Efficacy of Second Generation Direct-Acting Antiviral Agents for Treatment Na?ve Hepatitis C Genotype 1: A Systematic Review and Network Meta-Analysis

Background

The treatment of hepatitis C (HCV) infections has significantly changed in the past few years due to the introduction of direct-acting antiviral agents (DAAs). DAAs could improve the sustained virological response compared to pegylated interferon with ribavirin (PR). However, there has been no evidence from randomized controlled trials (RCTs) that directly compare the efficacy among the different regimens of DAAs.

Aim

Therefore, we performed a systematic review and network meta-analysis aiming to compare the treatment efficacy between different DAA regimens for treatment naïve HCV genotype 1.

Methods

Medline and Scopus were searched up to 25^th May 2015. RCTs investigating the efficacy of second generation DAA regimens for treatment naïve HCV genotype 1 were eligible for the review. Due to the lower efficacy and more side effects of first generation DAAs, this review included only second generation DAAs approved by the US or EU Food and Drug Administration, that comprised of simeprevir (SMV), sofosbuvir (SOF), daclatasvir (DCV), ledipasvir (LDV), and paritaprevir/ritonavir/ombitasvir plus dasabuvir (PrOD). Primary outcomes were sustained virological response at weeks 12 (SVR12) and 24 (SVR24) after the end of treatment and adverse drug events (i.e. serious adverse events, anemia, and fatigue). Efficacy of all treatment regimens were compared by applying a multivariate random effect meta-analysis. Incidence rates of SVR12 and SVR24, and adverse drug events of each treatment regimen were pooled using ‘pmeta’ command in STATA program.

Results

Overall, 869 studies were reviewed and 16 studies were eligible for this study. Compared with the PR regimen, SOF plus PR, SMV plus PR, and DVC plus PR regimens yielded significantly higher probability of having SVR24 with pooled risk ratios (RR) of 1.98 (95% CI 1.24, 3.14), 1.46 (95% CI: 1.22, 1.75), and 1.68 (95% CI: 1.14, 2.46), respectively. Pooled incidence rates of SVR12 and SVR24 in all treatment regimens without PR, i.e. SOF plus LDV with/without ribavirin, SOF plus SMV with/without ribavirin, SOF plus DCV with/without ribavirin, and PrOD with/without ribavirin, (pooled incidence of SVR12 ranging from 93% to 100%, and pooled incidence of SVR24 ranging from 89% to 96%) were much higher than the pooled incidence rates of SVR12 (51%) and SVR24 (48%) in PR alone. In comparing SOF plus LDV with ribavirin and SOF plus LDV without ribavirin, the chance of having SVR12 was not significantly different between these two regimens, with the pooled RR of 0.99 (95% CI: 0.97, 1.01). Regarding adverse drug events, risk of serious adverse drug events, anemia and fatigue were relatively higher in treatment regimens with PR than the treatment regimens without PR. The main limitation of our study is that a subgroup analysis according to dosages and duration of treatment could not be performed. Therefore, the dose and duration of recommended treatment have been suggested in range and not in definite value.

Conclusions

Both DAA plus PR and dual DAA regimens should be included in the first line drug for treatment naïve HCV genotype 1 because of the significant clinical benefits over PR alone. However, due to high drug costs, an economic evaluation should be conducted in order to assess the value of the investment when making coverage decisions.     

Evaluation of culture medium for nisin production in a repeated-batch biofilm reactor

In this study, a biofilm reactor with plastic composite support (PCS), made by high-temperature extrusion of agricultural products and polypropylene, was evaluated for nisin production using L. lactis strain NIZO 22186. The high-biomass density of the biofilm reactor was found to contribute to a significantly shorter lag time of nisin production relative to a suspended-cell reactor. In comparison to glucose (579 IU/mL), sucrose significantly increased the nisin production rate by 1.4-fold (1100 IU/mL). However, results revealed that high levels of sucrose (8% w/v) had a suppressing effect on nisin production and a stimulating effect on lactic acid production. A high concentration of MgSO4.7H2O at 0.04% (w/v) was found to reduce the nisin production, while concentrations of KH2PO4 of up to 3% (w/v) did not have any significant effect on growth or nisin production. The best of the tested complex media for nisin production using the PCS biofilm reactor consisted of 4% (w/v) sucrose, 0.02% (w/v) MgSO4.7H2O, and 0.1% (w/v) KH2PO4. Nisin production rate in the biofilm reactor was significantly increased by 3.8-fold (2208 IU/mL) when using the best complex medium tested.     

Bioproduction of vanillin using an organic solvent-tolerant <Emphasis Type="Italic">Brevibacillus agri</Emphasis> 13

Nowadays, majority of vanillin supplied to the world market is chemically synthesized from a petroleum-based raw material, raising a concern among the consumers regarding the product safety. In this study, an organic solvent-tolerant Brevibacillus agri 13 previously reported for a strong predilectic property was utilized as a whole-cell biocatalyst for bioproduction of vanillin from isoeugenol (IG). B. agri 13 is the first biocatalyst reported for bioproduction of vanillin at a temperature as high as 45°C. Both pH and temperature were found to affect vanillin production significantly. An extreme level of organic solvent tolerance of B. agri 13 allowed us to utilize it in a biphasic system using organic solvents generally considered as highly toxic to most bacteria. With an addition of butyl acetate at 30% (v/v) as an organic second phase, toxicity of IG exerted onto the biocatalyst was reduced dramatically while faster and more efficient vanillin production was obtained (1.7 g/L after 48 h with 27.8% molar conversion).     

