Dissertations / Theses on the topic 'Hepatitis C – Patients'

Bakgrund: Den vanligaste smittvägen för hepatit C är genom intravenöst drogmissbruk. Smittöverföring kan även ske via blodtransfusioner eller stickskador i vården. Det finns många fördomar förknippade med sjukdomen och risken är stor att dessa färgar mötet med patienter. Det är viktigt att som vårdpersonal vara medveten om hur den egna synen på sjukdomen kan påverka bemötandet. Syfte: Syftet var att belysa vilka erfarenheter patienter med hepatit C har av bemötandet i vården. Metod: Studien utformades som en allmän litteraturöversikt av tolv kvalitativa artiklar. Manifest innehållsanalys användes. Resultat: Patienter med HCV hade blandade erfarenheter av mottagandet: välkomnande, avvisande eller otryggt. Vidare ledde detta till erfarenheter av stöd eller diskriminering. Patienter kunde ha erfarenheter av professionellt stöd eller brist på professionellt stöd. Diskriminering kunde orsakas av antingen vårdpersonal eller organisation. Slutsats: På grund av stigmatisering kring sjukdomen är patienter med hepatit C en utsatt grupp i samhället. Vårdpersonalens kunskap är en viktig del i bemötandet. Det krävs utbildning för att kunna erbjuda en mer holistisk vård vid hepatit C än i dagsläget. Genom ökad kunskap kring både sjukdom och bemötande kan bemötandet påverkas positivt, det vill säga: mottagandet blir bättre, stödet ökar och diskrimineringen minskar.
Background: The most common route of transmission of hepatitis C is through intravenous drug abuse. Transmission can also occur through blood transfusion. There are many prejudices associated with hepatitis C. Chances are that this colors interactions with patients. It is important that healthcare professionals are aware of how their own perception of the disease may affect the encounter.  The Objective was to highlight the experiences patients with hepatitis C have of the encounter in the healthcare. Method: The study was designed as a general literature review of twelve qualitative articles. Manifest content analysis was used. Results: Patients with hepatitis C had mixed experiences of receipt: welcoming, rejecting or unsafe. This led to experiences of support or discrimination. Patients experienced professional support or lack of professional support. Discrimination could be caused either by healthcare professionals or the organization. Conclusion: Because of stigma surrounding the disease patients with hepatitis C are a vulnerable group in society. The knowledge of healthcare professionals is an important part of the encounter. It requires training to provide holistic care for hepatitis C. Increased knowledge about both the disease and patient-professional relation can positively affect the encounter: the reception gets better, support increases and discrimination is reduced.

The cost effectiveness of using novel HCV treatment option, telaprevir and boceprevir, should depend on patients’ respond to conventional PEG-INFα and ribavirin therapy. The study of pharmacogenomics, interleukin-28B (IL-28B) polymorphisms, accompanied with the information of HCV genotypes are suggested to have the strongest predictive value of treatment outcomes and prognosis of disease in individuals infected with HCV who are undergoing conventional PEG-INFα and ribavirin therapy. It is extremely valuable in HCV/HIV co-infected patients as these groups of patients require a complex treatment regimen and demonstrate poor sustained viral response (SVR) rate. The development of a fast and promising IL-28B genotyping assay is urgently needed. A total of 47 blood samples randomly selected from HCV and HIV co-infected patients were used in this investigation. The aims of this study are to evaluate and compare the performance of newly developed IL-28B HybProbe real-time PCR assay using LightCycler® system against Sanger Sequencing method in determining IL-28B polymorphisms on rs12979860 and rs8099917 and to estimate the prevalence of IL-28B polymorphisms among HCV/HIV co-infected patients in Hong Kong. In addition, the genotypic distribution of HCV among the same patient group is identified by using in-house Sanger Sequencing method. It was found that the newly developed IL-28B real-time HybProbe assay resulted in 100% concordance with the traditionally used Sanger Sequencing method. The allele frequencies of C and T were 96% and 4% in rs12979860 and T and G were 97% and 3% in rs8099917 respectively. The CC and TT wild type are predominating in rs12979860 and rs8099917 with frequencies of 93.62% and 95.74% respectively. The most favorable compound genotype CC/TT with both homozygous wild types on both SNPs was the most predominant type with a high prevalence of 93.61%. Among all the samples, 50% samples were found to be HCV genotype 1, 41.18% were genotype 6 and 8.82% were genotype 3. A simple and efficient IL-28B real-time HybProbe assay was developed in this study and proved to show excellent performance on IL-28B genotyping although further optimization is suggested before it can be applied in the clinical setting. The favourable wild type genotypes of rs12979860 and rs8099917 accounted for the most predominant genotypes which is similar to other findings obtained from an Asian population. A comparatively high prevalence of HCV genotype 6 was found in the HCV/HIV co-infected group. Future study with the information of treatment outcomes (HCV viral load) can further evaluate the predictive value of IL-28B polymorphisms on SVR in different HCV genotypes.
