A Multimodal Ayurveda and Mind-Body Therapeutic Intervention for Chronic Symptoms Attributed to a Postinfectious Syndrome: A Pilot Study

Objective: Evaluate feasibility and impact of a multimodal integrative therapeutic intervention in patients presenting with chronic symptoms attributed to a postinfectious syndrome. Design: This was a prospective longitudinal single-center pilot study conducted from January 2019 to December 2020. Setting/Location: University of Maryland Lyme Program, Baltimore Maryland. Subjects: Persons presenting for Lyme evaluation for symptoms attributed to Lyme disease. Interventions: Participants attended two 1-h individual instructional sessions consisting of Ayurveda-based dietary intervention and breath-coordinated mind-body practice to be used for home practice. Outcome measures: Standard measures of impact were obtained at baseline, 1, 3, 6, and 12 months using the following validated survey instruments: Perceived Stress Scale (PSS), PROMIS Global Health v1.2 (GH), and PROMIS 29 v2.0 survey. Results: From 216 patients presenting for Lyme evaluation, 19 participants enrolled with 84% completing the study (N = 16). Baseline PROMIS GH scores consisting of general Physical Health (GPH) and general Mental Health (GMH) scores were lower in the study population than in the general U.S. population. PROMIS 29 scores were higher for fatigue, anxiety, and pain than those in the general U.S. population. Over 12-month period, improvement in both the GPH and GMH was 6.09 (confidence interval [95% CI] = 2.71-9.46; p < 0.001) and 4.65 (95% CI = 1.50-7.80; p = 0.004), respectively. PROMIS 29 scores showed the greatest improvement in fatigue at -7.91 (95% CI = -12.34 to -3.48; p < 0.001), pain interference -5.08 (95% CI = -9.20 to -0.96; p = 0.016), and ability to participate in social roles and activities 7.48 (95% CI = 3.21-11.75; p = 0.001) and least with depression -1.82 (95% CI = -4.74 to 1.10; p = 0.223). Employment status had significant effects on almost all outcome scores. Postinfectious state was associated with improvement in anxiety and PSS scores. Conclusions: A multimodal Ayurvedic and breath-coordinated mind-body therapeutic intervention is feasible and a potential nonpharmacologic therapeutic option for persons presenting with pain, stress, fatigue, physical dysfunction, and sleep disturbance attributed to a postinfectious syndrome. Further research is needed to determine efficacy in this population and in other groups with similar symptom complexes due to postinfectious syndromes.

Hepatitis C cure and medications for opioid use disorder improve health-related quality of life in patients with opioid use disorder actively engaged in substance use

BACKGROUND

This study aims to determine whether Hepatitis C (HCV) treatment improves health-related quality of life (HRQL) in patients with opioid use disorder (OUD) actively engaged in substance use, and which variables are associated with improving HRQL in patients with OUD during HCV treatment.

METHODS

Data are from a prospective, open-label, observational study of 198 patients with OUD or opioid misuse within 1 year of study enrollment who received HCV treatment with the primary endpoint of Sustained Virologic Response (SVR). HRQL was assessed using the Hepatitis C Virus Patient Reported Outcomes (HCV-PRO) survey, with higher scores denoting better HRQL. HCV-PRO surveys were conducted at Day 0, Week 12, and Week 24. A mixed-effects model investigated which variables were associated with changing HCV-PRO scores from Day 0 to Week 24.

RESULTS

Patients had a median age of 57 and were predominantly male (68.2%) and Black (83.3%). Most reported daily-or-more drug use (58.6%) and injection drug use (IDU) (75.8%). Mean HCV-PRO scores at Day 0 and Week 24 were 64.0 and 72.9, respectively. HCV-PRO scores at Week 24 improved compared with scores at Day 0 (8.7; p<0.001). Achieving SVR (10.4; p<0.001) and receiving medications for OUD (MOUD) at Week 24 (9.5; p<0.001) were associated with improving HCV-PRO scores. HCV-PRO scores increased at Week 24 for patients who experienced no decline in IDU frequency (8.1; p<0.001) or had a UDS positive for opioids (8.0; p<0.001) or cocaine (7.5; p=0.003) at Week 24.

CONCLUSION

Patients with OUD actively engaged in substance use experience improvement in HRQL from HCV cure unaffected by ongoing substance use. Interventions to promote HCV cure and MOUD engagement could improve HRQL for patients with OUD.

PrEP Indications and PrEP Knowledge, Access, and Interest Among Individuals with HCV

Background

Individuals with hepatitis C (HCV) represent a population that may benefit from pre-exposure prophylaxis (PrEP), given the overlapping risk factors and transmission networks of HCV and HIV. This analysis assesses the prevalence of PrEP indications among individuals with HCV monoinfection and PrEP awareness, interest, and access in this population.

Methods

GRAVITY was an observational study for the collection of epidemiologic data from individuals with HCV and/or HIV in Washington DC and Baltimore, with the present analysis limited to HCV-monoinfected patients. The prevalence of PrEP indications was determined using epidemiologic survey responses. Bivariate and multivariable analyses assessed for associations between PrEP indications and PrEP awareness, access, and interest.

Results

Among 314 HCV-monoinfected participants, 109 (35%) had an indication for PrEP. Forty-eight (44%) had a drug use indication alone, 40 (37%) had a sexual indication alone, and 21 (19%) had both drug use and sexual indications. Eighty-five (27%) participants had heard of PrEP, 32 (10%) had been offered PrEP by a provider, 114 (38%) were interested or maybe interested in PrEP, and 6 (2%) were currently taking PrEP. On bivariate analysis, PrEP awareness was significantly associated with study site (P < .0001), race (P = .0003), age (P < .0001), and sexual PrEP indication (P = .04). However, only study site remained significant (P = .0002) on regression analysis.

Conclusions

Though indications for PrEP were prevalent among individuals with HCV in this cohort, most patients were unaware of PrEP, had never been offered PrEP, and were not using PrEP. These data support the need for improved PrEP implementation among people with HCV.

Suboptimal uptake, retention, and adherence of daily oral PrEP among people with OUD receiving HCV treatment

Background

Daily oral preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) prevents human immunodeficiency (HIV) among people who inject drugs (PWID). Despite rising HIV incidence and injection drug use (IDU), PrEP use remains low and there is limited research about uptake, adherence, and retention among PWID.

Methods

The ANCHOR investigation evaluated a community-based care model collocating hepatitis C virus (HCV) treatment, medication for opioid use disorder (OUD), and PrEP in individuals in Washington, DC, and Baltimore, Maryland. PrEP counseling was conducted from HCV treatment day 0 until week 24. Subjects could start any time during this window, were followed for 48 weeks, and were assessed for adherence by self-report and dried blood spot TDF analysis.

