July 10, 2010

NIH-Led Scientists Find Antibodies that Prevent Most HIV Strains from Infecting Human Cells

This image shows the atomic structure of the antibody VRC01 (blue and green) binding to HIV (grey and red). The precise site of VRC01-HIV binding (red) is a subset of the area of viral attachment to the primary immune cells HIV infects
Credit: NIAID VRC

National Institute of Allergy and
Infectious Diseases (NIAID)
http://www.niaid.nih.gov/

FOR IMMEDIATE RELEASE
Thursday, July 8, 2010

Media Contact:
Laura Sivitz
(301) 402-1663
niaidnews@niaid.nih.gov

Discovery to Advance HIV Vaccine Design, Antibody Therapy for Other Diseases

Scientists have discovered two potent human antibodies that can stop more than 90 percent of known global HIV strains from infecting human cells in the laboratory, and have demonstrated how one of these disease-fighting proteins accomplishes this feat. According to the scientists, these antibodies could be used to design improved HIV vaccines, or could be further developed to prevent or treat HIV infection. Moreover, the method used to find these antibodies could be applied to isolate therapeutic antibodies for other infectious diseases as well.

“The discovery of these exceptionally broadly neutralizing antibodies to HIV and the structural analysis that explains how they work are exciting advances that will accelerate our efforts to find a preventive HIV vaccine for global use,” says Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health. “In addition, the technique the teams used to find the new antibodies represents a novel strategy that could be applied to vaccine design for many other infectious diseases.”

Led by a team from the NIAID Vaccine Research Center (VRC), the scientists found two naturally occurring, powerful antibodies called VRC01 and VRC02 in an HIV infected individual's blood using a novel molecular device they developed that hones in on the specific cells that make antibodies against HIV. The device is an HIV protein that the scientists modified so it would react only with antibodies specific to the site where the virus binds to cells it infects.

The scientists found that VRC01 and VRC02 neutralize more HIV strains with greater overall strength than previously known antibodies to the virus.

The researchers also determined the atomic-level structure of VRC01 when it is attaching to HIV. This has enabled the team to define how the antibody works and to precisely locate where it attaches to the virus. With this knowledge, they have begun to design components of a candidate vaccine that could teach the human immune system to make antibodies similar to VRC01 that might prevent infection by the vast majority of HIV strains worldwide.

NIAID scientists Peter D. Kwong, Ph.D., John R. Mascola, M.D., and Gary J. Nabel, M.D., Ph.D., led the two research teams. A pair of articles about these findings appears today in the online edition of Science.

“We have used our knowledge of the structure of a virus—in this case, the outer surface of HIV—to refine molecular tools that pinpoint the vulnerable spot on the virus and guide us to antibodies that attach to this spot, blocking the virus from infecting cells,” explains Dr. Nabel, the VRC director.

Finding individual antibodies that can neutralize HIV strains anywhere in the world has been difficult because the virus continuously changes its surface proteins to evade recognition by the immune system. As a consequence of these changes, an enormous number of HIV variants exist worldwide. Even so, scientists have identified a few areas on HIV’s surface that remain nearly constant across all variants. One such area, located on the surface spikes used by HIV to attach to immune system cells and infect them, is called the CD4 binding site. VRC01 and VRC02 block HIV infection by attaching to the CD4 binding site, preventing the virus from latching onto immune cells.

“The antibodies attach to a virtually unchanging part of the virus, and this explains why they can neutralize such an extraordinary range of HIV strains,” says Dr. Mascola, the deputy director of the VRC.

With these antibodies in hand, a team led by Dr. Kwong, chief of the structural biology section at the VRC, determined the atomic-level molecular structure of VRC01 when attached to the CD4 binding site. They then examined this structure in light of natural antibody development to ascertain the steps that would be needed to elicit a VRC01-like antibody through vaccination.

Antibody development begins with the mixing of genes into new combinations within the immune cells that make antibodies. Examination of the structure of VRC01 attached to HIV suggested that, from a genetic standpoint, the immune system likely could produce VRC01 precursors readily. The researchers also confirmed that VRC01 does not bind to human cells—a characteristic that might otherwise lead to its elimination during immune development, a natural mechanism the body employs to prevent autoimmune disease.

In the final stage of antibody development, antibody-producing B cells recognize specific parts of a pathogen and then mutate, or mature, so the antibody can bind to the pathogen more firmly. VRC01 precursors do not bind tightly to HIV, but rather mature extensively into more powerfully neutralizing forms. This extensive antibody maturation presents a challenge for vaccine design. In their paper, Dr. Kwong and colleagues explore how this challenge might be addressed by designing vaccine components that could guide the immune system through this stepwise maturation process and facilitate the generation of a VRC01-like antibody from its precursors. The scientists currently are performing research to identify these components.

“The discoveries we have made may overcome the limitations that have long stymied antibody-based HIV vaccine design,” says Dr. Kwong.

The two research teams included NIAID scientists from the VRC, the Laboratory of Immunoregulation, and the Division of Clinical Research, all in Bethesda, Md.; as well as researchers from Beth Israel Deaconess Medical Center in Boston; Columbia University in New York; Harvard Medical School and Harvard School of Public Health in Boston; The Rockefeller University in New York City; and University of Washington in Seattle.

References:

Wu X et al. Rational design of envelope surface identifies broadly neutralizing human monoclonal antibodies to HIV-1. Science. DOI: 10.1126/science.1187659 (2010).

Zhou T et al. Structural basis for broad and potent neutralization of HIV-1 by antibody VRC01. Science. DOI: 10.1126/science.1192819 (2010).

NIAID conducts and supports research—at NIH, throughout the United States, and worldwide—to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at www.niaid.nih.gov.

The National Institutes of Health (NIH)—The Nation's Medical Research Agency—includes 27 Institutes and Centers and is a component of the U. S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

Source

July 9, 2010

Action Alert


Action Alert

(posted July 9, 2010)

The House of Representatives is about to decide the funding amount for viral hepatitis prevention Do not miss this opportunity to tell your Representative to support an increase of up to $50 million for viral hepatitis prevention in FY2011.

YOU MUST CONTACT YOUR REPRESENTATIVE NOW”

The House Appropriations Subcommittee on Labor, HHS, Education and Related Agencies is about to decide the funding amount for viral hepatitis prevention for the Division of Viral Hepatitis (DVH) at the Centers for Disease Control and Prevention for Fiscal Year 2011.

On July 14th, the House of Representatives will begin to mark up the FY2011 Labor-HHS-Education bill which includes funding for viral hepatitis prevention. Given a highly partisan Congress, the economy and the President’s discretionary funding freeze, we are hearing that Appropriators have been told to cut funding across the HHS agencies. The President’s FY2011 Budget proposed the slightest funding increase of $1.8 million to DVH as part of a broader $26 million initiative at the National Center for HIV, Viral Hepatitis, STD, and TB Prevention directed towards gay men, men who have sex with men (MSM) and transgender Americans at risk for HIV. While we support this increased funding and appreciate the need for these prevention programs, it does not support core prevention funding such as hepatitis B and C counseling, testing, and referral, in addition to delivering hepatitis A and B vaccine, and establishing a national surveillance system of chronic hepatitis B and C. HAP and coalition partners will continue to work with Appropriators to include broader prevention priorities in report language.

The greatest opportunity we have to fund hepatitis prevention services is in newly authorized money within health reform’s Prevention and Public Health Fund. We believe it will be an enormous missed opportunity to overlook one of the most underfunded chronic, infectious diseases that continues to take a heavy toll on the individuals infected and contribute to greater health system costs. Hepatitis services have historically been and continue to be critically underfunded and despite the new evidence-based Institute of Medicine recommendations, hepatitis received none of the $650 million in prevention and wellness funding authorized under the American Recovery and Reinvestment Act nor any of the FY2010 $500 million authorized under the Prevention and Public Health Fund.

Congressional staff have told us that any increase hinges upon Members of Congress hearing now directly from state and local constituents on why increased funding is needed. Please continue to help us fight for increased viral hepatitis prevention funding by contacting your Representative about the tremendous need in your area of the country. Please take a few minutes to make these important phone calls!

HOW YOU CAN HELP

It is urgent that your calls be made immediately. Please call your Representative’s Washington, DC office. Ask to speak to the staff person who handles healthcare issues. Whether you speak to this person directly or leave a message, tell them:

“My name is and I’m a constituent of Representative . I am calling to urge your office to weigh in with Chairman Obey of the Subcommittee on Labor- HHS-Education to support increased funding for CDC’s Division of Viral Hepatitis for a total of $50 million. I urge you to invest in hepatitis prevention by leveraging funds from health reform. Hepatitis B and C affects over 5 million Americans. Chronic viral hepatitis is the leading cause of liver cancer, one of the top 10 killers of Americans every year, and the leading cause of liver transplants each year. Congress has historically cut or flat funded the Division of Viral Hepatitis. Money for prevention of hepatitis B and C is critical to increase counseling, testing and referral in order to begin to get a handle on this potentially life-threatening and expensive, chronic disease.”

