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Gene Assay Differentiates Between Bacterial and Viral Infections

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Publishing in Science Translational Medicine, researchers at Stanford University School of Medicine have announced that they have made a breakthrough in their aim to create a diagnostic test that is able indicate when a patient is suffering from a bacterial infection that can be treated by antibiotics. The video below describes the differences between a bacterial and a viral infection.

Antibiotics have been tremendously beneficial to public health, but now their overuse could threaten us with deadly pathogens that won’t respond to antibiotics. Doctors are now encouraged to only prescribe antibiotics when they are absolutely necessary, and not just when patients request them or for minor illnesses whose cause is unknown. Unfortunately though, there is not an easy way to tell if such illnesses are due to a virus or bacterial infection.

“A lot of times you can’t really tell what kind of infection someone has,” explains Timothy Sweeney, MD, PhD, the lead author of the paper who is an engineering research associate at the Stanford Institute for Immunity, Transplantation and Infection. “If someone comes into the clinic, a bacterial or a viral infection often look exactly the same.”

“The idea to look for a diagnostic test came from our previous paper in Immunity last year,” says Assistant Professor of Medicine Purvesh Khatri, PhD, the study’s senior author. “In that paper, we found a common response by the human immune system to multiple viruses that is distinct from that for bacterial infections. We wondered whether we could exploit that difference to improve the diagnosis of bacterial or viral infections. But we needed a gene signature consisting of far fewer genes for the test to be clinically useful.”

To start developing a diagnostic assay, the investigative team utilized publicly available gene expression data from patients to identify genes whose expression is altered during an infection in the hopes of seeing patterns that distinguish whether an infection is viral or bacterial.

They found seven genes with changed expression, and created their test. It’s expected to be a huge improvement over tests that analyze the expression of hundreds of genes, the researchers posit. With so few genes involved, the new test will be accurate while also being cheaper and faster, they explain.

This new gene-expression assay for identifying bacterial infections will face two hurdles before it would be made available to the clinic. It must first be rigorously tested in a clinical setting. The data and test results for this work have until now all come from online digital data sets of gene expression from patients with different types of infections and not from current patients. The scientists validated the seven-gene test using blood samples from 96 seriously ill children, and found that the test was accurate. But secondly, it must be validated in large numbers of patient blood samples.

The test will also need to be fused with a device that is able to produce a result in about an hour. The preliminary version of the test takes too long for those who are critically ill or have sepsis – four to six hours.

In someone who is obviously very ill, explains Sweeney, giving antibiotics would be the answer. However, patients often have early-stage bacterial infections and doctors don’t realize the patient is in serious danger. The gene expression test would remove doubt in only minutes, thus allowing medical practitioners to prescribe necessary antibiotics faster, saving lives while reducing the amount of unnecessarily prescribed drugs.

Source: LabRoots

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FDA Releases Draft Guidances on Next-Generation Sequencing

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The FDA has issued two draft guidances that will provide regulatory oversight for the use of next-generation sequencing (NGS)-based tests.

The utilization of the novel technology—which can examine millions of DNA variants at one time—has been expanding as a means to inform risk and treatment decisions across multiple tumor types.

“The draft guidances are an important step in the development of NGS-based tests,” said Francis Collins, MD, PhD, director of the National Institutes of Health (NIH). “NIH sees great value in these guidances and encourages test developers to adopt the best practices outlined in the guidances so that high quality tests can become available to the patients who need them.”

The first draft guidance, titled, “Use of Standards in FDA’s Regulatory Oversight of Next Generation Sequencing (NGS)-Based In Vitro Diagnostics (IVDs) Used for Diagnosing Germline Diseases” provides recommendations for designing, developing, and validating NGS-based tests for rare hereditary diseases, and addresses the potential for using FDA-recognized standards to demonstrate how well a test predicts the presence or absence of a particular genomic change.

The second draft guidance, titled, “Use of Public Human Genetic Variant Databases to Support Clinical Validity for Next Generation Sequencing (NGS)-Based In Vitro Diagnostics” describes an approach wherein test developers may rely on clinical evidence from FDA-recognized public genome databases to support clinical claims for their tests and provide assurance of accurate clinical interpretation of genomic test results—allowing for an easier path for marketing clearance or approval.

