Safety and efficacy of direct-acting antivirals for the treatment of chronic hepatitis C in a real-world population aged 65 years and older

The availability of direct-acting antiviral agents (DAA) regimens has expanded the pool of patients eligible for treatment. However, data on the virologic response and tolerability of DAAs in elderly patients are lacking. We evaluated the efficacy and safety of DAAs in patients with advanced fibrosis/cirrhosis in real-life practice with the focus on those aged ≥65 years. Between January and December 2015, all consecutive patients with HCV-related advanced fibrosis/cirrhosis treated with DAA at eleven tertiary referral centres in Emilia Romagna (Italy) were enrolled. Regimen choice was based on viral genotype and stage of disease, according to guidelines. The primary end point was sustained virologic response 12 weeks after the end of treatment (SVR12). Overall, 282 of 556 (50.7%) patients evaluated were elderly, most of them with cirrhosis. Antiviral therapy was stopped prematurely in four (1.4%) patients. Two patients, both with cirrhosis, died during treatment due to worsening of liver/renal function. SVR12 was achieved by 94.7% and was comparable to that obtained in patients aged <65 (P=.074). Similar data were also reported in subgroup of patients aged ≥75 years. All patients with advanced fibrosis achieved virologic response. SVR12 was 80.8% in Child-Pugh-Turcotte (CTP)-B cirrhosis and 95.4% in CTP-A (P=.013). According to genotype, the SVR12 was achieved in 172 of 181 (95%) with genotype 1b cirrhosis and in 44 of 48 (91.7%) with genotype 2 cirrhosis. In conclusions, in a real-world setting, DAAs are safe and effective in elderly patients with HCV-related advanced fibrosis/cirrhosis, but SVR12 is lower with worsening CTP class.

Results and limitations of humeral head resurfacing: 105 cases at a mean follow-up of 5 years

BACKGROUND

The objective of this study was to assess clinical and computed-tomography (CT) outcomes at least 2 years after humeral head resurfacing to treat concentric gleno-humeral osteoarthritis.

HYPOTHESIS

Humeral head resurfacing provides similar outcomes to those achieved with stemmed humeral head implants.

MATERIALS AND METHODS

This single-centre retrospective study included 40 Copeland™ and 65 Aequalis™ humeral resurfacing heads implanted between 2004 and 2012. Mean patient age at diagnosis was 64 years. The diagnoses were osteoarthritis with an intact (68%) or torn (21%) rotator cuff, avascular necrosis (5%), osteoarthritis complicating chronic instability (3%), post-traumatic osteoarthritis (2%), and chronic inflammatory joint disease (1%). Validated clinical scores, radiographs, and CT before surgery and at last follow-up were compared.

RESULTS

During the mean follow-up of 56 months, complications occurred in 24 implants. Revision surgery with reverse shoulder replacement was required in 18 cases, after a mean of 43.6 months, to treat glenoid wear or a rotator cuff tear. At last follow-up, for the implants that did not require revision surgery, the mean Constant score was 64/100. The implants had a mean varus of 5° and mean retroversion of -13.3°. The mean increase in glenoid cavity depth was 2.4mm. Mean increases in medial and lateral humeral offset were 1.9mm and 2.7mm, respectively. Pre-operative factors significantly associated with failure were rotator cuff tear (P=0.017) and glenoid erosion (P=0.001).

DISCUSSION

We found a high failure rate related to glenoid wear or progressive rotator-cuff impairment, although CT showed no evidence of implant malposition or overstuffing. Previous studies of stemmed humeral head implants showed better outcomes. Given the low medium-term prosthesis survival rate, we now reserve humeral head resurfacing for concentric osteoarthritis without glenoid erosions or rotator cuff damage.

LEVEL OF EVIDENCE

IV, retrospective study.

Type 1 and type 2 autoimmune hepatitis in adults share the same clinical phenotype

BACKGROUND

Autoimmune hepatitis (AIH) is historically classified into type 1 and type 2 on the basis of the autoantibody profile, anti-nuclear and/or anti-smooth muscle antibodies being the serological markers of type 1 AIH, whereas anti-liver/kidney microsomal antibody type 1 and/or anti-liver cytosol antibody type 1 characterise type 2 AIH.

