Problems of Obesity in Drivers and Road Safety

Opinion

At the present time obesity is one of the most important medical, social and economic problems of contemporary society, which lead to a reduction in life expectancy and degeneration of its quality. It is called “non-communicable epidemic of the 21st century”. Over the past 20-25 years, both in developed and developing countries, the number of people suffering from not merely overweight, but obesity, has significantly increased. Abdominal obesity is one of the major indicators in the diagnosis of metabolic syndrome (MS), which is regarded to be a risk factor for the development of such severe pathologies as coronary heart disease and diabetes. Numerous studies have also shown the negative impact of obesity on labour productivity; its increasing prevalence requires an increase in financial expenditures on health care.

Drivers of motor transport are the most numerous and stable professional group among men of working age. The state of health determines their performance efficiency and, therefore, road safety. Driving a vehicle is accompanied by a high level of neuro-emotional stress, which is the leading factor in this professional activity, provoking and supporting chronic stress. Against the background of reduced physical activity and malnutrition, stress is considered as the main cause of a significant proportion of drivers with pre-obesity with a tendency to put on weight further. This fact, according to some authors, leads to the need to make changes in the construction of the car cabin, taking into account the increased anthropometric measurement of drivers. It was also determined that severe pathologies of the cardiovascular and endocrine systems which are frequently registered in this occupational group can cause rapid deterioration in the health condition of drivers who are at work and result in accidents on the road.

In the aspect of this problem, the data obtained by the authors in the study of 133 truck drivers engaged in the transportation of trucks in the city of Nizhny Novgorod (Russia) is of interest. It should be noted that a significant proportion of them are over 50 years old (64.2%) and with work experience of 30 years or more (67.1%); the average age of drivers was 50.76 ± 0.72 years, the driving experience - 30.73 ± 0.76 years. Overweight and obesity were determined by calculating body mass index. Analysis of the prevalence of MS was conducted in the following age groups: up to 40 years (22 people), 40-49 (40), 50-59 (82), and 60 years or more (29). According to the occupational experience, the drivers were also divided into 4 groups: 1st – with work experience less than 20 years (28 people), 2nd – 20-29 (29), 3rd – 30-39 (92), 4th – over 40 years old (24). For the diagnosis of MS the following criteria were used: the working criteria of the Committee of Experts of the US National Cholesterol Education Program on the detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III, ATP III), which are the most adapted to clinical practice. According to the ATP III classification, MS is diagnosed when there are abnormalities in any of the three or more of the five symptoms: abdominal obesity (waist circumference), triglycerides, high-density lipoprotein cholesterol, arterial pressure (AP), fasting plasma glucose. Working conditions in the studied group of truck drivers were characterized by exposure to the levels of noise and vibration increased relatively to the normative microclimate.

When driving on major highways during the period of intensive traffic, concentrations of aliphatic hydrocarbons, carbon monoxide and solid particles exceeding the maximum permissible levels were recorded in the cabs. According to the analysis of the conducted questionnaire, an unbalanced diet was established in this group (unreasonable day regimen, excessive consumption of fats, alcohol) and low physical activity – only 6.6% of truck drivers were engaged in fitness (swimming, running, morning gymnastics). Among the examined drivers, 33.5 ± 3.6% had a normal weight, the proportion of overweight persons was 66.4 ± 3.6%, including those with overweight – 38.7 ± 3.7%, and with obesity of varying degrees – 27.7 ± 3.4%. It should be noted that the proportion of obese people increased with age and was respectively 13.6 ± 7.7; 22.5 ± 6.6; 34.1 ± 5.2 and 27.7 ± 3.4, and the differences are significant between the first and third groups t1-3 = 2.2 (p <0.05).

During the examination, metabolic syndrome, i.e. the presence of abdominal obesity and two or more markers mentioned above was diagnosed in 65 drivers (37.6 ± 3.7%), which was almost 2 times higher than the average statistical indicators. The most frequent symptom of MS in the group of drivers was the combination of abdominal obesity with hypertension. With increasing age, there was a gradual growth of the frequency of MS, reaching 1.8 times (p> 0.05) in the oldest age group compared with the youngest. When analyzing the frequency of MS according to experience, a sharp increase was noted in the 4th group relative to the first three (2.5, 2.3 and 1.6 times, respectively) and these differences are statistically significant. Thus, this study showed that the peculiarities of the occupational activity of truck drivers increase the risk of metabolic syndrome development. Taking into account the drastic consequences of MS presence on health, it is necessary to take active preventive measures aimed at reducing the risk of developing MS in drivers, for at the early stage of metabolic disorders it is possible to prevent the transition of this symptom complex to more severe life-threatening pathological conditions. The system of prevention should include such areas as a reduction of the stress factors influence, the introduction of educational health programs, including the basics of a healthy lifestyle, sensible nutrition, and high physical activity.

