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.

PEPDar: A randomized prospective noninferiority study of ritonavir-boosted darunavir for HIV post-exposure prophylaxis

OBJECTIVES

PEPDar compared the tolerability and safety of ritonavir-boosted darunavir (DRV/r)-based post-exposure prophylaxis (PEP) with the tolerability and safety of standard of care (SOC). The primary endpoint was the early discontinuation rate among the per-protocol population.

METHODS

PEPDar was an open-label, randomized, multicentre, prospective, noninferiority safety study. Subjects were stratified by type of event (occupational vs. nonoccupational, i.e. sexual) and were randomized to receive DRV/r plus two nucleoside reverse transcriptase inhibitors (NRTIs) or SOC PEP. Twenty-two private or university HIV clinics in Germany participated. Subjects were ≥ 18 years old and had documented or potential HIV exposure and indication for HIV PEP. They initiated PEP not later than 72 h after the event and were HIV negative.

RESULTS

A total of 324 subjects were screened, the per-protocol population was 305, and 273 subjects completed the study. One hundred and fifty-five subjects received DRV/r-based PEP and 150 subjects received ritonavir-boosted lopinavir (LPV/r)-based PEP for 28-30 days; 298 subjects also received tenofovir/emtricitabine. The early discontinuation rate in the DRV/r arm was 6.5% compared with 10.0% in the SOC arm (P = 0.243). Adverse drug reactions (ADRs) were reported in 68% of DRV/r subjects and 75% of SOC subjects (P = 0.169). Fewer DRV/r subjects (16.1%) had at least one grade 2 or 3 ADR compared with SOC subjects (29.3%) (P = 0.006). All grades of diarrhoea, nausea, and sleep disorders were significantly less frequent with DRV/r, while headache was significantly more frequent. No HIV seroconversion was reported during follow-up.

CONCLUSIONS

Noninferiority of DRV/r to SOC was demonstrated. DRV/r should be included as a standard component of recommended regimens in PEP guidelines.

[Papulovesicular exanthem after a safari in South Africa]

A 68-year-old man presented with a papulovesicular exanthem, fever and malaise after a safari in South Africa. Based on the history, the typical clinical picture with an exanthema and eschar as well as the detection of antibodies against rickettsioses of the spotted fever group, we diagnosed African tick-bite fever which is due to R. africae. During treatment with doxycycline 200 mg/d, all symptoms resolved completely within 11 days. Rickettsioses should always be considered in patients presenting with exanthema, fever and malaise. Particularly the presence of one or multiple eschars on the skin manifesting as erythematous plaques with central necrosis is a pathognomic sign. The serological detection of antibodies against rickettsia species of the spotted fever group is the established diagnostic standard. Due to extensive cross-reactions it is not possible to distinguish between the members of one rickettsial group. Furthermore antibody titers rise late in the disease, frequently 2 or 3 weeks after the onset of symptoms. This underscores the importance of the clinical diagnosis.

Therapy and prophylaxis of opportunistic infections in HIV-infected patients: a guideline by the German and Austrian AIDS societies (DAIG/ÖAG) (AWMF 055/066)

INTRODUCTION

There was a growing need for practical guidelines for the most common OIs in Germany and Austria under consideration of the local epidemiological conditions.

MATERIALS AND METHODS

The German and Austrian AIDS societies developed these guidelines between March 2010 and November 2011. A structured Medline research was performed for 12 diseases, namely Immune reconstitution inflammatory syndrome, Pneumocystis jiroveci pneumonia, cerebral toxoplasmosis, cytomegalovirus manifestations, candidiasis, herpes simplex virus infections, varizella zoster virus infections, progressive multifocal leucencephalopathy, cryptosporidiosis, cryptococcosis, nontuberculosis mycobacteria infections and tuberculosis. Due to the lack of evidence by randomized controlled trials, part of the guidelines reflects expert opinions. The German version was accepted by the German and Austrian AIDS Societies and was previously published by the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF; German Association of the Scientific Medical Societies).

CONCLUSION

The review presented here is a translation of a short version of the German-Austrian Guidelines of opportunistic infections in HIV patients. These guidelines are well-accepted in a clinical setting in both Germany and Austria. They lead to a similar treatment of a heterogeneous group of patients in these countries.

Preliminary report: outbreak of Legionnaires disease in the cities of Ulm and Neu-Ulm in Germany, December 2009 - January 2010

Currently an investigation is ongoing to explore and control an outbreak of Legionnaires disease, affecting 65 people as of 22 January 2010, in the cities of Ulm and Neu-Ulm, south-west Germany. A hitherto unidentified wet cooling system in these twin cities is considered as the most likely source of infection.

Preliminary report: outbreak of Legionnaires’ disease in the cities of Ulm and Neu-Ulm in Germany, December 2009 - January 2010

Currently an investigation is ongoing to explore and control an outbreak of Legionnaires’ disease, affecting 65 people as of 22 January 2010, in the cities of Ulm and Neu-Ulm, south-west Germany. A hitherto unidentified wet cooling system in these twin cities is considered as the most likely source of infection.

[The evaluation of dry chemical laboratory methods. Their value within the framework of step-by-step diagnosis in general medicine]

In a prospective study involving eleven general practices, dry-chemical laboratory methods were compared with wet-chemical methods in the establishment of the diagnosis. The study included 658 patients in whom defined liver disease, lipid metabolic disturbances, diabetes mellitus or hyperuricemia were clinically suspected. In the "dry chemistry" group, between 12 and 29% fewer basic examinations (ESR, Hb, erythrocytes, leukocytes) were performed than in the "wet chemistry" group. In addition the number of analyses per patient in the so-called search program and among the subsequently requested laboratory analyses were also lower by about 21% in the "dry chemistry" group. This indicates that through the use of "dry chemistry", laboratory examinations can be used with greater selectivity. A further advantage of "dry chemistry" is the appreciably shorter time required to establish and report the diagnosis.

[Programmed after care of breast cancer. Results of a follow-up model after 2 years later]

In two years 359 patients with breast cancer were evaluated in a cooperative follow-up programme in which the organisation and documentation were done in hospital, the medical care and investigations by the family doctor. 72% of 316 evaluable patients remained in regular control. 63% chose the family doctor for follow-up while the others preferred hospital. In the first year 71-80% attended their appointments, in the second year 60-74%. Statistically significant parameters for detection of metastases were the following: general condition, local signs, palpable lymph nodes, markedly increased ESR, alkaline phosphatase, chest radiograph, and bone scan. Cumulative freedom from recurrence in the whole group diminished from 1.0 to 0.631 in 25 months, cumulative survival from 1.0 to 0.876 in 20 months. In both groups there were significant differences between stages I, II and III. Forty patients (16%) out of 250 developed a recurrence within 2.25 years, in five (2%) a second carcinoma developed. There was a high proportion of local recurrences (20 out of 40) and these often led to generalised disease (11 out of 20).

[Educational goals during the internship for general medicine]

The student is to be taught a wide spectrum of nonstationary practical care of sick and healthy people of every age and genus. He is to experience all daily events of a general practice and shall also become acquainted with the doctor, his assistants, and the doctor's family. The student ought to experience by his assistance in practice the increasing responsibility, the burden, and also the fulfillment of medical profession. General Medicine contributes to the education of the student by the famulature. Who chooses the medical profession, declares his readiness to help fellow-creatures and to accept medical responsibility for them. Medical education should intensify the readiness to help.