Results

One hundred ninety-eight participants were enrolled, of whom 185 (93%) were HIV negative. Twenty-nine individuals (15.7% of HIV-negative cohort) initiated PrEP. One hundred sixteen participants (62.7%) met 2014 Centers for Disease Control and Prevention (CDC) PrEP criteria due to IDU (82 [44.3%]), sex (9 [4.9%]), or both practices (25 [13.5%]). Providers recommended PrEP to 94 individuals (50.8%), and recommendation was associated with PrEP uptake. Median treatment duration was 104 days (interquartile range, 28–276 days), with 8 participants retained through week 48. Adherence was variable over time by self-report and declined by TDF analysis. No HIV seroconversions occurred.

Conclusions

This cohort of people with HCV and OUD experienced low uptake of PrEP despite the majority meeting CDC criteria. High rates of disruption and discontinuation, compounded by variable adherence, made TDF/FTC a suboptimal prevention strategy. Emerging modalities like long-acting formulations may address these barriers, but PWID have been excluded from their development to date.

599. Patient Beliefs Regarding Lyme Disease and Need for Antimicrobial Treatment when Referred for Lyme Evaluation

Background

Controversy and confusion surround the terminology for patients who have persistent symptoms after treatment for Lyme disease (LD) or may have been misdiagnosed with Lyme disease. While Infectious Diseases (ID) use the term Post treatment Lyme disease syndrome (PTLDS), patients tend to use the term Chronic Lyme disease (CLD) to describe the syndrome associated with persistent symptoms post treatment of LD. Many ID physicians are reluctant to see patients who identify themselves as having “Chronic Lyme” disease in some part due to reluctance to prescribe repeated courses of antibiotics. The purpose of this inquiry was to assess belief regarding Lyme disease and treatment.

Methods

Patients at the Integrated Lyme Program at the University of Maryland completed clinical intake forms which included questions on their familiarity and beliefs surrounding Lyme disease.

Results

We evaluated 146 patient records from our Lyme Program Registry which began in December 2018. There were 57 (34.5%) males and 108 (65.5%)females with mean age of 51 years. Forty seven percentage of patients were referred by a physician and 53 % were self-referred. Approximately 50% (71/146) were treated with less 30 days of antibiotics, 37% (54/146) were treated with 1-6 months of antibiotics and 11.6% (17/146) were treated with &gt;6months of antibiotics prior to their initial evaluation in our Lyme program. Sixty eight percentage of patients were familiar with the term CLD but only 44% percentage were familiar with term PTLDS. Approximately half of the patients ( 52%) believed that they currently had Lyme disease and 63% believed that their current symptoms were due to Lyme disease. Despite this only 18% believed that they needed antibiotics for Lyme disease at the time completing the form.

Conclusion

Patient referred to our Lyme center were more familiar with term CLD vs PTLDS. Many of them believed that they currently had LD and their symptoms were due to Lyme disease. Despite this, the majority did not feel that they needed antibiotics for Lyme Disease at the time of their clinical visit. More research is needed to better understand patient beliefs and understanding regarding Lyme disease.

Disclosures

All Authors: No reported disclosures

603. Misdiagnosis of Lyme Disease in Patients Referred to an Academic Lyme Center

Background

Confusion and controversy surround various aspects of Lyme Disease (LD) including diagnosis. Typically, the diagnosis of LD is based on tick exposure, clinical history, exam, and laboratory testing. Laboratory testing and interpretation can be confusing, difficult, and a source of misdiagnosis.

Methods

One hundred and fifteen records of patients referred to the Integrated Lyme Program at University of Maryland for evaluation of LD were analyzed. All patients underwent initial evaluation by Infectious Disease (ID) physician who made a determination regarding Lyme diagnosis based on history, exam, epidemiologic risk factors and laboratory test results. Pt were determined to have one of the following diagnoses: 1) Acute LD 2) Past LD 3) Post Treatment Lyme Disease Syndrome (PTLDS) 4) Misdiagnosed LD. Data was also collected on reasons for misdiagnosis based on record review, referral information and patient reported information.

Results

We evaluated 115 patient records from our Lyme Program Registry. There were 78 female (68%) and 37 males (32%). The mean age was 46 years (range 19 to 83). Of the 115 records analyzed, there were 8 (7%) patients with acute Lyme disease; 38 (33%) patients with past Lyme disease , 3 (2.6%) patients with PTLDS and 93 (81%) of patients who were misdiagnosed with LD. Patients were misdiagnosed for multiple reasons and by different people. Twenty three percent (21/93) were misdiagnosed based on false positive IGM Western Blot; 16% (15/93) were misdiagnosed based on misread IGG Western Blot and 14% (13/93) were misdiagnosed based on unconventional Lyme test. The remainder were misdiagnosed based on symptoms. Forty two percent (39/93) were misdiagnosed by PCP; 4.3%(3/93) were misdiagnosed by Urgent/Emergent care physician and 31% (29/93) were misdiagnosed by physicians’ self-referred as Lyme Literate Medical Doctor. The remainder were incorrectly self-diagnosed by patients based on symptoms.

Conclusion

Misdiagnosis of patients referred to Lyme Center is common and due to various reasons including misinterpretation of laboratory Lyme testing by healthcare providers and misinterpretation of symptoms by patients.

Disclosures

All Authors: No reported disclosures

859. Suboptimal Uptake, Retention, and Adherence of Daily Oral PrEP Among People with OUD Receiving HCV Treatment

Background

Daily oral pre-exposure prophylaxis (PrEP) with tenofovir/emtricitabine (TDF/FTC) effectively prevents HIV among people who use drugs (PWUD). Despite rising rates of HIV incidence and injection drug use, PrEP use remains low and limited research exists on PrEP adherence and retention in this population.

Methods

Based in Washington, DC and Baltimore, the ANCHOR investigation evaluated a community-based model of care collocating hepatitis C (HCV) therapy, medication for opioid use disorder (OUD), and PrEP in people with chronic HCV, OUD, and drug use within 1 year. PrEP counseling was offered from HCV treatment Day 0 until Week 24 and subjects could start any time during this window. PrEP patients were followed for 48 weeks and assessed for adherence by self-report and dried blood spot analysis of TDF.

ANCHOR PrEP study enrollment and participant retention along the PrEP continuum.

Results

198 participants enrolled in ANCHOR, of whom 185 (93%) were HIV-negative. 29 subjects (16% of HIV-negative group) initiated PrEP. 116 subjects (63%) met 2014 CDC criteria for PrEP initiation due to IDU (82, 44%), sex (9, 5%), or both (25, 14%). Those who initiated were more likely to meet both CDC sexual and IDU risk criteria than those who declined PrEP (P=0.006). Providers recommended PrEP to 94 subjects (51%), which was associated with uptake (P=0.02). While median treatment duration was 104 days (IQR 28, 276), only 8 subjects were retained through Week 48. The most common reason for discontinuation was side effects in 7 subjects or 24% of PrEP subgroup. Treatment interruptions occurred in one-third of the PrEP subgroup. Adherence of 4 to 7 pills per week was variable over time by self-report and declined by TDF analysis. No HIV seroconversions occurred.

Demographic and epidemiological background of the ANCHOR study population.