Ciliary Neurotrophic Factor Disturbances in Patients with Melancholic Depression-https://biomedres01.blogspot.com/2020/12/ciliary-neurotrophic-factor.html

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Ciliary Neurotrophic Factor Disturbances in Patients with Melancholic Depression

Short Communication

Ciliary neurotrophic factor (CNTF) is a 22-kDa cytokine belonging to the interleukin-6 family and is mainly expressed in glial cells of the central and peripheral nervous systems [1]. Ciliary neurotrophic factor is a neurotrophin which could act as a neuroprotective agent [2]. CNTF plays an important role in the regulation of neuronal development, neuroprotection and may also influence cognitive processes [3]. However, the physiological relevance of circulating CNTF still needs to establish. Depression is one of the most prevalent mental disorders and one of the main causes of disability worldwide. Depression now is a very complicated medical and social problem that in the next years will be only exacerbate. Thus, investigation of all aspects of pathogenetic mechanisms of depression is a very important task of the medicine [4]. Depression is characterized by an altered monoaminergic neurotransmission as well as a modulation of cytokines and other mediators in the central nervous system. In particular, disturbed neurotrophic factors may influence affective behavior including depression and anxiety [3]. There have been several reports regarding the detection of circulating CNTF in healthy individuals, patients with septic shock, systemic lupus erythematosus, rheumatoid arthritis, multiple myeloma and amyotrophic lateral sclerosis [1]. But there are no reports in the literature regarding circulating levels of CNTF in depression. The aim of the study was to investigate the levels of CNTF in blood serum in patients with melancholic depression.

Subjects and Methods

There were investigated 27 patients with melancholic depression at admission in the clinic of affective disorders of Moscow Research Institute of Psychiatry and 11 healthy volunteers (controls). Patient’s state was defined as a depressive episode in the frame of bipolar depressive disorder (type 2) (F32) and in the structure of recurrent depressive disorder (F33). Investigation was performed in accordance with Helsinki Declaration and the conclusion of local ethical committee of the Institute (№ 16 of 13.03.2017). CNTF concentration in blood serum was assessed by ELISA method using Thermo scientific multiskan FC (China) and Human Ciliary Neurotrophic Factor (hCNTF) ELISA kit, Cat. CSB-E-04527h (Cusabio Technology LLC, USA). Statistical analysis was performed using Wilcoxon-Mann-Whitney u-test. The difference was considered as significant at p<0.05.

Results and Discussion

At admission, before any treatment CNTF concentration in blood serum of patients with melancholic depression was 679.11 ± 63.09 pg/ml of serum. It was significantly for 71.7 % higher in comparison with healthy subjects (405.96 ± 91.91 pg/ml of serum, p<0.01). It is shown the first time in the literature that depression, in particular melancholic depression, is followed by increased of ciliary neurotrophic factor level in blood serum. Earlier we have shown that CNTF concentration was increased in patients with epilepsy [5, 6]. As it was said above CNTF plays an important role in neuroprotection and may influence cognitive processes [3]. It was shown that depression is followed by increased permeability of blood-brain barrier [7]. We can hypothesize that in pathological condition CNTF is synthesized and secreted in the brain in larger amounts, but it does not exhibit neuroprotective properties because it immediately leaks out into the blood stream through the damaged blood-brain barrier [6]. The similar changes were found in patients with autism spectrum disorders [2]. In conclusion we can state that in some clinical conditions – depression, autism, etc – ciliary neurotrophic factor cannot reveal its neuroprotective functions because of damaged blood-brain barrier, influences of oxidative stress on CNTF synthesis machinery and some other. Further investigations must be performed.

Focus on In Silico Aptamer Synthesis New Food for Thought-https://biomedres01.blogspot.com/2020/12/focus-on-in-silico-aptamer-synthesis.html

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Focus on In Silico Aptamer Synthesis New Food for Thought

Introduction

The improved knowledge about the etiology of several diseases as well as the discovery of the epidemiologic aspects in the onset of some of them, is changing the approach to cure and prevention. Each disease is seen as a unique phenomenon, to be addressed looking at the personal history and genetic profile of the patient. As a consequence, therapy and prevention are becoming increasingly customized, and cures tend to be minimally invasive. On the other side, effectiveness has to be preserved, and to this aim, research mimics Nature. For example, immunotherapy, aims to contrast cancer by inducing an immune response against upregulated cells. In this regard, the design and production of new antibodies and aptamers for targeted therapies is the focus of many researches. Several monoclonal antibodies have been approved [1], while other are under clinical trials, despite the occurrence of quite severe side effects, like auto-inflammatory immune response, that can reduce the effectiveness of the treatment. Aptamers, like monoclonal antibodies, are synthetized to perfectly fit a specific target. Their selectivity, low size, short half-life, low immunogenicity, high specificity, and low production costs make them formidable competitors of antibodies in both diagnosis and therapy [2].