Development of a whole-cell biocatalyst co-expressing P450 monooxygenase and glucose dehydrogenase for synthesis of epoxyhexane

Oxygenases-based Escherichia coli whole-cell biocatalyst can be applied for catalysis of various commercially interesting reactions that are difficult to achieve with traditional chemical catalysts. However, substrates and products of interest are often toxic to E. coli, causing a disruption of cell membrane. Therefore, organic solvent-tolerant bacteria became an important tool for heterologous expression of such oxygenases. In this study, the organic solvent-tolerant Bacillus subtilis 3C5N was developed as a whole-cell biocatalyst for epoxidation of a toxic terminal alkene, 1-hexene. Comparing to other hosts tested, high level of tolerance towards 1-hexene and a moderately hydrophobic cell surface of B. subtilis 3C5N were suggested to contribute to its higher 1,2-epoxyhexane production. A systematic optimization of reaction conditions such as biocatalyst and substrate concentration resulted in a 3.3-fold increase in the specific rate. Co-expression of glucose dehydrogenase could partly restored NADPH-regenerating ability of the biocatalyst (up to 38?% of the wild type), resulting in approximately 53?% increase in specific rate representing approximately 22-fold increase in product concentration comparing to that obtained prior to an optimization.     

A Simplified Positive-Sense-RNA Virus Construction Approach That Enhances Analysis Throughput

Here we present an approach that advances the throughput of a genetic analysis of a positive-sense RNA virus by simplifying virus construction. It enabled comprehensive dissection of a complex, multigene phenotype through rapid derivation of a large number of chimeric viruses and construction of a mutant library directly from a virus pool. The versatility of the approach described here expands the applicability of diverse genetic approaches to study these viruses.     

Effects of fed-batch fermentation and pH profiles on nisin production in suspended-cell and biofilm reactors

A biofilm reactor not only shortens the lag phase of nisin production, but also enhances nisin production when combined with an appropriate pH profile. Due to the substrate inhibition that takes place at high levels of carbon source, fed-batch fermentation was proposed as a better alternative for nisin production. In this study, the combined effects of fed-batch fermentation and various pH profiles on nisin production in a biofilm reactor were evaluated. The tested pH profiles include 1) a constant pH profile at 6.8 (profile 1), 2) a constant pH profile with an autoacidification after 4 h (profile 2), and 3) a step-wise pH profile with pH adjustment every 2 h (profile 3). When profile 1 was applied, fed-batch fermentation enhanced nisin production for both suspended-cell (4,188 IU ml⁻¹) and biofilm (4,314 IU ml⁻¹) reactors, yielded 1.8- and 2.3-fold higher nisin titer than their respective batch fermentation. On the other hand, pH profiles that include periods of autoacidification (profiles 2 and 3) resulted in a significantly lower nisin production in fed-batch fermentation (2,494 and 1,861 IU ml⁻¹ for biofilm reactor using profile 2 and 3, respectively) due to toxicity of excess lactic acid produced during the fermentation. Overall, this study suggested that fed-batch fermentation can be successfully used to enhance nisin production for both suspended-cell and biofilm reactors.     

Effects of pH profiles on nisin production in biofilm reactor

Apart from its widely accepted commercial applications as a food preservative, nisin emerges as a promising alternative in medical applications for bacterial infection in both humans and livestock. Improving nisin production through optimization of fermentation parameters would make nisin more cost-effective for various applications. Since nisin production by Lactococcus lactis NIZO 22186 was highly influenced by the pH profile employed during fermentation, three different pH profiles were evaluated in this study: (1) a constant pH profile at 6.8 (profile 1), (2) a constant pH profile with autoacidification at 4 h (profile 2), and (3) a stepwise pH profile with pH adjustment every 2 h (profile 3). The results demonstrated that the low-pH stress exerted during the first 4 h of fermentation in profile 3 detrimentally affected nisin production, resulting in a very low maximum nisin concentration (593 IU ml⁻¹). On the other hand, growth and lactic acid production were only slightly delayed, indicating that the loss in nisin production was not a result of lower growth or shifting of metabolic activity toward lactic acid production. Profile 2, in which pH was allowed to drop freely via autoacidification after 4 h of fermentation, was found to yield almost 1.9 times higher nisin (3,553 IU ml⁻¹) than profile 1 (1,898 IU ml⁻¹), possibly as a result of less adsorption of nisin onto producer cells. Therefore, a combination of constant pH and autoacidification period (profile 2) was recommended as the pH profile during nisin production in a biofilm reactor.     