Total duration, in days, on PrEP in the ANCHOR study. Discontinued participants are grouped by reason for cessation of therapy.

PrEP Adherence

Adherence to PrEP by ANCHOR study timepoint, assessed via self-report (above) and dried bloodspot analysis of tenofovir level (below).

Conclusion

In this cohort of people with OUD and HCV, 16% of subjects started PrEP. While clinical recommendation was associated with uptake, high rates of disruption and discontinuation, compounded by variable pill adherence, made daily oral TDF/FTC a suboptimal preventive strategy in this cohort. Emerging PrEP modalities like long-acting injectables have potential to address these barriers, but PWUD have been excluded from their research and development to date. Additional work to identify vulnerable individuals and to promote use, adherence, and retention will be critical in implementing PrEP more effectively in this key population.

Disclosures

Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

844. High Risk Behaviors, Suboptimal HIV Viral Suppression, and Limited PrEP Use among People Who Engage in Transactional Sex

Background

In the United States, high rates of HIV transmission persist, particularly due to sexual transmission in marginalized populations. Transactional sex (TS) is a known risk factor for HIV transmission, yet risk behaviors and engagement in HIV treatment and prevention among those who have TS are poorly understood.

Methods

GRAVITY is cross-sectional investigation of people living with HIV (PLWH) or HCV in Washington, DC and Baltimore, MD. Epidemiologic survey data were collected at a single timepoint. Patients who endorsed previous year sex in exchange for drugs, money, or shelter were considered positive for TS. Fisher’s exact test was used for statistical analysis.

Results

Of 500 participants, 81(16%) endorsed TS, the majority of whom were HIV+ (51, 63%) and used drugs daily or more (57,70%; see Table 1). PLWH with TS were more likely to be Black (44, 86%, p= 0.05) and Trans female (17, 33%, p&lt;0.01) than HIV- participants with TS. In the TS cohort, PLWH were more likely to engage in anal sex (38, 75%, p&lt; 0.01), have sex weekly or more (46, 90%; p&lt; 0.01), have sex with more than 2 partners (27, 77%, p=0.03), and have a history of syphilis (14, 27% p= 0.04) compared to HIV- participants. Only 21% and 35% of PLWH and 17% and 22% of HIV- always used condoms in vaginal sex and anal sex, respectively (p &gt;0.05). Though 41 (80%) PLWH took ART, only 19 (41%) reported viral suppression. Of HIV- participants, 59% had interest in starting Pre-Exposure Prophylaxis (PrEP), but few had been offered (3,10%), or ever taken PrEP (2,7%).

Table 1: Participant Characteristics and Associations with Transactional Sex and HIV Status

Conclusion

In this cohort of people with TS, there were high rates of HIV and racial, sexual, and gender minorities. Notably, PLWH had higher rates of frequent sex, multiple partners, and anal sex, as well as suboptimal viral suppression and condom use during anal sex. As such, PLWH +TS may be a consequential part of HIV transmission networks. While those without HIV also had frequent sex and suboptimal condom use, PrEP experience was limited. As the majority had interest in PrEP, targeted strategies to initiate and maintain PrEP in people with TS may be critical in preventing HIV acquisition. Interventions to identify TS, address high-risk behaviors, achieve and maintain viral suppression amongst +TS PLWH, and connect +TS HIV- individuals to PrEP are key to a comprehensive strategy to end the HIV epidemic.

Disclosures

Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

Concurrent Initiation of Hepatitis C and Opioid Use Disorder Treatment in People Who Inject Drugs

BACKGROUND

People who inject drugs have a high prevalence of hepatitis C virus (HCV) and significant disease associated with drug use; however, HCV treatment often occurs in absence of interventions to address opioid use disorder and drug use-related harms. The impact of concurrent initiation of opioid agonist therapy (OAT) on HCV treatment and drug use outcomes is unknown.

METHODS

In this prospective, open-label, observational trial at a harm reduction organization's drop-in center in Washington, DC, 100 patients with chronic HCV infection, opioid use disorder, and ongoing injection drug use were treated with sofosbuvir-velpatasvir for 12-weeks and offered buprenorphine initiation. The primary end point was sustained virologic response (SVR), and secondary end points included uptake of and retention in OAT, change in risk behavior, and determinants of SVR.

RESULTS

Eighty-two patients (82%) achieved SVR, which was not associated with baseline OAT status (P = .33), on-treatment drug use (P >.99), or imperfect daily adherence (P = .35) but was significantly associated with completing 2 or more 28-pill bottles of sofosbuvir-velpatasvir (P < .001) and receiving OAT at week 24 (P = .01). Of 67 patients not already receiving OAT at baseline, 53 (79%) started OAT. At week 24, 68 (68%) patients were receiving OAT. Receipt of OAT was associated with fewer opiate-positive urine drug screens (P = .003), lower human immunodeficiency virus risk-taking behavior scores (P < .001), and lower rates of opioid overdose (P = .04).

CONCLUSIONS

The Novel Model of Hepatitis C Treatment as an Anchor to Prevent HIV, Initiate Opioid Agonist Therapy, and Reduce Risky Behavior study demonstrates high uptake of buprenorphine collocated with HCV treatment, and it shows that concurrent initiation of OAT with HCV treatment can result in high rates of SVR while reducing risks associated with drug use.

CLINICAL TRIALS REGISTRATION

NCT03221309.

Long-term changes in hepatic fibrosis following hepatitis C viral clearance in patients with and without HIV

BACKGROUND

While acute changes in hepatic fibrosis are recognized shortly after achieving sustained virological response (SVR) using direct-acting antiviral therapies, long-term outcomes for the growing population of successfully treated patients with HCV remain uncertain. The aim of this study is to characterize long-term changes in fibrosis following SVR in patients with and without HIV and to identify potential factors associated with progression or regression of fibrosis.

METHODS

We completed a prospective longitudinal study of 162 subjects with HCV (34% HIV-coinfected) with pre-treatment fibrosis stage determined by liver biopsy and post-SVR transient elastography. Progression of fibrosis was defined as a two-stage or greater increase in fibrosis, while regression was defined as a two-stage or greater decrease at last follow-up. The median duration of follow-up was 4.1 years.

RESULTS

Fibrosis progression occurred in 4% of subjects while regression occurred in 7% and 89% were stable and did not differ by HIV coinfection. Fibrosis progression was associated with increased body mass index (BMI), hepatic steatosis and smoking pack-years. In a multivariable logistic regression, HIV coinfection (P=0.009), lower steatosis score (P<0.05) and lower smoking pack-years (P=0.0007) were associated with a lower fibrosis score at last follow-up.

CONCLUSIONS

We identify potentially important relationships between BMI, hepatic steatosis and smoking, and changes in hepatic fibrosis post-SVR in patients with and without HIV coinfection. Attention to modifiable risk factors such as body weight and smoking may reduce the risk of liver disease progression in the growing population of successfully treated chronic HCV patients.

