Adefovir dipivoxil alone or in combination with lamivudine in patients with lamivudine-resistant chronic hepatitis B

BACKGROUND AND AIMS

Adefovir dipivoxil possesses potent in vitro and in vivo antiviral activity in wild-type hepatitis B. This study assessed the safety and efficacy of adefovir dipivoxil alone and in combination with lamivudine compared with ongoing lamivudine therapy in patients with chronic hepatitis B with compensated liver disease and lamivudine-resistant hepatitis B virus (HBV).

METHODS

Fifty-nine hepatitis B e antigen (HBeAg)-positive patients with genotypic evidence of lamivudine-resistant HBV, serum alanine aminotransferase (ALT) level > or =1.2 times the upper limit of normal, and serum HBV DNA level > or =6 log(10) copies/mL despite ongoing treatment with lamivudine were randomized to adefovir dipivoxil 10 mg, lamivudine 100 mg, or addition of adefovir dipivoxil to ongoing lamivudine daily. The primary end point was the time-weighted average change from baseline in serum HBV DNA level (DAVG) up to week 16.

RESULTS

Rapid reductions in serum HBV DNA level were seen by 4 weeks in all recipients of adefovir dipivoxil; DAVG(16) was -0.07 in the lamivudine group compared with -2.45 and -2.46 log(10) copies/mL in the adefovir dipivoxil/lamivudine and adefovir dipivoxil monotherapy groups, respectively (P < 0.001). Median change from baseline in serum HBV DNA level at week 48 was 0.0, -3.59, and -4.04 log(10) copies/mL in the lamivudine, adefovir dipivoxil/lamivudine, and adefovir dipivoxil groups, respectively. ALT level normalized in 10 of 19 (53%) and 9 of 18 (47%) recipients of adefovir dipivoxil/lamivudine and adefovir dipivoxil, respectively, compared with 1 of 19 (5%) recipients of lamivudine. Three patients receiving adefovir dipivoxil or adefovir dipivoxil/lamivudine and none receiving lamivudine monotherapy were HBeAg negative at week 48 and one became hepatitis B surface antigen negative.

CONCLUSIONS

These data, limited to patients with compensated liver disease, indicate that adefovir dipivoxil alone or in combination with ongoing lamivudine therapy provides effective antiviral therapy in patients with lamivudine-resistant HBV.

Infectious complications after kidney transplantation: a single-center experience

Infectious complications after renal transplantation are associated with significant morbidity and mortality. The prevalence of infections in transplant recipients varies from country to country. This study sought to assess the overall incidence of post-transplant infectious complications at our research center in Iran, compared with other centers in the world. Between 2002 and 2004, 179 renal transplantations were performed in our center. Of these, 142 were studied and followed for 1 year. Immunosuppressive regimens were cyclosporine, mycophenolate mofetil, and prednisolone. The overall incidence of infections was 54.2%. The most common sites of infections were the urinary tract (41.5%) and the respiratory tract (6.3%). The most frequent causes of infections were Klebsiella (24%) and cytomegalovirus (CMV) (17.6%). Wound infection occurred in 4.9% of the patients. Three (2.1%) patients developed hepatitis C and 2 (1.4%) had mycobacterial infections. There was no case of Pneumocystis pneumonia. Overall mortality was 7.7%. Infection-related mortality was 3.5%. In conclusion, this study identifies infections as the cause of morbidity and mortality in the post-transplant period. There was a low incidence of tuberculosis (<2% yearly) and a high incidence of CMV disease in our recipients.

Haemorrhoids - a collagen disease?

OBJECTIVE

The cause of haemorrhoidal disease is unknown, epidemiological data and histopathological findings support the hypothesis that reduced connective tissue stability is associated with the incidence of haemorrhoids. Therefore the aim of this study was to analyse the quantity and quality of collagen formation in the corpus cavernosum recti in patients with III°/IV° haemorrhoids in comparison with persons without haemorrhoids.

METHOD

Haemorrhoidectomy specimens of 31 patients with III°/IV° haemorrhoids were examined. The specimens of 20 persons who died a natural death and who had no haemorrhoidal disease served as the controls. The amount of collagen was estimated photometrically by calculating the collagen/protein ratio. The collagen I/III ratio served as parameter for the quality of collagen formation and was calculated using cross polarization spectroscopy.