published_or_final_version
Medical Sciences
Master
Master of Medical Sciences

Thesis (M.Sc. (Hons.)) -- University of Western Sydney, 2007.
A thesis submitted towards the degree of Master of Nursing (Honours) in the University of Western Sydney, College of Health and Science, School of Nursing. Includes bibliographical references.

Chronic haemodialysis patients have a high prevalence of Hepatitis B and C virus infections both of which are associated with chronic liver disease and hepatocellular carcinoma Hepatitis B virus (HBV) was identified as a frequent cause of hepatitis during the early years of chronic haemodialysis therapy and strict adherence to infection control measures alone proved inadequate to control the transmission of infection between patients. A policy of regular screening of all patients and blood donations for hepatitis B surface antigen together with isolation of positive patients to separate dialysis units resulted in a significant decline in the incidence of new infections. Hepatitis B vaccination provided an important new means of protection. Despite the finding that haemodialysis patients did not respond to the vaccine as well as normal adults, randomized controlled trials showed significant protection in units with a previously high incidence of infection. Studies have identified both monocyte dysfunction and B cell inhibition by elevated levels of parathyroid hormone (PTH) as possible mechanisms for the reduced response in dialysis patients. Other factors which have been associated with this poor response include increased age, male gender, specific human leukocyte antigens, shorter time on a dialysis programme and poor nutritional status. One study has shown an increased response in patients receiving recombinant human erythropoietin and. there is in vitro evidence that nifedipine improves B cell proliferation in dialysis patients with hyperparathyroidism. Hepatitis C virus (HCV) infection in haemodialysis patients has been associated with blood transfusions in many studies. However, evidence exists that transmission between patients also occurs. There is disagreement as to what measures are necessary to prevent possible nosocomial spread. Some authors recommend isolation of HCV -infected patients to separate dialysis machines or units. There is also concern over the potential of dialyzer reuse to transmit the virus. A protocol for surveillance 0f hepatitis B and C infections was established in the dialysis unit at Groote Schuur Hospital while HCV positive patients were not isolated and reuse of dialyzers was continued for all patients. HBV -infected patients are dialyzed in a separate unit and their dialyzers are not reused. A trial of hepatitis B vaccination of all antibody negative patients was undertaken using four doses of a plasma-derived vaccine given intramuscularly at month 0,1 ,2 and 4.

INTRODUCTION. Sickness behavior is a highly organized adaptive strategy elicited by inflammation to support the organism’s defense against pathogens. It is characterized by changes in behavior, mood and cognition similar to those observed in patients with major depressive disorder. Despite its adaptive function, sickness behavioral changes may become prolonged and dysfunctional when the pathogen stimulus cannot be removed and may contribute to the development of depression in vulnerable patients. The study of the mechanisms linking inflammation to sickness behavior and depression would be crucial for a better understanding of the pathophysiology of depression and to develop new therapeutic approaches. HYPOTHESIS AND OBJECTIVES. Patients with a low-degree chronic inflammatory disease such as chronic hepatitis C (CHC), compared to healthy controls, would present changes in brain morphology, activity, connectivity and metabolism in areas linked to sickness behavior and depression, and that such alterations would be related to mood symptoms and inflammatory markers. The main objective of this thesis was to elucidate the clinical and neurobiological correlates of a prolonged sickness condition associated with chronic inflammation, such as CHC. STUDY 1: METHODS AND RESULTS. A systematic review with meta-analysis of neuroimaging research was conducted in CHC treatment naïve patients. A computerized literature search was performed in main databases from inception up until 1 May 2017 for peer-reviewed studies on structural or functional neuroimaging assessment of no treated patients without cirrhosis or