2900. High Rates of Experienced and Witnessed Opioid Overdose in PWID Receiving HCV Treatment: Data From the ANCHOR Study

Background

People who inject drugs (PWID) have significant morbidity and mortality associated with hepatitis C (HCV); however, harms associated with ongoing injecting drug use (IDU)—such as opioid overdose—may pose a more imminent risk, and often are not addressed as part of HCV treatment. Naloxone distribution is a simple, evidenced-based strategy to reduce mortality associated with opioid overdose.

Methods

ANCHOR is a single-center study embedded in an urban harm-reduction program evaluating treatment of HCV in PWID with chronic HCV, opioid use disorder (OUD), and IDU. Participants received HCV treatment and were offered collocated buprenorphine. At each study visit, patients self-reported experienced and witnessed overdose and were offered naloxone.

Results

The 100 enrolled participants are predominantly male (75%), median 57 years, black (93%) and inject opioids at least daily (58%). At baseline, 65% had ever experienced overdose, 91% had ever witnessed an overdose, and 35% had ever administered naloxone. Between day 0 and week 48, 15 patients (15%) experienced overdose; of which, 4 (4%) were fatal. The rate of experienced overdose was 15 overdoses per 100 person-years. In addition, 59 (59%) patients witnessed at least one overdose between day 0 and week 48. Seventy-three patients were dispensed naloxone at least once, and of those who witnessed an overdose, 48 (81%) administered naloxone. Nineteen (40%) patients who administered naloxone had never used naloxone before starting HCV treatment.

Conclusion

PWID with HCV, OUD, and ongoing IDU have high rates of personal and witnessed overdose during and after HCV treatment. Dispensing naloxone at HCV-related visits is highly acceptable among PWID, and results in high rates of naloxone utilization. To reduce morbidity and mortality in patients and their communities, ID providers should complement treatment of infections by prescribing naloxone for patients with OUD, ideally as part of a comprehensive package of harm reduction and OUD treatment.

Disclosures

All Authors: No reported Disclosures.

2897. Collocated Buprenorphine Is Associated with Improved HCV Visit Adherence in People Who Inject Drugs (PWID): Data From the ANCHOR Study

Background

Engaging PWID in HCV treatment and monitoring for reinfection is critical to eliminate HCV and improve health in people who use drugs. However, PWID are often marginalized and can be difficult to engage and retain in care. The collocation of HCV treatment with buprenorphine to treat opioid use disorder (OUD) may improve visit adherence in this population.

Methods

ANCHOR is a single-center study evaluating treatment of HCV in PWID with chronic HCV, OUD, and IDU. Participants receive sofosbuvir/velpatasvir x12 weeks and are offered collocated buprenorphine. HCV visits occur at weeks 4, 12, 24, 48, 72 and 96.

Results

At screening, the 100 enrolled patients were predominantly male (76%), black (93%), middle-aged (median 57years), injected opioids daily or more (58%), and were not on OAT (67%). Fifty-five (55%) patients were initiated on collocated buprenorphine at some point after day 0.

Being on collocated buprenorphine at the time of HCV visit was associated with increased likelihood of visit attendance at weeks 12 (P = 0.002), 24 (P = 0.01), 48 (P = 0.02), 72 (P = 0.003), and 96 (P = 0.04). For patients who attended study visits, being on collocated buprenorphine was associated with a shorter time between planned visit and actual visit at weeks 12 (P = 0.03), 24 (P = 0.04), and 48 (P = 0.04). When looking at patients not on collocated buprenorphine, being on noncollocated opioid agonist therapy vs. not being on OUD treatment did not impact visit adherence.

Conclusion

Evidence-based treatment of HCV and OUD are critical to improving health in PWID. The collocation of HCV treatment with office-based buprenorphine may improve adherence to visits and visit timing, especially in long-term follow-up. Infectious disease providers should offer collocated buprenorphine as a tool to improve long-term outcomes and engagement in this high-risk population.

Disclosures

All Authors: No reported Disclosures.

Testosterone in Men With Chronic Hepatitis C Infection and After Hepatitis C Viral Clearance

BACKGROUND

Hepatitis C virus (HCV) and hepatic dysfunction are associated with low total and free testosterone (TT and FT) and high sex hormone-binding globulin (SHBG). However, little is known about changes in testosterone following successful HCV treatment.

METHODS

We evaluated testosterone levels and the prevalence of low testosterone in a cohort of 327 men with chronic HCV infection (human immunodeficiency virus [HIV] coinfection = 150) and in a subset of 85 men with testosterone levels obtained pre-HCV treatment and after sustained virologic response (SVR). Median follow-up was 36 months.

RESULTS

Participants with active HCV at baseline had higher TT (P < .0001) and SHBG (P < .0001) compared with participants who had achieved SVR, whereas FT did not differ. Low TT (<10.4 nmol/L) was more prevalent in participants with SVR compared with active HCV (P = .002); however, low FT (<0.1735 nmol/L) was common (50% active HCV, 43% SVR) and did not different between groups. For participants with longitudinal determinations, TT and SHBG decreased significantly (P < .0001) while FT remained unchanged post-SVR. Low FT persisted after SVR (pre-treatment 58%, post-SVR 54%, P = .72). HIV status and change in aspartate aminotrasferase-to-platelet ratio were significant independent predictors of change in FT following SVR.

CONCLUSIONS

During active HCV infection, testosterone deficiency may be masked due to elevated SHBG. Despite improvements in SHBG following SVR, low FT was common and persisted after HCV clearance, indicating the need for enhanced awareness and screening using estimates of FT following successful treatment of chronic HCV.

CLINICAL TRIALS REGISTRATION

NCT01350648.

No Improvement in Hemoglobin A1c Following Hepatitis C Viral Clearance in Patients With and Without HIV

Hepatitis C clearance with directly acting antivirals (DAAs) may be associated with acute decreases in hemoglobin A1c (HbA1c). We prospectively evaluated 251 chronic hepatitis C virus (HCV)-infected subjects (31% human immunodeficiency virus [HIV] positive) pre- and post-DAA therapy (median follow-up 28 months). Changes in HbA1c and glucose were minimal and did not differ by sustained virologic response (SVR), HIV, diabetes, or fibrosis. Following SVR, mean change in HbA1c was -0.022 ± 0.53%; however, total and low-density lipoprotein cholesterol increased significantly. Subjects with HIV had smaller transaminase reductions after SVR. Sustained benefits in glycemia were not identified following HCV clearance irrespective of HIV, diabetes, or fibrosis stage, whereas lipid alterations may warrant further investigation.

1297. Characteristics for PrEP Uptake, Retention, and Discontinuation: Data From the ANCHOR Study

Background

People who inject drugs (PWID) have an increased risk for HIV, and HCV infection may foreshadow HIV acquisition in current epidemics. Studies of PWID have demonstrated a desire to obtain HCV treatment; however, use of pre-exposure prophylaxis (PrEP) in this population has not been well studied.