The production of aptamers started in 1990 [3], by means of the innovative SELEX technique, which is still in use both in the original version and also in several other updates [4]. It uses wide libraries of sequences to select, after several steps of severe selections, those with the highest affinity for the selected targets. With a conceptually similar procedure, ad hoc developed computer codes guess the possible shapes of several aptamer sequences and identify those with the highest affinity for the selected target [5]. The structure selection develops a multistep procedure that creates a pool of possible initial sequences, then samples the conformational space, producing the 3D shapes which are expected to be the most biologically relevant. Docking software select the best binding between a pair of macromolecules, using rigid or flexible roto-translations. The results are ranked according to the interaction energies between the two molecules, the desolvation and solvation energies associated with the interacting molecules, the entropic factors that occur upon binding [6].

A Case Study: Aptamer-Angiopoietin Complexes

In cancer therapy the role of angiopoietins in early detection is well established. As a matter of facts, both angiopoietin-1 (Ang1) and angiopoietin-2 (Ang2), and their natural receptors, Tie1, Tie2 appear as overexpressed in the presence of specific tumors [7] or blood diseases [8]. Angiopoietin-specific aptamers were selected both in vivo and in silico [9], although the in-silico predictions did not completely match with experimental data. In a recent paper a numerical investigation was used to predict the structure of 5 different aptamers [10] when complexed with Ang2. One of these sequences is Ang1-specific and used as a benchmark. The configurations of the complexes were obtained by using free software and ranked on the basis of an indicator which considers both the configurational and also the binding energy. This indicator was called effective affinity (EA). The procedure proposes hundreds of configurations for each sequence, whose mean properties were analyzed by using a complex network approach called Proteotronics [11,12]. In a nutshell, each complex was mapped into an impedance network whose topological and electrical features were used to produce an alternate ranking based on a novel indicator, Möbius (M) [13]. The mean features of each aptamer were in reasonable agreement with experimental data.9 However, after a deeper investigation, it clearly appeared that the samples given by the numerical procedure were not homogeneous. In particular, we found that the set of configurations produced for each aptamer was divided into two different types of conformers. In the conformer called hair, the aptamer is located on the head of the protein, in the other, called belt, the aptamer embraces the protein. Hair conformer reproduces the natural Ang2-Tie2 binding, while belt conformer suggests a new kind of binding. Both these conformers may result in high values of the effective affinity, because both correspond to complexes in which the aptamer and the target are very close to each other. In order to investigate the significance of the belt conformer, both EA and M indicators were used to perform a different scoring of the sequences [13]. The aptamer which is, in vivo, the best performing showed a prevalence of hair conformers among the highest score configurations, while a prevalence of belt conformers was detected among the highest score configurations of the aptamer which is, in vivo, the worst performing. The aptamers which are mutant sequences have not a specific characterization in terms of hair or belt conformers.

These results suggest different possible interpretations. For example, both the conformers can appear in real samples, although with different dissociation constants. In such a way, the relative abundance of hair/belt conformers in the pool of sequences representing each aptamer can be considered a measure of the complex stability. On the other hand, it has to be highlighted that the docking was performed by using the available Ang-2 crystallographic data, which refer, at the moment, to only a fragment of the protein. The protein works in vivo as a dimer, therefore a part of the surface which in simulations is assumed to be available for binding could, actually, be occupied by the other monomer. This makes the comparison between numerical simulations and experimental data quite questionable.

Conclusion

In silico docking is a powerful technique for the selection of aptamers with high affinity for an assigned target. Computational methods are becoming more and more rapid and effective, although a reliable ranking of their products, often several tens, still remains a challenging problem. In a recent investigation, we have shown that the introduction of a novel kind of scoring is necessary, especially when the software is unable to discriminate between quite different types of conformers, say, belt and hair. The present research opens the door to different conclusions. On one hand, both the conformers can be found in vivo, with different half-lives; the relative abundancies of the two conformers determines the stability of a real sample. On the other hand, it has to be emphasized that some of the belt conformers could not be realistic structures, since the aptamer occupies a part of protein surface which is not really available. Finally, an insilico investigation can be used, at present, only as a guide and an initial screening for the selection of high affinity aptamers, while crystallographic investigation still remains mandatory. To progress, it is necessary to gain more complete information about the target, so as design new indicators useful to ascertain the quality of the results.

