The impact of peginterferon alfa-2a plus ribavirin combination therapy on health-related quality of life in chronic hepatitis C

BACKGROUND/AIMS

Peginterferon alfa-2a plus ribavirin improves sustained virological responses compared with interferon alfa-2b and ribavirin, or peginterferon alfa-2a alone in chronic hepatitis C. We examined the impact of these treatments on health related quality of life (HRQOL).

METHODS

Patients (n=1121) were randomized to peginterferon alfa-2a weekly plus ribavirin or placebo, or interferon alfa-2b thrice weekly plus ribavirin. HRQOL was assessed with the SF-36 Health Survey and Fatigue Severity Scale (FSS).

RESULTS

Patients receiving peginterferon alfa-2a plus ribavirin reported better HRQOL than those receiving interferon alfa-2b plus ribavirin. These differences were statistically significant for three SF-36 domains and both FSS scores (p<=0.05). Patients receiving peginterferon alfa-2a plus placebo had the least impairment; adding ribavirin significantly decreased five domains of the SF-36 and both FSS scores. Sustained virological response was associated with improvement at follow-up on all SF-36 and FSS scores.

CONCLUSIONS

The effects of combination therapy on HRQOL and fatigue are less with peginterferon alfa-2a plus ribavirin than interferon alfa-2b plus ribavirin. Each medication in combination therapy with interferon and ribavirin, affects patients' quality of life differently. Understanding the relationship of specific therapeutic options to HRQOL may help physicians minimize the impact of therapy on HRQOL.

Leishmaniasis in patients with chronic renal failure: a diagnostic and therapeutic challenge for the clinician

BACKGROUND

The role of leishmaniasis in dialyzed or transplanted patients for chronic renal failure is generally neglected. In this study, the authors present a series of three cases of leishmaniasis (one visceral, one mucous and one muco-visceral) in patients with end-stage renal failure characterized by an atypical presentation and/or resistance to therapy.

CASE DESCRIPTION

Two patients had an atypical infection: the first patient demonstrated a mucosal form, while the second had visceral and mucosal involvement. These two presentations are very rare and, to the best of our knowledge, other autoctonous disease cases have never been described in Italy. In the first patient, a cycle of oral itraconazole was scarcely effective and poorly tolerated, while treatment with 15% topical paromomycin sulfate was successful. Patients two and three failed to respond to meglumine antimonate and amphotericin B lipid complex. A second cycle with liposomal amphotericin B was effective in both cases. In addition, a superior safety profile for liposomal amphotericin B in comparison with the lipid complex amphotericin B was observed.

CONCLUSIONS

These three cases highlight the problem of leishmaniasis in both renal transplanted and dialyzed patients and suggest that this infection could be far from infrequent in addition to being resistant to therapies. Leishmaniasis should be considered in the differential diagnosis of fevers of unknown origin and mucosal lesions in these patients, even in countries not at risk for mucosal leishmaniasis.

Cutaneous injection site reactions to long-term therapy with enfuvirtide

OBJECTIVE

Enfuvirtide is the first of a new class of antiretroviral agents. The drug is safe and well tolerated; injection site reactions are the most common adverse events. The aim of this study was the clinical and histopathological evaluation of injection site reactions in patients treated for 80 weeks.

MATERIALS AND METHODS

Six patients were evaluated. Five of them underwent cutaneous biopsies using a 4 mm punch. Sections were stained with haematoxylin-eosin, periodic acid-Schiff stain and Verhoeff's stain. Moreover, immunohistochemical studies were carried out using CD20, CD45Ro and CD34 antibodies.

RESULTS

Four different macroscopic patterns were presented: (a) no evidence of cutaneous lesions; (b) transient infiltrative lesions which auto-resolved within 24 h; (c) transient nodular lesions which auto-resolved within 7-15 days; and (d) stable lesions after more than 30 days with a scleroderma-like aspect. Histological examination showed three patterns: (1) an acute urticaria/vasculitis-like pattern with inflammation of the fat tissue; (2) a sub-acute pattern with an initial dermal sclerosis; (3) a chronic scleroderma-like pattern with connective tissue disposed around the adnexa, whose structure was intact. The immunohistochemical study evidenced a prevalence of T lymphocytes and a moderate neoangiogenesis.

