The CUPIC algorithm: an accurate model for the prediction of sustained viral response under telaprevir or boceprevir triple therapy in cirrhotic patients.

Triple therapy using boceprevir or telaprevir remains the reference treatment for genotype 1 chronic hepatitis C in countries where new interferon-free regimens have not yet become available. Antiviral treatment is highly required in cirrhotic patients, but they represent a difficult-to-treat population. We aimed to develop a simple algorithm for the prediction of sustained viral response (SVR) in cirrhotic patients treated with triple therapy. A total of 484 cirrhotic patients from the ANRS CO20 CUPIC cohort treated with triple therapy were randomly distributed into derivation and validation sets. A total of 52.1% of patients achieved SVR. In the derivation set, a D0 score for the prediction of SVR before treatment initiation included the following independent predictors collected at day 0: prior treatment response, gamma-GT, platelets, telaprevir treatment, viral load. To refine the prediction at the early phase of the treatment, a W4 score included as additional parameter the viral load collected at week 4. The D0 and W4 scores were combined in the CUPIC algorithm defining three subgroups: 'no treatment initiation or early stop at week 4', 'undetermined' and 'SVR highly probable'. In the validation set, the rates of SVR in these three subgroups were, respectively, 11.1%, 50.0% and 82.2% (P < 0.001). By replacing the variable 'prior treatment response' with 'IL28B genotype', another algorithm was derived for treatment-naïve patients with similar results. The CUPIC algorithm is an easy-to-use tool that helps physicians weigh their decision between immediately treating cirrhotic patients using boceprevir/telaprevir triple therapy or waiting for new drugs to become available in their country.

Identification of a duplicated V3 domain in NS5A associated with cirrhosis and hepatocellular carcinoma in HCV-1b patients.

BACKGROUND: The NS5A protein of the hepatitis C virus has been shown to be involved in the development of hepatocellular carcinoma. OBJECTIVES: In a French multicenter study, we investigated the clinical and epidemiological features of a new HCV genotype 1b strain bearing a wide insertion into the V3 domain. STUDY DESIGN: We studied NS5A gene sequences in 821 French patients infected with genotype 1b HCV. RESULTS: We identified an uncharacterized V3 insertion without ORF disruption in 3.05% of the HCV sequences. The insertion comprised 31 amino-acids for the majority of patients; 3 patients had 27 amino-acids insertions and 1 had a 12 amino-acids insertion. Sequence identity between the 31 amino-acids insertions and the V3 domain ranged from 48 to 96% with E-values above 4e(-5), thus illustrating sequence homology and a partial gene duplication event that to our knowledge has never been reported in HCV. Moreover we showed the presence of the duplication at the time of infection and its persistence at least during 12 years in the entire quasispecies. No association was found with extrahepatic diseases. Conversely, patients with cirrhosis were two times more likely to have HCV with this genetic characteristic (p=0.04). Moreover, its prevalence increased with liver disease severity (from 3.0% in patients without cirrhosis to 9.4% in patients with both cirrhosis and HCC, p for trend=0.045). CONCLUSIONS: We identified a duplicated V3 domain in the HCV-1b NS5A protein for the first time. The duplication may be associated with unfavorable evolution of liver disease including a possible involvement in liver carcinogenesis.

Interest of human papillomavirus DNA quantification and genotyping in paired cervical and urine samples to detect cervical lesions.