You can call your Representative at 202.225.3121. You will get the Capitol switchboard. Ask to be connected to your Representative’s office.

Thanks for taking the time to make these important phone calls!

Background
The Division of Viral Hepatitis received $19.3 million in FY2010. With this level of funding, DVH can only support states and cities with an average federal funding award of $90,000. This is only enough for a staff position of the Adult Viral Hepatitis Prevention Coordinator (AVHPC) and not for the provision of core prevention services. An estimated 65-75% of infected Americans do not know their status, compared with 20-30% who do not know their HIV status. Compared to prevention funding for HIV at $728 million, STD at $154 million and TB at $144 million, viral hepatitis is the most underfunded and defunded disease, representing less than 2 percent of the budget of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention.

Policymakers must be made aware of the consequences of continued inaction. The costs to the healthcare system generated by advanced liver disease associated with chronic hepatitis C infection will increase from $30 billion to $85 billion per year. Medicare will be especially hard hit because two-thirds of Americans with chronic hepatitis C infection are baby boomers and the vast majority (75 percent) is unaware; these patients will soon age into Medicare and are likely to progress to advanced liver disease unless they are identified, evaluated and treated soon. In addition to causing 15,000 deaths each year, hepatitis will continue to be the most common cause of non-AIDS-related death in co-infected Americans with HIV with as many as 25percent co-infected with hepatitis C and 10 percent with hepatitis B. Acute hepatitis B will continue to disproportionately impact African Americans, particularly in the southern states, and chronic hepatitis B among Asian Americans where it is the leading cause of death and 10 percent remain infected. Even with a safe and effective vaccine against hepatitis B, 3,000 Americans will continue to die and roughly 1,000 babies will still be infected at birth.

The following Representatives are of great importance at this juncture since they are all Appropriators. If you live in any of these jurisdictions, it is of the utmost importance that you contact your Representative as his or her constituent to weigh in on increased funds for viral hepatitis prevention:

Alabama
Jo Bonner (R)
Robert Aderholt (R)

Arkansas
Marion Berry (D)

Arizona
Ed Pastor (D)

California
Lucille Roybal-Allard (D)
Barbara Lee (D)
Michael Honda (D)
Sam Farr (D)
Adam Schiff (D)
Ken Calvert (R)
Jerry Lewis (R) (Ranking Member on full Appropriations committee)

Colorado
John Salazar (D)

Connecticut
Rosa Delauro (D)

Florida
Allen Boyd (D)
Debbie Wasserman Schultz (D)
Bill Young (R)
Ander Crenshaw (R)

Georgia
Sanford Bishop (D)
Jack Kingston (R)

Idaho
Michael Simpson (R)

Illinois
Jesse Jackson Jr. (D)
Mark Kirk (R)

Indiana
Pete Visclosky (D)

Iowa
Tom Latham (R)

Kansas
Todd Tiahrt (R) (Ranking Member on Labor-HHS Subcommittee)

Kentucky
Ben Chandler (D)
Harold Rogers (R)

Louisiana
Rodney Alexander (R)

Maryland
Dutch Ruppersberger (D)

Massachusetts
John Olver (D)

Michigan
Carolyn Kilpatrick (D)

Minnesota
Betty McCollum (D)

Missouri
Jo Ann Emerson (R)

Montana
Dennis Rehberg (R)

North Carolina
David Price (D)

New Jersey
Steve Rothman (D)
Rodney Frelinghuysen (R)

New York
Nita Lowey (D)
José Serrano (D)
Maurice Hinchey (D)
Steve Israel (D)

Ohio
Tim Ryan (D)
Marcy Kaptur (D)
Steve LaTourette (R)

Oklahoma
Tom Cole (R)

Pennsylvania
Chaka Fattah (D)
Patrick Murphy (D)

Rhode Island
Patrick Kennedy (D)

Tennessee
Lincoln Davis (D)

Texas
Chet Edwards (D)
Ciro Rodriguez (D)
Kay Granger (R)
John Culberson (R)
John Carter (R)

Virginia
Frank Wolf (R)

Washington
Norman Dicks (D)

West Virginia
Alan Mollohan (D)

Wisconsin
David Obey (D) (Chair of full Appropriations committee and Labor-HHS subcommittee)

The Hepatitis Appropriations Partnership (HAP) is a national coalition based in Washington, DC and includes community-based organizations, public health and provider associations, national hepatitis and HIV organizations, and diagnostic, pharmaceutical and biotechnology companies from all over the country. HAP works with policy makers and public health officials to increase federal support for hepatitis prevention, testing, education, research and treatment. Please contact Colin Schwartz at 202.434.8005 or cschwartz@NASTAD.org if you have any questions or need additional information.

Source

Rapid virological response as a predictor of sustained response in HCV-infected patients with persistently normal alanine aminotransferase levels: A multicenter study

Journal of Viral Hepatitis

Early View (Articles online in advance of print)
Published Online: 8 Jun 2010
© 2010 Blackwell Publishing Ltd
C. Puoti 1 , G. Barbarini 2 , A. Picardi 3 , M. Romano 4 , A. Pellicelli 5 , A. Barlattani 6 , F. Mecenate 7 , R. Guarisco 1 , O. M. Costanza 8 , L. Spilabotti 1 , L. Bellis 1 , M. E. Bonaventura 9 , O. Dell' Unto 1 , M. G. Elmo 10 , A. M. Nicolini 1 , L. Nosotti 11 and F. Soccorsi 5 , on behalf of the Club Epatologico Ospedaliero (Hospital Liver Club, CLEO)

1 Department of Internal Medicine and Liver Unit, Marino Hospital, Rome ; 2 Department of Infectious Diseases, San Matteo Hospital, Pavia ; 3 Liver Unit, Campus Biomedico University ; 4 Liver Unit, Sandro Pertini Hospital ; 5 Liver Unit, San Camillo Hospital ; 6 Liver Unit, San Giacomo Hospital ; 7 Liver Unit, Villa Betania Hospital ; 8 Molecular Biology Unit, Marino General Hospital, Rome ; 9 Department of Infectious Diseases, Rieti Hospital, Rieti ; 10 Department of Mental Health, Local Health Centre RM- A ; and 11 Department of Preventive Medicine of Migration, San Gallicano Hospital, Rome, Italy

Correspondence to Claudio Puoti, MD, Department of Internal Medicine and Liver Unit, Marino General Hospital, Via XXIV Maggio 5, 00047 Marino, Rome, Italy.
E-mail: puoti@epatologia.org

KEYWORDS
HCV • normal ALT • peginterferon • rapid virological response • ribavirin • sustained virological response

ABSTRACT
Summary. Rapid virological response (RVR) is now considered the strongest predictor of sustained virological response (SVR) in patients with HCV undergoing antiviral treatment, and thus, shorter antiviral treatment for these patients has been suggested. However, no data exist on the predictive value of RVR in HCV carriers with normal ALT values. A total of 137 patients with persistently normal ALT treated with peginterferon alfa 2a and ribavirin were studied. Fifteen patients dropped out early because of side effects, and in 10 patients with HCV-1 treatment was discontinued because of lack of early virological response (EVR). RVR was observed in 68% of the patients (42% patients with HCV-1, 90% HCV-2 and 64% HCV-3). An end-of-treatment response was observed in 86% of the patients (68% HCV-1, 100% HCV-2 and 91% HCV-3). SVR was maintained in 91 patients (46% HCV-1, 97% HCV-2 and 82% HCV-3). Overall, 92% patients with rapid response did obtain HCV eradication vs only 38% of those without rapid response. HCV-1 patients with baseline HCV RNA <400 × 103 IU/mL were more likely to achieve RVR and SVR than those with higher HCV RNA levels. We conclude that patients with genotype 1 and normal ALT who achieve HCV RNA negativity at week 4 may have a higher probability of eradicating their infection. Because of the concomitant favourable demographic and virological features often found in this particular subset of patients, the duration of therapy in these people might be shortened in the case of RVR. Persistently normal alanine aminotransferase levels patients with genotype 2 or 3 have a high chance of achieving SVR, so retesting of HCV RNA during treatment may have no additional practical value in these subjects.