CONCLUSIONS

In our experience, after a rather long period of treatment, cutaneous reactions comprised a variety of features largely independent of the virological and immunological outcome. The adnexa was unaltered in all patients, this indicating a tendency to a possible regression of the sclerotic lesions. Therefore, patients should be encouraged to rotate the sites of injection thus permitting the tissues to regenerate.

In vitro productive infection of non polarised cervical and rectal biopsies by syncytium-inducing and non syncytium inducing primary HIV-1 isolates

An in vitro model was used to study the transmission of HIV-1 primary isolates with different biological phenotype to cervical and rectal non polarised bioptic fragments. The method described allowed the productive infection of both cervical and rectal tissues and the virus produced could be propagated onto peripheral blood mononuclear cell cultures. Syncytium-inducing and non-syncytium inducing viral isolates were equally able to produce infection and replication.

Stability of the iterative solutions of integral equations as one phase freezing criterion

A recently proposed connection between the threshold for the stability of the iterative solution of integral equations for the pair correlation functions of a classical fluid and the structural instability of the corresponding real fluid is carefully analyzed. Direct calculation of the Lyapunov exponent of the standard iterative solution of hypernetted chain and Percus-Yevick integral equations for the one-dimensional (1D) hard rods fluid shows the same behavior observed in 3D systems. Since no phase transition is allowed in such 1D system, our analysis shows that the proposed one phase criterion, at least in this case, fails. We argue that the observed proximity between the numerical and the structural instability in 3D originates from the enhanced structure present in the fluid but, in view of the arbitrary dependence on the iteration scheme, it seems uneasy to relate the numerical stability analysis to a robust one-phase criterion for predicting a thermodynamic phase transition.

Re-treatment of patients with anti-HBe-positive chronic hepatitis B who relapsed after an initial course of lamivudine

AIM

To evaluate the efficacy of a long-term course of lamivudine monotherapy in patients with anti-HBe-positive chronic hepatitis B who relapsed after the first course of either lamivudine/interferon (n = 16; Group 1) or lamivudine (n = 20; Group 2).

METHODS

Biochemical and virological tests were performed every 3 months. At baseline and breakthrough, the region coding for the YMDD amino acid motif was sequenced.

RESULTS

The length of re-treatment averaged 24 months. The virological response peaked at 6 months (94.4%), and declined to 66.7% and 50% at 12 and 24 months, respectively. The rates of breakthrough were 2.9%, 31.4% and 48.6% at 6, 12 and 24 months, respectively. By the second year, responders amounted to 62.5% and 40% in Groups 1 and 2, respectively (P = 0.10). The 18 responders at month 24 are still on therapy after 25-51 months of treatment: 14 still maintain a response, nine from Group 1 and five from Group 2.

CONCLUSIONS

Re-treatment with lamivudine can control viral replication. This effect is maintained for the initial 12 months in two-thirds of patients, but afterwards the duration of response lessens due to the development of viral resistance.

Correlates of HIV-1 shedding in cervicovaginal secretions and effects of antiretroviral therapies

OBJECTIVES

To evaluate the determinants of HIV-1 RNA shedding in cervicovaginal secretions and the effects of antiretroviral therapy in a group of infected women.

METHODS

A total of 122 women from whom paired peripheral blood and cervicovaginal lavage samples were available were enrolled in the study. HIV-1 RNA was quantified in the plasma and cell-free fraction of cervicovaginal lavages by the nucleic acid sequence-based amplification assay (lower limit of detection 80 copies/ml).

RESULTS

Seventy-one per cent of the women had detectable viral load in the cervicovaginal lavage and this appeared to be correlated to plasma viral load and to the degree of immunodeficiency as expressed by the absolute number of CD4 cells. Antiretroviral-treated patients had a lower risk of shedding the virus in the genital tract, but this association was limited to patients treated with highly active antiretroviral therapy (HAART). However, in 25% of women with undetectable plasma viral load, a genital shedding of the virus was demonstrated.

CONCLUSION

Plasma viral load may fail as a marker of infectivity of genital secretions. HAART treatment seems to be more efficacious in suppressing viral shedding at the genital level. The female genital tract represents a distinct compartment for HIV-1 replication/evolution.

