Genotype does not affect pattern of HCV RNA decrease among responders during interferon treatment of chronic hepatitis C. Consensus Interferon Study Group

We assessed differences in the pattern of HCV RNA decrease for HCV genotypes 1, 2, and 3 during interferon treatment to determine if the lower response rates observed among genotype 1 patients were related to a slower decrease in HCV clearance. Serum HCV RNA values of 472 chronic hepatitis C patients treated with either consensus interferon (CIFN) or interferon alfa-2b (IFN alfa-2b) were evaluated. Neither virological sustained responders nor relapsers differed in the pattern of serum HCV RNA decrease based on genotype. Virological sustained responders infected with genotype 1 cleared HCV RNA as rapidly as sustained responders who were infected with genotype 2 or 3. Relapsers had a slower rate of serum HCV RNA decrease than did virological sustained responders. Nonresponders differed in the pattern of serum HCV RNA decrease based on genotype: HCV genotype 3 patients had the greatest decrease in serum HCV RNA; genotype 2 patients had an intermediate decrease; and genotype 1 patients had the least serum HCV RNA decrease. HCV genotype 1 patients treated with CIFN had a greater decrease in serum HCV RNA during therapy than did patients treated with IFN alfa-2b. However, there was no difference in the magnitude of serum HCV RNA decrease between the two interferon treatments for patients infected with genotype 2 or 3. In summary, both genotype and ultimate response to treatment are determinants of the pattern and rate of serum HCV RNA change during interferon therapy of chronic hepatitis C.

Biochemical and viral response to consensus interferon (CIFN) therapy in chronic hepatitis C patients: effect of baseline viral concentration. Consensus Interferon Study Group

OBJECTIVE

The effect of baseline viral concentration on response was assessed as part of a multicenter phase 3 trial evaluating the safety and efficacy of CIFN therapy for chronic HCV infection.

METHODS

Patients (n = 472) received either CIFN 9 microg or IFN alpha-2b 3 MU subcutaneously t.i.w. for 24 wk, followed by 24 wk of observation.

RESULTS

Efficacy was assessed by the percentage of patients who achieved normal ALT values or undetectable HCV RNA values (using RT-PCR with a sensitivity of 100 copies/ml). There was a clear relationship between baseline viral concentration and either ALT or HCV RNA response; patients with lower titer HCV RNA had better response rates. End-of-treatment HCV RNA responses were better for patients with low viral concentrations treated with CIFN (51%) than for patients treated with IFN a-2b (31%) (p = 0.03). ALT responses in patients with low viral concentrations were 60% for CIFN-treated patients and 27% for IFN alpha-2b-treated patients (p < 0.01) at the end of treatment. Patients with high titer HCV RNA were more likely to have a sustained HCV RNA response after treatment with CIFN 9 microg, compared with those treated with IFN alpha-2b (7% vs 0%, p = 0.03).

CONCLUSIONS

Both genotype and baseline viral concentration were independent factors that affected response to interferon.

Utility of hepatitis C virus serotypes in predicting response to treatment of chronic hepatitis C. Consensus Interferon Study Group

Hepatitis C virus (HCV) genotyping has been shown to predict response to interferon, but is expensive. HCV serotyping is less expensive and simpler, and may be similarly useful. Using data from a large, randomized trial comparing consensus interferon (CIFN) and interferon alfa-2b (IFN alfa-2b) in patients with chronic HCV, we evaluated response rates based on HCV serotypes versus genotypes. Patients included in this analysis received subcutaneous injection of 9 microg CIFN (n = 232) or 3 MU IFN alfa-2b (n = 240) three times weekly for 24 weeks followed by 24 weeks of observation. Serum HCV RNA concentrations were measured regularly during treatment and at the end of both the treatment and post-treatment periods. Response to interferon was similar for HCV antibody types and their corresponding genotypes. The end-of-treatment HCV RNA rate of response (defined as undetectable serum on two consecutive assessments) was 29% for serotype 1 versus 24% for genotype 1 after CIFN; and 14% versus 15%, respectively, after IFN alfa-2b. Independently of treatment, patients infected with serotype or genotype 2 or 3 had a better therapeutic response than those infected with serotype or genotype 1. Similar results were obtained based on HCV antibody typing and genotyping, suggesting the potential of the former for predicting response to interferon.

Diagnosis of crystal-induced arthritis by synovial fluid examination for crystals: lessons from an imperfect test

OBJECTIVE

Diagnosis of the crystal-induced arthritides is primarily based on microscopic identification of crystals in synovial fluid. Therefore, we aimed to estimate the operating characteristics of this test and demonstrate its clinical use.