Progressive Pan-Corporal Hemi- Hypertrophy: A Case Presentation-https://biomedres01.blogspot.com/2020/12/progressive-pan-corporal-hemi.html

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Progressive Pan-Corporal Hemi- Hypertrophy: A Case Presentation

Introduction

The hemi-hypertrophy is one of unusual abnormalities can be congenital which affects multi systems. Musculoskeletal involvement characterized as variable growth in different parts of body. It can be assumed as a part of syndromes like Beckwith-Wiedemann syndrome, Proteus syndrome, Klippel Trenaunay Weber syndrome or Hemi-hyperplasia- Multiple lipomatosis or can be happened as idiopathic event [1,2]. Tumors like Wilms and hepatoblastoma are among common tumors found in isolated hemi-hypertrophies [3]. Management of hemi- hypertrophy is usually conservative and according to encountered conditions can plan. We want to present a case of hemi-hypertrophy who had multiple pictures of such phenomenon.

Case Presentation

An 18 year’s old lady consulted for her appearance deformities. The problem was noticed from delivery, but progressively asymmetry changed her status. Her IQ went beyond average level, as well she had not any history of seizure or behavior problems. She was concern about left side facial hypertrophy which caused deviated upper lip and mallar area, as bizarre jowling face. However, facial hard tissue component seemed structurally and functionally normal (Figure 1). On the other hand, hypertrophic left side thoracolumbar subcutaneous tissues changed the posture. So, she suffered kyphoscoliosis with limitations in her carriers (Figure 2). In the lower limb, macrodactyly of some toes was significant bilaterally (Figure 3). In the reports of laboratory tests, there was not any abnormal values. Previous imaging studies demonstrated no sign of malignancy or visceral masses. The patient underwent two steps of debulking in face and trunk to decrease dysregulated adipose tissue volume.

Figure 1: left sided facial hemihypertrophy without malocclusion.

Figure 2: left sided hypertrophy of subcutaneous tissues of Trunk with Café au lait patches.

Figure 3: lower limb macrodactyly-especially in middle toes.

Discussion

Overgrowth of different parts of body is the main-stem in hypertrophy or hyperplasia events. Syndromic case are generally associated with genomic mutations affect structural proteins regulation [1]. Klippel Trenaunay Weber syndrome, Proteus syndrome, Beckwith-Wiedmann syndrome are among common syndromic forms of such hypertrophies [4]. Moreover, isolated hypertrophies (IH) are potential sources for tumors and knowledge about their diagnostic criteria, can be useful to manage if not lifesaving. So, Clericuzio introduced some criteria to diagnose and illustrated association between IH and tumors, though we know these are not exclusive [5]. In some isolated forms there are associations with genomic informations like chromosome 11p15, as shown by Shuman et al. [6]. Beyond this information, our case did not contained all criteria of each of syndromic forms nor presented isolated hyper trophy. She had complained deformed face and trunk and microscopic findings of surgery`s products following facial and trunk debulking were compatible with adipose and connective tissue. Illustration of clinical manifestations of bizarre postures, help new colleagues to determine their unknown patients and choose better decisions.

Microbiology and Chemical Preservation of Eggplants Sold in Five Popular Markets in Owerri, Imo State, Nigeria-https://biomedres01.blogspot.com/2020/12/microbiology-and-chemical-preservation.html

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Microbiology and Chemical Preservation of Eggplants Sold in Five Popular Markets in Owerri, Imo State, Nigeria

Introduction

The huge loss of fruits and vegetables to spoilage is becoming alarming. The enormous economic loss to farmers and reduction in gross domestic product (GDP) to producing nations has been the discourse in many international conferences. The high moisture contents and nutritional components of fruits and vegetables predispose it to both chemical and microbial spoilage [1-8]. Fruits, apart from its nutritional values have so many therapeutic potentials. Some contain phytochemical and antioxidant agents [9-11,5], while some have been employed in production of beverages, probiotics and prebiotics. Garden egg contains flavonoids, tropane, glycoalkaloids, argiuine, lanosterol, gramisterol, aspartic acid as important constituents [9]. The plant is reported to have analgesia, antipyretic, antioxidant, anti-inflammatory, antiasthmatic, hypolipidenic, hypotensive, antiplatelet, intraocular pressure reducing and anaphylactic reaction inhibitory activities [12].

The demand for garden egg is on the increase as it has gone beyond being a staple fruit to a more commercial commodity that is now a major source of income for producing households and marketers in the forest zone [13]. Since fruits are generally acidic, they are naturally amenable to preservation. Secondly, increased acidity can activate chemical reactions such as pectin which lowers water activity and reduces the possibility of microbial growth. Dehydration is among the oldest and most common forms of fruit preservation as moisture in the fruit is driven off; leaving a stable food that has moisture content below that at which microorganisms can grow. This research reports the microbiological quality of garden eggs and different chemical preservation methods.