Received January 2010; accepted for publication February 2010

DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1365-2893.2010.01319.x About DOI
 
Source

Ribavirin plasma concentration is a predictor of sustained virological response in patients treated for chronic hepatitis C virus genotype 2/3 infection

Journal of Viral Hepatitis

Early View (Articles online in advance of print)
Published Online: 1 Apr 2010
© 2010 Blackwell Publishing Ltd

C. Pedersen 1 , Å. Alsiö 2 , M. Lagging 2 , N. Langeland 3 , M. Färkkilä 4 , M. Rauning Buhl 5 , K. Mørch 3 , J. Westin 2 , P. Sangfelt 6 , G. Norkrans 2 and P. Brehm Christensen 1 for the NORDynamicIC Study Group

1 Department of Infectious Diseases, University of Southern Denmark, Odense C, Denmark and Department of Infectious Diseases, Herlev Hospital, Copenhagen, Denmark ; 2 Department of Infectious Diseases, Göteborg University, Göteborg, Sweden ; 3 Department of Infectious Diseases, Haukeland University Hospital and Institute of Medicine, University of Bergen, Bergen, Norway ; 4 Department of Gastroenterology, Helsinki University, Helsinki, Finland ; 5 Department of Infectious Diseases, Skejby Hospital, Aarhus University, Aarhus, Denmark ; and 6 Department of Infectious Diseases, Uppsala University Hospital, Uppsala, Sweden

Correspondence to Court Pedersen, Department of Infectious Diseases Q, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark. E-mail: court.pedersen@ouh.regionsyddanmark.dk

KEYWORDS
drug concentration • hepatitis C • ribavirin • treatment

ABSTRACT
Summary. In hepatitis C virus (HCV) genotype 1 infection, the likelihood of obtaining sustained virological response (SVR) is associated with higher ribavirin exposure. Such an association has not been demonstrated for HCV genotype 2/3 infection, where a fixed 800 mg daily dosing of ribavirin is generally recommended. The primary aim of this study was to investigate the correlation between ribavirin concentration at day 29 and therapeutic response in patients with HCV genotype 2/3 infection. A total of 382 patients were randomized to 12 or 24 weeks of treatment with pegylated interferon-alfa 2a 180 μg weekly and 800 mg ribavirin daily. Trough plasma concentration of ribavirin was measured at day 29 and week 12 and the primary outcome was SVR (HCV-RNA undetectable 24 weeks after treatment). Of the 382 patients, 355 had a ribavirin concentration available at day 29. SVR was 84% among patients with a ribavirin concentration ≥2 mg/L at day 29 compared to 66% in those with concentrations <2 mg/L (P = 0.002). The corresponding figures in the 12-week treatment group were 74% and 57% (P = 0.12), and in the 24-week treatment group 91% and 75% (P = 0.02), respectively. In a multivariate analysis, ribavirin concentration at day 29 was an independent predictor of SVR (P = 0.002). In conclusion, a higher plasma ribavirin concentration is associated with an increased likelihood of achieving SVR in HCV genotype 2/3 infection. Individualization of ribavirin dosing may be helpful in improving outcome, especially in the presence of unfavourable baseline characteristics. This, however, requires evaluation in a prospective trial.
Received October 2009; accepted for publication January 2010

DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1365-2893.2010.01303.x About DOI
 
Source

With Appreciation

I thought this was a truly special story and wanted to share it.
If only we had alot more Drs. like this.

A Piece of My Mind

Vol. 303 No. 18, May 12, 2010

With Appreciation

Ram Y. Gordon, MD
Flourtown, Pennsylvania
ram.gordon@gmail.com

JAMA. 2010;303(18):1790-1791.

I was in practice only three months when I met him. I had just finished my cardiology fellowship and, insecure about my lack of experience, strove for a serious, professional demeanor. My tie was straight, shirt pressed, white coat starched and buttoned. Above all, I sought to establish and maintain the boundaries of the patient-physician relationship.

"Mr M is an 82-year-old male with hypertension, hyperlipidemia, and chronic Lyme disease who presents with dizziness." His blood pressure was high and his ECG showed an asymptomatic atrial tachycardia. His stress test revealed ischemia and I referred him for cardiac catheterization.

He wrote me a note:

I am clear that you recommended I go ahead with the procedure. I "heard" that and paid attention. Yet I am making the decision not to go ahead based on what I feel I can do right now. I value and trust and feel comfortable with you, professionally and personally, and hope you will not write me off because I could not do what you recommended I do. I need to count on you for ongoing advice, expertise, help, and perspective. I will endeavor to be a good patient even though this decision will seem to you a mistake on my part. Yet I feel right about this decision.

I was surprised by his choice and was touched that he had written me with such eloquence. It was the first of many letters I would receive from him.

Mr M eventually acquiesced and underwent catheterization, which revealed coronary disease. We elected to treat it medically. Shortly thereafter, a letter arrived:

As has happened each time, I left you yesterday with added confidence, trust, zing, and a feeling that things-are-going-to-be-all-right. I know the cautions, but I also know the feeling and I am grateful to you for it.

Several months later, another note read:

I look forward to my appointments with you. Our conversations are good for my morale and good cheer, as well as my physical health.

Fifteen months after his initial visit, his blood pressure and lipids were controlled. His supraventricular tachycardia, which we called his "friend," as in "your friend was here, but now he's gone," had not affected his left ventricular function. He had chronic kidney disease and his legs were occasionally wobbly, but he otherwise felt well. A brief note from him read:

As you’ve known for quite a while now, I look to you with confidence and trust, an ace pro who cares and heartens, someone who is good news in this world.

Several months later, after an inpatient stay for a respiratory tract infection, he wrote:

I like reminding you of how much I value and honor your genuine commitment, the feeling you give of really seeing and hearing and caring. It's the other end of perfunctory. I am grateful you chose the career you did, and I, among surely so many, are grateful to be "in your light."

Mr M always wore a suit, even if our appointment was the only one on his agenda. His words were measured and he spoke in a deep baritone, as if he were giving a lecture. He had a long and distinguished career as an educator, teaching English at a local high school before becoming a nationally renowned advocate of teaching reform. He had published almost 20 books and had been featured in Time magazine. He reminded me of John Keating, the inspirational English teacher in the film Dead Poets Society. I looked forward to his appointments.

One day, he asked to learn more about me. I felt uncomfortable. He was my patient, not my friend. Our relationship, while cordial and warm, was one of physician and patient, and I was fairly certain that this line should not be crossed. But this request, from this particular patient, felt somehow different. On his next visit we discussed his stable cardiac disease and then spent 40 minutes talking about me. He was an expert interviewer and sought details of my life, my interests, and my choice of medicine as a career. I let him in.

I told him about my blue-collar Pittsburgh roots and the influence of my father, an ophthalmologist, who was the first person in his family to go to college. I told him that, like all children of physicians, I felt a constant unconscious pressure to go into medicine and was unsure of that decision until I saw patients with my father when I was 21 years old. On that day, I fell in love with the patient-physician interaction, and the marriage of science, art, and interpersonal relationships that defines clinical medicine. I told him about my mother's nurturing and about my gold-hearted grandfather, who should have been a social worker, but instead pumped gas for a living. I told him about meeting my wife in college and about my three children. When the conversation was over, and other patients were waiting, we parted. I felt that I had shared something special, something of myself, with a "friend."

I received a handwritten note several days later:

I have played through that wonderful conversation we had again and again in my mind—it's the scene from a joyous movie—us there in your office, you visiting with your father's patients for the first time, the extraordinary relationship with your grandfather and mother, your clarity from each, in what your work was going to be, and your joy in it. Often, people are moved most by stories of sadness or frustration or struggle. What was so moving to me about that conversation was that it was a story of extraordinary happiness. You were and are blessed, and so are the many of us who visit your orbit.

As a physician, I have always felt an obligation "to try and reach" every patient. Now, with Mr M, our relationship had grown closer.

Thereafter, his appointments became joyous reunions. Neuropathy had affected his fine motor movements, and I helped him button his dress shirt and adjust his tie. We would part with a hug, and his visit would lift my spirits for the rest of the day.

Although he was modest, I eventually persuaded him to share more about himself. He had a son and daughter, and two beloved granddaughters. He lived locally but had been born in his parents' bedroom in New Hampshire. He was valedictorian of his class and a champion tennis player in high school and had majored in French at a top liberal-arts college.

And, early in our discussions, it became obvious that he loved classic films. One visit, we discussed Frank Capra's It's a Wonderful Life, one of my favorite movies. He nonchalantly mentioned that he and Capra were good friends, and we talked for several minutes about their relationship. A few days later The It's a Wonderful Life Book by Jeanine Basinger was waiting for me on my desk. In it, the inscription read:

To my distinguished cardiologist, princely fellow, valued encourager, and friend. Like George Bailey, you are "the richest man in town."

I once mentioned that I shared a birthday with Fred Astaire and that my 5-year-old daughter loved his classic film Top Hat. Several days later, the complete Fred Astaire DVD series arrived on my desk with a warm note. Other movies followed and with each, a note highlighting some of the classic scenes, dances, and songs. Although I was deeply moved, I begged him on several occasions to stop giving me gifts. He insisted that it gave him great joy to think of me watching some of his favorite movies with my family. I felt he was sharing part of himself with me and accepted the films, knowing he would not take no for an answer.

