Epigenetic analysis of the IFNλ3 gene identifies a novel marker for response to therapy in HCV-infected subjects.

Chronic hepatitis C virus (HCV) infection is characterized by high interindividual variability in response to pegylated interferon and ribavirin. A genetic polymorphism on chromosome 19 (rs12979860) upstream of interferon-λ3 (IFNλ3) is associated with a twofold change in sustained virologic response rate after 48 weeks of treatment with pegylated interferon/ribavirin in HCV genotype 1 (GT1) treatment-naïve patients. We conducted epigenetic analysis on the IFNλ3 promoter to investigate whether DNA methylation is associated with response to HCV therapy. DNA samples from HCV GT1-infected subjects receiving an interferon-free paritaprevir-containing combination regimen (N=540) and from HCV-uninfected, healthy controls (N=124) were analysed for IFNλ3 methylation levels. Methylation was strongly associated with rs12979860 allele status whether adjusting for HCV status (r=65.0%, 95% CI: [60.2%, 69.5%]), or not (r=64.4%), both with P<2.2×10-16 . In HCV GT1-infected subjects, C/C genotypes had significantly lower methylation levels relative to C/T or T/T genotypes (P<1×10-14 ), with each T allele resulting in a nine-unit increase in mean methylation level. Methylation levels did not correlate with response in subjects treated for 12 or 24 weeks. However, non-C/C subjects with higher methylation levels were more likely to relapse when treatment duration was 8 weeks. This analysis suggests that methylation status of the IFNλ3 promoter region may be a useful parameter that identifies patients more likely to relapse following HCV therapy; however, continuing therapy for a sufficient duration can overcome this difference. These findings may provide mechanistic insight into the role of IFNλ3 genetic variants in HCV treatment response.

Serum miR-122 may serve as a biomarker for response to direct acting antivirals: effect of paritaprevir/R with dasabuvir or ombitasvir on miR-122 in HCV-infected subjects.

Circulating microRNAs (miRNA) have been intensely investigated as biomarkers in disease and therapy. Several studies have identified miR-122 as an important regulator of HCV replication. The effect of new therapies that directly target the HCV replication life cycle on circulating microRNA levels has not been elucidated. We performed expression profiling of circulating miRNA in serum in subjects treated with HCV direct-acting antiviral agents (DAAs). Serum miRNA levels were evaluated from two studies in HCV GT1-infected treatment-naïve subjects and prior nonresponders to pegylated interferon (pegIFN) and ribavirin (RBV) who received paritaprevir/ritonavir + dasabuvir + RBV for 12 weeks, and in treatment-naïve genotype (GT)1-3-infected subjects who received paritaprevir/ritonavir + ombitasvir ± RBV for 12 weeks. Over 100 different miRNA species were detected in serum. Of these, levels of miR-122 showed the most consistent change in response to treatment across all HCV genotypes. In all subjects, miR-122 showed an average four-fold reduction between baseline and week 2, and remained below baseline through post-treatment week 12 in subjects who achieved sustained virological response. In contrast, in subjects who did not achieve SVR, miR-122 levels began to return to baseline levels after the second week of treatment. The change in miR-122 levels was similar across genotypes, and was comparable with or without RBV. This is the first report comparing expression levels of circulating miRNA in HCV GT1-3 subjects treated with IFN-free combinations of DAAs. The results suggest that serum levels of miR-122 are reduced following treatment in subjects who achieve SVR, and correlate with HCV RNA levels across genotypes.

Pharmacokinetics and tolerability of paritaprevir, a direct acting antiviral agent for hepatitis C virus treatment, with and without ritonavir in healthy volunteers.

AIMS: Paritaprevir is a direct acting antiviral agent for use as part of a multidrug hepatitis C virus infection treatment regimen. To characterize the pharmacokinetics, safety, and tolerability of paritaprevir and determine an optimal dosing regimen for subsequent evaluations, clinical studies were conducted with paritaprevir alone or with ritonavir, a cytochrome P450 3A4 inhibitor anticipated to increase paritaprevir exposure. METHODS: Two phase 1, double-blind, placebo-controlled, parallel group studies were conducted in healthy volunteers (NCT00850044 and NCT00931281). Single dose study participants (n = 87) were randomized to one time administration of either paritaprevir or placebo, or paritaprevir with ritonavir or placebo. Participants (n = 38) enrolled in the multiple dose study received paritaprevir with ritonavir or placebo once or twice daily for 14 days. Pharmacokinetics, safety and tolerability were assessed throughout the study treatment periods. RESULTS: After single or multiple dose administration, paritaprevir displayed non-linear pharmacokinetics, with maximum plasma concentration and area under the plasma concentration-time curve increasing in a greater than dose proportional manner. Concomitant administration of 100 mg ritonavir increased paritaprevir exposure from a 300 mg dose approximately 30- to 50-fold and extended paritaprevir half-life. The tolerability of paritaprevir was similar with or without ritonavir. Asymptomatic, transient increases in bilirubin were observed but were not associated with abnormalities in other liver function tests. CONCLUSIONS: Paritaprevir exhibits non-linear pharmacokinetics with greater than dose proportional increases in exposure after single or multiple dosing. Co-administration with ritonavir increases paritaprevir exposure and half-life without adversely influencing tolerability.