encephalopathy, neuropsychiatric disease or substance use disorder with control group. The primary measures of interest varied according to the neuroimaging technique used and the secondary outcome were the correlation of these measures with neuropsychiatric symptoms. Meta-analysis was conducted when possible. Of 1403 records, 32 full-text articles were assessed for eligibility. The final sample was of 25 studies. The whole sample was of 509 patients of mild liver disease, and 491 healthy controls. A meta‐analysis of magnetic resonance spectroscopy studies showed increased levels of choline/creatine ratio, creatine and glutamate plus glutamine in basal ganglia and increased levels of choline/creatine ratio in centrum semiovale white matter in CHC patients. Other structural and functional brain abnormalities were also reported by individual studies as marker of neuroinflammation, oxidative stress and neuron-glia or axon-myelin integrity disruption. Central nervous system metabolic changes were mainly correlated with neurocognitive impairment and fatigue symptoms, thought controversial results were observed. STUDY 2: METHODS AND RESULTS. A cross-sectional, case-control study of 35 CHC no treated patients, and 30 healthy controls, age and sex matched. Exclusion criteria were decompensated cirrhosis or hepatocarcinoma, any chronic disease or inflammatory condition, any neuropsychiatric and substance use disorder. All patients were evaluated for perceived stress (PSS), depression (PHQ-9), fatigue and irritability through a visual analog scale (VAS), as well as serum levels of interleukin-6 (IL-6), prostaglandin E2 (PGE2) and oxidative stress markers. Functional magnetic resonance imaging was performed, measuring resting-state functional connectivity using a region-of-interest (seed)-based approach focusing on the bilateral insula, subgenual anterior cingulate cortex (sgACC) and bilateral putamen. Between-group differences in functional connectivity patterns were assessed with two-sample t-tests, while the associations between symptoms, inflammatory markers and connectivity patterns were analyzed with multiple regression analyses. We observed that CHC patients had higher PSS, PHQ-9 and VAS scores for fatigue and irritability, as well as increased IL-6 levels, PGE2 concentrations and antioxidant system activation compared to controls. Increased perceived stress and depressive symptoms were associated with changes in inflammatory marker levels and in functional connectivity between the insula and putamen, areas involved in interoceptive integration, emotional awareness, and orientation of motivational state. Of note, PGE2 and PSS scores accounted for 46% of the variance in functional connectivity between the anterior insula and putamen. CONCLUSIONS. The results supported the hypothesis of a direct or indirect involvement of hepatitis C virus in central nervous system disturbances and provide valuable information on the brain areas involved in perceived stress, fatigue and subclinical depressive symptoms during chronic inflammation, highlighting the crucial role of interoception in coordinating prolonged sickness behavior. Using the CHC disease as a model of low-grade inflammation, new neurobiological and neuroanatomical links between sickness behavior and chronic inflammatory conditions have been elucidated. These findings may be crucial in understanding pathophysiological mechanisms related with psychiatric diseases such as depression and open new research perspectives centered on the development of new therapeutic targets.
INTRODUCCIÓN. La conducta de enfermedad es una estrategia adaptativa y coordinada que tiene la finalidad de defender el organismo en contra de agente patógenos. Los cambios conductuales pueden persistir de forma prolongada y volverse disfuncionales. El estudio de los mecanismos subyacentes que relacionan la inflamación, conducta de enfermedad y depresión mejoraría el conocimiento de la fisiopatología de la depresión. HIPÓTESIS Y OBJETIVOS. Los pacientes con hepatitis C crónica (HCC) podrían presentar cambios cerebrales a nivel estructural, funcional, conectividad y metabolismo en áreas asociadas con la conducta de enfermedad y la depresión, y dichas alteraciones podrían estar relacionadas con síntomas anímicos y marcadores inflamatorios. El objetivo de esta tesis es elucidar los correlatos clínicos y neurobiológicos de la conducta de enfermedad prolongada asociada a HCC. ESTUDIO 1: MÉTODOS Y RESULTADOS. Realizamos revisión