Because genetic and genomic testing is dynamic, the FDA has stated that the guidances will provide a flexible and streamlined approach to oversight that is adapted to the novel nature of these tests. Adherence to the guidances will allow for variations in development and validation and accommodate the rapid evolution of NGS technologies, while still assuring they provide accurate and useful results, according to the FDA.

“The FDA values the input we received from genomics experts, industry, healthcare providers and patients from four public workshops and other outreach opportunities. Based on this input, we crafted draft recommendations that we believe will encourage innovation and advance the goal of precision medicine: to speed the right individualized treatments to patients sooner,” said Jeffrey Shuren, MD, JD, director of the FDA’s Center for Devices and Radiological Health in a statement.

Guidance documents represent the FDA’s current thinking on a particular subject. Draft guidances are undergoing finalization and the FDA encourages public comments regarding the draft during the 90-day comment period.

The guidances are part of the of the FDA’s engagement in the Precision Medicine Initiative (PMI), created by the White House in early 2015. The FDA’s role in the PMI is to create regulatory processes that encourage advances in genomic testing while assuring that NGS-based tests are safe and effective. The agency has been working with experts in the genomics community to conceptualize an approach that strikes a balance between safeguarding public health and promoting innovation.

“Targeting the right treatments to the right patients at the right time is the goal of the President’s Precision Medicine Initiative,” said FDA commissioner Robert Califf, MD, in a statement. “Soon, patients will have a much more complete picture of their health than in the past, informed by their genetic and genomic makeup. The FDA is preparing for this exciting approach at multiple levels.”

President Barack Obama called for $215 million in fiscal year 2016 to support the PMI. Of this total proposed budget, $130 million were allocated to the NIH to build a national, large-scale research cohort, and $70 million were allocated to the National Cancer Institute to lead efforts in cancer genomics as part of the PMI for oncology.

Thus far, the NIH has awarded funding to create a data and research support center, a participant technologies center, and a network of Healthcare Provider Organizations for the research cohort. They are also funding a biobank at Mayo Clinic as part of this initiative, which will support the collection, analyses, storage, and distribution for research use of biospecimens.

Source: ONC Live

Multiple Sclerosis, the Gut Microbiome & Potential Therapies

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The “signature” taxa are highlighted on the phylogenetic tree (cladogram) using GraPhlAn with red and green color indicating increase and decreases of abundance in the MS patients. Credit: Nature Scientific Reports/ Chen et al

Multiple sclerosis is an autoimmune disease of the central nervous system, and scientists in the field began to investigate the relationship between it and gut bacteria. Researchers began to look in patients suffering from the disease to see how their microbiomes differed from healthy people, and while those differences were small in some cases, there were changes nonetheless.

A report in May 2016 in the European Journal of Neurology showed that there are different characteristics in the microbiomes of children with or without MS. Specific types of bacteria were present at varying amounts in children with multiple sclerosis compared to healthy children. In particular, it was found that multiple sclerosis was connected to an increase in gut bacteria linked to inflammation and a decrease in gut bacteria that are thought to be anti-inflammatory.

A new study in Scientific Reports has also reaffirmed that MS patients have a microbiome that is unlike that of people without MS. “Although preliminary, our data suggest that patients with MS have reduced levels of good bacteria responsible for overall benefits obtained from consuming healthy foods, such as soybean and flaxseeds,” Ashutosh Mangalam, Assistant Professor of pathology at the University of Iowa Carver College of Medicine and senior author of the study.

“We identified certain bacteria which are increased or decreased in the gut of patients with MS compared to healthy controls,” he continues.

In light of the increasing amount of evidence that not only links the microbioe with MS, but the characterization of that relationship, a new review article in the Journal of Interferon & Cytokine Research (JICR) has suggested that the microbiome could be a target for the prevention and treatment of MS.

Until August 6, 2016, the article is freely available on the JICR website. In it, coauthors Justin Glenn and Ellen Mowry of Johns Hopkins University School of Medicine present the various mechanisms by which several scenarios such as altered levels of bacteria in the human gut, bacteriophage activity, viral infections targeting bacteria, or bacterial toxins, could affect the immune system or possibly, play a role in causing autoimmune disorders like MS. Knowing more about the details of these mechanisms may help identify new drug targets or preventive strategies.