METHODS

Medline was searched for relevant studies. Sensitivity and specificity of identification of crystals were calculated, as were measures of interobserver agreement. Likelihood ratios were calculated and curves constructed using the solutions to the Bayesian equations.

RESULTS

Four studies were identified. The rates of interobserver agreement were low; the false-negative rates in identifying calcium pyrophosphate crystals were particularly high. Only one study allowed calculation of the test operating characteristics, and this was a study that used synthetic crystals and therefore may not be directly useful in a clinical setting.

CONCLUSION

There is a paucity of data about the accuracy of crystal identification. As it is clearly not a perfectly sensitive and specific test, the most prudent diagnostic strategy, as with essentially all diagnostic tests, is to establish a posterior probability of disease from a prior probability, based on the clinical features of the patient. Determining the operating characteristics of this test in conventional and reference laboratories should be a research priority for high quality clinical research on crystal arthropathies.

Racial differences in responses to therapy with interferon in chronic hepatitis C. Consensus Interferon Study Group

The likelihood of a sustained response to a course of interferon in patients with chronic hepatitis C correlates with several clinical and viral factors, including age, viral genotype and initial levels of hepatitis C virus (HCV) RNA in serum. The role of race and ethnicity has not been assessed. We evaluated the association of race with response to interferon in a large randomized, controlled trial using either consensus interferon (9 microg) or interferon alfa-2b (3 million units) given three times weekly for 24 weeks. African-American patients participating in the study were similar to white patients in mean age (43 vs. 42 years) and baseline levels of HCV RNA (3.6 vs. 3.0 million copies/mL) but had lower rates of cirrhosis (5% vs. 12%) and more frequently had viral genotype 1 (88% vs. 66%: P =.004). Most strikingly, the rates of end-of-treatment and sustained virological responses were lower among the 40 African-American patients (5% and 2%) than among the 380 white patients (33% and 12%) (P =.04 and.07). Rates of response among Hispanic and Asian-American patients were not statistically different than non-Hispanic white patients. Median viral levels decreased by week 24 of therapy by 2.5 logs in white patients (from 3.0 to 0.012 million copies/mL) but by only 0.5 logs among African- American patients (from 3.6 to 1.8 million copies/mL). Thus, there are marked racial differences in virological responses to interferon in hepatitis C that must be considered in assessing trials of interferon therapy and in counseling patients regarding treatment. The differences in response rates are as yet unexplained.

Efficacy of interferon treatment for patients with chronic hepatitis C: comparison of response in cirrhotics, fibrotics, or nonfibrotics

Chronic hepatitis C patients (472 patients) were treated with consensus interferon (CIFN) or interferon (IFN) alfa-2b for 6 months in a large multicenter trial. Efficacy was assessed by clearance of hepatitis C virus (HCV) RNA using reverse transcription polymerase chain reaction (RT-PCR) (<100 copies/mL), normalization of serum alanine aminotransferase (ALT), and histological improvement. The purpose of these analyses was to compare these efficacy parameters in nonfibrotics, fibrotics, and cirrhotics. Patients with chronic HCV and cirrhosis showed the same benefit from IFN treatment as noncirrhotic patients when efficacy was assessed by clearance of serum HCV RNA or by histological benefit. Sustained HCV RNA response rates were similar when measured among nonfibrotic (11%), fibrotic (13%), and cirrhotic (11%) patients. Improvement in histologic activity index (HAI) scores was noted among all 3 groups. Cirrhotic patients had a lower sustained ALT response rate (12%) than did nonfibrotic patients (23%). Ninety percent of nonfibrotics, but only 71% of fibrotics and 67% of cirrhotics, who sustained a virological response normalized their ALT. This suggests that cirrhotic patients may clear the hepatitis C virus without normalization of ALT levels. The pattern of both HCV RNA clearance over time and ALT decrease was similar among nonfibrotics, fibrotics, and cirrhotics. Tolerability to IFN therapy was similar among the 3 groups except that more cirrhotics required dose reduction because of thrombocytopenia. In patients with cirrhosis, ALT levels may be a less appropriate endpoint in the measurement of response to therapy. We conclude that liver cirrhosis should not be a reason for excluding patients from therapy because both cirrhotic and fibrotic HCV patients benefit from IFN therapy not only by clearance of virus but by improvements in liver histology.

