Deep-sequencing reveals broad subtype-specific HCV resistance mutations associated with treatment failure

A percentage of hepatitis C virus (HCV)-infected patients fail direct acting antiviral (DAA)-based treatment regimens, often because of drug resistance-associated substitutions (RAS). The aim of this study was to characterize the resistance profile of a large cohort of patients failing DAA-based treatments, and investigate the relationship between HCV subtype and failure, as an aid to optimizing management of these patients. A new, standardized HCV-RAS testing protocol based on deep sequencing was designed and applied to 220 previously subtyped samples from patients failing DAA treatment, collected in 39 Spanish hospitals. The majority had received DAA-based interferon (IFN) a-free regimens; 79% had failed sofosbuvir-containing therapy. Genomic regions encoding the nonstructural protein (NS) 3, NS5A, and NS5B (DAA target regions) were analyzed using subtype-specific primers. Viral subtype distribution was as follows: genotype (G) 1, 62.7%; G3a, 21.4%; G4d, 12.3%; G2, 1.8%; and mixed infections 1.8%. Overall, 88.6% of patients carried at least 1 RAS, and 19% carried RAS at frequencies below 20% in the mutant spectrum. There were no differences in RAS selection between treatments with and without ribavirin. Regardless of the treatment received, each HCV subtype showed specific types of RAS. Of note, no RAS were detected in the target proteins of 18.6% of patients failing treatment, and 30.4% of patients had RAS in proteins that were not targets of the inhibitors they received. HCV patients failing DAA therapy showed a high diversity of RAS. Ribavirin use did not influence the type or number of RAS at failure. The subtype-specific pattern of RAS emergence underscores the importance of accurate HCV subtyping. The frequency of “extra-target” RAS suggests the need for RAS screening in all three DAA target regions

Aspectos clínicos y tratamiento endoscópico de la hemorragia digestiva por lesión de Dieulafoy Clinical aspects and endoscopic management of gastrointestinal bleeding from Dieulafoy's lesion

Objetivo: conocer la incidencia, forma de presentación, localización y resultados del tratamiento endoscópico en la hemorragia digestiva causada por lesión de Dieulafoy. Material y métodos: se revisaron de forma retrospectiva todos los casos de hemorragia digestiva por lesión de Dieulafoy entre los años 2000 y 2006. Se recogieron los principales datos clínicos y endoscópicos, tipo de tratamiento empleado, eficacia del mismo, recidiva, complicaciones y mortalidad durante el ingreso. Resultados: se encontraron 41 pacientes, 26 varones y 15 mujeres, con edad media de 71,19 años. La lesión de Dieulafoy fue la causa del 1,55% de los casos de hemorragia digestiva aguda en el periodo estudiado. La incidencia de hemorragia digestiva por lesión de Dieulafoy fue de 2,2 casos por cada 100.000 habitantes y año. La mayoría de los pacientes presentaban hemorragia activa en el momento de la endoscopia (85,36%) y comorbilidad (92,68%). La localización más frecuente fue el estómago (60,97%), seguida del duodeno (29,26%). El tratamiento endoscópico logró la hemostasia inicial en el 100% de los casos. Tres pacientes (7,31%) presentaron recidiva hemorrágica, todos ellos habían sido tratados inicialmente con esclerosis con adrenalina y respondieron adecuadamente a un segundo tratamiento endoscópico. Ningún paciente precisó cirugía. La mortalidad durante el ingreso fue del 4,87%. Conclusiones: la lesión de Dieulafoy es una causa poco frecuente, pero potencialmente grave, de hemorragia digestiva y puede aparecer en cualquier punto del tracto gastrointestinal. El tratamiento endoscópico es eficaz y presenta pocas complicaciones. La esclerosis única con adrenalina se asocia a un mayor riesgo de recidiva hemorrágica.Objective: the aim of the study was to assess the incidence, clinical presentation, location, and response to endoscopic therapy of gastrointestinal bleeding from Dieulafoy's lesion. Material and methods: all consecutive episodes of gastrointestinal bleeding due to Dieulafoy's lesion seen between 2000 and 2006 were retrospectively reviewed. All main clinical and endoscopic data were collected: type and efectiveness of endoscopic therapy, rebleeding, complications, and mortality during hospitalization. Results: we found 41 patients, 26 males and 15 females, median age of 71.19 years. Dieulafoy's lesion accounted for 1.55% of all gastrointestinal bleeding episodes during the study period. The incidence of Dieulafoy's lesion was 2.2 cases/100.000 inhabitants/year. Active bleeding at endoscopy was present in 85.36%, and comorbidity in 92.68%. The stomach was the most frequent location (60.97%), followed by duodenum (29.26%). Endoscopic therapy achieved initial hemostasis in all cases. Three patients (7.31%) initially treated with epinephrine injection showed rebleeding and properly responded to a second session of endoscopic therapy. No surgery was needed. The mortality rate during hospitalization was 4.87%. Conclusions: Dieulafoy's lesion is an uncommon, but potentially severe cause of gastrointestinal bleeding. It may be found in any location within the gastrointestinal tract. Endoscopic therapy is effective and safe. Injected epinephrine alone is associated with a higher risk of rebleeding