“This informative review presents the facts behind the notion that the nature of the intestinal microbial population may influence the development of autoimmune diseases, such as MS,” explains Journal of Interferon & Cytokine Research Co-Editor-in-Chief Ganes C. Sen, of the Department of Immunology at Cleveland Clinic Foundation.

Source: LabRoots

Bacteria with Antibiotic Resistance MCR-1 Gene Found for the First Time in U.S. Patient, Raises Concern

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Recently, that fear intensified when the Department of Defense announced that it discovered for the first time a strain of the bacteria Escherichia coli (E. coli) infecting a patient in the U.S. that carries the gene called mcr-1. The gene makes the bacteria resistant to colistin, a polymyxin, which is a class of antimicrobials considered to be a “last resort” to treat patients with multidrug-resistant infections. Polymyxins are also used in livestock.

The woman, a resident of Pennsylvania, responded to other antibiotics and has now recovered. But what makes the discovery especially concerning, according to the U.S. Centers for Disease Control and Prevention (CDC), is that the mcr-1 gene, first identified in China last year, was found not on a chromosome but on a plasmid, a transportable piece of DNA. When a resistance gene is part of the genome, it is only spread to the offspring of that bacterium, but when it is on a plasmid, it can easily be spread to other bacteria, making them resistant to antibiotics. Since the mcr-1 gene was found on a plasmid, it can move to other bacteria and make them resistant to the polymyxin antibiotics.

The CDC and other public health experts are examining close contacts of the Pennsylvania woman, including healthcare practitioners and family members, to see if any of them acquired this resistant strain of E. coli and may be at risk for spreading the bacteria that contain the mcr-1 gene to others.

Particularly concerning for health experts, though not yet a threat, is the possibility that the mcr-1 gene could transfer to bacteria that are already resistant to other last resort drugs, such as carbapenem-resistant Enterobacteriaceae, commonly called CRE, which causes death in half of all cases. (Read also CRE Superbugs Rising Threat in U.S.)

Since the discovery of the gene in China last year, health experts have now found at least one type of bacteria that harbors themcr-1 gene on every continent. In addition to the woman in Pennsylvania, researchers in the U.S. have found other examples of the mcr-1 gene, in pigs’ intestines.

Starting next fall, up to eight labs in the U.S. will have all the technology and instrumentation needed to detect resistant organisms suspected in human samples. Those labs will serve as reference laboratories for the U.S. states and territories.

According to Jean Patel, PhD, Director of the Office of Antibiotic Resistance of the CDC, the new labs will be able to detect new forms of antibiotic resistance—including mutations that allow bacteria to survive the effects of the last-resort drugs like colistin—and report these findings to CDC. That will allow faster investigations and infection control for future resistance threats, says Dr. Patel.

Dr. Patel explains that the new efforts are another layer in the focus that the CDC already has on improving antibiotic use. “Expect to have a conversation with your doctor when an antibiotic is being considered. There’s likely to be more watchful waiting to see if the infection progresses rather than quickly reaching for an antibiotic.”

People can also expect more testing if there is a potential infection and an antibiotic is being considered, says Dr. Patel. For example, while many healthcare practitioners often prescribe an antibiotic over the phone if a woman has a urinary tract infection, experts say it’s much more likely now that providers will require a urine culture. They will wait for results about whether there is an infection and for identification and the antibiotic susceptibility pattern of the bacteria before prescribing an antibiotic drug.

Dr. Patel says that many diagnostic tests have become better and faster, like strep tests, which now come in rapid versions that allow results during an office visit. In fact, various tests for infectious diseases have been improved to provide more timely,sensitive and specific results. Such tests can help quickly determine whether antibiotics are needed and allow for a more appropriate choice of antimicrobial therapy that targets the specific bacteria causing the patient’s infection.

Source: LTO

eAcademy: Development and Validation of Cortisol-Cortisone LCMSMS

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Developing an LC-MS/MS assay for hormones measurement and learning how to determine the fitness-for-purpose of new method based on validation data are the main objectives of the webinar “Development and Validation of Cortisol-Cortisone LCMSMS” by Dr Kartika Sari Henry.