RESULTS

Patients with haemorrhoids had a significantly reduced collagen/protein ratio (42.2 ± 16.2μg/mg vs 72.5±31.0μg/mg; P= 0.02) and a significantly reduced collagen I/III ratio (2.0±0.1 vs 4.6±0.3; P<0.001) compared with persons without haemorrhoidal disease. There was no correlation with patients' age or gender.

CONCLUSIONS

 There is a fundamental disorder of collagen metabolism in patients with haemorrhoidal disease. It remains unclear whether this is due to exogenous or endogenous influences.

Safety and results of dobutamine stress echocardiography in women versus men and in patients older and younger than 75 years of age

The purpose of this retrospective study was to examine 732 consecutive patients who underwent dobutamine stress echocardiography (DSE) in order to compare the safety and result profiles of this test between women versus men and in patients > or = 75 and < 75 years of age. Our study included 416 women (57%) and 316 men (43%; mean age 62 +/- 12 years [range 16 to 93]). Patients were divided into 3 age groups: (1) group I (n = 179): < 55 years (mean 47 +/- 6), (2) group II (n = 447): 55 to 74 years (mean 64 +/- 5), and (3) group III (n = 106): > or = 75 years (mean 80 +/- 4). DSE was more likely to have negative results in women than in men (prevalence of positivity = 20% vs 31%, p = 0.001), but DSE had a similar safety profile in both genders. Women required lower doses of dobutamine and atropine to reach an end point. There was a similar incidence of test positivity in older and younger patients (23% in group I, 24% in group II, and 30% in group III, p = NS). DSE was generally a safe test in patients > or = 75 years, but there was a different safety profile in the elderly group compared with younger patients--specifically, more frequent asymptomatic hypotension (7% in group I, 13% in group II, and 25% in group III, p = 0.0002) and ventricular arrhythmias (26% in group I, 30% in group II, and 41% in group III, p = 0.04), but less frequent chest pain (32% in group I, 23% in group II, and 17% in group III, p = 0.009). Multivariate analysis suggested that the baseline usage of beta blockers was also a major determinant of the safety and ischemia profile during DSE. In conclusion, there were significant gender- and/or age-specific differences in the safety and test result profile of DSE. These differences should be considered when performing or interpreting DSE, particularly in women and in patients aged > or = 75 years.

Liposomal amphotericin B (AmBisome�) efficacy in confirmed invasive aspergillosis and other filamentous fungal infections in immunocompromised hosts: a pooled analysis

A pooled efficacy analysis applying current diagnostic standards for case selection was performed on previously published trials of liposomal amphotericin B for invasive filamentous fungal infections (IFFI). Favourable responses were observed in 51% of microbiologically confirmed cases of proven or probable IFFI. Despite the limitations inherent in a retrospective analysis of pooled studies, the response rates observed in this analysis were consistent with previous reports for antifungal therapy with amphotericin B deoxycholate or voriconazole in the treatment of invasive aspergillosis.

Switching from twice-daily raltegravir plus tenofovir disoproxil fumarate/emtricitabine to once-daily elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate in virologically suppressed, HIV-1-infected subjects: 48 weeks data

BACKGROUND

Pill burden, dosing frequency, and concerns about safety and tolerability are important obstacles to maintaining adequate medication adherence. Raltegravir (RAL) is indicated for twice-daily dosing and when taken with emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF), it becomes a twice-daily multiple-tablet regimen. Elvitegravir (EVG)/cobicistat (COBI)/FTC/TDF, STB, is the first approved once-a-day integrase strand transfer inhibitor (INSTI) containing single-tablet regimen that combines EVG, an INSTI, and COBI, a novel pharmacoenhancer, with the preferred nucleos(t)ide backbone of FTC/TDF.

METHODS

This was a 48-week prospective, single-arm open-label study of the switch to STB in virologically sup-pressed HIV-1-infected adult patients on FTC/TDF and twice-daily RAL for at least 6 months. Objectives were to evaluate the tolerability and safety of a regimen simplification to once-a-day STB, while maintaining viral suppression through 48 weeks.

RESULTS

Forty-eight individuals in the United States were enrolled. The median age was 44 years, 96% were male, and 83% were White. The median time on RAL + FTC/TDF treatment prior to enrollment was 34 months. Ninety-six percent of participants cited regimen simplification as the reason to enroll in the switch study. At base-line, the median CD4 count was 714 cell/µL and estimated glomerular filtration rate (eGFR) was 105 mL/min. At week 48, all assessed study participants remained viro-logically suppressed to the lower limit of quantification (HIV-1 RNA<50 copies/mL) and maintained high CD4 cell count (median, 751 cells/mL) and stable eGFR (median, 100.5 mL/min). STB was well tolerated with no discontinuations, no study drug-related serious adverse events, and no study drug-related grade 3/4 adverse events.