Methods

The ANCHOR study is an ongoing single-center study evaluating treatment of HCV in PWID. Enrolled patients have chronic HCV, opioid use disorder, and inject opioids. Patients are treated with sofosbuvir/velpatasvir and offered PrEP. Patients complete baseline community health worker (CHW)-administered surveys, physician assessment of PrEP eligibility, and are offered PrEP uptake.

Results

Of 89 enrolled patients, 49 (55%) met CDC criteria for PrEP, and 21 (24%) patients started PrEP. Reasons for not starting PrEP are in Figure 1. Though most patients are black (n = 82, 92.1%) and heterosexual (n = 81, 91%), these patients were less likely to start PrEP (P = 0.0068 and P = 0.0283, respectively). Baseline interest in starting PrEP was correlated with uptake (P = 0.0023), however, self-identifying as high-risk for HIV acquisition or meeting CDC criteria for PrEP were not. Though more patients endorsed sharing of injection equipment to a CHW than a physician (17% vs. 7%), endorsement to a physician rather than CHW was associated with starting PrEP (P = 0.0307). To date, 13 (62%) patients discontinued PrEP, 7 (54%) due to side effects.

Conclusion

Preliminary results of the ANCHOR study support that engagement in HCV care provides an opportunity for PWID to participate in PrEP intake; however, we found relatively low uptake in these patients, despite over half meeting CDC criteria. Our findings highlight the importance of counseling by physicians for initiation of PrEP, and suggest that improved communication between CHW and physician regarding risk behaviors could improve uptake. These data also reinforce that patients must be counseled and managed for side effects in order to retain them in care. Given the increasing opioid epidemic in the United States, more consideration needs to be given regarding how to incorporate PrEP into care, and how to effectively target and improve interest in PrEP for high-risk populations with poor uptake, including minorities and PWID.

Disclosures

C. Gross, Merck, Pfizer, Johnson and Johnson: Shareholder, stock. E. Rosenthal, Gilead Sciences, Merck: Grant Investigator, Grant recipient.

Expansion of Treatment for Hepatitis C Virus Infection by Task Shifting to Community-Based Nonspecialist Providers: A Nonrandomized Clinical Trial

Background

Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection has resulted in high rates of disease cure; however, not enough specialists currently are available to provide care.

Objective

To determine the efficacy of HCV treatment independently provided by nurse practitioners (NPs), primary care physicians (PCPs), or specialist physicians using DAA therapy.

Design

Nonrandomized, open-label clinical trial initiated in 2015. (ClinicalTrials.gov: NCT02339038).

Setting

13 urban, federally qualified health centers (FQHCs) in the District of Columbia.

Patients

A referred sample of 600 patients, of whom 96% were black, 69% were male, 82% were treatment naive, and 20% had cirrhosis. Seventy-two percent of the patients had HCV genotype 1a infection. The baseline characteristics of patients seen by each provider type were similar.

Intervention

Patients were assigned in a nonrandomized but specified manner to receive treatment from 1 of 5 NPs, 5 PCPs, or 6 specialists. All providers underwent an identical 3-hour training session based on guidelines. Patients received treatment with ledipasvir-sofosbuvir, which was provided on site, according to U.S. Food and Drug Administration labeling requirements.

Measurements

Sustained virologic response (SVR).

Results

516 patients achieved SVR, a response rate of 86% (95% CI, 83.0% to 88.7%), with no major safety signals. Response rates were consistent across the 3 provider types: NPs, 89.3% (CI, 83.3% to 93.8%); PCPs, 86.9% (CI, 80.6% to 91.7%); and specialists, 83.8% (CI, 79.0% to 87.8%). Patient loss to follow-up was the major cause of non-SVR.

Limitation

Nonrandomized patient distribution; possible referral bias.

Conclusion

In a real-world cohort of patients at urban FQHCs, HCV treatment administered by nonspecialist providers was as safe and effective as that provided by specialists. Nurse practitioners and PCPs with compact didactic training could substantially expand the availability of community-based providers to escalate HCV therapy, bridging existing gaps in the continuum of care for patients with HCV infection.

Primary Funding Source

National Institutes of Health and Gilead Sciences.

Successful Retreatment of Chronic HCV Genotype-1 Infection With Ledipasvir and Sofosbuvir After Initial Short Course Therapy With Direct-Acting Antiviral Regimens

BACKGROUND

The optimal retreatment strategy for chronic hepatitis C virus (HCV) patients who fail directly-acting antiviral agent (DAA)-based treatment is unknown. In this study, we assessed the efficacy and safety of ledipasvir (LDV) and sofosbuvir (SOF) for 12 weeks in HCV genotype-1 (GT-1) patients who failed LDV/SOF-containing therapy.

METHODS

In this single-center, open-label, phase 2a trial, 34 participants with HCV (GT-1) and early-stage liver fibrosis who previously failed 4-6 weeks of LDV/SOF with GS-9669 and/or GS-9451 received LDV/SOF for 12 weeks. The primary endpoint was HCV viral load below the lower limit of quantification 12 weeks after completion of therapy (sustained virological response [SVR]12). Deep sequencing of the NS3, NS5A, and NS5B regions were performed at baseline, at initial relapse, prior to retreatment, and at second relapse with Illumina next-generation sequencing technology.

RESULTS

Thirty-two of 34 enrolled participants completed therapy. Two patients withdrew after day 0. Participants were predominantly male and black, with median baseline HCV viral load of 1.3 × 10(6) IU/mL and Metavir fibrosis stage 1 and genotype-1a. Median time from relapse to retreatment was 22 weeks. Prior to retreatment, 29 patients (85%) had NS5A-resistant variants. The SVR12 rate was 91% (31/34; intention to treat, ITT) after retreatment. One patient relapsed.

CONCLUSIONS

In patients who previously failed short-course combination DAA therapy, we demonstrate a high SVR rate in response to 12 weeks of LDV/SOF, even for patients with NS5A resistance-associated variants.

CLINICAL TRIALS REGISTRATION

NCT01805882.

Four-Week Direct-Acting Antiviral Regimens in Noncirrhotic Patients With Hepatitis C Virus Genotype 1 Infection: An Open-Label, Nonrandomized Trial

BACKGROUND

Treatment of chronic hepatitis C virus (HCV) infection with direct-acting antivirals (DAAs) for 6 weeks achieves sustained virologic response (SVR) rates of 95% in some patients. If effective, shorter therapeutic courses could improve adherence and treatment costs.

OBJECTIVE

To determine factors predictive of SVR to 4 weeks of DAA treatment in patients with stage F0 to F2 liver fibrosis.

DESIGN

Open-label, nonrandomized, phase 2a trial. (Clinical Trials.gov: NCT01805882).

SETTING

Single-center.

PATIENTS

50 treatment-naive and predominantly African American patients with HCV genotype 1 infection and early-stage liver fibrosis were sequentially enrolled into 2 treatment groups.

INTERVENTION

25 participants received a 3-drug regimen consisting of ledipasvir and sofosbuvir plus GS-9451 for 4 weeks, and 25 received a 4-drug regimen consisting of ledipasvir, sofosbuvir, GS-9451, and GS-9669 for 4 weeks.