Materials and Methods

Sample Collection and Preparation

Four hundred fresh garden eggs were collected randomly from five markets (Ekeonunwa, Ihiagwa, Relief, Ezeobodo and Nekede) in Imo state, Nigeria. Two hundred samples were subjected to microbiological analysis without treatment with preservatives, while the remaining two hundred were treated with different concentrations of preservatives before subjecting to routine microbiological analysis.

Microbiological Analyses of Samples

Ten grams of fresh eggplants were rinsed in ninety milliliters of sterile distilled water to obtain 101 dilution. Further dilutions were made decimally until 105 dilution was obtained. One-tenth milliliter (0.1ml) of the fifth dilution was plated in duplicates onto freshly prepared surface dried Nutrient agar (NA), Potato Dextrose Agar (PDA) and MacConkey agar (MCA). The inocula were spread evenly before incubated at ambient temperature (28±020C) [14- 16].

Preparation of Preservatives and Treatment of Samples

Two hundred milliliters of distilled water were sterilized in a 500mls conical flask. This was repeated in four sets. Different concentrations (10g, 5g, 3g, and 1g) of ascorbic acid was dissolved in the sterile distilled water and shaken vigorously. The procedure was repeated with sodium metabisulphite and sodium benzoate. Twenty grams (20g) of fresh eggplants were suspended on the prepared preservatives and left to stand on the bench for 24h. The microbiological procedure was repeated for the samples treated with the preservatives.

Enumeration and Characterization of Microbial Isolates

The number of viable colonies developed were enumerated and express as colony forming unit per grams [15,16]. The characterization and identification of bacteria and fungi isolates were based on the colonial morphology, microscopic and standard biochemical test [17-21].

Results

Table 1 shows the total microbial populations prior to the addition of preservatives. Counts ranged between 3.3 x 105 - 1.43 x 107 for heterotrophic bacteria, 1.0 x 105 – 1.45 x 107 for heterotrophic fungi and 1.0 x 104 – 3.2 x 104 for coliform bacteria. Table 2 shows the biochemical and carbohydrate characterization of bacteria isolated from the untreated samples. Four species of bacteria namely, Staphylococcus aureus, Bacillus subtilis, and Micrococcus luteus and Enterococcus fàecalis were isolated. Four fungal species namely Rhizopus nigrican, Saccharomyces cerevisiae, Aspergillus and Fusarium species were isolated from the sample as shown in Table 3. Table 4 shows the total count and colony characterization of bacterial isolates after treatment with different concentrations of preservatives. Samples treated with ascorbic acid did not show any effect, especially at concentrations 1g and 3g, as the organisms grew luxuriantly. Remarkable result was evident at concentrations 5g and 10g as there was reduction on both microbial population and diversity.

Table 1: Total microbial population on garden eggs before treatment with preservatives.

Note: EKM, Ekeonuwa market; IHM, Ihiagwa market; RFM, Relief market; EZM, Ezeobodo market; NKM, Nekede market.

Table 2:Biochemical characterization and carbohydrate formation test of bacteria isolated from samples.

Note: Cat, catalase; Oxi, oxidase; In, indole; MR, methyl red; Cit, citrate; NO3, Nitrate reduction; Glu, glucose; Suc, sucrose; Mal, maltose; Mann, Mannose; Xyl, xylose; Lac, lactase: +S, gram positive spherical (round) shape: +R, gram positive rod shape.

Table 3: Colonies and microscopic characterization of fungal isolates.

Table 4: Total count and colony characterization of Bacteria isolated on samples treated with preservatives.

There was significant decrease in both cells counts and bacterial types in samples treated with sodium benzoate. The higher concentrations (5g and 10g) inhibited the growth of the organisms. Sodium metabisulphite was stimulatory and the bacterial populations increased with concentration of the preservatives. The effects of preservatives on the fungal isolates on the samples is shown in Table 5. The higher concentrations (5g and 10g) of sodium benzoate and sodium metabisulphite showed significant inhibition on the growth of the fungal isolates. Ascorbic acid showed a stimulatory effect on the growth of bacteria and fungi. The percentage occurrence of bacteria and fungi isolated from the samples is shown in Table 6. The yeasts, Saccharomyces species and the bacterium, Enterococcus faecalis were dominant species isolated from the samples. The distribution of the bacteria and fungi isolated across the sample locations (markets) is shown in Table 7. Saccharomyces, Bacillus and Enterococcus faecalis were isolated in the sample across the markets.

Table 5: Total count and colony characterization of Fungi isolated on samples treated with preservatives.

Table 6:Percentage distribution of Bacteria and Fungi in samples.

