Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Endoscopic closure of the natural orifice transluminal endoscopic surgery (NOTES) access site to the peritoneal cavity by means of transmural resorbable sutures: an animal survival study

BACKGROUND AND STUDY AIMS

Endoscopic closure of the transgastric access site is still a critical area of active research and development into natural orifice transluminal surgery (NOTES). To date, no endoscopic technique has utilized resorbable transmural sutures for closure of the NOTES gastrostomy.

MATERIAL AND METHODS

Endoscopic gastrostomy closure by means of resorbable sutures was performed in ten female domestic pigs in an animal survival study. Peritoneal cavity access was gained through the anterior gastric wall using the percutaneous endoscopic gastrostomy (PEG) technique and an 18-mm balloon dilator. NOTES exploration of the gallbladder and tubal ligation were performed prior to endoscopic gastrostomy closure. Necropsy was performed 3 weeks post procedure.

RESULTS

Mean suturing time was 26 minutes (range 14 - 35 minutes). In total 90 % (9/10) of gastrostomy closures were performed by means of two transmural resorbable sutures. One gastrostomy was closed using a single resorbable suture. One case of gallbladder perforation occurred during peritoneoscopy and the pig was sacrificed due to subsequent peritonitis 2 days after the procedure. All other pigs (9/10) were found to be healthy 3 weeks after the NOTES procedure and were sacrificed as planned per protocol. Of all the 17 sutures that were applied in the remaining nine pigs, 16 (94 %) had been absorbed, releasing the pledgets intraluminally. During laparotomy no signs of injury to adjacent organs were found in any of these nine animals. In 8/10 pigs (80 %) the gastrostomy site did not burst with pressures exceeding 100 mmHg. Two suturing sites did burst at pressures of 57 and 62 mmHg, respectively.

CONCLUSIONS

Endoscopic transmural suturing enables rapid and easy placement of leak-proof resorbable sutures and is suitable for closure of the NOTES transgastric access.

Endoscopic full-thickness plication (Plicator) with two serially placed implants improves esophagitis and reduces PPI use and esophageal acid exposure

BACKGROUND AND STUDY AIMS

Recently, several endoluminal procedures for the treatment of gastroesophageal reflux disease (GERD) have been introduced. Most of these techniques have been abandoned because they lack long-term efficacy or have serious side effects. In a recently published prospective randomized, sham-controlled trial, the Plicator was shown to be effective at controlling reflux symptoms and esophageal acid exposure. In all previous studies, only a single implant was used. The aim of the present pilot study was to determine the safety and efficacy of two serially placed Plicator implants.

PATIENTS AND METHODS

Thirty-seven patients requiring maintenance therapy with proton pump inhibitors (PPIs) were enrolled in this single-center pilot study. All patients received two Plicator implants. Exclusion criteria were hiatus hernia larger than 3 cm, grade IV esophagitis, Barrett's esophagus, and esophageal motility disorders. The primary study end point was at least 50 % improvement in the GERD Health-Related Quality of Life (HRQL) score. Secondary end points included GERD medication use, esophageal acid exposure, esophagitis grade, and heartburn/regurgitation scores.

RESULTS

Thirty-seven patients underwent endoscopic full-thickness plication using two serially placed Plicator implants. At 6 months after treatment, the proportion of patients achieving at least 50 % improvement in GERD-HRQL score was 68 %. Complete cessation of PPI treatment was achieved in 59 % of patients. In pH studies conducted at 6 months (n = 29), median percentage of time for which pH was below 4 decreased by 36 %, with 28 % of patients experiencing pH normalization. There were no serious adverse events requiring intervention.

CONCLUSIONS

Endoscopic full-thickness plication using two serially placed Plicator implants was both safe and effective in reducing esophagitis, GERD symptoms, medication use, and esophageal acid exposure.

[A young man with acute generalised jaundice and intermittent epigastric pain]

HISTORY

A 24-year-old Iraqi was admitted to our hospital with acute generalised jaundice and intermittent epigastric pain. His family doctor suspected a viral hepatitis. Two days prior admission the patient had consumed large quantities of alcohol and had subsequently taken analgetic dosages of paracetamol and acetylsalicylic acid.