BACKGROUND: Cervical cancer is caused by persistent infection with high-risk human papillomavirus (HR-HPV). Conventional human papillomavirus (HPV) testing requires cervical sampling. However, vaginal and urine self-sampling methods are more acceptable for patients and result in increased participation when they are available in screening programs. In this context, we have developed a non-invasive screening method via the detection of HPV DNA in urine samples. PURPOSE: To compare HPV viral loads and genotypes in paired cervical and urine samples, and to assess correlation between virological and cytological results in women seeking gynecological consultation. METHODS: Paired urine and cervical specimens were collected and analyzed from 230 of 245 women participating in the previously described prospective PapU study. HPV DNA detection and quantification were performed using a real-time PCR method with short fragment PCR primers. Genotyping was carried out using the INNO-LiPA HPV genotyping assay. RESULTS: The prevalence of HPV in the 230 paired urine and cervical smear samples was 42 and 49 %, respectively. Overall agreement for HPV positivity and negativity between the paired samples was 90 % (κ = 0.80). High HPV viral load in both cervical and urine samples was associated with cytological abnormalities. HPV-positive women were mostly infected with HR-HPV types. The agreement between high- and low-risk HPV (LR-HPV) detection in both samples was 97 % (κ = 0.95 for HR-HPV and κ = 0.97 for LR-HPV). CONCLUSIONS: High concordance rates for HPV-DNA quantification and high/low-risk HPV genotyping in paired urine/cervical samples suggest that urinary HPV DNA testing could be useful for cervical lesion screening.

[Mutation analysis of ISDR and V3 domains of hepatitis C virus NS5A region before interferon therapy with or without ribavirin]. / Analyse des mutations des domaines ISDR et V3 de la protéine NS5A du virus de l'hépatite C avant le traitement par l'interféron avec ou sans ribavirine.

AIM OF THE STUDY: The hepatitis C virus (HCV) non-structural NS5A protein has been controversially implicated in the resistance of HCV to interferon therapy in clinical studies. In Japan, mutations in the interferon sensitivity-determining region (ISDR) in the NS5A gene were associated with response to interferon therapy in patients infected with genotype 1b. In contrast, studies from Europe did not confirm such association. More recently, it has been suggested that the V3 domain outside the putative ISDR might also have amino acids changes that may be involved in the resistance to IFN. In this study, the relationship between NS5A mutations in ISDR and V3 domains and virological response to therapy were investigated. MATERIALS AND METHODS: The NS5A gene was sequenced from 35 HCV genotype 1b infected patients at D0 of a prospective clinical trial of interferon therapy and interferon plus Ribavirin combination therapy. RESULTS: In the ISDR domain, we did not observe any significant differences in amino acids changes between responders (1.7 +/- 1.8, n = 19, range 0-6) and non-responders (1.1 +/- 0.8, n = 14, range: 0-3), (P = 0.483), to therapy before the beginning of treatment. In the V3 domain, we found more mutations in responders (6.5 +/- 1.9, range: 2-11) than in non-responders (4.7 +/- 1.2, range: 3-8) (P = 0.0013), before the beginning of treatment. CONCLUSION: Our results confirm that, in Europe, the ISDR domain is not predictive for treatment success but suggest that the V3 domain have greater variability in responders than non-responders.

Calcium fractional absorption and metabolism assessed using stable isotopes differ between postpartum and never pregnant women.

Determining the fractional absorption (FA) of calcium using the incorporation into urine of stable isotopes given intravenously (IV) and orally has become a routine procedure. We investigated the FA of calcium in two groups of (2-3 mo) postpartum women lactating (LACT) (n = 6) and nonlactating (PPNL) (n = 6), and in never pregnant (NP) women (n = 7). The women consumed a controlled diet containing 30-33 mmol/d calcium (Ca) for 21 d. On d 7 of the controlled diet, the women received 0.05 mmol of 42Ca IV and 0.25 mmol 44Ca orally in milk. Urine samples (24-h) were collected for the next 14 d and morning blood samples were collected from fasting subjects before dosing and at 24 and 48 h after receiving the isotopes. Milk samples from the LACT women were collected from each feeding beginning 24 h before to 72 h after dosing. There were no significant differences in the FA of calcium as measured by stable isotope incorporation into urine (23.8 +/- 2.9%), serum (24.0 +/- 3.4%) or milk (23.6 +/- 3.6%) of LACT women. The fractional calcium absorption measured in urine of the postpartum women (LACT and PPNL, 23.8 +/- 2.9% and 25.0 +/- 3.3%, respectively) did not differ but was greater (P < 0.028) than that of the NP women (17.3 +/- 1.3%). The postpartum LACT and PPNL women had a reduced urinary excretion of calcium (P < 0.01) compared with the NP women. There was a significantly greater incorporation (P < 0.001) by LACT women of the oral isotope dose into milk than into urine. Calcium FA can be determined from incorporation of stable isotopes into breast milk and serum as well as urine.