[Opinions and attitudes of youngsters about sexually transmitted diseases]

A group of 1.085 students (582 M, 503 F) attending high school (742) and nursing school (343) filled in an anonymous questionnaire on their sexual habits and their knowledge of contraception and sexually transmitted diseases. Overall, 57% of the study population had already a complete sexual intercourse at a mean age of 16,4 (SD +/- 1,8). 74% had 1-3 sexual partners, whereas 28% had more than 3. All students affirmed that it was possible to prevent sexually transmitted diseases and 92,6% indicated correct methods. However 10% of students did not know that AIDS is transmitted sexually as 47% hepatitis B. The responses made by nursing students were more correct that those of high school students.

HIV-1 phenotypic susceptibility to lopinavir (LPV) and genotypic analysis in LPV/r-naive subjects with prior protease inhibitor experience

The relationship between phenotypic susceptibility to lopinavir (LPV) and genotypic pattern was investigated in LPV-naive, protease inhibitor (PI)-experienced subjects. Protease sequences of 100 HIV isolates with ascertained susceptibility (determined by Antivirogram) to LPV were analyzed (VircoGen). Two different thresholds (2.5- and 10-fold) were used for defining reduced susceptibility. Mutations were classified as LPV/r (the actual formulation of LPV that combines LPV with low-dose ritonavir) mutations according to the International AIDS Society-USA. Thirty-four isolates showed reduced LPV susceptibility (2.6- to 75.9-fold). Fold resistance to LPV correlated with the number of total and LPV/r mutations (Spearman coefficient = 0.62 and 0.74, respectively; P < 0.001). Current PI therapy (P = 0.002) and indinavir administration (P < 0.001), >5 LPV/r mutations (P < 0.0012), and detection of L10FIRV, K20MR, M46IL, I54VL, A71VT, G73SA, V82AFTS, I84V, and M90L were associated with LPV resistance in univariate analysis. Factors independently associated with LPV resistance were K20MR (odds ratio [OR], 13.9; 95% confidence interval [CI], 1.3-145.1; P = 0.028), I54VL (OR, 131.7; 95% CI, 10.5-1654.7; P < 0.001), G73SA (OR, 19.2; 95% CI, 1.4-273.7; P = 0.029), and I84V (OR, 177.5; 95% CI, 6.0-5232.5; P = 0.003) mutations and >9 protease mutations (OR, 18.6; 95% CI, 1.6-213.0; P = 0.019). Sixteen of 34 and 18 of 34 isolates with reduced LPV susceptibility showed >10-fold or <10-fold LPV resistance, respectively. Linear regression analysis demonstrated that each additional LPV mutation and I54VL accounted for much of the fold resistance to LPV (adjusted R2 = 0.70). In conclusion, for PI-experienced patients requiring salvage therapy, switching to LPV should be based on the number of baseline mutations and the presence of mutation 54.

Mutational patterns of paired blood and rectal biopsies in HIV-infected patients on HAART

Blood and concurrent rectal biopsy samples of human immunodeficiency virus type 1 (HIV-1)-positive highly active antiretroviral therapy (HAART)-treated patients were tested for genotypic resistance by direct sequencing of reverse transcriptase (RT) and protease (PR) regions to compare the patterns of resistance in these compartments. Fourteen subjects (five with undetectable plasma viral load (pVL) and nine persistently viremic) were studied. Four of five patients with undetectable pVL also had undetectable mucosal HIV RNA; sequence analyses from proviral DNA (PBMCs and rectal biopsy) were obtained with none or few resistance-associated mutations and no alteration of susceptibility profile. All viremic patients, and one with negative pVL, had detectable levels of mucosal HIV RNA (1.93-4.21 log(10) copies/mg); sequences of HIV RNA (plasma and/or rectal biopsy) were also obtained, and multiple mutations generally compatible with current/past medications were detected. Overall, 40 HIV-1 PR and 42 RT sequences were analyzed, yielding a total of 42 PR and 47 RT sequence pairs (plasma/tissue-RNA; plasma-RNA/tissue-DNA; PBMC/tissue-DNA; tissue-DNA/RNA; tissue-RNA/PBMC-DNA; PBMC-DNA/plasma-RNA), which almost always differed at the total amino acid level (median percentage discordance 8.08% in the PR, 4.8% in RT). The median percentage of resistance position discordance equaled 88.8% (IQR = 20-100) in the PR and 74.55% (IQR = 31.75-100%) in the RT pairs, respectively. Different resistance levels were detected by means of a computer-assisted interpretation of mutational profiles. The results support the multiform evolution of HIV genotype in various body compartments and emphasize the participation of intestinal mucosa in HIV genotype selection. Samples from diverse tissues should be used for resistance evaluation to obtain a complete picture of drug resistance for antiretroviral-treated patients.