Recently, I saw him for the final time in my office. A note followed:

I wonder how many people walk out of an appointment with their doctor feeling healthier, happier, more affirmed, more zesty, than when they went in. I look forward as much to the conversations—they are pure gold as far as I’m concerned. I am grateful I know you. With appreciation, Mr M.

Two months later, he developed a fever and chills but delayed going to the emergency department so that he and his wife could finish watching The Ghost and Mrs Muir on a Sunday afternoon. He was admitted and quickly transferred to the ICU. His last words to me before being intubated were "There's my fine, princely fellow." He spent the final two weeks of his life sedated and on hemodialysis. Finally, his family could bear it no longer and withdrew care, giving him the peaceful and dignified death he deserved.

His death hit me like a ton of bricks. I felt as though I had lost a grandfather. I was his physician, and his cardiac issues always came first. But his office visits, telephone calls, and letters were special gifts. I could not deny their importance to me. My medical training had imprinted on me the principle that evenhanded distance is the appropriate relationship between physician and patient. I wondered if we had crossed any lines that reduced my medical objectivity. Had I served him well as his cardiologist? Had I become too close to a patient?

Ultimately, I found peace in the realization that medicine is an art and that interpersonal relationships are at its core. Mr M was an exceptional person. To deny his proffered "friendship" would have been to miss out on an amazing relationship with a fellow human being. Understanding his nature also made me a more effective physician. On some level, I used these insights to build trust, gain his approval, and improve his adherence to a complicated medical regimen. His survival as a patient was built partially on his belief in me. I never met him socially nor did I share any activities with him outside the professional office setting. Nevertheless, I was deeply moved when his family invited me to sit with them during Mr M's memorial service. Shortly after his death, I received a beautiful bouquet of flowers and a note, written in an unfamiliar hand:

Dear Dr Gordon,
How do you tell someone they make a life difference to you?
You are, and have been, such a "special" light in our lives.
Please know that Mr M and I love you dearly.
Sincerely, Mrs M

With Mr M's passing and my reaction to it, I felt compelled to address a question: What did this relationship mean to me? The answer did not come easily and required some earnest soul-searching. In the end, I realized that his many medical problems challenged me to grow as a young physician; his remarkable character and life story inspired me to grow as a person.

Acknowledgment: I thank Jerold, Elizabeth, and Assaf Gordon and Rachel Ledewitz Gordon for their thoughtful comments and review of this essay. I am also deeply indebted to Mrs M and her family for their kindness in allowing me to share Mr M's story.

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor

Source

Improper Anesthesia Practice Causes Hepatitis Outbreak


Anesthesiologist reused contaminated single-use propofol vial on multiple patients

Publish date: Jul 9, 2010

FRIDAY, July 9 (HealthDay News) -- An anesthesiologist who reused a contaminated single-use propofol vial on multiple endoscopy patients caused an outbreak of hepatitis infection affecting 13 patients at two clinics, according to a report published in the July issue of Gastroenterology.

Bruce Gutelius, M.D., of the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues investigated outbreaks of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among patients at the two clinics who had received anesthesia from the same anesthesiologist. The investigators reviewed medical charts, conducted patient interviews and site visits, and performed infection control assessments. The investigators also did molecular sequencing of available patient isolates.

At one clinic, the researchers identified six cases of HCV infection and six cases of HBV infection, and at the other clinic, one case of HCV infection; all the cases were associated with the outbreak. HCV quasispecies sequences from the patients were found to be nearly identical (96.9 to 100 percent) to those from the patients considered to be the infection source. The investigators write that the anesthesiologist used a single-use vial of propofol on multiple patients, and conclude that the likely cause of the viral transmission was the reuse of syringes to redose patients, which contaminated the vials for later patients.

"Gastroenterologists are urged to review carefully the injection, medication handling, and other infection control practices of all staff under their supervision, including providers of anesthesia services," the authors write.

Abstract
Full Text (subscription or payment may be required)

Source

Also See:
Hepatitis C Virus Infections from Unsafe Injection Practices at an Endoscopy Clinic in Las Vegas, Nevada, 2007–2008

A Guide to Clinical Trials

A researcher looks at a blood smear under the microscope.

What Is a Clinical Trial?

A clinical trial is a research study involving human volunteers to evaluate new ways to prevent, diagnose, or treat diseases. Clinical trials help determine if experimental treatments are safe, effective, or better in some way than standard treatments.

What Are the Benefits of Participating in a Clinical Trial?

Clinical trials are essential to the advancement of medicine. By participating in a trial, a patient may have access to a treatment that is new or better than the standard treatment. By participating in a trial you are also helping others who may benefit from the findings in the future. Some patients also receive free medical care or are paid for their participation.

Why Is It Especially Important for Female and Minority Patients to Participate?

Diseases affect everyone, but not in the same way. Therefore, it is important to have people of all races, ages, backgrounds, and genders participate so that the best way of preventing, diagnosing, or treating every kind of disease for every kind of person can be discovered.

Are Clinical Trials Safe?

Before an experimental treatment can be applied to people, it is carefully studied in the laboratory to determine its effectiveness and safety. Clinical trials are reviewed at both the national level by the Food and Drug Administration (FDA) and at the local level by an institutional review board (IRB). Each hospital or clinic where a clinical trial is to take place has an IRB made up of health-care professionals, patient advocates, and community leaders who review the trial for safety and fairness.

Possible participants are also carefully screened – by thorough analysis of a patient’s medical history, physical examinations, and possibly other tests – to ensure that they are the best possible candidates for the experimental treatment. During the trial, patients are carefully monitored to track how the treatment is affecting their condition. Since participation in a clinical trial is voluntary, a patient can stop at any time for any reason.

What Should I Consider Before Participating in a Clinical Trial?

Before participating, you must be provided with an “informed consent” document explaining the risks and potential benefits of the trial. Be sure to read over this information carefully. It is important to fully understand the purpose of the trial and what to expect.

You will want to find out if the treatment will interact with any of your current medications or affect any other medical conditions you may have. You should be informed about what tests or procedures, such as biopsies or blood draws, will be performed, and you should consider your comfort level with what will be done. Also, think about whether you are prepared for any anticipated side effects, pain, or discomfort that may be involved.

Another consideration is how the trial will affect your daily life. Think about how long the study lasts, if it will fit in your work schedule and personal life, and if you can commit to it. Will the hours at the clinic require that you take time off work? How many visits will be involved?

If you do decide to participate, you will be required to sign an informed consent document, and a copy will be given to you. The document will include the contact information for someone you can call should any questions or concerns arise during the trial.

Are There Costs Associated With Participating in a Clinical Trial?

This is an important question you should discuss with your doctor. There may be extra costs for participating in a study that may or may not be covered by your insurance carrier. Some examples of extra costs include additional doctor visits, special blood tests, or the cost of administering experimental treatments.

Are There Different Types of Clinical Trials?

Yes, clinical trials are classified into phases as described below:
  • Phase 1: These trials constitute the initial testing in humans and usually involve a small number of patients. The primary goal of Phase 1 trials is to demonstrate the safety of the drug or drugs being given. Sometimes Phase 1 trials test the safety of a new drug under development as well as dosage and frequency of administration; others test the safety and efficacy of a particular dosage when two or more drugs are given in combination.
  • Phase 2: Once a drug or a combination of drugs is shown to be safe in initial Phase 1 trials, it has to be shown to be effective – the primary goal of Phase 2 trials. These trials are generally longer, typically lasting several months and involve more people, up to several hundred, to prove that the drug or combination of drugs is effective in a larger patient group.
  • Phase 3: This type of trial involves large-scale testing in several hundred to several thousand people for a thorough understanding of a treatment’s benefits and side effects in a wide range of patients. Phase 3 studies are usually “randomized” studies in which a patient is randomly assigned to either the standard arm (treatment that has been approved as the current standard therapy by the FDA) or to the experimental arm (patients are given a new drug or new combination of drugs). The assignment is made by a computer or other coinflip mechanism. If the standard treatment with a new drug is being compared to the standard treatment alone, patients in the standard arm may be given a placebo (an inactive substance that has no medicinal value) in conjunction with the standard therapy while patients in the experimental arm will receive the standard therapy in conjunction with the new therapy. The FDA usually requires a successful Phase 3 study showing that a new treatment is better than the standard of care before they will consider the treatment for FDA approval.
  • Phase 4: Further analysis of a treatment is considered in these types of trials, exploring such issues as cost-effectiveness, long-term effectiveness, or how a drug affects a patient’s quality of life.
These four phases describe treatment trials. There are many other types of trials in which patients may be asked to participate, such as prevention, diagnostic, screening, and quality-of-life trials.

