Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Abstract P4-13-26: Efficacy, safety, and treatment decision-making in the AVANTI German observational study of first-line bevacizumab (BEV)-containing therapy for locally advanced, recurrent, or metastatic breast cancer (aBC)

Background: In Europe, BEV is approved as first-line therapy for metastatic breast cancer in combination with either paclitaxel (PAC) or capecitabine (CAP).

Methods: The ongoing multicenter non-interventional AVANTI study aims to determine the safety and efficacy of first-line BEV–PAC or BEV–CAP in the context of routine oncology practice in Germany and to assess selection criteria that influence therapy choice. Eligible patients (pts) have previously untreated aBC and no contraindications for BEV. Chemotherapy schedule, diagnostics, and frequency of follow-up visits are at the physician's discretion. Data are collected for 1 year after the start of BEV, with 6-monthly follow-up for 1.5 years after the end of documented observation or BEV discontinuation, whichever occurs first.

Results: Between Oct 2009 and Feb 2015, 2168 pts treated at 331 German centers received BEV–PAC (N=1774) or BEV–CAP (N=394). The most common reasons driving treatment choice were efficacy (66% BEV–PAC, 60% BEV–CAP), guidelines (55% BEV–PAC, 50% BEV–CAP), and tolerability (40% BEV–PAC, 45% BEV–CAP). Compared with pts receiving BEV–PAC, the BEV–CAP subgroup included relatively fewer pts with ≥3 metastatic sites, visceral metastases, and stage IV disease at diagnosis, and relatively more pts with triple-negative aBC (TNBC) and prior (neo)adjuvant chemotherapy. At the time of data cut-off for this interim analysis (Mar 1, 2015), median duration of observation was 10.8 months (range <0.1–47.5). BEV was typically continued for longer than chemotherapy (median 5.9 months [95% CI 5.6–6.3] vs 4.6 months [95% CI 4.4–4.9], respectively). Among pts with hormone receptor-positive disease, only 9% received concurrent endocrine therapy with BEV. The most common reason for stopping treatment was disease progression (483 of 1529 [32%] who had stopped BEV–PAC; 157/345 [46%] who had stopped BEV–CAP). At data cut-off, 1245 pts (57%) had experienced a PFS event. Median PFS was 10.1 months (95% CI 9.6–10.7) overall, 10.7 months (95% CI 10.1–11.3) for BEV–PAC, and 8.1 months (95% CI 6.6–9.0) for BEV–CAP. Median PFS in clinically important subgroups was: TNBC 7.1 months (95% CI 6.2–8.0); ≥3 metastatic sites 9.7 months (8.7–11.2); anthracycline- and/or taxane-pretreated 9.2 months (8.5–9.9); ≥65 years old 9.9 months (9.1–10.7). Safety was consistent with the well-established safety profiles of the two regimens. Grade ≥3 adverse events occurred in 17% of pts (16% BEV–PAC, 18% BEV–CAP). There were no new safety signals.

Conclusions: Interim results of this large non-interventional study indicate that first-line BEV-containing regimens represent an active and well-tolerated therapy option for aBC. Data collection in non-inferiority studies based on routine clinical practice typically differs from that in prospective clinical trials. Nevertheless, these results from AVANTI suggest that the efficacy and tolerability of BEV–PAC and BEV–CAP seen in the E2100, RIBBON-1, and TURANDOT trials can be replicated in routine oncology practice. Further analyses focusing on the incidence, management, and potential risk factors for elevation of blood pressure are ongoing.

Citation Format: Müller V, Jakob A, Aktas B, Grafe A, Fett W, März W, Bruch H, Pott D, Klare P, Boller E, Kiewitz C, Schneeweiss A. Efficacy, safety, and treatment decision-making in the AVANTI German observational study of first-line bevacizumab (BEV)-containing therapy for locally advanced, recurrent, or metastatic breast cancer (aBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-26.

Human retroelements may introduce intragenic polyadenylation signals

In the human genome, the insertion of LINE-1 and Alu elements can affect genes by sequence disruption, and by the introduction of elements that modulate the gene's expression. One of the modulating sequences retroelements may contribute is the canonical polyadenylation signal (pA), AATAAA. L1 elements include these within their own sequence and AATAAA sequences are commonly created in the A-rich tails of both SINEs and LINEs. Computational analysis of 34 genes randomly retrieved from the human genome draft sequence reveals an orientation bias, reflected as a lower number of L1s and Alus containing the pA in the same orientation as the gene. Experimental studies of Alu-based pA sequences when placed in pol II or pol III transcripts suggest that the signal is very weak, or often not used at all. Because the pA signal is highly affected by the surrounding sequence, it is likely that the Alu constructs evaluated did not provide the required recognition signals to the polyadenylation machinery. Although the effect of pA signals contributed by Alus is individually weak, the observed reduction of "sense" oriented pA-containing L1 and Alu elements within genes reflects that even a modest influence causes a change in evolutionary pressure, sufficient to create the biased distribution.

The role of conversion in laparoscopic colorectal surgery: Do predictive factors exist?

BACKGROUND

This study was performed to analyze the reasons for conversion of laparoscopic colorectal procedures to open surgery and to identify risk factors.

METHODS

All patients who underwent laparoscopic colorectal surgery at our institution were enrolled in a prospective trial. The causes of conversion were analyzed. Statistical analysis, including a logistic regression model, was performed to identify factors that would predict an increased risk of conversion.