Later chronotype is associated with higher hemoglobin A1c in prediabetes patients

The circadian system is known to play a role in glucose metabolism. Chronotype reflects the interindividual variability in the phase of entrainment. Those with later chronotype typically prefer later times in the day for different activities such as sleep or meals. Later chronotype has been shown to be associated with metabolic syndrome, increased diabetes risk and poorer glycemic control in type 2 diabetes patients. In addition, “social jetlag”, a form of circadian misalignment due to a mismatch between social rhythms and the circadian clock, has been shown to be associated with insulin resistance. Other sleep disturbances (insufficient sleep, poor sleep quality and sleep apnea) have also been shown to affect glucose metabolism. In this study, we explored whether there was a relationship between chronotype, social jetlag and hemoglobin A1c (HbA1c) levels in prediabetes patients, independent of other sleep disturbances. A cross-sectional study was conducted at the Department of Family Medicine, Ramathibodi Hospital, Bangkok, from October 2014 to March 2016 in 1014 non-shift working adults with prediabetes. Mid-sleep time on free day adjusted for sleep debt (MSFsc) was used as an indicator of chronotype. Social jetlag was calculated based on the absolute difference between mid-sleep time on weekdays and weekends. The most recent HbA1c values and lipid levels were retrieved from clinical laboratory databases. Univariate analyses revealed that later MSFsc (p = 0.028) but not social jetlag (p = 0.48) was significantly associated with higher HbA1c levels. Multivariate linear regression analysis was applied to determine whether an independent association between MSFsc and HbA1c level existed. After adjusting for age, sex, alcohol use, body mass index (BMI), social jetlag, sleep duration, sleep quality and sleep apnea risk, later MSFsc was significantly associated with higher HbA1c level (B = 0.019, 95% CI: 0.00001, 0.038, p = 0.049). The effect size of one hour later MSFsc on HbA1c (standardized coefficient = 0.065) was approximately 74% of that of the effect of one unit (kg/m²) increase in BMI (standardized coefficient = 0.087). In summary, later chronotype is associated with higher HbA1c levels in patients with prediabetes, independent of social jetlag and other sleep disturbances. Further research regarding the potential role of chronotype in diabetes prevention should be explored.     

Emulsification efficiency of adsorbed chitosan for bacterial cells accumulation at the oil–water interface

The use of bacterial cell or biocatalyst for industrial synthetic chemistry is on the way of significant growth since the biocatalyst requires low energy input compared to the chemical synthesis and can be considered as a green technology. However, majority of natural bacterial cell surface is hydrophilic which allows poor access to the hydrophobic substrate or product. In this study, Escherichia coli (E. coli) as a representative of hydrophilic bacterial cells were accumulated at the oil–water interface after association with chitosan at a concentration range of 0.75–750 mg/L. After association with negatively charged E coli having a ζ potential of ?19.9 mV, a neutralization of positively charged chitosan occurred as evidenced by an increase in the ζ potential value of the mixtures with increasing chitosan concentration up to +3.5 mV at 750 mg/L chitosan. Both emulsification index and droplet size analysis revealed that chitosan-E. coli system is an excellent emulsion stabilizer to date because the threshold concentration was as low as 7.5 mg/L or 0.00075 % w/v. A dramatic increase in the surface hydrophobicity of the E. coli as evidenced by an increase in contact angle from 19 to 88° with increasing chitosan concentration from 0 to 750 mg/L, respectively, resulted in an increase in the stability of oil-in-water emulsions stabilized by chitosan-E. coli system. The emulsion was highly stable even the emulsification was performed under 20 % salt condition, or temperature ranged between 20 and 50 °C. Emulsification was failed when the oil volume fraction was higher than 0.5, indicating that no phase inversion occurred. The basic investigation presented in this study is a crucial platform for its application in biocatalyst industry and bioremediation of oil spill.     

Online recovery of nisin during fermentation and its effect on nisin production in biofilm reactor

An online removal of nisin by silicic acid coupled with a micro-filter module was proposed as an alternative to reduce detrimental effects caused by adsorption of nisin onto producer, enzymatic degradation by protease, and product inhibition during fermentation. In this study, silicic acid was successfully used to recover nisin from the fermentation broth of Lactococcus lactis subsp. lactis NIZO 22186. The effect of pH (at 6.8 and 3.0) during adsorption process and several eluents (deionized water, 20% ethanol, 1 M NaCl, and 1 M NaCl + 20% ethanol) for desorption were evaluated in a small batch scale. Higher nisin adsorption onto silicic acid was achieved when the adsorption was carried out at pH 6.8 (67% adsorption) than at pH 3.0 (54% adsorption). The maximum recovery was achieved (47% of nisin was harvested) when the adsorption was carried out at pH 6.8 and 1 M NaCl + 20% ethanol was used as an eluent for desorption. Most importantly, nisin production was significantly enhanced (7,445 IU/ml) when compared with the batch fermentation without the online recovery (1,897 IU/ml). This may possibly be attributed to preventing the loss of nisin due the detrimental effects and a higher biomass density achieved during online recovery process, which stimulated production of nisin during fermentation.