How Can I Find a Clinical Trial?

There are many Web sites that list current clinical trials for a variety of diseases and conditions. ASH recommends the following:
http://www.clinicaltrials.gov/
www.cancer.gov/clinicaltrials
http://www.centerwatch.com/

Talk with your doctor to find out if joining a clinical trial is right for you.

Source

Consensus Interferon (Infergen) Label Changed to Include Data on Dosing with Ribavirin

SUMMARY: The U.S. Food and Drug Administration (FDA) this week announced that the label information for consensus interferon alfa, also known as interferon alfacon-1 or Infergen, for the treatment of chronic hepatitis C has been updated to include new information about using the drug in combination with ribavirin and weight-based dosing, as well as which patients are unlikely to benefit from treatment. Use of Infergen as monotherapy is not recommended unless a patient is unable to take ribavirin.
Below is the text of an FDA announcement describing the changes.

Infergen (interferon alfacon-1) Label Revision

On July 2, 2010, FDA approved revised labeling for Infergen (interferon alfacon-1) to include information on combination therapy with weight-based dosing of ribavirin. The label was placed in PLR (Physicians Labeling Rule) format and the major labeling changes include revisions to the following sections:

1) Indications and Usage section to include information describing when patients are unlikely to benefit from retreatment. This section reads as follows:

INFERGEN (interferon alfacon-1) is indicated for treatment of chronic hepatitis C in patients 18 years of age or older with compensated liver disease. This indication is based on clinical trials conducted using INFERGEN as monotherapy prior to the time that combination treatment was the standard of care and on a single trial evaluating INFERGEN in combination with ribavirin in patients who failed to respond to previous treatment with a pegylated interferon and ribavirin.

The following points should be considered when initiating treatment with INFERGEN:
  • Use of monotherapy with an interferon such as INFERGEN for the treatment of hepatitis C is not recommended unless a patient is unable to take ribavirin.
  • The safety and efficacy of the combination of INFERGEN/ribavirin in treatment-naive patients or in patients co-infected with HBV or HIV-1 have not been evaluated.
  • Patients with the following characteristics are less likely to benefit from retreatment with combination therapy: response of < 1 log10 drop HCV RNA on previous treatment, Genotype 1, high viral load (> 850,000 IU/mL), African American race, and/or presence of cirrhosis.
  • No safety and efficacy data are available for treatment of longer than one year.
2) Dosage and Administration section was updated to include dose recommendations for retreatment in combination with weight-based dosing of ribavirin for the treatment of chronic hepatitis C as follows:
 
Combination Treatment with INFERGEN/Ribavirin Dosing
 
The recommended dose of INFERGEN is 15 mcg daily administered as a single subcutaneous injection in combination with weight-based ribavirin at 1,000 mg-1,200 mg (< 75 kg and >75 kg) orally in two divided doses for up to 48 weeks. [see Clinical Studies (14.3), Medication Guide for instructions].
 
Ribavirin should be taken with food. INFERGEN/ribavirin should not be used in patients with creatinine clearance < 50 mL/min [see CONTRAINDICATIONS (4)].
 
Dose Modifications
 
If a serious adverse reaction develops during the course of treatment [see WARNINGS and PRECAUTIONS (5)] discontinue or modify the dosage of INFERGEN and/or ribavirin until the adverse event abates or decreases in severity. If persistent or recurrent serious adverse events develop despite adequate dosage adjustment, discontinue treatment. Upon resolution or improvement of the adverse reaction, resuming INFERGEN and/or ribavirin may be considered.
 
INFERGEN/Ribavirin Combination Therapy Dose Modifications
 
Stepwise dose reduction from 15 mcg to 9 mcg and from 9 mcg to 6 mcg may be necessary for serious adverse reactions.
 
Please refer to updated label for complete guidelines for dose modifications and discontinuation of INFERGEN and/or ribavirin based on depression or laboratory parameters.
 
3) The WARNINGS and PRECAUTIONS section was updated and placed in the order of importance of each toxicity of concern. Many of the toxicities are considered class labeling among the interferon products.
 
4) The Adverse Event section was updated to remove antiquated information and to include information about safety from the INFERGEN/RBV study (DIRECT Trial/IRHC-001 and IRHC-002).
 
5) Clinical Studies section was updated to include information regarding study IRHC-001/IRHC-002/DIRECT Trial. Specifically,
 
Subsequent Treatment with Combination INFERGEN/Ribavirin
 
This study (DIRECT Trial/ IRHC-001 and IRHC-002) was a randomized, open-label, multi-center, US-based study comparing the safety and efficacy of two doses of INFERGEN (9 mcg or 15 mcg) administered daily plus ribavirin (1000 mg or 1200 mg weight based dosed) administered daily for 48 weeks to subjects who were nonresponders to previous pegylated interferon plus ribavirin (Peg-IFN/ribavirin) therapy. Prior non-response was defined as a < 2 log10 decline in viral load (VL) while undergoing at least 12 weeks of previous Peg-IFN/ribavirin therapy with > 80% adherence or a detectable VL at end-of-treatment after completing at least 24 weeks of therapy. Study subjects had a mean age of 50 yrs, 70% were male, mean weight of 89 kg, 19% were African Americans, 65% were Caucasians, 66% had high VL (> 850,000 IU/mL), 95% were infected with genotype 1, 54% had evidence of bridging fibrosis, 25% had evidence of cirrhosis on biopsy, and 50% had steatosis. Approximately 80% of the patients were null responders (< 2 log10 drop in viral load during their previous Peg-IFN/ribavirin therapy). The median washout period between previous treatment and day 1 of INFERGEN therapy was 448 days (15 months) and 506 days (16.8 months) for the 9 mcg and 15 mcg groups, respectively. The use of hematopoietic growth factors was not permitted in the DIRECT Trial.
 
In study IRHC-001, 515 subjects were randomized to INFERGEN 9 mcg plus ribavirin (n=171), INFERGEN 15 mcg plus ribavirin (n=172), or no treatment (n=172). In study IRHC-002, 144 patients in the no treatment arm of study IRHC-001 were re-randomized to either INFERGEN 9 mcg plus ribavirin (n=74) or INFERGEN 15 mcg plus ribavirin (n=70).
 
Subjects were treated for up to 48 weeks. The primary endpoint was sustained virological response (SVR), defined as undetectable HCV RNA 24 weeks after the end of treatment using a sensitive qualitative assay (TMA LOD <10 IU/mL). None of the subjects in the no-treatment arm of study IRHC-001 achieved an SVR.
 
Combined SVR results from IRHC-001 and IRHC-002 according to baseline characteristics are shown in Table 8 of the package insert. The overall SVR rate for INFERGEN 9 mcg/ribavirin was 5% (13/245) compared to 95 (21/242) for INFERGEN 15 mcg/ribavirin. Based on these results, INFERGEN 15 mcg is the recommended starting dose.
 
6) The Contraindications, and the Animal Toxicology and/or Pharmacology section was also updated.
 
Additionally the Medication Guide was revised to provide information on combination therapy with weight-based dosing of ribavirin and to provide information on the risk associated with interferon therapy.
 
The complete revised label can be accessed at the FDA web site.
 
Infergen is a product of Three Rivers Pharmaceuticals, Warrendale, PA.
 
7/9/10
 
Source
R Klein and K Struble, U.S.Food and Drug Administration. Infergen (interferon alfacon-1) label revision: combination therapy, weight-based dosing, and label format. Hepatitis Update. July 7, 2010.

Source

Also See:
Three Rivers Pharmaceuticals Announces FDA Approval Of Expanded Labeling of INFERGEN®

GlobalData's report available-"Hepatitis C (HCV)–Pipeline Assessment and Market Forecasts to 2016"

The Hepatitis C (HCV) Market is Forecast to Show High Growth Until 2016

FOR IMMEDIATE RELEASE

PRLog (Press Release) – Jul 09, 2010 – GlobalData’s analysis suggests that the global hepatitis C market was worth $4.4 billion in 2009. It is forecast to grow at a Compound Annual Growth Rate (CAGR) of 9.8% for the next seven years to reach $8.5 billion by 2016. The high projected growth rate is primarily attributable to a strong pipeline. The increase in the prevalence of the disease and the availability of new first-in-class therapies with better safety and efficacy profiles are expected to drive the growth of the hepatitis C market.

GlobalData analyzed the current competitive landscape for HCV drugs and found that the current market competition is weak. There are six commonly used approved products for the treatment of HCV. The combination therapy of Peginterferon alfa 2 b from Merck and Peginterferon alfa 2a from Roche are the two approved combination therapies present in the market for the treatment of HCV. Generics do not hold a major share in the market. GlobalData’s analysis of the entire competitive landscape of the branded products shows weak competition between the available treatments for HCV. The competition is weak because most products have low-moderate efficacy with low safety profiles and are branded premium or combination products. The market has a huge potential for molecules with better safety and efficacy profiles.