CONCLUSIONS

All participants switching to 1 tablet once-a-day STB from a twice-daily RAL + FTC/TDF regimen remained virologically suppressed. STB was well tolerated. Switching to STB may be a viable option for virologically suppressed patients wanting to simplify from a twice-daily RAL-containing regimen.

Effect of energy and protein levels on feedlot performance and carcass characteristics of Mehraban ram lambs

Fifty four Mehraban ram lambs (6-to 8-month old, initial live weight 35.4 +/- 4.2 kg) were assigned to a completely randomized design consisting of 9 groups and were fed for 70 days with diets containing three levels of energy (2.3, 2.5 and 2.7 Mcal metabolizable energy per kg dry matter) and three levels of protein (10.5, 12.5 and 14.5 percentage in dry matter). Either energy or protein levels alone significantly affected most of the parameters of lamb performance, but their interaction effect was significant only for feed conversion ratio, cold carcass weight, tail weight, flap weight and back fat (subcutaneous fat) depth. The lowest level of energy (2.3 Mcal ME per kg DM) resulted in a significant decrease in lamb performance as compared with other energy levels. Increasing energy concentration of the diet resulted in significant increases in fat percentage, but significantly decreased the moisture and protein content of the Longissimus dorsi muscle. Increased dietary protein level increased the daily DMI and ADG and at the same time improved the FCR. Hot and cold carcass weights increased significantly with increasing dietary CP levels, but dressing percentage was similar amongst the dietary protein densities. Dietary CP levels had no significant effect on the chemical composition of the Longissimus dorsi muscle. At the lowest energy level (2.3 Mcal ME per kg DM), dietary protein level had a significant effect on FCR (Table 4); with the diet containing 10.5% protein having the highest FCR. At the medium and low energy levels the lowest level of dietary protein concentration resulted in smaller carcasses. The highest level of protein along with the medium energy concentration resulted in smaller tail weights. Flap weight was significantly smaller at low energy concentration along with medium and low protein level. The lowest back fat depth was found in lambs fed on the low energy diet containing medium to high levels of protein.

Controlled drug delivery of ciprofloxacin from ultrasonic hydrogel

Ciprofloxacin is an antibacterial fluoroquinolone that stops the DNA synthesis, after penetration into the bacterial cells. This drug is applied in the curing of bacterial infections, as well as in antibiotics to treat urinary infections in women, infectious diarrhea and typhoid fever. The objective of the present work is to study controlled release of ciprofloxacin by hydrogel prepared by ultrasound. For this, first the swelling properties of hydrogel and then the absorption of drug were evaluated. The swollen hydrogel was dried in oven (50°C) and was ready for release experiments. During release, the loaded powder of the hydrogel was added to a buffer solution of pH 7.4, similar to human body condition. Then drug concentration was measured using a UV-visible (UV-Vis) spectrophotometer and a calibration curve. The results showed that the hydrogel is sensitive to pH, which makes it a good candidate for ciprofloxacin delivery in intestine. In addition, it was shown that the drug absorption is proportional with the swelling content of the hydrogel and the drug concentration in the loading process. The chemical structure and morphology of the hydrogels and loaded drug were characterized using Fourier transform infrared, UV-Vis, scanning electronic microscopy and thermal gravimetric analysis spectroscopy. According to the results presented here, acrylic-based hydrogels can be used in biomedical fields, especially for controlled drug release.

The stimuli-response characters of hydrogels prepared using ultrasound

The present work was an attempt to investigate the parameters that can affect the process of hydrogel formation in the presence of ultrasound. These parameters were concentrations of the reactants, the reaction medium, and acoustic factors. The monomers were acrylic acid and acrylamide, and the cross-linker was methylene bis acrylamide. Pulsed power ultrasound was irradiated to the reaction mixture from the tip of a probe unit. The swelling behaviors of the obtained hydrogels were investigated in various buffer solutions, at different temperature values, and using different ionic salts. The results show that ultrasonic irradiation significantly reduces reaction time and increases efficiency. Additionally, increasing glycerol in the solution changes the viscosity of the reaction for the better and increases the reaction rate. However, ionic strength and pH were not significantly effective in this respect. Another major finding was that increasing ultrasonic power and pulse hastens the reaction. Cationic salts were effective in this order: Na+>Ca2+>Fe3+. The hydrogel was responsive to pH, temperature, and salts. These findings provide a better understanding of hydrogel synthesis and enable us to control the pertinent parameters.