The webinar focuses on troubleshooting of some common problems in method validation and recognition of advantages and disadvantages of LC-MS/MS assay in comparison with immunoassay for cortisol and cortisone quantification.

New IFCC App!

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The Communications and Publications Division (CPD) is pleased to announce the release of a new IFCC app on both iOS and Android platforms. The app is free to download from iTunes or Google Play and is a new communication tool for use by all IFCC officers, member society members, and other lab medicine professionals.

The app gives direct access to the IFCC website, provides the latest news from IFCC and an overview of IFCC events. Everything in one place, accessible with a single click.

The IFCC app enables you to browse the latest issues of the eNewsletter and eJournal, even when you are offline. It also provides access to eAcademy eLearning programs and IFCC calendar of upcoming conferences and other events. It can be used on both mobile phones as well as tablets.

IFCC is a global organisation advancing excellence in laboratory medicine for better healthcare worldwide; a network of 102 Full/Affiliate Member Societies in 90 countries as well as 46 Corporate Members, comprising of >45,000 senior laboratory medicine specialists.

Khosrow Adeli, Chair, Communications and Publications Division (CPD)

Available both in Android and iOS stores, you can search for the app by using “ifcc”.
Apple Store (iphone) – Google Play (android)

Stay in touch with IFCC, go to your App Store and download the IFCC app!

Benign Bacteria Block Mosquitoes from Transmitting Zika, Chikungunya Viruses

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Matthew Aliota, assistant scientist in the Department of Pathobiological Sciences in the School of Veterinary Medicine, works with a strain of Aedes aegypti mosquito in a research lab insectary in the Hanson Biomedical Sciences Building. Photo Credit: JEFF MILLER

Matthew Aliota, a scientist at the UW–Madison School of Veterinary Medicine (SVM) and first author of the paper—published July 1 in the journal Scientific Reports—says the bacteria could present a “novel biological control mechanism,” aiding efforts to stop the spread of Zika virus.

Thirty-nine countries and territories in the Americas have been affected by the Zika epidemic, and it is expected that at least 4 million people will be infected by the end of the year. Scientists believe the virus is responsible for a host of brain defects in developing fetuses, including microcephaly, and has contributed to an uptick in cases of a neurological disorder called Guillain-Barre syndrome. There are not yet any approved Zika virus vaccines or antiviral medications, and ongoing mosquito control strategies have not been adequate to contain the spread of the virus. Researchers led by Jorge Osorio, a UW–Madison professor of pathobiological sciences, and Scott O’Neill of the the Eliminate Dengue Program (EDP) and Monash University in Melbourne, Australia, are already releasing mosquitoes harboring the Wolbachia bacterium in pilot studies in Colombia, Brazil, Australia, Vietnam, and Indonesia to help control the spread of dengue virus. Their work is supported by the Bill and Melinda Gates Foundation.

An important feature of Wolbachia is that it is self-sustainable, making it a very low-cost approach for controlling mosquito-borne viral diseases that are affecting many tropical countries around the world. “In two of our initial study sites in Australia, approximately 90 percent of the mosquitoes continue to be infected with Wolbachia after initial release more than six years ago” says O’Neill. EDP has now received additional endorsement from the World Health Organization’s Vector Control Advisory Group to conduct further pilot studies and scale up in endemic areas.

Wolbachia can be found in up to 60 percent of insects around the world, including butterflies and bees. While not typically found in the Aedes aegypti mosquito—the species that also transmits dengue, chikungunya, and yellow fever viruses—O’Neill discovered in the early 1990s that Wolbachia could be introduced to the mosquito in the lab and would prevent the mosquitoes from transmitting dengue virus.

Zika virus belongs to the same family as dengue virus and Aliota and Osorio—with co-authors Stephen Penaido at SVM and Ivan Dario Velez, at the Universidad de Antioquia in Medellin, Colombia—asked whether Wolbachia-harboring Aedes aegypti may also be effective against Zika virus. They were also interested in studying the mechanisms behind Zika virus infection and transmission in mosquitoes.