For further details, please click or add the below link to your browser:
http://www.globaldata.com/reportstore/Report.aspx?ID=Hep

GlobalData analyzed the hepatitis C pipeline and found it to be strong. The pipeline for hepatitis C consists of around 63 molecules currently in development. Most of these molecules are first-in-class and are promising better safety and efficacy profiles. There are approximately three molecules in the Phase III clinical trial development stage. For example, SCH 503034 (Merck, albinterferon alfa-2b (Human Genome Sciences, Inc. (HGS)), RG7128 (Roche) and VX-950 (Vertex and Tibotec pharmaceuticals) are among the most promising molecules in pipeline for the treatment of hepatitis C. A strong clinical pipeline coupled with high unmet needs in the hepatitis C market is expected to help sustain the market’s high growth rate during the forecast period.

The global HCV market is attractive, with high levels of unmet need. The unmet need in the market is around 70%, which is approximately $3 billion. Some of the unmet needs in this market are due to the lack of availability of effective treatment options and the moderate safety profiles of the marketed drugs. The efficacy of the marketed products in HCV market is only moderate. The safety profiles of the products available to treat HCV are low and some serious side effects are associated with the drugs that may even lead to death in rare cases.

The adverse effects of the drugs include problems with pregnancy, mental health problems, blood related disorders and autoimmune disorders. Patients using the standard interferon combination therapy to treat HCV soon develop resistance against these drugs and must wait for novel therapies to enter the market. Apart from various drugs that are available for the treatment of HCV, certain biosimilars like interferon alfa-2a and interferon beta-1a can also drive the HCV market in future. There is huge untapped potential in the current HCV market which could be captured by novel molecules, targeted to fulfill the current void left by the existing treatment options. Thus the HCV market has high potential for further research and development (R&D) activities.

GlobalData, the industry analysis specialist, has released a new report, “Hepatitis C - Drug Pipeline Analysis and Market Forecasts to 2016”. The report is an essential source of information and analysis on the global hepatitis C (HCV) market. The report identifies the key trends shaping and driving the global HCV market. The report also provides insights into the prevalent competitive landscape and the emerging players expected to cause significant shifts in the positioning of the existing market leaders. Most importantly, the report provides valuable insight into the pipeline products within the global hepatitis C sector.

For further details, please click or add the below link to your browser:
http://www.globaldata.com/reportstore/Report.aspx?ID=Hep

Visit our report store: http://www.globaldata.com/reportstore

GlobalData is an industry analysis specialist, providing business information products and services. GlobalData’s highly qualified team of analysts, researchers, and solution consultants use proprietary data sources, tools and techniques to gather, analyze and represent the latest and the most reliable information essential for a business to sustain a competitive edge.
GlobalData is a UK-based company with presence across North America, Europe and Asia Pacific and has a broad product offering that ranges from interactive databases, reports and custom solutions. It is a comprehensive source of insights and analysis with coverage including oil & gas, power, alternative energy, nuclear power, petrochemicals, medical equipment and healthcare industries.

Source

Liver Enzymes: A Look at AST and ALT

From Charles Daniel, former About.com Guide
Updated September 05, 2008

About.com Health's Disease and Condition content is reviewed by the Medical Review Board

Liver enzymes allow doctors to learn about the health of your liver. There are thousands of these enzymes in the liver and blood stream, but two of them -- known as aminotransferases AST and ALT -- are especially useful for determining liver disease.
What Are Aminotransferases?

Aminotransferases are chemicals the liver uses to help make the energy-storage molecule glycogen. Aspartate aminotransferase, or AST, is found in the liver, but also the brain, pancreas, heart, skeletal muscle, kidneys and lungs. Alanine aminotransferase, or ALT, is primarily found in the liver. To remember the difference between the two, I use the "L" in ALT to remind me of the liver.

Why Are AST and ALT Useful?

Because these enzymes are found in liver cells (hepatocytes) which have lots of contact with your blood supply, AST and ALT can "leak" into the blood if the hepatocytes are damaged. Blood tests can determine the level of these enzymes in your blood and doctors can use this information to form a diagnosis. Abnormally high levels of both liver enzymes show that liver cells have been damaged, but they can't tell what caused the damage. Because AST is located in many places in the body, high levels of AST alone don't suggest liver disease (a notable, but rare, exception is Wilson's disease). However, the ratio of AST to ALT, or the level of AST compared to the level of ALT, provides many clues to what's going on inside. Based on these ratios, doctors can focus their attention on a particular kind of liver disease. Here are some common guidelines used for liver disease:
  • An AST:ALT ratio equal to one (the level of ALT is higher or equal to AST), but the levels are very high, suggests acute viral hepatitis or drug-related hepatitis.
  • An AST:ALT ratio higher than 2:1 (two times the level of AST to ALT) is very suggestive of alcoholic liver disease.
  • An AST:ALT ratio higher than one (where the level of AST is higher than the ALT) could also indicate cirrhosis in a person that doesn't have alcoholic hepatitis.
Because increased enzyme levels can be seen in other diseases (heart attack, obesity, diabetes mellitus, mononucleosis), they are just one piece of a larger puzzle. To give doctors a complete clinical picture, enzyme levels must be used with other blood tests, patient examination and medical history.
What Are the Normal AST and ALT Levels?

The normal levels of AST and ALT vary from person to person and depend on your BMI, or the ratio of your height and weight. A small amount of AST and ALT is normally in your blood, so it's really a large increase over your normal level that indicates a problem. For people with acute viral hepatitis, they might have aminotransferase levels higher than 1,000 IU/L. This stands for International Units per Liter (of blood) and is a unit of measurement that labs use for many medical tests. Common ranges for AST and ALT are:
  • AST 2-45 IU/L
  • ALT 2-40 IU/L
How Are Liver Enzymes Tested?

To test for AST and ALT, a doctor needs to order an enzyme test, which usually consists of several additional tests like albumin, bilirubin and prothrombin time. A technician will draw a sample of your blood and send it to a lab to be tested. The results are sent to your doctor.

Sources:
Pratt DS, Kaplan MM. Evaluation of Liver Function. In: AS Fauci, E Braunwald, DL Kasper, SL Hauser, DL Longo, JL Jameson, J Loscaizo (eds), Harrison’s Principles of Internal Medicine, 17e. New York, McGraw-Hill, 2008.

Source 

Working With Your Liver's Clock Benefits Hepatitis C

July 6, 2010

While most of us check the time throughout the day to stay on schedule, few realize that the liver also has a timed agenda. By heeding your liver's innate clock, those with Hepatitis C can help relieve some of the extra burden on this multi-tasking organ.

by Nicole Cutler, L.Ac.

Chronic Hepatitis C is a worldwide problem, infecting the livers of an estimated four million people in the U.S. alone. Until a guaranteed cure is devised for Hepatitis C, those with the virus must make every effort to support their liver's health by relieving it of unnecessary tasks. While there are a variety of strategies employed to support liver health, one that is often overlooked is working with the liver's schedule.

In charge of a long list of life-sustaining functions, the liver is an extremely busy organ. A few of its crucial duties, include:

· Producing bile, which helps carry away waste and breaks down fats in the small intestine during digestion.

· Producing certain proteins for blood plasma.

· Making cholesterol and special proteins to help carry fats through the body.

· Converting excess glucose into glycogen for storage.

· Converting poisonous ammonia to urea (urea is an end product of protein metabolism and is excreted in the urine).

· Clearing the blood of drugs and other poisonous substances.

· Resisting infections by producing immune factors and removing bacteria from the bloodstream.

Not surprisingly, the liver can't accomplish all of its amazing feats simultaneously. All of the body's organs, including the liver, have periodic cycles where different functions are emphasized at different times. The liver is no different, with a cycle completing every 24 hours.

The Liver Cycle

Although scientists are just beginning to recognize the phases of the liver's cycle, the following appear to describe the hepatic clock:

· The liver synthesizes complex chemicals and processes toxins the most when the production of bile is lowest.

· Along the same lines, chemical synthesis and toxin processing is lowest while the liver's production of bile is highest.

· Because bile is needed for food processing, the liver makes a greater proportion during the day - and less at night.

· Bile production is assumed to be at its highest at 9am and lowest at 9pm.

· After 9pm, the liver switches to its other primary functions, synthesizing chemicals and processing accumulated toxins.

· The cycle begins shifting around 3am, when the liver slows chemical synthesis and readies itself for bile production.

· The liver cycle shifts again around 3pm, when chemical synthesis begins to increase and bile production decreases.