MEASUREMENTS

The primary efficacy end point was SVR12 (HCV RNA level below the lower limit of quantification at posttreatment week 12).

RESULTS

Forty percent (10 of 25) (95% CI, 21% to 61%) of patients in the 3-drug group and 20% (5 of 25) (CI, 7% to 41%) of those in the 4-drug group achieved SVR12. Exploratory analysis suggested that lower baseline HCV viral load, younger age, and HCV genotype 1b were associated with SVR12. Ten patients had baseline HCV variants conferring greater than 20-fold resistance in vitro to at least 1 study DAA; all had viral relapse. Forty-eight percent (12 of 25) of patients receiving the 3-drug regimen and 72% (18 of 25) of those receiving the 4-drug regimen had adverse events, most of which were mild. One participant was lost to follow-up.

LIMITATION

Nonrandomized study design and small sample of patients with early-stage fibrosis.

CONCLUSION

Combination DAA therapy with 3 or 4 drugs for 4 weeks was well-tolerated but resulted in limited cure rates.

PRIMARY FUNDING SOURCE

National Institute of Allergy and Infectious Diseases, National Cancer Institute, and Clinical Center Intramural Program; supported in part by a cooperative research and development agreement between the National Institutes of Health and Gilead Sciences.

High adherence to all-oral directly acting antiviral HCV therapy among an inner-city patient population in a phase 2a study

Background

As treatment for chronic hepatitis C (HCV) virus has evolved to all-oral, interferon-free directly acting antiviral (DAA) therapy, the impact of these improvements on patient adherence has not been described.

Methods

Medication adherence was measured in 60 HCV, genotype-1, treatment-naïve participants enrolled in a phase 2a clinical trial at the National Institutes of Health and community clinics. Participants received either ledipasvir/sofosbuvir (LDV/SOF) (90 mg/400 mg) (one pill) daily for 12 weeks, LDV/SOF + GS-9451 (80 mg/day) (two pills) daily for 6 weeks, or LDV/SOF + GS-9669 (500 mg twice daily; three pills, two in the morning, one in the evening) for 6 weeks. Adherence was measured using medication event monitoring system (MEMS) caps, pill counts and patient report.

Results

Overall adherence to DAAs was high. Adherence declined over the course of the 12-week treatment (p = 0.04). While controlled psychiatric disease or symptoms of depression did not influence adherence, recent drug use was a risk factor for non-adherence to 12-week (p = 0.01), but not 6-week regimens. Adherence as measured by MEMS was lower than by patient report.

Conclusions

Adherence to short courses of DAA therapy with 1–3 pills a day was excellent in an urban population with multiple risk factors for non-adherence.

Electronic supplementary material

The online version of this article (doi:10.1007/s12072-015-9680-7) contains supplementary material, which is available to authorized users.

Moderate Sustained Virologic Response Rates With 6-Week Combination Directly Acting Anti-Hepatitis C Virus Therapy in Patients With Advanced Liver Disease

BACKGROUND

Treatment of genotype 1 hepatitis C virus (HCV) infection with combination directly acting antivirals (DAA) for 8-24 weeks is associated with high rates of sustained virologic response (SVR). We previously demonstrated that adding a third DAA to ledipasvir and sofosbuvir (LDV/SOF) can result in high SVR rates in patients without cirrhosis. In this study, we investigated whether a similar regimen would yield equivalent rates of cure in patients with advanced liver fibrosis.

METHODS

Fifty patients were enrolled at the Clinical Research Center of the National Institutes of Health and associated healthcare centers. Enrollment and follow-up data from April 2014 to June 2015 are reported here. Eligible participants were aged ≥18 years, had chronic HCV genotype 1 infection (serum HCV RNA ≥2000 IU/mL), and stage 3-4 liver fibrosis. HCV RNA was measured using a reverse-transcription polymerase chain reaction assay.

RESULTS

Of patients treated with LDV, SOF, and the NS3/4A protease inhibitor GS-9451 for 6 weeks, 76% (38 of 50; 95% confidence interval, 60%-85%) had SVR achieved 12 weeks after the end of treatment. There was no statistically significant difference in treatment efficacy between treatment-naive patients (72%, 18 of 25) and those with treatment experience (80%; 20 of 25) (P = .51). Overall, 11 patients (22%) experienced virologic relapse, and 1 (2%) was lost to follow-up at 4 weeks after treatment. No serious adverse events, discontinuations, or deaths were associated with this regimen.

CONCLUSIONS

Adding a third DAA to LDV/SOF may result in a moderate SVR rate, lower than that observed in patients without cirrhosis. Significant liver fibrosis remains an impediment to achieving SVR with short-duration DAA therapy.

CHINESE CLINICAL TRIALS REGISTRATION

CT01805882.

Ledipasvir and sofosbuvir for hepatitis C genotype 4: a proof-of-concept, single-centre, open-label phase 2a cohort study

BACKGROUND

Worldwide, although predominantly in low-income countries in the Middle East and Africa, up to 13% of hepatitis C virus (HCV) infections are caused by HCV genotype 4. For patients with HCV genotype 1, the combination of ledipasvir and sofosbuvir has been shown to cure high proportions of patients with excellent tolerability, but this regimen has not been assessed for the treatment of HCV genotype 4. We assessed the efficacy, safety, and tolerability of 12 weeks of combination therapy with ledipasvir and sofosbuvir for patients with chronic HCV genotype 4 infections.

METHODS

In this single-centre, open-label cohort, phase 2a trial, patients with HCV genotype 4 who were treatment naive or interferon treatment experienced (HIV-negative) were sequentially enrolled at the Clinical Center of the National Institutes of Health, Bethesda, MD, USA. We gave patients 12 weeks of ledipasvir (90 mg) and sofosbuvir (400 mg) as a single combination tablet once per day. The primary efficacy endpoint was sustained viral response at 12 weeks (SVR12), as measured by the proportion of patients with HCV RNA concentrations less than the lower limit of quantification (COBAS TaqMan HCV test, version 1.0, 43 IU/mL). The primary safety endpoint was the frequency and severity of adverse events. We did our analyses on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT01805882.

FINDINGS

Between Sept 16, 2013, and Nov 2, 2014, we recruited 21 patients. 20 (95%) of 21 patients completed 12 weeks of treatment and achieved SVR12 (95% CI 76-100), including seven patients with cirrhosis. One patient was non-adherent to study drugs and withdrew from the study, but was included in the intention-to-treat analysis. No patients discontinued treatment because of adverse events and no grade 3 or 4 adverse events occurred that were related to study medications. The most common adverse events were diarrhoea (two patients), fatigue (three patients), nausea (two patients), and upper respiratory infections (two patients).

INTERPRETATION

Ledipasvir and sofosbuvir treatment for 12 weeks was well tolerated by patients with HCV genotype 4 and resulted in 100% SVR for all patients who received all 12 weeks of study drugs, irrespective of previous treatment status and underlying liver fibrosis. This is the first report of a single-pill, all-oral, interferon-free, ribavirin-free treatment for patients with HCV genotype 4.