A comparison of reverse transcription-polymerase chain reaction and branched-chain DNA assays for hepatitis C virus RNA in patients receiving interferon treatment. Consensus Interferon Study Group

Measurement of hepatitis C virus (HCV) RNA may be beneficial in managing the treatment of patients with chronic HCV infection. In a phase 3 study comparing consensus interferon (IFN) and IFN-alpha2b treatment in patients with chronic HCV infection, serum samples were assayed for HCV RNA using two different assays: a quantitative multicycle reverse transcription-polymerase chain reaction (RT-PCR) method and the Quantiplex branched-chain DNA (bDNA) method. Lower and upper detection limits were 100 copies ml-1 and 5 x 10(6) copies ml-1, respectively, for the RT-PCR method, and 3.5 x 10(5) and 4 x 10(7) genome equivalents ml-1, respectively, for the bDNA method. The two assays were generally concordant over the common range of detectability. The major discrepancy was where PCR still indicated detectable virus in the sample but the bDNA result was negative. Assessment of serum samples during IFN treatment demonstrated that 37% of samples were negative for HCV RNA by bDNA but positive by RT-PCR. Differences were also noted in the quantification of baseline HCV RNA by genotype. These data suggest that HCV patients could be categorized as treatment responders by the bDNA assay when the more sensitive RT-PCR assay indicates lack of complete viral response.

Accessible dental care for children

The development of a school-based comprehensive and cost-efficient oral health care program requires careful planning centered on the needs expressed by the community. Gaining the support and the cooperation of school officials and parents creates an environment that has a significantly greater opportunity for success. Location, appropriate design of the facility and support from a local charitable organization further insure excellent access and expeditious care.

[Arterial switch: aortocoronary bypass with interposition of polytetrafluoroethylene (Gore-tex) vascular graft]

We report a case of an infant with transposition of the great arteries accompanied by an unusual coronary artery pattern, in whom an expanded polytetrafluorethylene (Gore-tex) graft to the right coronary artery was used during surgical correction (switch arterial), with a postsurgical follow-up time of 8 months.

Early hepatitis C virus-RNA responses predict interferon treatment outcomes in chronic hepatitis C. The Consensus Interferon Study Group

In previous studies employing interferons (IFNs) in the treatment of chronic hepatitis C, there have been few reliable predictors of sustained responses. We retrospectively evaluated the predictive value of hepatitis C virus (HCV)-RNA measurements in the first few months during consensus interferon (CIFN) treatment using a sensitive reverse-transcriptase polymerase chain reaction assay to determine sustained responses. Data from two large treatment trials, one of IFN-naive patients and one of retreated relapsers and nonresponders, were used, including serum samples at 2-week intervals in the naive study and 8-week intervals in the retreatment study. Patients received initial CIFN (9 microgram) treatment for 6 months and were assessed 6 months after treatment. There were 28 sustained viral responders of 232 CIFN-treated patients. Of the sustained responders, 48% had already cleared HCV RNA from serum (<100 copies/mL) by week 2, 78% by week 4, 81% by week 6, and 96% by week 12. Patients with early HCV-RNA clearance were more likely to have sustained responses than those who responded later. Early clearance of HCV from serum was also associated with greater likelihood of a sustained response to 48 weeks of retreatment with 15 microgram CIFN. Ninety-five percent of the sustained responders were HCV-RNA-negative by week 8 of retreatment. Early assessment of HCV RNA may help in the prediction of sustained responses to IFN and allow the value of continued treatment to be determined early in the course of IFN therapy.

Issues concerning the development of a competency-based assessment system for dentistry

The issue of standards of competence and assessment is central to professions. For the dental profession there have been suggestions that a change from overall competence to specific fields of competence would be a more suitable mechanism to assess whether an individual was competent. This paper examines the implications of such proposed changes and highlights several key issues, answers to which need to be provided prior to adopting new proposals. Failure to do so may well provide additional problems without addressing shortcomings in the present system.

[Double-outlet left ventricle with subaortic interventricular defect and pulmonary stenosis: surgical correction with cryopreserved aortic homograft]

Double outlet left ventricle with subaortic ventricular septal defect and pulmonary stenosis is a very rare congenital heart disease. We present a case of this cardiopathy which underwent correction consisting of ventricular septal defect closure and right ventricular outflow tract reconstruction using a cryopreserved aortic homograft, with a postsurgical follow-up time of 18 months.

[Familial auricular fibrillation]

INTRODUCTION AND OBJECTIVE

We present two families with atrial fibrillation in 20 of 50 members, during three generations, with known cardiac rhythms, in order to communicate their infrequent existence and the most relevant clinical facts.

METHOD

Clinical situation, evolution, ECG and ECHO findings, treatments and complications related with the disease are investigated.