Thus, the liver is most prepared to aid digestion with its synthesis of bile between 9am and 9pm. This is important information for those with chronic Hepatitis C who want to work with - and not against their liver.

Practical Application of the Liver Clock

Although our busy lifestyles often dictate when we eat and when we sleep, those with Hepatitis C could benefit from scheduling necessities around their liver's needs. Since bile production is down late at night, eating a big meal past 9pm puts an additional strain on the liver. Thus, experts advise eating the last meal of the day long before the nine o'clock hour.

In addition, the liver's schedule of producing chemicals and detoxification (crucial for liver health) is best accomplished without additional demands. For this reason, most experts suggest retiring for the night close to 9pm whenever possible. Although this seems extremely early for many adults, those who try it report achieving a deeper and more restful sleep.

The liver's clock may not mesh with a modern, busy schedule. However, eating early and going to bed early cooperates with your liver's natural rhythm. By taking small steps to conform to your liver's cycle, those with Hepatitis C can remove the extra challenge that multi-tasking can place on their liver.

Source

July 8, 2010

Blood Basics

 The Components of Blood and Their Importance



Blood Basics

Blood is a specialized body fluid. It has four main components: plasma, red blood cells, white blood cells, and platelets. Blood has many different functions, including:
  • transporting oxygen and nutrients to the lungs and tissues
  • forming blood clots to prevent excess blood loss
  • carrying cells and antibodies that fight infection
  • bringing waste products to the kidneys and liver, which filter and clean the blood
  • regulating body temperature
The blood that runs through the veins, arteries, and capillaries is known as whole blood, a mixture of about 55 percent plasma and 45 percent blood cells. About 7 to 8 percent of your total body weight is blood. An average-sized man has about 12 pints of blood in his body, and an average-sized woman has about 9 pints.

The Components of Blood and Their Importance

Many people have undergone blood tests or donated blood, but hematology – the study of blood – encompasses much more than this. Doctors who specialize in hematology (hematologists) are leading the many advances being made in the treatment and prevention of blood diseases. If you or someone you care about is diagnosed with a blood disorder, your primary care physician may refer you to a hematologist for further testing and treatment.

Plasma

The liquid component of blood is called plasma, a mixture of water, sugar, fat, protein, and salts. The main job of the plasma is to transport blood cells throughout your body along with nutrients, waste products, antibodies, clotting proteins, chemical messengers such as hormones, and proteins that help maintain the body's fluid balance.

Red Blood Cells (also called erythrocytes or RBCs)

Known for their bright red color, red cells are the most abundant cell in the blood, accounting for about 40-45 percent of its volume. The shape of a red blood cell is a biconcave disk with a flattened center – in other words, both faces of the disc have shallow bowl-like indentations (a red blood cell looks like a donut).

Production of red blood cells is controlled by erythropoietin, a hormone produced primarily by the kidneys. Red blood cells start as immature cells in the bone marrow and after approximately seven days of maturation are released into the bloodstream. Unlike many other cells, red blood cells have no nucleus and can easily change shape, helping them fit through the various blood vessels in your body. However, while the lack of a nucleus makes a red blood cell more flexible, it also limits the life of the cell as it travels through the smallest blood vessels, damaging the cell’s membranes and depleting its energy supplies. The red blood cell survives on average only 120 days.

Red cells contain a special protein called hemoglobin, which helps carry oxygen from the lungs to the rest of the body and then returns carbon dioxide from the body to the lungs so it can be exhaled. Blood appears red because of the large number of red blood cells, which get their color from the hemoglobin. The percentage of whole blood volume that is made up of red blood cells is called the hematocrit and is a common measure of red blood cell levels.

White Blood Cells (also called leukocytes)

White blood cells protect the body from infection. They are much fewer in number than red blood cells, accounting for about 1 percent of your blood.

The most common type of white blood cell is the neutrophil, which is the “immediate response” cell and accounts for 55 to 70 percent of the total white blood cell count. Each neutrophil lives less than a day, so your bone marrow must constantly make new neutrophils to maintain protection against infection. Transfusion of neutrophils is generally not effective since they do not remain in the body for very long.

The other major type of white blood cell is a lymphocyte. There are two main populations of these cells. T lymphocytes help regulate the function of other immune cells and directly attack various infected cells and tumors. B lymphocytes make antibodies, which are proteins that specifically target bacteria, viruses, and other foreign materials.

Platelets (also called thrombocytes)

Unlike red and white blood cells, platelets are not actually cells but rather small fragments of cells. Platelets help the blood clotting process (or coagulation) by gathering at the site of an injury, sticking to the lining of the injured blood vessel, and forming a platform on which blood coagulation can occur. This results in the formation of a fibrin clot, which covers the wound and prevents blood from leaking out. Fibrin also forms the initial scaffolding upon which new tissue forms, thus promoting healing.

A higher than normal number of platelets can cause unnecessary clotting, which can lead to strokes and heart attacks; however, thanks to advances made in antiplatelet therapies, there are treatments available to help prevent these potentially fatal events. Conversely, lower than normal counts can lead to extensive bleeding.

Complete Blood Count (CBC)

A complete blood count (CBC) test gives your doctor important information about the types and numbers of cells in your blood, especially the red blood cells and their percentage (hematocrit) or protein content (hemoglobin), white blood cells, and platelets. The results of a CBC may diagnose conditions like anemia, infection, and other disorders. The platelet count and plasma clotting tests (prothombin time, partial thromboplastin time, and thrombin time) may be used to evaluate bleeding and clotting disorders.

Your doctor may also perform a blood smear, which is a way of looking at your blood cells under the microscope. In a normal blood smear, red blood cells will appear as regular, round cells with a pale center. Variations in the size or shape of these cells may suggest a blood disorder.

Normal blood smear.
The four larger cells shown are called granulocytes, a type of white blood cell.

Abnormal blood smear with variation in the size and color of the red blood cells.

Where Do Blood Cells Come From?

Blood cells develop from hematopoietic stem cells and are formed in the bone marrow through the highly regulated process of hematopoiesis. Hematopoietic stem cells are capable of transforming into red blood cells, white blood cells, and platelets. These stem cells can be found circulating in the blood and bone marrow in people of all ages, as well as in the umbilical cords of newborn babies. Stem cells from all three sources may be used to treat a variety of diseases, including leukemia, lymphoma, bone marrow failure, and various immune disorders.

Where Can I Find More Information?

If after further exploration of the Blood: The Vital Connection Web site you find that you are interested in learning more about blood diseases and disorders, here are a few other resources that may be of some help:

Articles From Hematology, the ASH Education Program Book
The American Society of Hematology (ASH) Education Book, updated yearly by experts in the field, is a collection of articles about the current treatment options available to patients. The articles are categorized here by disease type. If you are interested in learning more about a particular blood disease, we encourage you to share and discuss these articles with your doctor.

Results of Clinical Studies Published in Blood
Search Blood, the official journal of ASH, for the results of the latest blood research. While recent articles generally require a subscriber login, patients interested in viewing an access-controlled article in Blood may obtain a copy by e-mailing a request to the Blood Publishing Office.

Other Resources
This section includes a list of Web links to patient groups and other organizations that provide information.

Source

Thrombocytopenia and the risk of bleeding during treatment with peginterferon alfa and ribavirin for chronic hepatitis C

J Hepatol. 2010 Jun 1. [Epub ahead of print].

Roomer R, Hansen BE, Janssen HL, de Knegt RJ.

Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.

Abstract

BACKGROUND & AIMS: Chronic HCV patients with baseline thrombocytopenia are often excluded from treatment with peginterferon alfa and ribavirin or undergo many dose reductions of peginterferon alfa. The aim of this study was to investigate the correlation between thrombocytopenia and the occurrence of bleedings during antiviral treatment for HCV infection. METHODS: In this single center cohort study 2876 visits of 321 patients treated with peginterferon alfa and ribavirin were evaluated for thrombocytopenia, bleedings and dose reductions during HCV treatment. RESULTS: Mean platelet count at baseline was 207,000/mul for non-cirrhotic patients (n=253) and 132,000/mul for cirrhotic patients (n=68). Mean platelet drop was 42% from 191,000 to 113,100/mul (range 8000-284,000/mul). Severe thrombocytopenia (platelet counts <50,000/mul) was observed in 30 patients (9.3%) at 166 visits and 9 patients developed platelet counts <25,000/mul at 15 visits. Forty-eight bleedings were observed in 27 patients (8.4%). Only one bleeding, due to gastrointestinal angiodysplasia, was defined as severe. However, this patient did not have severe thrombocytopenia at the time of bleeding. During visits, patients reported more minor bleedings when platelet counts were <50,000/mul compared to visits with platelet counts 50,000/mul (11.4% vs. 1.1%, p<0.001). In the multivariate analysis, platelet count of <50,000/mul was a significant predictor of bleeding (p<0.001). CONCLUSION: Severe bleedings did not occur in patients with platelet counts below 50,000/mul; based on these findings, treatment with peginterferon alfa and ribavirin appears to be safe in patients with platelet counts below 50,000/mul although platelet counts below 25,000/mul were rare. Copyright © 2010. Published by Elsevier B.V.