Table 7:

Discussion

The results obtained shows that the eggplants were contaminated with diverse microorganisms. Some of these isolates have been found to be associated with certain food borne illnesses, most of which arise from improper handling, preparation and poor food storage facilities [22,23], also can cause food spoilage [23,24]. The presence of some pathogenic bacteria such as Bacillus subtilis, Enterococcus faecalis, Micrococcus luteus and Staphylococcus aureus is worrisome because of their public health importance. Bacillus subtilis is a spore former that can withstand adverse effects of preservative(s). These structures pose resistant to environmental stress such as heat, ultraviolet radiation, chemical disinfectant and desiccation [23]. The presence of Enterococcus faecalis associated with faecal contamination is notable causative agent of food borne gastroenteritis and bacterial diarrhea disease [23,25-27].

Reported that some strains of Aspergillus flavus produce aflatoxins, which are cancerous in mammals including human. The presence of these microorganisms is an indication of the use of contaminated water by food handler and soil where they are cultivated [23,25,26]. Saccharomyces cerevisiae and Bacillus species are the major fermentative organisms and may influence microbial food deterioration and spoilage [26,28]. Results shows that the chemical preservatives used were effective against microbial growth at different concentrations. This was evident in the reduction of bacterial and fungal count over time. Chemical preservatives have been used to improve the shelf lives of food substances as they inhibit, retard or arrest the growth of microorganisms [7,29-31]. Investigation of antimicrobial activities of the three preservatives used showed that sodium benzoate was more effective on both bacterial and fungal species.

This was also reported by [32]. This was evident as samples treated with sodium benzoate had a lower microbial count as well as decrease in microbial diversities. The low hydrogen ion concentration, (pH) could account for the reduction in both microbial populations and diversities [32-34]. The higher bacteria contamination shown in samples treated with sodium metabisulphite indicates a stimulatory response rather than antagonistic response. Sodium metabisulphite was very effective against fungi at higher concentrations, whereas ascorbic acid was stimulatory to the growth of fungi, especially the yeasts, Saccharomyces. This study has established microbiological safety of eggplants treated with chemical preservatives. The use of chemical preservatives in appropriate concentration in addition to other hurdles techniques recommended by [30] could serve as a check in the control of microbial contamination.

Efficacy and Safety of Elbasvir/Grazoprevir Combination Therapy for Chronic Hepatitis C-https://biomedres01.blogspot.com/2020/12/efficacy-and-safety-of.html

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Efficacy and Safety of Elbasvir/Grazoprevir Combination Therapy for Chronic Hepatitis C

Introduction

Eradication of hepatitis C virus is crucial for risk reduction of human hepatocarcinogenesis [1-3]. Direct-acting antiviral (DAA) agents such as telaprevir (TVR) [4-6] and simeprevir (SMV) [7-11] are the first ones that were introduced for the treatment of patients with chronic hepatitis C virus (HCV) infection from 2011 to 2013. Although these DAAs have improved the overall efficacy of chronic hepatitis C (CHC) treatment, TVR or SMV was used in combination with pegylated interferon (PEG-IFN) and ribavirin (RBV). A significant population of patients with CHC were compelled to discontinue or skip scheduled treatments with triple therapy consisting of PEG-IFN, RBV, and TVR or SMV since this treatment regimen caused a wide variety of side effects such as anemia and liver dysfunction. Moreover, administration of PEG-IFN is accompanied by the appearance of high fever and general malaise, which sometimes impair the patients’ quality of life. To overcome such disadvantages of triple therapy consisting of PEG-IFN, RBV, and TVR or SMV, combination therapy with asunaprevir (ASV) and daclatasvir (DCV) was approved in 2014 as the first IFN-free regimen [12-15]. Compared with treatment regimens including IFN, this combination therapy can be applied to a broad range of patients.

Even the elderly patients with comorbidities have become good candidates for this IFN-free regimen. Different from IFN-based regimens, the efficacy of the combination therapy with ASV and DCV was not affected by patient characteristics, such as sex and age, or the presence of liver fibrosis and IL28B polymorphism. Although the combination therapy with ASV and DCV was safe with minimal adverse effects, the efficacy of this regimen was dependent upon the presence of baseline viral mutations that conferred resistance to the treatment. In addition, some patients were unable to continue the treatment due to side effects such as liver dysfunction. Combination therapy with sofosbuvir (SOF) and ledipasvir (LDV) is a second generation IFN-free regimen that can eliminate HCV bearing mutations resistant to ASV and DCV. A phase III trial of combination therapy with SOF and LDV in Japan resulted in a remarkable success in the achievement of sustained viral responses (SVR) due to an additive effect of the two drugs [16]. Despite of extremely high elimination rates in CHC patients treated with SOF and LDV, two major concerns regarding this combination have been raised. Firstly, SOF is excreted by the kidneys and thus its use was contraindicated in patients with advanced kidney diseases. Secondly, combination therapy with SOF and LDV may have some toxic effects on cardiac functions leading to QT interval prolongation [17]. Combination therapy with elbasvir (EBR) and grazoprevir (GZR) is a third generation IFN-free regimen for CHC. A phase III trial of combination therapy with EBR and GZR has provided evidence that, this combination regimen is safe even in patients with advanced kidney diseases [18]. In the present study, we examined the efficacy and safety of EBR/GZR combination therapy in patients with CHC. Our results suggest that combination therapy with EBR and GZR is very effective even in elderly patients bearing impaired heart and kidney functions.