Population-based survival after childhood lymphoblastic leukaemia in time periods corresponding to specific clinical trials from 1979 to 1998--a report from the Childhood Cancer Registry of Piedmont (Italy)

This study evaluated the outcome after childhood acute lymphoblastic leukaemia (ALL) in a population aged 0-14 years served by the Childhood Cancer Registry of Piedmont (CCRP) during the accrual periods to nationwide clinical studies run by the Italian Association for Paediatric Haematology and Oncology (AIEOP). In the time period considered (March 1979-December 1998) the CCRP recorded 498 incident cases of ALL. The living status on 31 December 2000 was known for 497 cases. Overall survival at 5 years was 74.1% standard error (S.E.) 2.0%). It increased from 58.6% (S.E. 4.9%) for cases diagnosed in March 1979-July 1982 to 87.3 (S.E. 3.6) in May 1995-December 1998. Results observed from data in our population-based study in Piedmont were similar to those presented in the nationwide clinical trials. Survival was better (statistically significant) for children aged 1-4 years, with a white blood cell (WBC) count lower than 10 000 x 10(3) cells/litre and for B-precursor ALL. Differences by immunophenotype were statistically significant only in the univariate analyses. Girls showed a non-statistically significant survival advantage over boys. Results of the present study show the impact on the population of recent clinical trials and emphasise the role of population-based cancer registries in evaluating childhood cancer care delivery in a given population.

Newly Diagnosed HIV-1 Infections in Pregnancy: Evidences from a Cohort Study in South-Eastern Italy

The authors report and discuss the characteristics of 22 women who discovered their HIV seropositivity while pregnant. Most of the women had never been tested for HIV and this occurred not only for 'not at risk' women but also for sexual partners of HIV-infected men. Several infections were diagnosed late in pregnancy when most women were already immunodeficient. An implementation of HIV prenatal testing as an early standard clinical practice, should be promoted in all women, regardless of the presence of risk factors.

Natural course of acute hepatitis C: a long-term prospective study

BACKGROUND

Acute hepatitis C has a high chronicity rate which appears to be significantly reduced by early antiviral treatment. However, it is unclear if all acutely infected patients should be treated, and when. In this prospective study, patients with a well-documented diagnosis of acute hepatitis C were evaluated to define the natural course, the rate of chronicity, and host and virus-related factors which might predict a self-limiting or chronic evolution requiring early antiviral treatment.

METHODS

From 1995 to 2000, 40 consecutive patients with a community-acquired AHC were enrolled. Liver tests, anti-hepatitis C virus antibodies and hepatitis C virus RNA levels were monitored. Median follow-up was 35 months (range 12-68).

RESULTS

A total of 24/40 patients had symptomatic disease including 20 with jaundice; 13/40 patients had prompt serum hepatitis C virus RNA clearance and ALT normalisation within 12 weeks; in 12/13 patients this pattern remained unchanged during follow-up. Overall, 27/40 patients remained hepatitis C virus RNA positive with fluctuating ALT levels. Older age and jaundice were predictive of resolution whereas there was no correlation with other host factors, viral genotype or viral load.

CONCLUSIONS

Our data demonstrate that spontaneous resolution can occur in about 30% of AHC patients. This favourable outcome rarely occurs in patients with anicteric AHC or in those with jaundice but with persistent viremia for more than 12 weeks from onset; early antiviral treatment for these patients may avoid or reduce chronicity.