sistemática con meta-análisis de estudios sobre neuroimagen en pacientes con HCC no tratados. Se llevó a cabo una búsqueda computerizada de los estudios de neuroimagen publicados en las principales bases de datos. La variable primaria dependió de la técnica de neuroimagen utilizada. De 1403 estudios encontrados, 25 fueron seleccionados. La muestra final comprendió 509 pacientes con HCC y 491 controles sanos. En los meta-análisis de los estudios de espectroscopia se observaron niveles incrementados de la ratio entre colina y creatina, de la creatina y de glutamato plus glutamina en los ganglios basales de pacientes. Las alteraciones metabólicas en el sistema nervioso central estaban relacionadas a alteraciones neurocognitivas de forma controvertida. ESTUDIO 2: MÉTODOS Y RESULTADOS. Estudio transversal, caso-control, que compara 35 pacientes de ambos sexos, entre 18 y 55 años, con HCC sin tratar y 30 controles sanos. Se evaluaron el estrés percibido (PSS), depresión (PHQ-9), fatiga e irritabilidad mediante escala visual analógica (VAS), así como las concentraciones séricas de interleuquina-6 (IL-6), prostaglandina E2 (PGE2) y marcadores de estrés oxidativo. Se realizó una resonancia magnética cerebral funcional estudiando la conectividad cerebral en estado de reposo, mediante la selección a priori de regiones de interés: ínsula bilateral, cortex cingulado anterior subgenual (sgACC), y el putamen bilateral. Las asociaciones entre síntomas clínicos, marcadores inflamatorios y patrones de conectividad funcional fueron analizadas mediante regresión múltiple. Los pacientes con HCC presentaban puntuaciones mayores en las escalas de PSS, PHQ-9, VAS-F y VAS-I, un incremento de las concentraciones séricas de IL-6 y PGE2 y una mayor activación del sistema anti-oxidativo comparado con los controles sanos. El incremento del estrés percibido y los síntomas depresivos estaban asociados a alteraciones de los marcadores inflamatorios y de la conectividad entre ínsula y putamen. Los niveles de PGE2 y los valores de PSS eran responsables del 46% de la variación de la conectividad funcional entre ínsula anterior y putamen. CONCLUSIONES. Los resultados observados proporcionan información importante sobre las áreas cerebrales involucradas en el estrés percibido y los síntomas depresivos subclínicos durante un estado de inflamación crónica. Se han podido ilustrar nuevos enlaces neurobiológicos y neuroanatómicos entre la conducta de enfermedad e la inflamación crónica que podrían ayudar en la comprensión de mecanismos fisiopatológicos relacionados con la depresión, y abrir nuevas perspectivas de investigación centradas en el desarrollo de nuevas dianas terapéuticas.

Hepatitis C Virus (HCV) is a small RNA virus that progresses to chronicity in 50-80% of infected individuals. Direct-acting antivirals (DAAs) are revolutionary treatments for HCV with 90-98% cure rates. However, over time, chronic HCV infections can result in advanced liver disease, including cirrhosis. Patients with advanced fibrosis experience a poor response to vaccination, recurrent infections and increased risk for hepatocellular carcinoma (HCC). These outcomes are, in part, a consequence of immune dysfunction. Increased inhibitory receptor and Galectin-9 (GAL-9) expression is a possible mechanism promoting lymphocyte dysfunction. In this study, blood samples were collected from chronic HCV patients with different degrees of liver fibrosis. I conducted a 13-parameter flow stain on the peripheral blood mononuclear cells (PBMC) of these patients. Next, I measured the expression of inhibitory receptors (PD-1, CTLA-4, LAG-3, TIGIT and TIM-3) and GAL-9 on bulk T cell and NK cells of 15 chronic HCV patients with no to moderate fibrosis (F0-F2) and 15 with advanced fibrosis (F3-F4). To analyze receptor co-expression, I employed t-distributed stochastic neighbor embedding (t-SNE) analysis to dimensionally reduce the multi-parametric data. Notably, I found that F3-F4 patients had higher frequencies of >3 inhibitory receptor co-expression on NK cells. Moreover, t-SNE analysis of bulk T cells revealed that F3-F4 patients manifest a higher frequency of cells in the clusters with CD25+TIGITmed-hi CD4+ T cells and PD-1medLAG-3med-hiGAL-9med-hi CD4+ T cells. t-SNE analysis of NK cells also showed that F3-F4 patients manifest a higher frequency of cells in the cluster with CD25+TIGITmed-hiTIM-3med-hi CD56Dim NK cells and CCR7+ PD-1medLAG-3med-hiGAL-9med-hi CD56Dim NK cells. Lastly, the frequency of cells in these clusters was found to positively correlate with patient’s extent of liver damage. In conclusion, I identified phenotypes of immune dysregulation that could explain the increased susceptibility to infection and HCC in chronic HCV patients with advanced fibrosis. These phenotypes could identify targets for combinatorial checkpoint blockade therapy to potentially improve immune function in these patients.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior
Chronic hepatitis C has been associated with non-organ-specific autoantibodies (NOSA) production. Despite of increasing number of researches about this subject, there is no agreement among the authors of which autoantibodies are produced during combinated therapy of interferon and ribavirin or the clinical relevance of NOSA in patientâs organism. Our aim was to evaluate the profile of NOSA in patients with chronic hepatitis C who attended to Walter CantÃdio Hospital (HUWC) and received combinated antiviral therapy (interferon-ribavirin). A total of 34 patients with hepatitis C were studied. Anti-nuclear antibody (ANA), anti-smooth muscle antibody (SMA), anti-liver/kidney microsomal antibody type 1 (LKM-1) and anti-mitochondrial antibody (AMA) were detected by indirect immunofluorescence. The presence of NOSA was related to clinical and epidemiological variables and to the outcome of antiviral combination therapy with interferon-alfa and ribavirin. Patients were classified as nonresponders, relapsers or long-term responders depending on the outcome of treatment. In our study, before therapy, 23 patients were NOSA positive (SMA was detected in 6 patients, SMA and AMA in 10 and SMA, AMA and ANA in 7). On the 24th week of treatment, 24 patientes were NOSA positive (SMA was detected in 4 patients, SMA and AMA in 10, ANA and SMA in 1, ANA and AMA in 1 and SMA, AMA and ANA in 8). NOSA behavior did not show significant variation during treatment. The overall rate of long-term response was 26,5% (9/34). Long-term response occurred in 17,4% (4/23) of NOSA positive patients and 45,5% (5/11) of NOSA negative patients. Positivity of autoantibodies was not associated with gender, age, viral genotype or aminotransferase levels. In conclusion, ANA was the only NOSA associated with treatment outcome. The absence of NOSA might indicate a significantly higher chance for viral clearance in response to combination therapy for chronic hepatitis C infection.
A hepatite crÃnica pelo vÃrus C tem sido associada à produÃÃo de autoanticorpos nÃo-ÃrgÃo especÃficos (NOSA). Apesar do aumento do nÃmero de pesquisas nessa Ãrea, ainda nÃo existe um consenso entre quais autoanticorpos tÃm seus nÃveis elevados devido ao tratamento combinado de interferon e ribavirina, nem sua influÃncia no desfecho do mesmo ou a relevÃncia clÃnica da presenÃa desses autoanticorpos no organismo do pacientes. O objetivo do presente estudo foi avaliar o perfil de NOSA em pacientes com hepatite C crÃnica atendidos no Hospital UniversitÃrio Walter CantÃdio (HUWC) e submetidos à terapia combinada de interferon-alfa e ribavirina. Para isso, um total de 34 pacientes com hepatite C foram estudados. Os anticorpos anti-nuclear (FAN), anti-mÃsculo liso (SMA), anti-microssomal de fÃgado e rim do tipo 1 (LKM-1) e anti-mitocÃndria (AMA) foram detectados atravÃs de imunofluorescÃncia indireta. A presenÃa de NOSA foi relacionada a variÃveis clÃnicas e epidemiolÃgicas e à resposta ao tratamento. Os pacientes foram classificados, em relaÃÃo à resposta ao tratamento, como nÃo respondedores, recidivantes ou respondedores (resposta virolÃgica sustentada). Em nosso estudo, 23 pacientes foram NOSA reagentes (SMA foi detectado em 6 pacientes, SMA e AMA em 10 e SMA, AMA e FAN em 7). Na 24 semana de tratamento, 24 pacientes foram NOSA reagentes (SMA foi detectado em 4 pacientes, SMA e AMA em 10, FAN e SMA em 1, FAN e AMA em 1 e SMA, AMA e FAN em 8). A variaÃÃo dos tÃtulos dos autoanticorpos durante o tratamento nÃo foi significativa. O percentual total de respondedores foi de 26,5% (9/34). A resposta virolÃgica sustentada foi obtida por 17,4% (4/23) dos pacientes NOSA reagentes e 45,5% (5/11) dos pacientes nÃo reagentes para NOSA. A presenÃa de autoanticorpos nÃo foi associada a gÃnero, idade, genÃtipo viral ou nÃveis de transaminases. Conclui-se que o FAN foi o Ãnico NOSA significativamente associado à resposta à terapia. A ausÃncia de NOSA indica uma tendÃncia à resposta virolÃgica sustentada no tratamento da hepatite C crÃnica.