Pharmacokinetics and dose recommendations for cyclosporine and tacrolimus when coadministered with ABT-450, ombitasvir, and dasabuvir.

ABT-450, ombitasvir, and dasabuvir are direct-acting antiviral agents (DAAs) that have been developed for combination treatment of chronic hepatitis C virus (HCV) infection. Because these DAAs have metabolic and transporter profiles that overlap with cyclosporine and tacrolimus disposition, there is potential for drug interactions. Two Phase 1 studies assessed effects of ABT-450 (150 mg coadministered with ritonavir 100 mg once daily), ombitasvir (25 mg once daily), and dasabuvir (400 mg twice daily) on the pharmacokinetics, safety, and tolerability of a single dose of cyclosporine (30 mg) or tacrolimus (2 mg) in healthy volunteers (N = 12 per study). In the presence of steady-state concentrations of all 3 DAAs, dose-normalized cyclosporine concentration at 24 hours (C24), and area under the concentration-time curve from time 0 to infinity (AUC(∞)) were 15.8-fold and 5.8-fold, respectively, and dose-normalized tacrolimus C24 and AUC(∞) were 17-fold and 57-fold, respectively, of either agent alone. Cyclosporine and tacrolimus half-lives increased from 7 to 25 h and 32 to 232 h, respectively. There were no major safety or tolerability issues in these studies. The results suggest that cyclosporine and tacrolimus doses and dosing frequency should be reduced in HCV-infected posttransplant patients being treated with this 3-DAA regimen.

Journal pricing issues: an economic perspective.

Scientific journal prices have increased markedly in the past two decades, outpacing inflation by severalfold. Such increases challenge the librarian's ability to manage acquisitions resources effectively and threaten the mission of the health sciences library as a resource for present and future scientific information needs. Explanations for serial price increases vary with the point of view considered. Publishers, librarians, faculty, and consumers of scientific information perceive the situation differently. This paper provides an economic analysis of each group's views. Particular emphasis is given to the aspects of journal publishing and pricing that foster price increases. In addition, the paper examines the problems of dual-pricing structures and narrowly focused journals that cater to subspecialties of medicine. Suggested responses to subscription rate increases are offered to curtail further increases and to avoid the potential detrimental effects of reduced library collections. Since one of the underpinnings of education is threatened by reductions in library collections, actions must be taken by publishers, librarians, faculty, and professional associations to ameliorate the present situation and to limit additional increases in serial prices.

Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of 'open' and 'closed' formats.

OBJECTIVE: To compare the effects of change from an open to a closed intensive care unit (ICU) format on clinical outcomes, resource utilization, teaching, and perceptions regarding quality of care. DESIGN: Prospective cohort study; prospective economic evaluation. SETTING: Medical ICU at a university-based tertiary care center. For the open ICU, primary admitting physicians direct care of patients with input from critical care specialists via consultation. For the closed ICU, critical care specialists direct patient care. PATIENTS: Consecutive samples of 124 patients admitted under an open ICU format and 121 patients admitted after changing to a closed ICU format. Readmissions were excluded. MAIN OUTCOME MEASURES: Comparison of hospital mortality with mortality predicted by the Acute Physiology and Chronic Health Evaluation II (APACHE II) system; duration of mechanical ventilation; length of stay; patient charges for radiology, laboratory, and pharmacy departments; vascular catheter use; number of interruptions of formal teaching rounds; and perceptions of patients, families, physicians, and nurses regarding quality of care and ICU function. RESULTS: Mean +/- SD APACHE II scores were 15.4 +/- 8.3 in the open ICU and 20.6 +/- 8.6 in the closed ICU (P=.001). In the closed ICU, the ratio of actual mortality (31.4 percent) to predicted mortality (40.1 percent) was 0.78. In the open ICU, the ratio of actual mortality (22.6 percent) to predicted mortality (25.2 percent) was 0.90. Mean length of stay for survivors in the open ICU was 3.9 days, and mean length of stay for survivors in the closed ICU was 3.7 days (P=.79). There were no significant differences between periods in patient charges for radiology, laboratory, or pharmacy resources. Nurses were more likely to say that they were very confident in the clinical judgment of the physician primarily responsible for patient care in the closed ICU compared with the open ICU (41 percent vs 7 percent; P<.Ol), and nurses were the group most supportive of changing to a closed ICU format before and after the study. CONCLUSIONS: Based on comparison of actual to predicted mortality, changing from an open to a closed ICU format improved clinical outcome. Although patients in the closed ICU had greater severity of illness, resource utilization did not increase.