measurement of allergen content in SIT preparations, dosing protocols, and selection of clinical endpoints to enable dose-response effects to be compared across studies.

Pulsed dye laser as an excellent choice of treatment for lupus tumidus: a prospective study

BACKGROUND

Clinical manifestations of cutaneous lupus erythematosus (CLE) vary widely, and different subtypes of this autoimmune disease exist. Tumidus subtype (LT) has been recently separated from the chronic subtypes and is now considered an independent entity due to its particular clinical and histological features. Different treatments are usually prescribed for CLE. Our group has experience of CLE effectively treated with pulsed dye laser (PDL). It was our impression that better responses were achieved in the LT subtype, but no controlled prospective studies with PDL have been specifically performed.

MATERIALS AND METHODS

A prospective study was performed on 10 patients with histologically confirmed LT treated with PDL. All patients were treated with 595 nm PDL using the 10 mm spot size at 0.5 ms pulse width and a fluence of 8 J/cm(2). Biopsies were taken before and 4 weeks after treatment and were stained with haematoxylin-eosin.

RESULTS

Evaluation after PDL treatment showed clinical improvement in all of them without side-effects and reduction of the dermal lymphocytic infiltrate in 9/10 of the patients. Epidermal changes were absent in all patients. Mucin deposition persisted only in one patient. However, 50% of the patients developed new lesions nearby or distant to the treated zones.

CONCLUSIONS

PDL therapy is an effective and fast treatment option for acute flares of LT; however, it does not prevent recurrences. A histological improvement has been confirmed in this study. Purpura seems to be necessary to achieve a good response.

Anti-viral therapy in haemodialysed HCV patients: efficacy, tolerance and treatment strategy

BACKGROUND

In end-stage renal disease (ESRD) patients, hepatitis C virus (HCV) eradication improves patient and graft survival.

AIM

To determine optimal use of erythropoietin (EPO) and ribavirin, to compare ribavirin concentrations with those of HCV patients having normal renal function and to evaluate sustained virological response (SVR) in a prospective observatory of ESRD candidates for renal transplantation.

METHODS

Thirty-two naïve patients were treated with Peg-IFN-α2a and ribavirin. Two different schedules of ribavirin and EPO administration were used: starting ribavirin at 600mg per week and adapting EPO when haemoglobin (Hb) fell below 10g/dL (adaptive strategy) or starting ribavirin at 1000mg per week while increasing EPO from the start of treatment (preventive strategy).

RESULTS

Patients treated with the adaptive strategy had lower median Hb levels (9.6 vs. 10.9g/dL, P=0.02) and more frequent median Hb levels below 10g/dL (58 vs. 5%, P=0.0007) despite lower median ribavirin doses (105 vs. 142mg/day, P<0.0001) than patients treated with the preventive strategy. There was a trend for more frequent transfusion in patients treated with the adaptive strategy than in patients treated with preventive strategy (50 vs. 20%, P=0.08). Compared to patients with normal renal function, ESRD patients had lower ribavirin concentrations during the first month (0.81 vs. 1.7mg/L, P=0.007) and similar concentrations thereafter. SVR was reached in 50%.

CONCLUSIONS

Pegylated interferon (Peg-IFN) and an adapted schedule of ribavirin are effective in ESRD patients. Increasing EPO from the start of treatment provides better haematological tolerance. The optimal dosage of ribavirin remains unresolved, in light of frequent side effects.