Postpartum iron status in nonlactating participants and nonparticipants in the special supplemental nutrition program for women, infants, and children.

BACKGROUND: Iron deficiency, a pervasive problem among low-income women of childbearing age, threatens maternal health and pregnancy outcomes. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was designed to alleviate health problems and provides supplemental nutritious foods, nutrition education, and health care referrals. OBJECTIVES: The aim of this study was to examine the benefits associated with participation in WIC in terms of biochemical tests of postpartum iron status in nonlactating women. DESIGN: WIC participants (n = 57) and eligible nonparticipants (n = 53), matched by race and age, were followed bimonthly over 6 mo postpartum. Finger stick blood samples (500 microL) were collected for measurement of plasma ferritin, transferrin receptor (TfR), and hemoglobin (Hb). RESULTS: The mean (+/-SE) Hb concentration of participants exceeded that of nonparticipants from months 2 through 6. At 6 mo, the mean Hb concentration of participants was significantly higher than that of nonparticipants (8.01+/-0.12 and 7.63+/-0.12 mmol/L, respectively; P< 0.05) and the prevalence of anemia was significantly lower (17% and 51%, respectively; P<0.05). TfR and ferritin concentrations (consistently within the reference ranges) and dietary iron intakes did not differ significantly between participants and nonparticipants and were not correlated with Hb concentrations. CONCLUSIONS: Our results suggest that WIC participants were significantly less likely to become anemic if uninterrupted postpartum participation lasted for 6 mo. The lack of correlation among iron status indicators suggests that the lower mean Hb concentration in nonparticipants at 6 mo may not have been related to improved iron status in participants but to other nutrient deficiencies or differences in access to health care and health and nutrition education.

Effect of beta-carotene supplementation and lactation on carotenoid metabolism and mitogenic T lymphocyte proliferation.

BACKGROUND: Information is lacking regarding the effects of beta-carotene supplementation, early lactation, or both on circulating carotenoid concentrations and T lymphocyte proliferation. OBJECTIVES: This study investigated the effects of short-term beta-carotene supplementation (30 mg/d for 28 d) during early lactation (days 4-32 postpartum) on circulating carotenoid concentrations and on the T lymphocyte proliferative response to phytohemagglutinin. DESIGN: Subjects aged 19-39 y were paired [lactating (4 d postpartum) and nonlactating (never pregnant, healthy women)] and randomly assigned to receive either beta-carotene or a placebo. During the study, subjects provided eight 24-h food records for analysis with the NUTRITIONIST IV and US Department of Agriculture carotenoid databases. Nonfasting blood samples were collected at baseline and at 28 d. Plasma analysis included quantification of alpha-carotene, beta-carotene, lutein, lycopene, retinol, and alpha-tocopherol, complete differential blood cell counts, and lymphocyte proliferative activity. RESULTS: beta-Carotene supplementation increased beta-carotene (P < 0.001) and alpha-carotene (P < 0.05) concentrations but did not affect lycopene concentrations significantly. Supplemented women showed significant decreases in plasma lutein (P < 0.03), as did lactating subjects (P < 0.02). Neither lactation nor beta-carotene supplementation affected the T lymphocyte proliferative response to phytohemagglutinin. CONCLUSIONS: Our results suggest that beta-carotene supplementation as well as some events related to parturition, initiation of lactation, or both alter circulating concentrations of lutein. beta-Carotene supplementation does not enhance T lymphocyte immune competence in healthy women.

Elevated leptin concentrations in pregnancy and lactation: possible role as a modulator of substrate utilization.