Magister Public Health - MPH (Public Health)
Egypt has the highest burden of Hepatitis C Viral infection (HCV) in the world with 10% between 15- 60 years old having HCV antibodies and 7% having chronic HCV infection. HCV is more concentrated among rural, aged, less educated, and poor population groups in addition to patients who require frequent blood transfusion or on renal dialysis, and injection drug users. Despite advancement in antiviral treatments with higher than 90% sustained virologic response (efficacy), access remains limited. The government strategy tied expanding the access to antiviral treatment to a price reduction through subsidies, but an expansion of HCV treatment coverage was not observed. This suggests a broader range of barriers in addition to the financial affordability.

Co-infection with HIV in patients with chronic HCV infection is a common occurrence, which accelerates disease progression and the rate of liver fibrosis. Current literature report conflicting results on the effect of HIV co-infection on HCV at the genetic level. This thesis sets out to further explore the genetic variation of HCV in this group of patients, and use new techniques which may impact upon the diagnosis and management of HCV. In resource-limited settings such as sub-Saharan Africa, there is a paucity of data concerning rates of active HCV infection in patients with HIV infection. The limited infrastructure and financial restrictions are contributing factors in this. Consequently, cheaper and novel diagnostic procedures are required to promote testing in these important cohorts. A real-time PCR assay for use with pooled plasma and dried plasma spot specimens was developed to screen a large cohort of HIV-infected individuals from Ghana and assess its suitability for screening in such a setting. The prevalence of active HCV infection in this cohort was similar to previous estimates from blood donors but was much lower than estimates from serological tests, highlighting the potential risks in relying on these tests alone in this region. The diversity of strains found within this population agreed well with previous studies. As the yield of HCV infections was low in Ghana, further studies were completed with the UK and European cohort. A deep sequencing approach was utilised to two effects. The first focussed on a specific notable polymorphism – Q80K in the NS3 gene – to determine whether deep sequencing would benefit the clinic in the detection of this polymorphism at low frequencies, which are below the threshold of detection by traditional population sequencing. The second use of deep sequencing aimed to determine the impact of HIV co-infection on the presence of resistance associated mutations occurring at baseline, studying the largest cohort to date. The Q80K polymorphism was not observed in any sample as a minority variant, suggesting that the current clinical procedures for pre-treatment screening are suitable and provide sufficient sensitivity. Overall, resistance mutations were relatively common among patients and it was observed that, generally, there were no differences in the prevalences of resistance mutations between HCV mono-infected and HIV/HCV co-infected patients. This finding is in agreement with previous small-scale studies. This work has direct clinical implications on the use of deep sequencing for screening patients for the presence of resistance mutations. Furthermore, it suggests that co-infected individuals are not at risk of further complications for the treatment of HCV.

Hepatitis C virus (HCV) is a positive strand RNA virus that is the leading cause of chronic hepatitis. HCV infections are an important health problem because >80% of patients become chronically infected and many develop chronic hepatitis. With approximately 400 million chronic HCV infections worldwide, understanding the pathogenesis of this disease is of critical importance in order to develop appropriate therapies and/or vaccine strategies. Strong proliferative and cytotoxic T cell responses that target multiple HCV proteins are detected in patients with self-limited infection. Conversely, HCV-specific T cell responses are minimal during acute infection in patients who become chronically infected. It is thought that the genetic diversity of HCV plays a crucial role in establishing persistence. Chronic viral hepatitis is characterized by infiltration of T lymphocytes in the liver, which are thought to play a pivotal role in disease progression. Although virus-specific T cells can be isolated from both peripheral blood and from liver biopsy samples of chronically infected patients, there appears to be a compartmentalization of HCV-specific T cells in the liver. However, the presence of virus-specific T cells is inefficient for viral clearance. Because HCV is known to be highly variable in sequence, the detailed characterization of the interaction of individual HCV-specific CTL clones with autologous viral sequences might be important for understanding the mechanisms by which HCV is able to establish a chronic infection. We isolated three intrahepatic CD8+ CTL clones from two individuals with chronic HCV infection and compared the recognition of prototype and