AIM

To evaluate whether such a distinction is justified on the basis of different expression of the disease in adults.

METHODS

Twenty-six adult patients with type 2 AIH and 52 age- and sex-matched patients with type 1 AIH, representative of the entire cohort of adults with type 1 AIH, were compared at onset and during follow-up.

RESULTS

At diagnosis, median age was 26 years (range 17-53), female sex 86%, acute presentation 43%, severe liver histology 54%, cirrhosis 14%, complete response to treatment 52%, progression of the disease 17%, and median disease duration 72 months (range 12-280). HLA-DRB1*0301 was present in 26%, HLA-DRB1*0401 in 23% and HLA-DRB1*0701 in 25%. Clinical presentation, biochemical parameters, severe liver histology, genetic profile, response rate and progression of the disease were identical between type 1 and type 2 AIH.

CONCLUSION

There is not enough clinical, biochemical, histological or genetic reason to subdivide adults with autoimmune hepatitis into type 1 and type 2 on the basis of the autoantibody profile, and the term 'autoimmune hepatitis' without qualification should be preferred.

Fenoverine: a novel synchronizer of smooth muscle motility by interference with cellular calcium flow

Several in vivo and in vitro test models were used to study the mechanism of action of fenoverine, a novel synchronizer of smooth muscle motility. In vivo, the effects of fenoverine were tested in the rabbit proximal colon, recording its ability to modify the electromyographic activity, either spontaneous or electrically elicited, in the presence or absence of atropine. Fenoverine did not influence the spontaneous motility nor did it modify the effects of atropine, but it significantly reduced the contractions elicited by electrical stimulation. In vitro, isolated rabbit and rat colon and isolated rat myometrium were used. In rabbit colon, fenoverine failed to influence the spontaneous motility as well as the effects of atropine, while significantly inhibiting the electrically elicited excitatory junction potential. Fenoverine also significantly inhibited the isometric contractions induced in rat myometrium and colon by electrical stimulation, by depolarization with hyperpotassic solution, as well as those induced by acetylcholine in calcium-free/EGTA medium, with ID50 ranging from 8.10(-7) to 3.1.10(-6) M except in the isolated colon following K+ depolarization (5.10(-5) M), all actions compatible with a calcium-modulating mechanism. Based on the reported data, it is concluded that fenoverine does not act as a muscarinic or opiate-receptor antagonist, but that its main mechanism of action is due to modulation of the calcium gradient across the muscular cell membrane by regulating the influx of the extracellular calcium and/or the release of the intracellular pool.

Ultrastructural and cytochemical characterization of subcellular fraction of plasmalemmal origin obtained from uterine longitudinal smooth muscle

The role of Ca2+-ATPase as the driving force for active calcium uptake, involved in the relaxation of smooth muscle, was studied. It was shown by immunocytochemistry that Ca2+-ATPase activity was localized at the plasma membrane level of longitudinal smooth muscle of pregnant rat uteri (18-20 days). To study calcium regulation in uterine longitudinal smooth muscle, 2 microsomal fractions (F1 and F2) were obtained, enriched in plasma membrane material (Lalanne et al., 1984, in: Calcium Regulation in Smooth Muscles. INSERM series, 124, pp. 283-292). In the present paper this material is characterized at both morphologic and cytochemical levels. Both fractions are ultrastructurally heterogeneous: (a) thin sections clearly show 2 populations that differ in vesicular shape and size; (b) negative staining also shows differences in membrane structure, which could be related to biochemical differences and/or to the well known heterogeneity of the plasma membrane. Two reactions (PATAg and concanavalin A-biotin-avidin-ferritin), allowing visualization of cell coat glycans, were performed on F1 and F2 and on thin sections of longitudinal smooth muscle. Plasma membrane and almost all the vesicles of F1 and F2 are reactive. It is concluded that these 2 fractions are characteristic enough for studying, at the molecular level, the ability of plasma membrane to control calcium circulation in uterine smooth muscle.