PMID: 20561709 [PubMed - as supplied by publisher]

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Kenner Boy Dies Of Rare Bacterial Infection

John Lopez Contracted Bacteria While Walking On Beach

POSTED: 3:58 pm CDT July 8, 2010
UPDATED: 7:07 pm CDT July 8, 2010

KENNER, La. --

It was supposed to be a fun family trip to the coast to check out a car show, but it ended with the death of a 12-year-old Kenner boy.

John Lopez, lovingly called "John-John" by friends and family, unknowingly contracted a deadly bacteria after walking in the water.

"They were there for a car show and within 24 hours, he got ill with this parasite," said John's sister, Crissy Harvard.

John walked on the beach, and only his feet touched the water. A short time later, he became sick. Doctors said he was infected by a bacteria called Vibrio Vulnificus, which is rare. But for people like John, who had existing medical problems, the infection is deadly.

"When you have chronic disease like HIV, liver problems, you're predisposed, and infection could form and it could be fatal," said WDSU medical editor Dr. Corey Hebert.

Hebert said you can get this infection if you are in salt water with an exposed cut or scratch, or a pre-existing condition. John's family said he had a small sore on his foot, and suffered from Hepatitis C.

Doctors said if he had survived, he would have lost his arms and legs. But on Saturday, John-John passed away.

"This is horrible. It breaks my heart," said his mother, Wendy Harvard. "He's only 12. He just made 12."

Hebert said not everyone is at risk for this infection. Those with pre-existing conditions are most at risk, but he said everyone should pay attention to their bodies.

"When you walk through brackish water and get cut, don't ignore it," Hebert said. "Go to your doctor if it turns red or if you feel really bad."

The Vibrio Vulnificus bacteria can cause heart failure, loss of limbs or even death.
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See Also: Vibrio Vulnificus

The recent breakthroughs in the understanding of host genomics in hepatitis C

European Journal of Clinical Investigation

Early View (Articles online in advance of print)

Published Online: 6 Jul 2010

Journal Compilation © 2010 Stichting European Society for Clinical Investigation Journal Foundation

Andri Rauch * , Janine Rohrbach * and Pierre-Yves Bochud †
* University Clinic of Infectious Diseases, University Hospital Bern and University of Bern, Bern , † Department of Medicine, Service of Infectious Diseases, Institute of Microbiology, University Hospital and University of Lausanne, Switzerland

Correspondence to Andri Rauch, MD, University Clinic of Infectious Diseases, Inselspital PKT2B, 3010 Bern – Switzerland. Tel.: +41 31 632 15 74; fax: +41 31 632 31 76; e-mail: andri.rauch@insel.ch

Copyright Journal Compilation © 2010 Stichting European Society for Clinical Investigation Journal Foundation

KEYWORDS
Hepatitis C treatment • hepatitis C virus • host genomics • interleukin 28B • spontaneous clearance
Eur J Clin Invest 2010

ABSTRACT

Background Hepatitis C Virus (HCV) infection is spontaneously resolved in about 30% of acutely infected individuals. In those who progress to chronic hepatitis C, HCV therapy permanently eradicates infection in about 40% of cases. It has long been suspected that host genetic factors are key determinants for the control of HCV infection.

Design We will review in this study four genome-wide association studies (GWAS) and two large candidate gene studies that assessed the role of host genetic variation for the natural and treatment-induced control of HCV infection.

Results The studies consistently identified genetic variation in interleukin 28B (IL28B) as the strongest predictor for the control of HCV infection. Importantly, single nucleotide polymorphisms (SNPs) in IL28B strongly predicted both spontaneous and treatment-induced HCV recovery. IL28B is located on chromosome 19 and encodes interferon-λ, a type III interferon with antiviral activity, which is mediated through the JAK-STAT pathway by inducing interferon-stimulated genes. The SNPs identified in the GWAS are in high linkage disequilibrium with coding or functional non-coding SNPs that might modulate function and/or expression of IL28B. The role of the different IL28B alleles on gene expression and cytokine function has not yet been established.

Conclusions These findings provide strong genetic evidence for the influence of interferon-λ for both the natural and treatment-induced control of HCV infection, and support the further investigation of interferon-λ for the treatment of chronic hepatitis C. Furthermore, genetic testing before HCV therapy could provide important information towards an individualized HCV treatment.

Received 9 April 2010; accepted 9 June 2010

DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1365-2362.2010.02337.x About DOI

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Hemochromatosis (Iron Storage Disease) Awareness

July is hemochromatosis (iron storage disease) awareness month. Hemochromatosis occurs when the body absorbs too much iron from foods (and other sources such as vitamins containing iron). If this iron buildup is untreated, it can, over many years, damage the body's organs. Learn the symptoms and how to stay healthy.


Hemochromatosis (Iron Storage Disease) Awareness

July is hemochromatosis (iron storage disease) awareness month. Hemochromatosis occurs when the body absorbs too much iron from foods (and other sources such as vitamins containing iron). If this iron buildup is untreated, it can, over many years, damage the body's organs. Learn the symptoms and how to stay healthy.

What is hemochromatosis?

Hemochromatosis occurs when the body absorbs too much iron from foods (and other sources such as vitamins containing iron). This disease causes extra iron to gradually build up in the body's tissues and organs, a term called iron overload. If this iron buildup is untreated, it can, over many years, damage the body's organs.

What are the causes?

Although hemochromatosis can have other causes, in the United States the disease is usually caused by a genetic disorder. A person who inherits the defective gene from both parents may develop hemochromatosis. The genetic defect of hemochromatosis is present at birth, but symptoms rarely appear before adulthood. Because one inherits genes from his or her parents, this type of the disease is also called hereditary hemochromatosis.

What are the symptoms?

Early indications of hemochromatosis include the following symptoms:
  • Fatigue (feeling very tired)
  • Weakness
  • Weight loss
  • Abdominal pain
  • Joint pain
Because these symptoms also occur with other diseases, hemochromatosis can be difficult to diagnose in its early stages.

How is it detected?

If your doctor suspects you have iron overload associated with hemochromatosis, there are two blood tests – serum transferrin saturation and ferritin levels – which may be used to help make the diagnosis. The tests measure how much iron is in the body. You can have these tests done in your doctor's office.

If hemochromatosis is detected early, treatment can slow its progress and prevent serious problems. However, if the disease is not detected and treated early, it can cause more serious problems. These problems include arthritis, heart problems, and liver problems (such as cirrhosis and liver cancer).

If you think you have symptoms like those of hemochromatosis or if you have a close blood relative who has hemochromatosis, you should ask your health care provider to check the amount of iron in your blood.

What is the treatment?

Treatment consists of periodically taking blood from the arm, much like giving blood. The treatment is safe and effective. Patients can expect a normal life span if they start treatment before organ damage has begun.

Most people with hemochromatosis should be checked at least once a year to be sure that their iron level is within the normal range. If the iron level is too high, phlebotomy treatments are needed to keep extra iron from building up in the body.

Tips for Living Well with Hemochromatosis

There is much you can do to make sure your life is as normal and healthy as possible.
  • Check-ups: Have the amount of iron in your blood checked regularly.
  • Phlebotomy: Make sure to get phlebotomies when you need them. Phlebotomy is the best treatment for hemochromatosis. Hemochromatosis cannot be treated by changing your diet alone.
  • Iron pills: Don't take iron pills, supplements, or multivitamin supplements that have iron in them. Eating foods that contain iron is fine.
  • Vitamin C: Vitamin C increases the amount of iron your body absorbs. Avoid taking pills with more than 500 mg of vitamin C per day. Eating foods with vitamin C (such as oranges) is fine.
  • Food: Don't eat raw fish or raw shellfish. Cooking destroys germs harmful to people with hemochromatosis. People with hemochromatosis are at greater risk for bacteremia, a bacterial infection of the blood stream.
  • Alcohol: If you choose to drink alcohol, drink very little. Women should have no more than one drink a day. Men should have no more than two drinks a day. However, if you have liver damage, do not drink any alcohol.
  • Exercise: You can exercise as much as you want. The CDC and the American College of Sports Medicine offers the following physical activity recommendations: Adults should engage in moderate-intensity physical activities (indicated by someincreasein breathingor heart rate) for at least 30 minutes on preferably all days of the week.
More Information

 
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URL for this page: http://www.cdc.gov/Features/Hemochromatosis/