In the study, the team infected mice with Zika virus originally isolated from a human patient and allowed mosquitoes from Medellin to feed on the mice either two or three days after they were infected. The mosquitoes were either harboring the same strain of the Wolbachia bacteria (called wMel) used in field studies or were Wolbachia-free and the mice had levels of virus in their blood similar to humans infected with Zika virus.

An additional group of mosquitoes, both wild-type and Wolbachia-infected, was allowed to feed instead from a membrane containing sheep’s blood spiked with a high concentration of Zika virus, per other standard laboratory studies.

Four, seven, ten, and 17 days after the mosquitoes fed on Zika-virus-infected blood the researchers tested them for Zika virus infection, assessed whether the virus had disseminated—or spread to other tissues in the mosquito, and examined whether the virus made its way to the mosquito saliva, where it must be present to be transmitted.
“The first site of replication for arboviruses is the mosquito midgut,” says Aliota. “It eventually leaves the midgut and is swept in their blood to secondary tissues and eventually to the salivary glands, where it replicates more and is eventually spit out.”

They found that mosquitoes carrying Wolbachia were less likely to become infected with Zika virus after feeding on viral blood, and those that were infected were not capable of transmitting the virus in their saliva.

“We saw reduced vector competence in Aedes aegypti with Wolbachia,” says Osorio, defined as the intrinsic ability of an insect to support the development or replication of a pathogen like a virus and then transmit it. “Mosquitoes with Wolbachia were less capable of harboring Zika virus, and though they do get infected with Zika, it is to a lesser extent than wild-type mosquitoes.”

They also found that where mosquitoes got their blood meal—whether from mice or the membrane—impacted their infection and transmission status. This has implications for other laboratory-based Zika virus studies, Aliota says.

Though mice had a lower concentration of virus in their blood than the blood contained in the membrane, mosquitoes that fed on the mice were infected at higher rates than those that were membrane-fed. The levels of virus found in the mice were also more similar to those seen in human infections.

Non-Wolbachia-containing mosquitoes that acquired Zika virus from mice were also capable of transmitting the virus in a shorter number of days, and in less time than other studies have shown. Additionally, the researchers learned that a relatively low percentage of Zika-virus-transmitting mosquitoes may be sufficient to sustain an outbreak.
“A surprisingly low percentage of mosquitoes are actually capable of transmitting the virus,” Aliota says, “but given the size of the outbreak, and that we think mosquitoes are the driver of the outbreak, the results were somewhat unexpected. It just goes to show you how much we still need to understand about the basic biology of this virus.”

The study is one of the first to study Zika virus transmission dynamics using a living host, says Aliota.

Importantly, the team also confirmed that the strain of Wolbachia used does not impact the Aedes aegypti mosquito, which is important to the success of field studies.

Once inside a mosquito, Wolbachia is passed from mother to offspring, so newborn mosquitoes will contain the bacteria and incorporate it into the wild population. EDP hopes to see greater than 80 percent of Aedes aegypti mosquitoes in study areas harboring Wolbachia. According to Osorio, mosquitoes carrying Wolbachia in the study site in Medellin are close to reaching that number.

Other studies show Wolbachia prevents mosquito transmission of yellow fever virus—which is causing an outbreak in Africa—and, in another study published in late April in PLOS Neglected Tropical Diseases, Aliota, Osorio and their UW–Madison and Universidad de Antioquia colleagues showed that Wolbachia prevents Colombian Aedes aegypti from transmitting chikungunya virus.

Like Zika virus, chikungunya emerged out of Africa and spread to the Americas. It is now transmitted by mosquitoes on every inhabited continent around the globe, says Aliota. The virus can cause fever, chronic joint pain, fatigue, nausea, and a rash. There is no cure or specific treatment.

Aliota and Osorio continue to study Wolbachia in mosquitoes in relation to these viruses, monitoring for changes or developments that could affect ongoing field releases. So far the findings have been encouraging, Aliota says.

“Our findings are complementary to results described earlier in the month in Cell Host & Microbe by our colleagues with EDP-Brazil, which is really exciting and really promising,” he says.

The Zika virus study was funded in part by the National Institutes of Health.