RESULTS

A total of 300 laparoscopic or laparoscopic-assisted procedures for both benign and malignant diseases were performed within 5 years. Mean patient age was 61.4 years (range, 17-93). There were 218 women and 82 men. Major complications occurred in 8.6%, and 30-day-mortality rate was 1.1%. Postoperative hospitalization was 13.9 days (range, 6-47). Conversion occurred in 22 cases (7.3%). The mean age of the converted group was 64.7 years (range, 31-93). Postoperative hospital stay was 15.0 days (range, 10-25). The main reasons for conversion to open surgery were inflammation, obesity, anesthetic problems, technical difficulties, intraoperative complications, and intraoperative decisions concerning oncological resection. The conversion rate was 14.6% in patients who underwent sigmoid resection for diverticular disease. By univariate analysis, statistically significant factors defining a higher risk of conversion were male gender (p = 0.0029), age from 55 to 64 years (p = 0.0015), extreme body status (p = 0.0001), and diagnosis of diverticular disease (p = 0.0011). According to the logistic regression model, all four factors combined would give a probability of conversion of 70.3%.

CONCLUSIONS

The risk factors contributing to the possibility of conversion included male gender, age between 55 and 64 years, extreme body status, and diverticular disease. Using these data, patients with an increased likelihood of conversion can be identified. However, if conversion is necessary, laparoscopic colorectal surgery can be safely applied to the patients with no additional morbidity.

Anorexia Nervosa: therapy and theory

The reciprocal interaction between psychotherapy and theoretical assumptions is illustrated through observations of anorexia nervosa. Traditional psychoanalysis, with its emphasis on interpretation of unconscious processes, was found to be rather ineffective, whereas an approach evoking active participation on the part of the patient led to better treatment results. The experience of being listened to appeared to be of utmost importance. The characteristic deficits in self-concept and body awareness could be related to a paucity or an absence of confirming responses in the early mother-child interactions. This concept reinforced the focus on encouragement of initiative and autonomy during therapy.

Frieda Fromm-Reichmann: a seminar in the history of psychiatry. III. Personal reminiscences of Frieda Fromm-Reichmann

I should like to make a personal remark before offering this very brief sketch of Frieda Fromm-Reichmann's life and activities. When I started to put my notes together I experienced an extraordinary bewilderment: she had died on April 28, 1957. I had a reaction of disbelief--it can't possibly be a quarter of a century, because her influence has remained so active and alive, not only in the people who had actually known her but also in many younger colleagues, who have a sense of personal relationship to her.

Treatment in anorexia nervosa

A discussion of "Anorexia Nervosa and the Psychotherapeutic Hospital," by Ian Story Ph.D. "Anorexia Nervosa" is a misnomer. "Anorexic" patients do not suffer from loss of appetite but actively pursue self-starvation and are frantically preoccupied with food, and even more with their size and shape. It is not an illness of weight and nutrition but a desperate effort to establish a sense of control to counteract deficits in the sense of effectiveness and the self-concept. After a childhood of overconformity, these patients are ill prepared to meet the demands for independence and self-assertion that growing up implies. Traditional treatment has emphasized the restitution of weight, which, however, is insufficient for cure. For effective treatment, reparation of the underlying personality deficits is essential. Story's paper on the therapeutic hospital describes the desperate plight of chronic anorexic patients in whose early treatment this important factor had been neglected.

Developmental considerations of anorexia nervosa and obesity

The differentiation of the distinct clinical syndrome of anorexia nervosa from atypical cases is based on the following distinguishing features: a relentless pursuit of thinness; an almost delusional disturbance of body image; an inability to correctly identify hunger from other bodily or tension states; a lack of an identity awareness; and a paralyzing sense of ineffectiveness. This sense of ineffectiveness, pervasive of all thought and action, is connected with the perception of the self as acting only in response to the demands of others and is camouflaged by negativism and defiance. The core developmental issues of being unable to experience the control over one's own body and of lacking the conviction of living one's own life are based on the severe deficits in autonomy and initiative, originating from the distortion and mislabeling of feelings, sensation and moods in early childhood. The treatment process focuses on evoking awareness in these patients of their impulses, feelings and needs as originating within themselves as an essential step in the development of a sense of competence and self-esteem.

Psychotherapy in eating disorders

This paper emphasizes that neither obesity nor severe malnutrition represents a uniform clinical psychiatric picture. The therapist must always pay attention to and integrate the various factors involved in eating disorders such as the underlying personality problems, resolution of the interactional conflicts within the family and correction of the abnormal nutritional states.

The similarities and differences of both obesity and anorexic states are described. Primary or typical anorexia nervosa is differentiated from the atypical kinds. The importance of early developmental factors of how the child differentiates inner and outer stimuli, the appropriate or inappropriate responses to these and the manner in which these early experiences later affect somatic, social and psychological self concepts are discussed.

Various parameters and modalities of treatment are described based on the author's long-term experiences with a large number of patients.

Physiologic correlates of affect during psychotherapy

Eight physiologic parameters were correlated with global ratings of affect intensity in four psychotherapeutic interviews with one patient. Highly significant covariation of affect with five of the eight physiologic parameters was obtained. It was concluded that affect intensity may be a useful psychologic parameter in studying psychophysiologic relationships in psychotherapy.