autologous HCV sequences. These CTL recognized epitopes within the NS2 (amino acids 957-964) or NS3 (amino acids 1402-1410 and 1406-1415) proteins in the context of HLA B37, B8, or A2.1, respectively. The corresponding predominant autologous HCV sequences (SDWAANGL, ELAAKLVGL, ALRGMGLNAV, respectively) differed from the HCV-1 prototype sequences used for screening (RDWAHNGL, ELAAKLVAL, KLVALGINAV, respectively) at one to five residues. For each CTL clone, recognition of the autologous HCV sequence required significantly higher peptide concentrations than did recognition of the HCV-1 sequence; for two of the clones, recognition was minimal or absent at peptide concentrations as high as 25μM. When the HLA A2.1-restricted HCV NS3-specific T cell clone was analyzed further, we found that it was cross-reactive with peptide sequences from at least three other HCV strains. The clone recognized target cells loaded with synthetic peptides derived from sequences of genotype 1b; HCVTW (KLSALGIHAV), HCVJA (KLTGLGLNAV),and HCVBK (KLSGLGINAV). This HCV-specific T cell clone was also able to recognize target cells that were loaded with a peptide derived from an autologous protein, cellular retinoic acid binding protein I (CRABP I). When we generated HLA A2.1-restricted HCV NS3-specific T cell lines from the peripheral blood of two additional patients, almost one half of the cell lines could lyse target cells loaded with the CRABP I peptide. These data show that intrahepatic HCV-specific CD8+ CTL clones can be relatively inefficient at recognizing autologous viral epitopes and that some viral-specific CTL can recognize autoantigens in vitro. There is little information regarding the composition and stability of the liver-infiltrating T cell repertoire during chronic HCV infection. To address this issue, we used TCR complimentarity determining region 3 (CDR3) length analysis to examine the T lymphocytes in sequential biopsy samples from five individuals chronically infected with HCV. We found that although almost all TCRBV families were represented in the liver, 25-85% had skewed spectratype profiles, indicative of the presence of clonally expanded T cells. Further analysis using TCRBJ-primed run-off reactions revealed that the intrahepatic repertoires were not stable, as many expansions that existed in one biopsy sample were not detected in the other. Some expansions persisted, however, and sequencing of TCRBV-J transcripts identified CDR3 sequences that were maintained in two individuals for 10 or 45 months. Furthermore, although some expansions were found in the periphery, most were represented only in the liver. These data suggest that there is an evolution of the immune response during chronic HCV infection and that the response is largely concentrated in the liver of these individuals. Based on our observations regarding the function of intrahepatic HCV-specific CTL and the dynamics of the intrahepatic repertoire during chronic HCV infection, we propose a model in which the co-evolution of HCV quasispecies and HCV-specific T cells contribute to both viral persistence and immunopathology.

Hepatitis C virus (HCV) is a positive strand RNA virus that is the leading cause of chronic hepatitis. HCV infections are an important health problem because >80% of patients become chronically infected and many develop chronic hepatitis. With approximately 400 million chronic HCV infections worldwide, understanding the pathogenesis of this disease is of critical importance in order to develop appropriate therapies and/or vaccine strategies. Strong proliferative and cytotoxic T cell responses that target multiple HCV proteins are detected in patients with self-limited infection. Conversely, HCV-specific T cell responses are minimal during acute infection in patients who become chronically infected. It is thought that the genetic diversity of HCV plays a crucial role in establishing persistence. Chronic viral hepatitis is characterized by infiltration of T lymphocytes in the liver, which are thought to play a pivotal role in disease progression. Although virus-specific T cells can be isolated from both peripheral blood and from liver biopsy samples of chronically infected patients, there appears to be a compartmentalization of HCV-specific T cells in the liver. However, the presence of virus-specific T cells is inefficient for viral clearance. Because HCV is known to be highly variable in sequence, the detailed characterization of the interaction of individual HCV-specific CTL clones with autologous viral sequences might be important for understanding the mechanisms by which HCV is able to establish a chronic infection. We isolated three intrahepatic CD8+ CTL clones from two individuals with chronic HCV infection and compared the recognition of prototype and autologous HCV sequences. These CTL recognized epitopes within the NS2 (amino acids 957-964) or NS3 (amino acids 1402-1410 and 1406-1415) proteins in the context of HLA B37, B8, or A2.1, respectively. The corresponding predominant autologous HCV sequences (SDWAANGL, ELAAKLVGL, ALRGMGLNAV, respectively) differed from the HCV-1 prototype sequences used for screening (RDWAHNGL, ELAAKLVAL, KLVALGINAV, respectively) at one to five