Source: LabManager

Cholesterol Testing: Is Fasting Necessary?

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The recommendations were published as a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. No U.S. guidelines for adults have been published yet recommending such a change.

Blood cholesterol levels, including total, LDL (“bad”), and HDL (“good”) cholesterol as well as triglycerides, are checked in order to predict the risk of a cardiovascular event such as a heart attack. Fasting for 9-12 hours before checking cholesterol levels with a lipid profile has long been thought to provide a more accurate reading and is “preferred” according to the most recent U.S. guidelines published in 2013.

However, the new European guidelines are based on more than a dozen published studies that reported on over 300,000 patients who had not fasted and then had blood drawn to check their cholesterol levels. The studies found that the risk of cardiovascular events was predicted as well as, or better than, it was for patients who had fasted before the test.

Fasting ahead of a cholesterol test can be difficult for many people, including older adults, children and people with diabetes. Many other people simply forget and remember only when asked and then must reschedule the test. Others may put off having the test so they don’t have to fast.

To make it easier for people to get recommended testing, fasting should not be required, according to the new European guidelines. However, if an individual’s non-fasting triglyceride result from an initial test is greater than 5 mmol/L (440 mg/dL), then the lipid profile should be repeated when the person has fasted.

In a press release about the new guidelines, Borge Nordestgaard, MD, a professor in the Department of Clinical Medicine at the University of Copenhagen and a lead author of the guidelines said, “We hope that non-fasting cholesterol testing will…reduce the global burden of cardiovascular disease and premature death.” Denmark has had recommendations for non-fasting cholesterol tests since 2009.

So far, no recommendations for adults eliminating fasting before a cholesterol test have been issued in the U.S. Cholesterol values are usually compared to cut-off levels that were established using data from studies on people who fasted before testing. But that may eventually change as more studies evaluate cholesterol levels in people who have not fasted and as the evidence from those studies is used to update guidelines.

“Evolving evidence that would support a change for the U.S. will be considered as guidelines undergo updates and revision,” said Robert Eckel, MD, former president of the American Heart Association.

It remains to be seen when a change in recommendations might occur in the U.S. “Guidelines are reevaluated on a periodic basis and it’s expected that the new information on not fasting before a cholesterol test will be evaluated,” says Philip Greenland, MD, a member of the American College of Cardiology Prevention of Cardiovascular Disease Section Council. “Once that evaluation happens, it’s certainly possible that a revision in the current recommendations, last updated in 2013, could occur.”

Until U.S. guidelines change, adults who are to undergo cholesterol testing should follow the directions given by their healthcare practitioners before scheduling the test and should tell the person drawing the blood sample whether or not they have fasted.

Source: AACC Lab Tests Online

Newer tests could cut hep C diagnosis steps in half

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1. Newer tests could cut hep C diagnosis steps in half

Going from two steps to one could increase the number of patients who are diagnosed and streamline the cascade of care

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-0065

URL goes live when the embargo lifts

Data suggest that several commercially available tests for hepatitis C virus core antigen (HCVcAg) are highly sensitive and specific and could transform the current two-test screening process for HCV into a single test. A single-process diagnostic for chronic HCV infection could streamline the cascade of care in low- and middle-income countries where HCV is prevalent, but patients are often lost to follow-up. The systematic evidence review, published in Annals of Internal Medicine, will inform an upcoming World Health Organization (WHO) guideline on HCV screening.

Up to 150 million people are affected with HCV, with about 75 percent of those cases occurring in low-and middle-income countries. To make diagnosis of HCV cost-effective, a low-cost screening test for HCV antibodies is followed by a more expensive nucleic acid test (NAT) in patients who test positive for the HCV antibodies. This two-step process presents a major obstacle to diagnosis and treatment because a significant proportion of patients either do not undergo testing or do not follow up after an initial positive screen. This issue needs to be addressed to achieve the ambitious HCV elimination strategy proposed by WHO.

To evaluate the accuracy of HCVcAg tests for diagnosing active HCV infection among adults and children, researchers reviewed 44 published studies that compared any of 5 commercially-available HCVcAg tests with a NAT reference standard. The data showed that several HCVcAg assays are highly sensitive and specific and could feasibly replace NAT for HCV detection. The authors suggest that HCVcAg should be explored for point-of-care testing so that more patients could be diagnosed and treated.