INVESTIGATIONS

Besides an otherwise inconspicuous physical examination the laboratory results revealed a distinct hemolysis with macrocytic, hyperchromic anaemia and negative Coombs-test. Indirect bilirubin was initially 25.2 mg/dl, LDH 2367 U/l and reticulocytes 4.4 %; haptoglobin and transferrine levels were correspondingly low. A hemoglobinopathies was excluded by hemoglobin-electrophoresis and a blood-smear. DIAGNOSIS, TREATMENT AND FURTHER COURSE: A glucose-6-phosphate dehydrogenase deficiency (G6PDD) was suspected and subsequently confirmed within three days. Acetylsalicylic acid, the most probable trigger, and other possible triggers like ciprofloxacin, metamizole, and cotrimoxazole were avoided; the jaundice faded rapidly, and the laboratory-parameters almost normalized.

CONCLUSION

In patients with acute jaundice, abdominal pain, and signs of hemolysis collection of accurate anamnestic information is essential. In case of a young male with positive family-history, applicable ethnical origin, and intake of potential oxidative stressors a G6PDD should be suspected and result in requesting specific tests. Analgetic therapy with metamizole must be strictly avoided.

Outpatient chemotherapy with gemcitabine and oxaliplatin in patients with biliary tract cancer

This phase II study was conducted to determine the efficacy and toxicity of a gemcitabine (GEM) and oxaliplatin (OX) chemotherapy protocol in patients with unresectable biliary tract cancer (BTC). Patients were treated with GEM 1000 mg m⁻² (30 min infusion) on days 1, 8, 15, and OX 100 mg m⁻² (2 h infusion) on days 1 and 15 (gemcitabine and oxaliplatin (GEMOX-3 protocol), repeated every 28 days. The data were collected according to the Simon 2-stage design for a single centre phase II study (α=0.05; β=0.2). Primary end point was response rate; secondary end points were time-to-progression (TTP), median survival, and safety profile. Thirty-one patients were enrolled in the study between July 2002 and April 2005. Therapeutic responses were as follows: partial response in eight patients (26%, 95% confidence interval (CI) 14–44), stable disease in 14 patients (45%, 95%CI 29–62), resulting in a disease control rate of 71%. Nine patients (29%, 95%CI 16–47) had progressive disease. Median TTP was 6.5 months. Median overall survival was 11 months. Common Toxicity Criteria (CTC) Grade 3–4 toxicities were transient thrombocytopenia (23%), peripheral sensory neuropathy (19%), leucopenia (16%), and anaemia (10%). In conclusion the GEMOX-3 protocol is active and well tolerated in patients with advanced BTC. It can be applied in an outpatient setting with three visits per month only.

Outpatient chemotherapy with gemcitabine and oxaliplatin in advanced biliary tract cancer; a phase II study

14006

Background: Biliary tract cancer is a heterogeneous tumor entity with a poor prognosis if unresectable. There is a need for an effective, safe and patient friendly treatment. Methods: Patients with typical histology for cholangiocarcinoma, adequate haematological, renal and liver function, measurable tumor formation, life expectancy for more than 3 months, and written informed consent were treated with Gemcitabine 1000mg/m2 (30 min infusion) day 1, 8, 15 and Oxaliplatin 100mg/m2 (2 h infusion) day 1 and 15. Chemotherapy cycles were repeated every 28 days (GEMOX-3 protocol). The data were collected according to the Simon 2-step design for a single centre phase II study (α=0.05; β=0.2). Planned sample size 29. Primary endpoint was the response rate; secondary endpoints were time to progression, median survival and safety profile. Results: Thirty-one consecutive patients were enrolled between July 2002 and April 2005. The efficacy was as follows: partial response 8 pts (26%), stable disease 14 pts (45%). Thus, the disease control rate was 71%, while 9 pts (29%) had progressive disease. Median time to progression was 6.5 months. Median overall survival after start of treatment was 10.4 months, after initial diagnosis it was 15.6 months. National Cancer Institute Common Toxicity Criteria grade 3–4 toxicities were transient thrombocytopenia in 23% of patients, peripheral sensory neuropathy 19%, leukopenia 16% and anaemia 10%. Conclusion: The GEMOX-3 protocol is active and well tolerated in patients with advanced biliary tract cancer. It can be applied in an outpatient setting with three treatments per month only. The positive results of this and other phase II trials underscore the importance of a large controlled clinical trial to verify the data.