FUNDING

NIAID, National Cancer Institute and Clinical Center Intramural Program. The study was also supported in part by a Cooperative Research and Development Agreement between NIH and Gilead Sciences.

Virologic response following combined ledipasvir and sofosbuvir administration in patients with HCV genotype 1 and HIV co-infection

IMPORTANCE

There is an unmet need for interferon- and ribavirin-free treatment for chronic hepatitis C virus (HCV) infection in patients co-infected with human immunodeficiency virus (HIV).

OBJECTIVE

To evaluate the rates of sustained virologic response (SVR) and adverse events in previously untreated patients with HCV genotype 1 and HIV co-infection following a 12-week treatment of the fixed-dose combination of ledipasvir and sofosbuvir.

DESIGN, SETTING, AND PARTICIPANTS

Open-label, single-center, phase 2b pilot study of previously untreated, noncirrhotic patients with HCV genotype 1 and HIV co-infection conducted at the Clinical Research Center of the National Institutes of Health, Bethesda, Maryland, from June 2013 to September 2014. Patients included those receiving antiretroviral therapy with HIV RNA values of 50 copies/mL or fewer and a CD4 T-lymphocyte count of 100 cells/mL or greater or patients with untreated HIV infection with a CD4 T-lymphocyte count of 500 cells/mL or greater. Serial measurements of safety parameters, virologic and host immune correlates, and adherence were performed.

INTERVENTIONS

Fifty patients with HCV genotype 1 never before treated for HCV were prescribed a fixed-dose combination of ledipasvir (90 mg) and sofosbuvir (400 mg) once daily for 12 weeks.

MAIN OUTCOMES AND MEASURES

The primary study outcome was the proportion of patients with sustained viral response (plasma HCV RNA level <12 IU/mL) 12 weeks after end of treatment.

RESULTS

Forty-nine of 50 participants (98% [95% CI, 89% to 100%]) achieved SVR 12 weeks after end of treatment, whereas 1 patient experienced relapse at week 4 following treatment. In the patient with relapse, deep sequencing revealed a resistance associated mutation in the NS5A region conferring resistance to NS5A inhibitors, such as ledipasvir. The most common adverse events were nasal congestion (16% of patients) and myalgia (14%). There were no discontinuations or serious adverse events attributable to study drug.

CONCLUSIONS AND RELEVANCE

In this open-label, uncontrolled, pilot study enrolling patients co-infected with HCV genotype 1 and HIV, administration of an oral combination of ledipasvir and sofosbuvir for 12 weeks was associated with high rates of SVR after treatment completion. Larger studies that also include patients with cirrhosis and lower CD4 T-cell counts are required to understand if the results of this study generalize to all patients co-infected with HCV and HIV.

TRIAL REGISTRATION

clinicaltrials.gov Identifier:NCT01878799.

Virological response after 6 week triple-drug regimens for hepatitis C: a proof-of-concept phase 2A cohort study

BACKGROUND

Direct-acting antiviral drugs have a high cure rate and favourable tolerability for patients with hepatitis C virus (HCV). Shorter courses could improve affordability and adherence. Sofosbuvir and ledipasvir with ribavirin have high efficacy when taken for 8 weeks but not for 6 weeks. We assessed whether the addition of a third direct-acting antiviral drug to sofosbuvir and ledipasvir would allow a shorter treatment duration.

METHODS

In this single-centre, open-label, phase 2A trial, we sequentially enrolled treatment-naive patients with HCV genotype 1 infection into three treatment groups: 12 weeks of sofosbuvir and ledipasvir; 6 weeks of sofosbuvir, ledipasvir, and GS-9669; or 6 weeks of sofosbuvir, ledipasvir, and GS-9451. Patients and investigators were not masked to treatment assignment. The primary endpoint was the propotion of patients with sustained viral response at 12 weeks after treatment completion (SVR12), assessed by serum HCV RNA concentrations lower than 43 IU/mL (the lower limit of quantification). We did an intention-to-treat analysis for the primary endpoint and adverse events. This study is registered with ClinicalTrials.gov, number NCT01805882.

FINDINGS

Between Jan 11, 2013, and Dec 17, 2013, we enrolled 60 patients, and sequentially assigned them into three groups of 20. We noted an SVR12 in all 20 patients (100%, 95% CI 83-100) allocated to sofosbuvir and ledipasvir for 12 weeks; in 19 (95%, 75-100) of the 20 patients allocated to sofosbuvir, ledipasvir, and GS-9669 for 6 weeks (one patient relapsed 2 weeks after completion of treatment); and in 19 (95%, 75-100%) of the 20 patients allocated to sofosbuvir, ledipasvir, and GS-9451 for 6 weeks (one patient was lost to follow-up after reaching sustained viral response at 4 weeks). Most adverse events were mild and no patients discontinued treatment. Two serious adverse events occurred (pain after a post-treatment liver biopsy and vertigo), both unrelated to study drugs.

INTERPRETATION

In this small proof-of-concept study, two different three-drug regimens that were given for 6 weeks resulted in high cure rates for HCV infection with excellent tolerability. Addition of a third potent direct-acting antiviral drug can reduce the duration of treatment required to achieve sustained viral response in patients with chronic HCV genotype 1 infection without cirrhosis.

FUNDING

National Institute of Allergy and Infectious Diseases (NIAID), National Cancer Institute and Clinical Center Intramural Program, German Research Foundation, National Institutes of Health, Gilead Sciences.

Re-treatment of chronic hepatitis C virus genotype 1 infection after relapse: an open-label pilot study

BACKGROUND

The interferon (IFN)-free regimen of sofosbuvir and ribavirin for 24 weeks was recently approved to treat chronic hepatitis C virus (HCV) genotype 1 (GT-1) infection for patients ineligible for IFN. However, sofosbuvir plus ribavirin therapy is associated with relapse in 15% to 30% of patients with HCV GT-1. Neither the mechanism of relapse nor the optimal re-treatment strategy for these patients is defined.

OBJECTIVE

To assess the safety and efficacy of sofosbuvir plus ledipasvir in patients with chronic HCV GT-1 that relapsed after sofosbuvir plus ribavirin therapy.

DESIGN

Phase 2a, open-label study. (ClinicalTrials.gov: NCT01805882).

SETTING

Single U.S site.

PATIENTS

14 patients with HCV GT-1 that relapsed after treatment with sofosbuvir plus ribavirin for 24 weeks were re-treated with sofosbuvir plus ledipasvir for 12 weeks.

MEASUREMENTS

HCV RNA concentration and population sequencing to detect NS5B S282T mutations.

RESULTS

All 14 patients treated with sofosbuvir plus ledipasvir for 12 weeks achieved a sustained virologic response, including 7 with advanced liver disease (Knodell Histology Activity Index score of 3 or 4) and 1 with a detectable NS5B S282T mutation after sofosbuvir plus ribavirin therapy. Sofosbuvir plus ledipasvir was well-tolerated with few adverse events. Four grade 3 events (elevated serum creatinine in a patient with baseline renal insufficiency, hypercholesterolemia, and hypophosphatemia) occurred. There were no grade 4 events or treatment discontinuations.