Comparison of pinaverium bromide, manganese chloride and D600 effects on electrical and mechanical activities in rat uterine smooth muscle

The effects of pinaverium bromide, were compared with those of D600 and manganese chloride (Mn), on membrane potentials, ionic currents and isometric contractions in uterine smooth muscle strips from pregnant rats. Pinaverium bromide (10(-7) - 10(-6) M) depressed twitch contractions and K-contractures within 15-20 min while D600 (2 X 10(-6) M) and Mn (10(-3) M) abolished both contractions. D600 and pinaverium bromide were more potent inhibitors in K-depolarized preparations than in polarized tissues. At a supramaximal dose (10(-5) M), pinaverium bromide decreased the rate of rise, amplitude, and rate of repolarization of the action potential, and prolonged the potential duration. The inward Ca current was depressed and the reduction in Cai was responsible for the decrease in K current. Pinaverium bromide (10(-5) M) depressed the myometrial contractions induced in Ca-free solution by acetylcholine (10(-4) M) and by prolonged membrane depolarizations. Mn (2.5 X 10(-3) M) only reduced the Ach-induced contraction and D600 (10(-5) M) had no effect on intracellular Ca stores. The results indicate that pinaverium bromide has Ca channel blocking properties similar to those of currently used Ca antagonists; it may also exert an effect to depress contractions supported by intracellular Ca release.

Contractions of rat uterine smooth muscle induced by acetylcholine and angiotensin II in Ca2+-free medium

The effects of acetylcholine (ACh, 10(-4)M) and angiotensin II (Ang II, 10(-6) M) have been studied on the mechanical and electrical activities of rat myometrial strips perfused in Ca2+-free EGTA-containing solutions. Both ACh and Ang II produced transient contractions, the amplitude of which can be taken as a measurement of the amount of Ca2+ present in a drug-sensitive Ca2+ store. The degree of filling of this store depended on the external Ca2+ concentration, and on the presence of contractile responses during the Ca2+ loading period. The existence of two pathways (either direct or transcytoplasmic) is suggested for Ca2+ uptake into the internal Ca2+ store. The rate of filling of the Ca2+ store in 2.1 mM-Ca2+-containing solution was faster (time to half-maximal response, t 1/2 = 29 +/- 2.2 s, n = 4) than the rate of depletion in Ca2+-free solution (t 1/2 = 3 +/- 0.3 min, n = 3). The gradual depletion of this store was much slower at 18 degrees C than at 35 degrees C, and in the presence of vanadate which is known to inhibit Ca2+-ATPases. Methoxyverapamil (D600, 10(-6)-10(-5) M) had no appreciable effect on the direct Ca2+ uptake or on the release of Ca2+ from the store by ACh and Ang II. Mn2+ (10(-3) M) completely inhibited the direct pathway to the internal Ca2+ store and also reduced the release of Ca2+. ACh and Ang II induced repetitive depolarizations close to zero potential which did not parallel the transient contractions as a function of the time of perfusion in Ca2+-free solution. Applications of 2 mM EGTA, 135 mM K+ or Ca2+ antagonists which suppressed or reduced the drug-induced depolarizations did not affect appreciably the drug-induced contractions. These results suggest that myometrial cells have an intracellular Ca2+ store sensitive to different stimulus substances. This store is not affected by depolarization of the plasma membrane and is certainly different from that described in voltage-clamp experiments.

Increase of progesterone receptor by tamoxifen as a hormonal challenge test in breast cancer

In 25 cases of postmenopausal breast cancer, estradiol receptor (ER) and progesterone receptor (PR) were measured in cutaneous metastatic nodules before and after administration of 30 mg of tamoxifen per day for 1 week. No response was recorded in ER-poor cases. However, in tumors containing greater than 10 fmol ER per mg cytosol protein, 6 of 14 cases showed an increase in PR of greater than 30 fmol/mg cytosol protein. The presence or absence of PR before administration of tamoxifen did not discriminate systematically between hormone-responsive and nonresponsive tumors. These findings demonstrate in vivo that biochemical changes brought about by an agent binding to ER can be observed only in ER-positive cases. In addition they suggest that, in these ER-positive cases responding to tamoxifen by increase of PR, the simultaneous or sequential administration of both antiestrogen (rescuing PR) and progestagen (decreasing PR) may allow better hormonal control of the disease.