Energy needs are increased during pregnancy and lactation. These increased energy needs may be met through partitioning of nutrients for energy utilization which is under hormonal control. The objective of the present studies was to determine if changes in plasma leptin occurred during pregnancy and lactation and if the changes were related to prolactin. Plasma leptin and prolactin were measured longitudinally in 9 women through pregnancy and lactation. In a second study, leptin and prolactin were measured 4 days and 28 days postpartum in 21 lactating women. Mean plasma leptin during the three trimesters of pregnancy was significantly higher (29.3+/-2.8 ng/ml) when compared to mean leptin during the three time periods of lactation (19.3+/-3.2 ng/ml) and control groups (9.8+/-1.4 ng/ml). Plasma leptin was elevated early in pregnancy and remained elevated throughout pregnancy. In the second study, the mean plasma leptin in the lactating women was significantly higher 4 days postpartum (17.3+/-3.7 ng/ml) and 28 days postpartum (19.2+/-3.9 ng/ml) when compared to controls (11.6+/-1.2 ng/ml). Prolactin in the control subjects (24+/-4 ng/ml) was significantly lower than in the pregnant (202+/-16 ng/ml) and lactating (108+/-26 ng/ml) groups. Similar observations were made in the second study (controls 20+/-2 ng/ml; lactation 28 days 159+/-21 ng/ml). Leptin during lactation was lower than in pregnancy but higher than control subjects. Regression analysis suggested that BMI and prolactin can be used as predictors of leptin in pregnancy and lactation. The increase in leptin and prolactin early in pregnancy suggests an association between the two hormones. Results of the present studies and research done by other investigators presents a strong role for leptin during pregnancy and lactation. Leptin is regulated by factors other than adiposity especially in reproductive women leading to our hypothesis that there are leptin and prolactin mediated effects on substrates used for energy utilization during pregnancy and lactation.

Authorship: can you claim a byline?

Decisions about bylines, although seemingly straightforward, can "breed ill-will," "wreck friendships," and "even damage careers" if decisions are not in accord with professional guidelines and common sense. Editors have attempted to promote responsible authorship by creating Uniform Requirements. According to the International Committee of Medical Journal Editors, each author must have made a substantial contribution to all 3 of the following conditions to qualify for authorship: conceiving and designing the work represented by the article or analyzing and interpreting data; drafting the article or revising it critically for important intellectual content; and giving final approval of the version to be published. Despite these guidelines, bylines continue to include grafters and guests. Researchers believe guidelines for authorship are necessary but suggest the existing Uniform Requirements may be overly restrictive and easily misinterpreted. Editors will need to work with researchers to reach consensus on realistic and appropriate guidelines for authorship.

Distribution of a stable isotope of chromium (53Cr) in serum, urine, and breast milk in lactating women.

To determine the fate and distribution of chromium during lactation, six lactating women (25-38 y old) were given three doses of the tracer 53Cr (7.55 micromol/d, or 400 microg/d) on days 1, 2, and 3 of the study. Diet records, blood samples taken while subjects were fasting, and 24-h composite milk and urine samples were collected from day 0 to day 6. Fasting blood samples, morning milk samples, and 24-h urine samples were also collected on days 8, 10, 15, 30, 60, and 90. 53Cr and natural and total chromium concentrations in biological fluids were measured with gas chromatography-mass spectrometry and total urinary chromium was measured with atomic-absorption spectrometry. 53Cr was detectable in serum 2 h after dosing and continued to be detected from day 30 to day 60. Changes in total serum chromium concentration in response to the oral dose suggested that chromium concentrations in blood were not tightly regulated. 53Cr was not detected in breast milk and no significant changes in natural chromium concentration in milk were observed in response to the oral doses, suggesting that breast-milk chromium concentrations are independent of intake. The estimated chromium intake of exclusively breast-fed infants was 2.5 nmol/d (0.13 microg/d), below the lower end of the range of estimated safe and adequate daily dietary intakes (10-40 microg/d) for infants 0-6 mo of age. The baseline chromium concentration in urine and the minimum 53Cr absorption in lactating women were comparable with values for nonpregnant, nonlactating subjects. Chromium losses in breast milk do not appear to be compensated for via increased absorption or decreased excretion.

Acute and chronic resistive exercise increase urinary chromium excretion in men as measured with an enriched chromium stable isotope.

