New direct-acting antiviral agents for the treatment of hepatitis C virus infection and perspectives

Until recently, the standard of care (SOC) for patients with chronic hepatitis C virus (HCV) infection has consisted of a combination of pegylated interferon-α [corrected] plus ribavirin, administered for 24- to 48-weeks depending on the HCV genotype. The sustained virologic response rate for this SOC has been only about 50% in patients infected with genotype 1 HCV, the most prevalent genotype in Europe and North America. HCV therapy has been revolutionised recently by the approval of two direct-acting antiviral agents (DAA) against the NS3/4A serine protease for use in genotype 1 HCV, the ketoamide inhibitors boceprevir and telaprevir. The novel SOC marks the beginning of an extraordinary new era in HCV therapy. We review this new SOC with an emphasis on practical issues related to protease inhibitors, e.g. prescribing guidelines, futility rules and management of adverse events. We also give a perspective on what to expect in the coming years. Newer DAA with simplified dosing regimens and/or minimal toxicity which, when used in combination, will lead to viral eradication in most if not all CHC patients who undergo treatment. The novel agents in clinical development are paving the way for future interferon-sparing regimens.     

Ofatumumab monotherapy in rituximab-refractory follicular lymphoma: results from a multicenter study

New treatments are required for rituximab-refractory follicular lymphoma (FL). In the present study, patients with rituximab-refractory FL received 8 weekly infusions of ofatumumab (CD20 mAb; dose 1, 300 mg and doses 2-8, 500 or 1000 mg; N = 116). The median age of these patients was 61 years, 47% had high-risk Follicular Lymphoma International Prognostic Index scores, 65% were chemotherapy-refractory, and the median number of prior therapies was 4. The overall response rate was 13% and 10% for the 500-mg and 1000-mg arms, respectively. Among 27 patients refractory to rituximab monotherapy, the overall response rate was 22%. The median progression-free survival was 5.8 months. Forty-six percent of patients demonstrated tumor reduction 3 months after therapy initiation, and the median progression-free survival for these patients was 9.1 months. The most common adverse events included infections, rash, urticaria, fatigue, and pruritus. Three patients experienced grade 3 infusion-related reactions, none of which were considered serious events. Grade 3-4 neutropenia, leukopenia, anemia, and thrombocytopenia occurred in a subset of patients. Ofatumumab was well tolerated and modestly active in this heavily pretreated, rituximab-refractory population and is therefore now being studied in less refractory FL and in combination with other agents in various B-cell neoplasms. The present study was registered at www.clinicaltrials.gov as NCT00394836.     

Chemoimmunotherapy with ofatumumab in combination with CHOP in previously untreated follicular lymphoma

An international, Phase II trial was conducted to assess two doses of ofatumumab, a human CD20 monoclonal antibody, combined with cyclophosphamide (750 mg/m²), doxorubicin (50 mg/m²), prednisone (100 mg days 3–7) and vincristine (1·4 mg/m²) (O‐CHOP), as frontline treatment for follicular lymphoma (FL). 59 patients with previously untreated FL were randomized to ofatumumab 500 mg (n = 29) or 1000 mg (n = 30) day 1, with CHOP on day 3 every 3 weeks for six cycles. Median duration of FL was 0·1 years for both dose groups; 34% and 38% of patients had high‐risk Follicular Lymphoma International Prognostic Index (FLIPI) scores in the 500‐ and 1000‐mg dose groups, respectively. Overall response rate was 90% for the 500‐mg group and 100% for the 1000‐mg group. 62% of patients achieved complete response (CR)/unconfirmed CR (CRu). 76% of patients with FLIPI score 3–5 attained CR/CRu. Longer follow‐up time is needed for analysis of survival end points. The most common Common Terminology Criteria grade 3–4 investigator‐reported adverse events were leucopenia (29%) and neutropenia (22%). No deaths have been reported. O‐CHOP was safe and efficacious in patients with previously untreated FL, including high‐risk FLIPI groups. This trial was registered at www.clinicaltrials.gov (NCT00494780).     

Quality assessment of online patient education resources for peripheral neuropathy

Given its practicality, the internet is a primary resource for patients afflicted with diseases like peripheral neuropathy. Therefore, it is important that the readily available online resources on peripheral neuropathy are tailored to the general public, particularly concerning readability. Patient education resources were downloaded from the US National Library of Medicine, Mayo Clinic, National Institute of Neurological Disorders and Stroke, Neuropathy.org , GBS/CIDP Foundation International, Hereditary Neuropathy Foundation, Charcot‐Marie‐Tooth Association, Foundation for Peripheral Neuropathy, and Neuropathy Action Foundation websites. All patient education material related to peripheral neuropathy was evaluated for its level of readability using the Flesch Reading Ease (FRE) and Flesch‐Kincaid Grade Level. The FRE scores averaged 43.4 with only the US National Library of Medicine scoring above 60 (76.5). The Flesch‐Kincaid Grade Level scores averaged 11.0. All scores were above a seventh‐grade level except the US National Library of Medicine, which had a score of a fifth‐grade reading level. Most Americans may not fully benefit from patient education resources concerning peripheral neuropathy education on many of the websites. Only the US National Library of Medicine, which is written at a fifth‐grade level, is likely to benefit the average American.     