RESULTS

The presence of atrial fibrillation in 20 members is demonstrated, although one of them was on sinus rhythm at the time of the study; 3 patients had left ventricular enlargement on the ECHO study; the clinical situation was good in all patients except two who died because of complications related to the arrythmia and a third patient that had a brain stroke. The patients received different treatments because they where controlled by different physicians; the possible lethal proarrythmic effect in such cases must be taken into account.

CONCLUSION

Familiar atrial fibrillation is a very infrequent arrythmia, usually well tolerated, that follows a dominant autosomic hereditary pattern. The use of antiagregants is advised because of the risk of embolism, or the use of anticoagulants in the presence of associated risk factors. Electric cardioversion has been show not be useful. The possible proarrythmic effect of some antiarrythmic agents, used in the control of cardiac frequency, must be taken into account.

An evaluation of tumour vascularity as a prognostic indicator in uveal melanoma

Experimental and clinical evidence suggests that tumour angiogenesis plays a role in the tendency for certain neoplasms, including cutaneous melanomas, to metastasize. We evaluated whether tumour vasculature is associated with the rate of metastases in patients with melanoma of the choroid or ciliary body. The study was based on a group of 63 patients enucleated between 1976 and 1984 with paraffin-embedded tissue blocks available for sectioning and with known survival status as of December 1988. Vessel endothelial cells were highlighted with Ulex europaeus agglutinin I (UEA-I) conjugated with peroxidase. UEA-I-stained microvessels were counted at varying levels in the tumour (apex, centre and base) without knowledge of patient outcome. Patients with (n = 30) and without (n = 33) metastases had similar total vessel counts (P = 0.31). There was no evidence of greater vessel density in tumours that had metastasized, by level within the tumour. Similar results were obtained in multivariate analyses. Findings of this study suggest that tumour microvessel density is unrelated to patient survival in uveal melanoma.

Analysis of voice outcomes in pediatric patients following surgical procedures for laryngotracheal stenosis

OBJECTIVE

To evaluate long-term (> 2 years) voice function and corresponding anatomical features in children who have undergone augmentation procedures for laryngotracheal stenosis.

DESIGN

Follow-up survey assessment.

SETTING

Academic pediatric referral center.

PATIENTS OR OTHER PARTICIPANTS

The families of 50 patients were contacted by mail, and completed home questionnaires. Of these 50 patients, 33 agreed to participate in a comprehensive hospital-based voice assessment, and 28 of these underwent fiberoptic endoscopy.

INTERVENTIONS

Hospital-based evaluation and parental questionnaire.

MAIN OUTCOME MEASURES

(1) Perceptual voice assessment from taped samples by using the Vocal Profile Analysis protocol performed by 3 speech and language therapists, (2) fiberoptic laryngeal endoscopy assessment performed by 3 otolaryngologists, and (3) parental assessment of voice by questionnaire. The conditions of the patients were categorized by etiology, the degree of stenosis, coexisting laryngeal lesions, and the type of surgical procedure that was done based on a review of medical records.

RESULTS

Eight of 33 patients were judged perceptually by using an amended version of the Vocal Profile Analysis scheme to have "normal" voices. In the remaining 25 patients, abnormalities were demonstrated in the parameters, including harshness (52%), whisper (36%), ventricular band phonation (21%), continuity (27%), mean pitch (27%), and falsetto voice (12%). By using endoscopy, 3 of 25 larynges were judged to be anatomically normal. Abnormalities that were found in the other patients included altered vocal fold mobility (42%), abnormal subglottis (38%), supraglottic vibration (31%), and anterior commissure blunting (31%). Supraglottic vibration corresponded with the perceptual judgment "ventricular band phonation type," and was seen in children with glottic insufficiency. Only 12% of parents indicated by questionnaire that deterioration of voice and dissatisfaction with voice function occurred after surgical procedures were performed.

CONCLUSIONS

A substantial proportion of children who have undergone laryngotracheal surgical procedures for stenosis demonstrate chronic voice and endoscopic abnormalities. The effects of these surgical procedures and preexisting laryngeal abnormalities on voice continue to be difficult to establish in the pediatric population. Careful management by speech and language therapists who are familiar with such children is essential for optimal voice function.