Survival trends of childhood cancer during the period 1978-1994 in Italy: a first report from the Italian cancer registries

This article shows the survival trends of childhood cancers diagnosed from 1978 to 1994 in Italy. A first analysis presents a survival increase for all the diagnostic categories and in both sexes, with the exception of Hodgkin's disease, for which five-year survival is stable at 97%. The results of this analysis show that five-year survival changes from 54% to 72% for all cancers, from 56% to 70% for non Hodgkin's lymphomas, from 53% to 64% for central nervous system tumours, from 59% to 78% for acute lymphatic leukaemia, from 18% to 42% for acute non lymphatic leukaemia, from 30% to 62% for neuroblastoma and from 33% to 71% for malignant bone tumours. Concerning international comparisons, the overall Italian rates and their increases are very similar to the USA ones. Instead, if we consider a comparison between survival trends in Italy and survival trends observed in some European countries, like Great Britain, Slovakia and Denmark, it is evident that in Italy there is a faster improvement of prognosis for almost all diagnostic categories.

Survival analysis of childhood tumours: data from the Italian cancer registries

This study shows the childhood cancer survival rates of 1,315 cases incident in the 1990-1994 period in Italy. The observed survival shows an increase over the previous period in almost all diagnostic groups. In particular, 5-year survival attained 72% overall, 78% for acute lymphatic leukaemia, about 100% for Hodgkin's disease, 70% for non Hodgkin's lymphomas, 64% for central nervous system tumours, 87% for retinoblastoma, 80% for renal tumours, 67% for hepatic tumours, 71% for bone tumours, and 70% for soft tissue sarcomas. Finally, the findings are comparable to those in other countries (USA, Great Britain, Australia, Slovakia) and they show a progressive improvement in survival.

Lamivudine/interferon combination therapy in anti-HBe positive chronic hepatitis B patients: a controlled pilot study

BACKGROUND/AIMS

In this study, lamivudine-interferon (LAM/IFN) combination therapy was compared to LAM monotherapy to verify if the combination treatment might improve efficacy and reduce the emergence of LAM-resistant mutants.

METHODS

Fifty patients with anti-HBe-positive chronic hepatitis B were treated for 12 months with LAM at 100mg/day (26 pts) or with IFN at 5MU t.i.w.+LAM 100mg/day (24 pts). Serum ALT, HBV DNA and IgM anti-HBc were monitored during treatment and a 6-month follow-up. The polymerase gene was amplified by PCR and the region coding for YMDD motif was directly sequenced.

RESULTS

All patients normalized ALT and cleared HBV DNA during treatment. The response was maintained until the end of therapy in the LAM/IFN group, while in 5/26 initial responders treated with LAM alone, a virological and biochemical breakthrough was observed after 6-10 months, and selection for YMDD variants resulted. After therapy discontinuation, most patients relapsed; the response rate after 6 months was 17% in the LAM/IFN group and 19% in the LAM group.

CONCLUSIONS

In anti-HBe-positive chronic hepatitis B, a 12-month course of LAM/IFN combination therapy is as beneficial as LAM monotherapy, however, the combination regimen appeared to prevent or delay the emergence of YMDD variants.

Evaluation of a rapid immunochromatographic test for serodiagnosis of visceral leishmaniasis

The purpose of this study was to compare the performance of a rapid immunochromatographic dipstick test for the qualitative detection of circulating antibodies to the leishmanial recombinant antigen K39 with that of a classical immunofluorescent antibody test for serodiagnosis of visceral leishmaniasis. Sera from 143 Italian subjects, including 69 patients with clinically suspected visceral leishmaniasis, 23 patients with hypergammaglobulinemia and 51 healthy controls, were tested. The immunochromatographic test was performed according to the manufacturer's instructions, using antigen-impregnated nitrocellulose paper strips. The immunofluorescent antibody test was performed according to an established method, using promastigotes of Leishmania infantum zymodeme Montpellier 1 as antigen. In 11 patients, diagnosis of active Leishmania infection was established by microscopic examination of biopsy samples and/or clinical response to meglumine antimoniate. Results of the two tests correlated for all but two sera examined. In two patients, one with proven infectious mononucleosis and one with bacterial pneumonia, the immunofluorescent antibody test was positive and the dipstick test was negative. In the restricted sample of patients in whom a definitive diagnosis was established, the immunochromatographic test was positive in 11 of 11 patients with confirmed Leishmania infection and negative in 103 of 103 subjects who either had other documented diseases or were healthy controls, showing 100% sensitivity and 100% specificity.