LIMITATION

Small sample size.

CONCLUSION

The fixed-dose combination of sofosbuvir plus ledipasvir was efficacious in a small cohort of patients with HCV GT-1 that relapsed after sofosbuvir plus ribavirin therapy, even in the setting of advanced liver disease. Larger studies are needed to confirm these preliminary efficacy results.

PRIMARY FUNDING SOURCE

National Institute of Allergy and Infectious Diseases, National Institutes of Health, National Cancer Institute, and Gilead Sciences.

Extra-abdominal desmoid fibromatosis--a sarcoma unit review of practice, long term recurrence rates and survival

INTRODUCTION

Desmoid fibromatosis (DF) carries a significant morbidity and a recognised mortality. Despite this there are currently limited diagnostic or treatment algorithms specific to cases of extra-abdominal DF. Historically surgical excision has formed the cornerstone of treatment. Recently however a paradigm shift has meant many practitioners now adopt a more conservative approach, placing emphasis on active surveillance, function preserving resections, and non-surgical oncologic therapies.

METHODS

We performed an 8-year retrospective review of all cases of extra-abdominal DF managed within our region to assess the consistency of diagnostics, management and long-term outcome.

RESULTS

47 eligible cases were identified. Mean age at diagnosis was 41.3 years (1-81 years). Disease location and speciality of diagnosing practitioners were varied. Management was generally inconsistent. Variation was seen in imaging, biopsy techniques, MDT involvement and management. At a median follow up of 4.9 years our local recurrence rate was 19%.

DISCUSSION

The optimal management of DF is unknown. This has led to a lack of formalised guidance for practitioners managing this challenging condition, resulting in inconsistencies and areas for improvement in current management. We propose a diagnostic pathway which may improve consistency of care, reduce potentially unnecessary surgery and the associated morbidity, and significantly increase the rate of complete (R0) surgical resections when surgery is deemed appropriate whilst not significantly worsening oncological outcome. Specifically we propose all cases should be imaged appropriately (usually with MRI), undergo a planned biopsy (by radiologically guided core needle biopsy) and be managed centrally in conjunction with multidisciplinary sarcoma units.

Sofosbuvir and ribavirin for hepatitis C genotype 1 in patients with unfavorable treatment characteristics: a randomized clinical trial

IMPORTANCE

The efficacy of directly acting antiviral agents in interferon-free regimens for the treatment of chronic hepatitis C infections needs to be evaluated in different populations.

OBJECTIVE

To determine the efficacy and safety of sofosbuvir with weight-based or low-dose ribavirin among a population with unfavorable treatment characteristics.

DESIGN, SETTING, AND PATIENTS

Single-center, randomized, 2-part, open-label phase 2 study involving 60 treatment-naive patients with hepatitis C virus (HCV) genotype 1 enrolled at the National Institutes of Health (October 2011-April 2012).

INTERVENTIONS

In the study's first part, 10 participants with early to moderate liver fibrosis were treated with 400 mg/d of sofosbuvir and weight-based ribavirin for 24 weeks. In the second part, 50 participants with all stages of liver fibrosis were randomized 1:1 to receive 400 mg of sofosbuvir with either weight-based or low-dose 600 mg/d of ribavirin for 24 weeks.

MAIN OUTCOMES AND MEASURES

The primary study end point was the proportion of participants with undetectable HCV viral load 24 weeks after treatment completion (sustained virologic response of 24 weeks [SVR24]).

RESULTS

In the first part of the study, 9 participants (90%; 95% CI, 55%-100%) achieved SVR24. In the second part, 7 participants (28%) in the weight-based group and 10 (40%) in the low-dose group relapsed after treatment completion leading to SVR24 rates of 68% (95% CI, 46%-85%) in the weight-based group and 48% (95% CI, 28%-69%; P = .20) in the low-dose group. Twenty individuals participated in a pharmacokinetic-viral kinetic substudy, which demonstrated a slower loss rate of infectious virus in relapsers than in participants who achieved SVR (clearance, 3.57/d vs 5.60/d; P = .009). The most frequent adverse events were headache, anemia, fatigue, and nausea. There were 7 grade 3 events including anemia, neutropenia, nausea, hypophosphatemia, and cholelithiasis or pancreatitis. No one discontinued treatment due to adverse events.

CONCLUSION AND RELEVANCE

In a population of patients with a high prevalence of unfavorable traditional predictors of treatment response, a 24-week regimen of sofosbuvir and weight-based or low-dose ribavirin resulted in SVR24 rates of 68% and 48%, respectively.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01441180.

Sources of variation of Escherichia coli concentrations in bivalve molluscs

Bivalve molluscs can concentrate contaminants, including pathogenic microorganisms, from the water column during their normal filter-feeding activity. In the European Union, the risk of human and animal faecal contamination in bivalves is estimated by determining the concentration of Escherichia coli in time-series samples from production areas. A structured field study was undertaken to determine the extent to which such concentrations varied between sites, sampling occasions and shellfish species and to determine the residual variability of the method. E. coli was enumerated in three species of bivalve mollusc (Crassostrea gigas, Mytilus spp. and Pecten maximus) co-located in each of three geographically separate commercial shellfisheries. The data were subjected to analysis of variance (ANOVA). This showed that the effects of site, sampling occasion, species and site/sampling occasion interaction were all significant. The proportion of variation due to site was markedly greater than that due to other factors. Post-ANOVA analysis showed that the concentration of E. coli in P. maximus was significantly higher than in the other two species. Mytilus spp. and C. gigas exhibited comparable levels of E. coli. The observed standard deviation of the most probable number method in the study was 0.33 log(10).

Effect of HIV on liver fibrosis among HCV-infected African Americans

Degree of liver fibrosis largely determines treatment urgency for hepatitis C virus (HCV). This retrospective study examined fibrosis stages and predictive factors in African Americans with HCV monoinfection and human immunodeficiency virus (HIV)/HCV coinfection. Nearly 50% of patients had early-stage fibrosis in the study, despite the long duration of infection in many patients. HIV was associated with the early fibrosis group. These results indicate that a large proportion of patients with HCV infection, including those with HIV, could possibly await more-effective and better-tolerated treatment.

Decitabine for Acute Myeloid Leukemia in a Patient Undergoing Hemodialysis

Treatment of patients with Acute Myeloid Leukemia (AML) undergoing hemodialysis is especially challenging since there are no specific management guidelines for the administration of cytotoxic agents in these patients. Well established chemotherapy protocols may be unsuitable in such cases because of altered drug pharmacokinetics, increased risk for complications, and underlying co-morbidities. In addition, these patients are at an increased risk for complications such as tumor lysis syndrome. Herein, we report the first use of decitabine in a patient on hemodialysis. He presented with a new diagnosis of AML and achieved hematologic remission following the use of induction chemotherapy and maintenance decitabine.