Note: For an embargoed PDF, please contact Cara Graeff. For an interview with the lead author, Dr. J. Morgan Freiman, please contact Elissa Snook at elissa.snook@bmc.org or 617-638-6823.

 

2. Long-term pioglitazone use is safe and effective for patients with nonalcoholic fatty liver disease and diabetes

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-1774

Editorial: http://www.annals.org/article.aspx?doi=10.7326/M16-1303

URL goes live when the embargo lifts

Long-term use of pioglitazone appears to be safe and effective for patients with both nonalcoholic steatohepatitis (fatty liver disease) and prediabetes or type 2 diabetes mellitus. Results of a randomized, controlled trial are published in Annals of Internal Medicine.

Nonalcoholic fatty liver disease is reaching epidemic proportions and is the most common chronic liver condition in obese patients with prediabetes or type 2 diabetes. However, the condition is often overlooked and undertreated in these patients. This is a concern because patients with fatty liver disease and type 2 diabetes have an increased risk for vascular complications and are at the highest risk for cirrhosis and liver cancer. Pioglitazone is a medication in the class known as thiazolidinediones. Thiazolidinediones target insulin resistance and adipose tissue dysfunction or inflammation that promotes liver “liptoxicity” in fatty liver disease. For this reason, pioglitazone may be more helpful in treating patients with both fatty liver disease and prediabetes or type 2 diabetes.

Researchers randomly assigned 101 patients with prediabetes or type 2 diabetes and biopsy-proven fatty liver disease to either pioglitazone, 45 mg/d or placebo for 18 months, followed by an 18-month open-label phase with pioglitazone treatment. All patients were prescribed a low-calorie, weight-loss diet. After 3 years, patients were examined for a reduction in fatty liver disease activity without worsening of fibrosis and other histologic outcomes. They found that treatment with pioglitazone was associated with long-term metabolic and histologic improvements. These results suggest that fatty liver disease progression may be halted and the natural history of the disease may be modified with the use of pioglitazone in patients with prediabetes or type 2 diabetes.

Note: For an embargoed PDF, please contact Cara Graeff. The lead author, Dr. Kenneth Cusi, can be contacted directly at Kenneth.Cusi@medicine.ufl.edu or 352-278-5508.

3. Advanced practice clinicians and primary care docs show similarities in prescribing and referral practices for three common conditions

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-2152

Editorial: http://www.annals.org/article.aspx?doi=10.7326/M16-1326

URL goes live when the embargo lifts

Despite physicians’ perceptions, advanced practice clinicians (nurse practitioners and physician assistants) are no more likely than doctors to provide low-value health care, or services that do not comply with approved guidelines. The findings, based on a comparison of treatment for three common conditions, are published in Annals of Internal Medicine.

In response to the looming shortage of primary care physicians, many have advocated for expanding the role of advanced practice clinicians (APCs). Studies have shown that APCs provide care of about the same quality as physicians. However, the concern is that APCs may also provide more wasteful or low-value health services than physicians.

In this observational study, researchers reviewed medical records from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey between 1997 and 2011 to compare use of low-value services among U.S. APCs and physicians. They looked for guideline-discordant prescribing of antibiotics for upper respiratory infections, referral to imaging for low back pain and headache, and referrals to other physicians for all three conditions. This large national comparison showed that APCs and physicians ordered low-value health services with similar frequency, dispelling physicians’ perceptions that APC’s provide lower-value care than they do.

The author of an accompanying editorial suggests that the study findings provide more questions than answers. For example, a variety of practice setting factors may influence clinical decision-making. The author writes that primary care physicians have substantially greater training and clinical experience, which may be required for correct diagnosis and more comprehensive care when patients are more medically complex. An important question is how to best combine the skills of APCs and physicians for efficient comprehensive primary care.

Note: For an embargoed PDF, please contact Cara Graeff. For an interview with the lead author, Dr. John Mafi, please contact Enrique Rivero at ERivero@mednet.ucla.edu or 310-794-2273

Source: Eurekalert

 

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