Has the Rolling Uterus Finally Gathered Moss? Somatization and Malingering of Cognitive Deficit in Six Cases of “Toxic Mold” Exposure

This article reports six cases of litigants claiming neuropsychiatric impairment due to toxic mold exposure. In spite of recent growth in personal injury claims due to mold, numerous reviews of the literature have failed to find an association between environmental exposure to mold and neuropsychiatric and/or neuropsychological damage. We report data on six patients claiming harm, 4 of whom revealed a long history of somatization by history and psychological testing, and 2 of whom were shown to be malingering based on multiple indicators of non-credible performance. Of the 6 patients, only the 2 somatoform patients who were also depressed showed credible evidence of neuropsychological dysfunction. We review two other studies that have examined the link between mold exposure and cognitive impairment and discuss their limitations in view of the presenting behaviors of these 6 patients. Until the literature has established a credible link between mold and neuropsychiatric/neuropsychological impairment, jurists and clinicians must consider the ethics and potential harm of exposing somatoform patients to multiple unwarranted medical evaluations. Principles for forensic evaluations in this special population are reviewed.     

Assessing clinical discharge data preferences among practicing surgeons

Background

It is believed that many postoperative patient readmissions can be curbed via optimization of a patient's discharge from hospital, but little is known about how surgeons make the decision to discharge a patient. This study explored the criteria that surgeons preferentially value in their discharge decision-making process.

Materials and methods

All surgical faculty and residents at a U.S. academic medical center were surveyed about the relative importance of specific criteria regularly used to make a discharge decision. Demographic and professional information was collected about each surgeon as well. A Kruskal–Wallis and Fisher's exact test were used to describe one-way analysis of variance between groupings of surgeons. Ordered logit regressions were used to analyze variations across multiple subgroups. Factor analysis was used to further characterize statistically relevant groupings of criteria.

Results

In total, 88 (49%) of the invited surgeons responded to the survey. Respondents reported statistically less reliance on common Laboratory tests and Patient demographics when making discharge decisions preferring Vital signs, Perioperative factors, and Functional criteria. Surgeon-specific factors that influenced discharge criteria preferences included years of clinical education and gender. Factor analysis further identified subtle variations in preferences for specific criteria groupings based on clinical education, gender, and race.

Conclusions

Surgeons use a wide range of clinical data when making discharge decisions. Typical measures of patient condition also appear to be used heterogeneously with a preference for binary rather than continuous measures. Further understanding the nature of these preferences may suggest novel ways of presenting discharge-relevant information to clinical decision makers to optimize discharge outcomes.     

Unstable SCFE: Review of Treatment Modalities and Prevalence of Osteonecrosis

Background

The treatment of unstable slipped capital femoral epiphysis (SCFE) is rapidly evolving with the ability to correct epiphyseal alignment using the modified Dunn technique. Adopting a new treatment method depends on confirming that it achieves its goals, produces few, nonserious complications with no lasting sequelae, and improves the natural history of the disorder compared with known treatment methods. As such, the rates of osteonecrosis and complications after current treatments of unstable SCFE must be compared with those of newer surgical techniques.

Questions/purposes

We therefore addressed the following questions: (1) What is the rate of osteonecrosis of the femoral head after treatment of unstable SCFE? (2) What treatment modalities have been used for unstable SCFE and (3) what are the reported complications?

Methods

We performed a systematic electronic literature search for the keywords unstable and slipped capital femoral epiphysis and identified 199 articles. Of these, 60 met our inclusion criteria. Fifteen articles were included for analysis.

Results

The literature concerning the treatment and results of unstable SCFE is retrospective Level IV data that suggest an overall rate of osteonecrosis of 23.9%. Multiple treatment modalities were used for unstable SCFE treatment with varying, inconsistently recorded complications over the reporting period.

Conclusions

We found limited data concerning the rate of osteonecrosis and complications after treatment of unstable SCFE. Considering recent widespread interest in the modified Dunn procedure and the possibility of iatrogenic osteonecrosis, there is a need for prospective studies to identify complications and establish outcome based on standardized scores for established and emerging treatments of unstable SCFE.