Cachectic effect of ciliary neurotrophic factor on innervated skeletal muscle

Recombinant human ciliary neurotrophic factor (rh-CNTF) was reported to attenuate skeletal muscle wasting in rats after unilateral transection of the sciatic nerve (M. E. Helgren, S. P. Squinto, H. L. Davis, D. J. Parry, T. G. Bolton, C. S. Heck, Y. Zhu, G. D. Yancopoulos, R. M. Lindsay, and P. S. DiStefano. Cell 76: 493-504, 1994). Under the experimental conditions reported herein, the absolute masses of the denervated gastrocnemius and soleus muscles were not increased in mature or immature rats of either sex by treatment with rhCNTF. At the highest doses of rhCNTF (1 and 0.1 mg/kg), increases in the ratio of the masses of the denervated to the contralateral innervated gastrocnemius and soleus muscles could be attributed entirely to a muscle-wasting effect on the contralateral innervated muscle rather than any muscle-sparing effect on the denervated muscle. The muscle-wasting effects of rhCNTF were associated with reductions in body weight gain and reduced food intake. Pair-fed rats lost less body weight and skeletal muscle mass than rhCNTF-injected freely fed rats but experienced significantly greater loss of visceral mass. Male rats displayed greater loss of body weight and skeletal muscle mass than female rats. Recombinant inhibitors of the cachectic cytokines, tumor necrosis factor and interleukin-1, did not significantly alter the wasting effects of rhCNTF. These findings demonstrate that, in contrast to its well-characterized trophic effects on cells of the nervous system, rhCNTF causes atrophy of skeletal muscle by mechanisms involving both anorexia and cachexia based on the results of pair-feeding experiments.

[Doppler echocardiography in the postoperative assessment of the arterial switch in the repair of transposition of the great arteries and double outlet right ventricle]

OBJECTIVE

To evaluate the usefulness of Doppler-echocardiography in the follow-up of anatomical repair in transposition of great arteries and double outlet of right ventricle.

PATIENTS AND METHODS

108 Doppler-echo studies, in a follow-up protocol of the first 32 consecutive patients who successfully passed anatomical repair, were analyzed. The mean age for operation was 50 days (6-472 days) (25 patients before 21 days of age) with a mean follow-up time of 406 days (1 day-4.5 years). We studied subjective impression of left ventricular function and its quantification by systolic shortening fraction, the functioning of four heart valves; diagnosis and quantification of stenosis in arterial sutures of neoaorta and neopulmonary, the most useful windows and planes and, finally, the difficulties found during the examination.

RESULTS

Thirteen patients (41%) showed a low left ventricular shortening fraction, though 85% of these patients had anomalous ventricular septal motion. Neoaortic valve insufficiency was detected in 12 patients (37%) (mild in 10 and moderate in 2) and neopulmonary valve regurgitation in 14 patients (44%) (mild in 11 and moderate in 3). Stenosis of arterial sutures was detected in: 2 (6%) patients at neopulmonary artery and 1 (3%) at neoaortic artery. The biggest technical difficulty was found in the neopulmonary artery evaluation.

CONCLUSIONS

1) Doppler echocardiography is an excellent method for anatomical and functional evaluation in these patients and is necessary in their follow-up evaluations; 2) Surgical results obtained in this series are good; 3) Left ventricle fractional shortening is misleading in the evaluation of ventricular function in these patients because of the high incidence of abnormal ventricular septal motion, and 4) The study of neopulmonary arteries is often very difficult.

Psychopharmacologic treatment of negative schizophrenic symptoms

Diverse pharmacologic agents have been reported to be effective in treating negative schizophrenic symptoms (NSS). In light of this large and growing literature, as well as of reconceptualizations of the underlying pathophysiology of NSS, the time may have come to reject models that assume "irreversibility" of NSS. However, flaws in existing studies prevent closure regarding the reversibility of, and by inference the treatability of, NSS. Guidelines for future studies are articulated, e.g., the need to distinguish primary from secondary NSS, to include drug-free subjects with a predominance of NSS in clinical trials, and to use well-validated and psychometrically sound instruments for assessing NSS.

Dystrophic calcification of silicone scleral buckling implant materials

In six patients, removal of solid silicone scleral buckling implant materials that had been in place between eight and 21 years disclosed gray-white deposits firmly adherent to the silicone. Four of the six patients had culture-proven infections, whereas two had no evidence of infection and had negative cultures. One of these two patients, however, had intermittent pain, which was the indication for removal of the implant. Analysis of the deposits disclosed that they were calcium phosphate. The exact mechanism responsible for the calcification on the silicone material is unknown. Dystrophic calcification can occur without infection in injured tissue wherein extracellular deposits of devitalized cells, blood cells, and lipids may act as a nidus for calcification. In the presence of infection, bacteria may serve as such a nidus. Additionally, it is possible that biofilm produced by the bacteria had a role in the deposition of calcium phosphate, as well as in its firm adhesion to the silicone materials. We considered the possibility of similar deposits developing on intraocular silicone lenses.