Both exercise and chromium exert beneficial effects on insulin function. The mechanism by which exercise improves insulin response may involve an alteration in Cr metabolism. To determine the effects of acute and chronic resistive exercise on urinary Cr losses, we measured the effects of acute resistive exercise and 16 wk of resistive exercise training on urinary Cr losses of 10 men 53-63 y of age. Subjects consumed diets in compliance with the American Heart Association Phase I diet with a Cr content of 30 +/- 4 microg/d. Sixteen weeks of resistive exercise training led to approximately 40% increases in upper and lower body strength, increases in fat-free mass and decreases in the percentage of body fat. An enriched stable isotope of Cr, 53Cr, was employed to differentiate the exogenously administered Cr from the native endogenous Cr. Both acute and chronic resistive exercise increased 53Cr losses. These data demonstrate that the improvements in body composition due to resistive exercise are associated with increased urinary Cr losses that are consistent with increased absorption.

Magnesium supplementation in patients with congestive heart failure.

OBJECTIVE: To evaluate several potential clinical indicators of magnesium status (diet, blood, urine, 24-hour load retention) in patients with congestive heart failure before, during, and after oral magnesium supplementation. METHODS: Twelve patients with New York Heart Association class II-III heart failure and 12 age and sex matched healthy control subjects were supplemented with 10.4 mmol oral magnesium lactate for 3 months. For the determination of magnesium status, samples of whole blood, serum, plasma, red blood cells, and urine (24-hour) were collected. Four-day dietary intake records were reviewed. A 4-hour IV magnesium load retention study was performed before and 3 months after magnesium supplementation. A non-supplemented control group was similarly studied. RESULTS: At baseline, magnesium intakes for all groups were below the RDA. No significant differences were seen in serum, plasma, ultrafiltrates of serum or plasma or red cell magnesium concentrations among groups over time. At baseline 5/27 subjects (19%) compared to 11/27 subjects (41%) after supplementation demonstrated normal magnesium retentions (< 25%). Magnesium excretions among groups were significantly different during supplementation. Percent magnesium retentions among groups were not different. CONCLUSIONS: Supplementation with 10.4 mmol oral magnesium daily for 3 months did not significantly alter blood levels or magnesium retention; however, patients demonstrated lower retention of magnesium after supplementation. Differences in magnesium retention was not related to basal magnesium intake, blood levels or excretion. Unfortunately, even an intensive effort at characterizing magnesium status did not identify a clinical indicator of utility for differentiating patients with congestive heart failure before, during, and after 3 months of magnesium supplementation.

A longitudinal study of urinary calcium, magnesium, and zinc excretion in lactating and nonlactating postpartum women.

Postpartum lactating (n = 12) and nonlactating (n = 11) women and never pregnant women (n = 14) collected urine samples and diet records 2 d each month for 6 mo to determine whether postpartum women conserved urinary calcium, magnesium, or zinc. Mean daily excretions were analyzed by repeated-measures analysis of variance and covariance to assess group and time effects. Lactating women excreted less urinary calcium (1-6 mo) than never pregnant (n = 8) and nonlactating (n = 4) women who did not use oral contraceptives (P < 0.01); however, excretion rose (P < 0.05) by 3 mo postpartum. In the nonlactating and never pregnant groups, women using oral contraceptives excreted less urinary calcium than the other women (P < 0.01). Lactating women excreted less urinary zinc (1-6 mo) than did control and non-lactating women (P < 0.01). Mechanisms may possibly be operating during lactation that depress urinary calcium for > or = 2 mo and urinary zinc < or = 6 mo postpartum.

Zinc needs and homeostasis during lactation.