No significant financial relationships to disclose.

Hepatitis C virus infection in intravenous drug users

Intravenous drug use (IVDU) remains a major means of hepatitis C virus (HCV) transmission. In this study, 101 drug users were studied prospectively after cessation of IVDU. Of these, 75.8% were anti-HCV positive, and 71.4% had elevated levels of alanine aminotransferase. These levels decreased significantly within 1 month of IVDU cessation (p 0.02). Liver biopsies showed minimal or mild fibrosis in 32 (71%) of 45 subjects, and severe fibrosis in two (4.4%) subjects. Anti-HCV-positive intravenous drug users in this study presented with mild liver disease and variable stages of disease progression. Biochemical disease activity might be affected by IVDU.

No impact of repeated endoscopic screens on gastric cancer mortality in a prospectively followed Chinese population at high risk

BACKGROUND

Gastric cancer (GC) is the leading cause of cancer deaths in China. Our study prospectively evaluated the impact of repeated endoscopic screens on GC mortality in a high-risk population in China.

METHODS

Between 1989 and 1999, a population-based gastroscopic screening was conducted in 4,394 residents of Linqu County, China, a region with the highest rates of GC worldwide. Residents ages 35 to 64 years received initial gastroscopies with biopsies in 1989. Repeated endoscopies were performed in 1994 and 1999. Cancer occurrences and deaths were actively monitored throughout the entire period until July 2000. Mortality from GC was compared with expected values based on mortality rates obtained for Linqu in the 1990-1992 Chinese Cancer Mortality Survey.

RESULTS

Between March 1989 and July 2000, 39,303 person-years were accumulated; 85 new GCs occurred, 29 (34.5%) were in early stage. Fifty-eight cases (68%) were identified at one of the screens. The number of observed deaths from GC (37) was close to the expected (36.8). The standardized mortality ratio was 1.01 (95% CI 0.72-1.37) for the entire cohort, 1.13 (95% CI 0.77-1.57) for males, and 0.65 (95% CI 0.26-1.32) for females.

CONCLUSIONS

Despite high population coverage with repeated screens, no reduction in GC mortality was observed in this high-risk population in China.

Impaired granulocyte oxidative burst and decreased expression of leucocyte adhesion molecule-1 (LAM-1) in patients with Wegener's granulomatosis

Neutrophils are the target of autoantibodies in Wegener's granulomatosis (WG). In this study, granulocyte function and surface marker expression were investigated in patients with WG. The oxidative burst in response to phorbol myristate acetate (PMA) was tested with granulocytes of 25 patients with histologically proven WG. A significantly diminished percentage of oxygen radical-producing cells was found in patients with active disease. Surface antigen expression of CD11b and LAM-1 was analysed on granulocytes of 20 patients with WG. Whereas the expression of CD11b was normal, surface expression of LAM-1 was decreased in nine cases with WG. The decrease of LAM-1 correlated with disease activity. Phagocytosis of Escherichia coli was tested in 10 patients with WG, and normal values were found in all cases. We conclude that down-regulation of LAM-1 may be a marker of disease activity in WG. The altered response to PMA may indicate functional changes in granulocyte reactivity due to autoantibody-induced damage of the granulocyte membrane.

[Reduced "oxidative burst" in a granulocyte subpopulation in a case of Sweet syndrome]

Oxidative burst was defective in 50% of peripheral blood neutrophils in a case of Sweet syndrome with leukemoid granulocytosis. Phagocytosis was normal. We suggest that the decreased ability to produce oxygen radicals observed in this patient might lead to a compensatory recruitment of hematopoietic growth factors. Consecutive activation, increased chemotaxis and adhesion of polymorphonuclear granulocytes might be the cause of the neutrophilic dermal infiltrate of Sweet syndrome.