Patients and Methods

Patients and Treatment Schedule

Sixty-two patients with CHC received combination therapy with EBR and GZR at Kindai University Hospital from November 2016. Patients were included in this retrospective study if their sustained virologic responses at 12 weeks (SVR12) were able to be evaluated. A total of 40 patients were enrolled in the study. The combination therapy was administered for a total of 12 weeks, followed by 12 weeks observation. Patients received oral administration of 50 mg of EBR and 100 mg of GZR once daily for a total of 12 weeks. Ethical permission of this study was granted by the Review Boards of Kindai University Faculty of Medicine.

Quantification of HCV-RNA

HCV-RNA levels were measured using the Roche COBAS Taqman test with lower and upper limits of quantitation of 15 IU/mL and 8.0 log IU/mL.

HCV Mutation Analysis

HCV NS5A and NS3/4A mutations that confer drug resistance were examined using PCR-invader, CycleavePCR, and direct sequencing. Serum samples isolated from 13 patients were subjected to HCV mutation analysis.

Results

Patients

Sixty-two patients with CHC received combination therapy with EBR and GZR at our hospital from November 2016. Forty patients were included in the study, as their SVR12 were evaluable. As shown in Table 1 the median age of the patients was 74 years; 29 (73%) were over the age of 65 and 18 (45%) were over the age of 75. Thus, the number of elderly patients in our study was higher than that in the phase III clinical trial conducted in Japan [18]. In addition, 12 patients (30%) had cirrhosis and 7 (18%) had a previous history of liver cancer that was cured. There were 2 patients (5%) who had been previously treated with DAA; one patient was refractory to combination therapy with DCV and ASV, whereas the other patient had experienced breakthrough with DCV and ASV and then relapsed with subsequent SOF and LDV (Table 1)

Baseline Resistance-Conferring Mutations in NS5A

The presence of NS5A mutations was examined in 13 patients. NS5A mutations were not detected in six patients (15%), seven patients (18%) had Y93 mutations, and two patients (5%) had L31 mutations (Table 1).

Table 1: Patient background.

Virologic Response

All 40 patients (100%) achieved end-of-treatment-response (ETR). Two patients had relapsed during the subsequent 12-week observation period. Thus, SVR12 was achieved in 38 patients (95%) (Figure 1).

Figure 1: SVR12 was achieved in 38 patients (95%).

Virologic Relapse

Two patients who had previously been treated with DAA relapsed after the 12-week treatment. One of the patients was refractory to combination treatment with DCV and ASV and had acquired Y93H (100%) and L31M, V (>20%) mutations prior to the administration of EBR and GZR. The other patient achieved breakthrough with DCV and ASV and then relapsed with subsequent combination treatment with SOF and LDV. This patient also had resistance mutations of Y93H (>20%) and L31M, V (>20%) prior to the administration of EBR and GZR (Table 2). Thus, the presence of baseline mutations in NS5A resistant to DAA was strongly associated with relapse after EBR and GZR in patients with DAA failure.

Table 2:Characteristics of patients who did not achieve SVR.

Baseline NS5A (Y93) Resistance-Conferring Mutation and Antiviral Efficacy of EBR and GZR Therapy in DAAnaïve patients

Five DAA-naïve patients had Y93H mutations in NS5A. Four patients had a high frequency of resistance-conferring mutations (≥50%). However, all patients achieved SVR12 (Table 3). Thus, the presence of baseline mutations in NS5A resistant to DAA did not affect the rates of SVR12 in DAA-naive patients treated with EBR and GZR.

Table 3: Baseline resistance-conferring mutations in NS5A in DAA-naïve patients.

Anti-viral Efficacy and Safety of EBR/GZR Therapy for Patients with Cardiovascular Disease

A total of 21 (52.5%) among the 40 patients had cardiovascular diseases. All 21 patients achieved SVR12, and none had side effects, including heart disease (Figure 2). Thus, combination therapy with EBR and GZR is safe even patients with cardiovascular diseases.