During lactation there is an increased maternal loss of essential trace element zinc that is secreted into milk. During the first six months of lactation a mean of approximately 1.1 mg d-1 of zinc is secreted into human milk, which decreases to 0.6 mg d-1 during the next six months of lactation. The increased maternal need for zinc must be met through an increased dietary intake or homeostatic mechanisms which could compensate for the secretion of zinc into milk. These homeostatic mechanisms may include an increase in absorption, reduced excretion (urine and faecal endogenous losses) and the use of maternal pools of zinc, such as bone. Enhanced zinc absorption during lactation has been reported for lactating women whose intake of zinc is less than half of the current recommendation. Urinary zinc excretion by lactating women has also been observed to be significantly decreased up to 6 months postpartum compared to women who have never been pregnant. Approximately 30% of total body zinc is associated with bone. During lactation maternal bone resorption and reduction in one mineral content has been observed. Since urinary zinc excretion is reduced during lactation, this bone resorption could supply a portion of the zinc that is incorporated into milk. Thus, during lactation, homeostatic mechanisms which include an enhanced zinc absorption, reduced urinary zinc excretion and zinc from bone resorption could partially compensate for the secretion of zinc into human milk. These homeostatic mechanisms need to be considered when dietary recommendations for zinc intake are made for lactating women.

Magnesium homeostasis: conservation mechanism in lactating women consuming a controlled-magnesium diet.

This study was undertaken to determine whether lactating women consuming a low-magnesium diet compensate for magnesium secreted into breast milk by decreasing urinary magnesium losses. Six lactating (L) women, six nonlactating (NL) women (75 +/- 5 and 61 +/- 5 d postpartum, respectively), and seven never-pregnant (NP) women were studied while consuming a constant magnesium intake of 8.97 +/- 0.01 mmol/d for 20 d. After a 5-d stabilization period on the controlled diet, 24-h urine and fecal samples were collected for the next 15 d. The L women excreted significantly less (P < 0.01) urinary magnesium (2.10 +/- 0.35 mmol/d) than the NP women (3.45 +/- 0.37 mmol/d). No significant differences were detected in mean apparent magnesium absorption among the three groups of women, because of large individual variations of fecal magnesium and small sample size. L women apparently compensated for magnesium losses in breast milk (1.04 +/- 0.06 mmol/d) by reducing urinary magnesium losses (1.38 mmol/d) when consuming 8.97 mmol Mg/d.

Breast milk chromium and its association with chromium intake, chromium excretion, and serum chromium.

Chromium metabolism of lactating women was evaluated by measuring diet, breast milk, urine, and serum chromium in 17 subjects 60 d postpartum. Breast milk chromium concentration was similar for the 3 d of collection with a mean +/- SE concentration of 3.54 +/- 0.40 nmol/L (0.18 ng/mL). Dietary intake and urinary chromium values were also similar for each of the 3 collection days. Total chromium intake of lactating mothers (0.79 +/- 0.08 mumol/d) was greater than that of reference female subjects (0.48 +/- 0.02). There was a significant correlation (r = 0.84) between serum chromium and urinary chromium excretion. If a breast milk volume of 715 mL is assumed, chromium intake of exclusively breast-fed infants is < 2% of the estimated safe and adequate daily intake of 10 micrograms. In summary, breast milk chromium content is independent of dietary chromium intake and serum or urinary chromium values. Chromium intake also did not correlate with serum or urine chromium but there was a significant relationship between serum and urinary chromium concentrations.

Plasma and erythrocyte magnesium changes following a glucose challenge during pregnancy.

This study examined the effects of pregnancy and glucose loading on plasma and erythrocyte (RBC) magnesium (Mg) concentrations. In a completely randomized design with repeated measures, 15 nonpregnant, 15 early pregnant (13-17 weeks) and 15 late pregnant (28-34 weeks) women ingested 100 g glucose. Blood was collected at 0, 30, 60, 120 and 180 minutes to evaluate changes in Mg levels. Fasting plasma Mg concentrations decreased slightly but not significantly as gestational age of the groups increased. Fasting RBC Mg concentrations were significantly higher (p less than 0.05) in late pregnant women compared with early pregnant and nonpregnant women. Plasma Mg responses to a glucose challenge in nonpregnant women exhibited a curvilinear pattern whereas responses in pregnant women appeared unaffected by the glucose challenge. RBC Mg concentrations for nonpregnant and early pregnant women failed to respond to the glucose challenge whereas it decreased in a linear pattern during late pregnancy. The diabetogenic effect of late pregnancy appears to affect RBC Mg. This redistribution of Mg during late pregnancy could suggest a possible role for RBC as a Mg pool.