Pitfalls in the color Doppler diagnosis of valvular regurgitation

Color Doppler flow mapping of the regurgitant jet is frequently used as a means of assessing the severity of valvular regurgitation. Although convenient, this method of assessing valvular regurgitation is subject to a number of hemodynamic and technical factors that may limit its accuracy. Variations in hemodynamic and structural factors such as orifice size, jet geometry, receiving chamber constraints, afterload, fluid viscosity, heart rate, and cardiac output may have profound effects on the measured regurgitant jet area. Variations in scanning and machine factors, such as scanning direction, Doppler angle, frame rate, color display algorithms, pulse repetition frequency (PRF), system gain, packet size, carrier frequency, wall filter, and transmit power have been shown to alter the measured regurgitant jet area significantly. Despite these limitations, color flow Doppler provides a relatively reliable noninvasive method for semiquantitative assessment of valvular regurgitation. Obviously, standardization of the design and application of the various available color mapping algorithms, as well as other machine and hemodynamic factors, would help provide more reliable and reproducible quantitative information about the degree of valvular insufficiency.

Switch from a ZDV/3TC-based regimen to a completely once daily (QD) regimen of emtricitabine/tenofovir DF fixed dose combination plus a third QD agent (SONETT)

Objectives

To assess the efficacy and safety of a treatment switch from a twice-daily (BID) regimen containing zidovudine (ZDV) and lamivudine (3TC) plus a third agent to a once daily (QD) regimen containing the fixed-dose combination of tenofovir DF/emtricitabine (TDF/FTC, Truvada^®) plus a divergent third QD agent in HIV-1 infected patients.

Methods

Prospective, 48-week, non-randomised, single-group, open-label, study. Fifty-one patients on stable ZDV/3TC-containing HAART, with HIV-1 RNA < 50 copies/ml and CD4+ T-cell count > 50 cells/μl, were switched to TDF/FTC plus a third agent. Plasma HIV-1 RNA, CD4+ and CD8+ T-cell counts were assessed at baseline and weeks 4, 12, 24, 36 and 48 post-switch.

Results

During the 48-week study, 10 patients discontinued prematurely, including three due to adverse events (AEs). At week 48, plasma HIV-1 RNA was < 50 copies/ml in 40 patients (78.4%). No patient experienced virological failure (defined as HIV-1 RNA ≥50 copies/ml at two consecutive post-baseline measurements) during the study. Immunologic control was maintained, with no significant changes in CD4+ or CD8+ T-cell counts. A statistically significant improvement from baseline in haemoglobin level was observed at week 48 (median change 0.8 g/dl; p < 0.001). There was also a statistically significant decrease in total cholesterol concentration at week 48 (-26.0 mg/dl; p = 0.001) in a subset of patients (n = 22) entering the study with elevated total cholesterol. Treatment was well tolerated and no treatment-related grade 3 or 4 AEs were seen.

Conclusions

Results from this study support switching from a ZDV/3TC-containing HAART regimen to a completely QD regimen of TDF/FTC plus a third agent. Virologic and immunologic control are maintained, with apparent benefits in haemoglobin.

Gastric remnant perforation due to trocar site herniation after laparoscopic Roux-en-Y gastric bypass

A 39-year-old woman was admitted with colicky left upper-quadrant pain, dyspnoea, low-grade fever, tachycardia and a subtle left upper-quadrant tenderness without leucocytosis. Computed tomography revealed a distended gastric remnant due to small-bowel loop herniation at the trocar site. The patient underwent a diagnostic laparoscopy as her general condition worsened. Perforation across the staple line was seen and repaired. The postoperative period was uneventful. As a rare complication of laparoscopic Roux-en-Y gastric bypass, small-bowel obstruction is of great importance because it can lead to gastric remnant perforation if not managed correctly. There have been rare reports of trocar site herniation as a cause of small-bowel obstruction following laparoscopic Roux-en-Y gastric bypass. Prompt diagnostic laparoscopy should be considered. This is the first case reported in which the excluded stomach was perforated due to trocar site herniation of the small-bowel loop. It should be noted that the tissue around the perforation is fragile and proper tension should be employed when it is repaired. Generally, an omental patch is not encouraged.