Figure 2:All 21 patients achieved SVR12, and none had side effects, including heart disease.

Anti-viral Efficacy and safety of EBR/GZR Therapy for Patients with Advanced kidney diseases (eGFR<30)

Five of the 40 patients had advanced kidney diseases with eGFR<30. All 5 patients achieved SVR12, and none had side effects (Table 4). Thus, combination therapy with EBR and GZR is safe even patients with advanced kidney diseases.

Table 4: Side effects leading to discontinuation of the therapy.

Side Effects leading to Discontinuation of EBR/GZR Therapy

Combination therapy with EBR and GZR was discontinued in one patient (2.5%) due to an increased level of alanine aminotransferase (ALT, 261 IU/mL) at week 10. The treatment was re-initiated after the reduction of ALT levels to complete the 12- week regimen (Table 5).

Table 5: Patients with advanced kidney diseases (eGFR<30).

Discussion

The Japanese phase III trial of combination treatment with EBR and GZR in DAA-naïve patients revealed that 96.5% of HCVinfected patients with liver cirrhosis and 97.1% of patients with compensated liver cirrhosis achieved SVR12 [18]. As for the presence of baseline NS5A mutations conferring resistance to DAA, the Japanese phase II and phase III trials disclosed that 93.1% of patients bearing such NS5A mutations achieved SVR12, suggesting that the presence of mutations do not affect the elimination rates of HCV in this combination therapy. [18]. In line with these trials, 38 of 40 patients (95%) achieved SVR12 in this study. The two patients who did not achieve SVR12 experienced treatment failure in prior DAA treatment. Moreover, they acquired mutations in Y93 and L31 prior to the initiation of EBR and GZR therapy. Thus, DAA-experienced patients who have already acquired resistance due to multiple mutations in NS5A may not be suitable candidates for EBR and GZR therapy. On the other hand, all of 38 DAA-naïve patients achieved SVR12 in this study. Although five of these patients had Y93H mutations and 4 had a high frequency (≥50%) of resistance-conferring mutations, they all achieved SVR12. This suggests that the presence of resistance-conferring mutations does not influence the efficacy of EBR and GZR therapy in DAAnaive patients. Although our study included a higher proportion of elderly patients and those with more advanced liver fibrosis as compared with the Japanese phase III trial, all of our patients achieved SVR. Therefore, combination therapy with EBR and GZR may be an effective treatment option for DAA-naïve patients with advanced liver cirrhosis. This study population consisted of a high proportion of patients with cardiovascular diseases.

It should be emphasized that combination therapy with EBR and GZR led to achievement of SVR 12 in all patients with cardiovascular diseases and none of such patients discontinued this treatment due to cardiovascular side effects. These data are in stark contrast with those of previous studies regarding combination therapy with SOF and LDV in which such treament may have some toxic effects on cardiac functions leading to QT interval prolongation [17]. Furthermore, several reports suggest that HCV infection and cirrhosis may cause QT interval prolongation and cardiovascular diseases such as angina [19-20]. Indeed, a significant population of patients who received combination therapy with SOF and LDV developed cardiovascular side effects, leading to discontinuation of the treatment. Our findings strongly suggest that combination therapy with EBR and GZR is safe and effective treatment option for patients with heart diseases. Both EBR and GZR are metabolized by CYP3A and can be administered safely to patients with kidney diseases. In phase II and phase III trials (C-SURFER), combination therapy with EBR and GZR treatment led to SVR12 in 99.1% of the patients with advanced stages of chronic kidney disease without serious adverse events [21].

In the present study, 5 of the 40 patients had advanced kidney diseases with eGFR<30, and all 5 patients achieved SVR12 without developing any side effects (Table 4). Thus, consistent with previous reports, this combination therapy was found to be a safe and effective treatment option for patients with advanced kidney diseases. These dat altogether strongly support the idea that combination therapy with EBR and GZR is safe and effective even in elderly CHC patients with cardiovascular and kidney diseases. One patient (2.5%) developed side effects that led to discontinuation of the therapy due to the elevation of serum ALT levels. The patient skipped the treatment for 2 weeks and then was re-started after the confirmation of reduction of ALT levels to complete the 12- week regimen (Table 5). Clinical course of this patient suggest that close and careful monitoring of liver enzymes is might be required in combination therapy with EBR and GZR. In conclusion, we demonstrated that combination therapy with EBR and GZR is an effective treatment option for DAA-naïve patients bearing advanced kidney diseases and cardiovascular diseases. Given the fact that an SVR rate of over 95% was achieved with DAAs further studies focusing on improvement of the safety are required. It is no doubt that combination therapy with EBR and GZR is one of such candidates that can be easily applied to the elderly CHC patients bearing a wide variety of comorbidities.

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