residues. For each CTL clone, recognition of the autologous HCV sequence required significantly higher peptide concentrations than did recognition of the HCV-1 sequence; for two of the clones, recognition was minimal or absent at peptide concentrations as high as 25μM. When the HLA A2.1-restricted HCV NS3-specific T cell clone was analyzed further, we found that it was cross-reactive with peptide sequences from at least three other HCV strains. The clone recognized target cells loaded with synthetic peptides derived from sequences of genotype 1b; HCVTW (KLSALGIHAV), HCVJA (KLTGLGLNAV),and HCVBK (KLSGLGINAV). This HCV-specific T cell clone was also able to recognize target cells that were loaded with a peptide derived from an autologous protein, cellular retinoic acid binding protein I (CRABP I). When we generated HLA A2.1-restricted HCV NS3-specific T cell lines from the peripheral blood of two additional patients, almost one half of the cell lines could lyse target cells loaded with the CRABP I peptide. These data show that intrahepatic HCV-specific CD8+ CTL clones can be relatively inefficient at recognizing autologous viral epitopes and that some viral-specific CTL can recognize autoantigens in vitro. There is little information regarding the composition and stability of the liver-infiltrating T cell repertoire during chronic HCV infection. To address this issue, we used TCR complimentarity determining region 3 (CDR3) length analysis to examine the T lymphocytes in sequential biopsy samples from five individuals chronically infected with HCV. We found that although almost all TCRBV families were represented in the liver, 25-85% had skewed spectratype profiles, indicative of the presence of clonally expanded T cells. Further analysis using TCRBJ-primed run-off reactions revealed that the intrahepatic repertoires were not stable, as many expansions that existed in one biopsy sample were not detected in the other. Some expansions persisted, however, and sequencing of TCRBV-J transcripts identified CDR3 sequences that were maintained in two individuals for 10 or 45 months. Furthermore, although some expansions were found in the periphery, most were represented only in the liver. These data suggest that there is an evolution of the immune response during chronic HCV infection and that the response is largely concentrated in the liver of these individuals. Based on our observations regarding the function of intrahepatic HCV-specific CTL and the dynamics of the intrahepatic repertoire during chronic HCV infection, we propose a model in which the co-evolution of HCV quasispecies and HCV-specific T cells contribute to both viral persistence and immunopathology.

Thesis (M.A.)--Boston University
PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you.
HIV infected patients with hepatitis C virus (HCV) infection are at increased risk of faster fibrosis progression and end-stage liver disease compared to patients with HCV alone. Why HIV /HCV -coinfected patients progress more rapidly to advanced liver disease is unknown, though several studies suggest that HIV -related immunosuppression may play a role. We have recently shown that low absolute CD4+ counts are also prevalent in patients with liver cirrhosis who are HIV seronegative. Furthermore, HIV seronegative cirrhotic patients with low absolute CD4+ counts have normal CD4+ percentages. This CD4+ "discordance" among patients with liver disease points towards an alternate mechanism for low CD4 T cell counts, other than HIV-induced immunosuppression. In this retrospective study, we compared the prevalence of CD4 Tcell discordance in HIV/HCV-coinfected patients and patients with HIV alone. We also examined clinical and laboratory exam findings associated with this discordant profile. We show that discordance between absolute CD4 counts and CD4 T -cell percentages was significantly associated with HIV/HCV-coinfection as well as leucopenia. We also found that a physical exam finding of hepatomegaly, splenomegaly, and/or spider angiomata as well as certain laboratory markers of advanced liver disease (eg, AST/ALT > 1) may be associated with CD4 T-cell discordance. We conclude that among patients co infected with HIV and HCV, CD4+ discordance may be an important screening tool in patients with possible underlying liver disease. Low CD4+ counts in these patients may correlate not only with advanced HIV immunosuppression, but may indicate underlying liver disease when accompanied by a normal CD4+ percentage.
2031-01-01

Submitted by Ana Maria Fiscina Sampaio (fiscina@bahia.fiocruz.br) on 2012-08-29T20:58:12Z No. of bitstreams: 1 Sidelcina Rugieri Pacheco Prevalencia de enfecção pelo virus da hepatite c....pdf: 867639 bytes, checksum: 379cd008d8b47ad5e4f6b594cffcdace (MD5)
Made available in DSpace on 2012-08-29T20:58:12Z (GMT). No. of bitstreams: 1 Sidelcina Rugieri Pacheco Prevalencia de enfecção pelo virus da hepatite c....pdf: 867639 bytes, checksum: 379cd008d8b47ad5e4f6b594cffcdace (MD5) Previous issue date: 2010
Fundação Oswaldo Cruz. Centro de Pesquisas Gonçalo Moniz. Salvador, Bahia, Brasil
Os indivíduos com anemia falciforme são considerados como pertencentes aos grupos de risco para infecção pelo vírus da hepatite C (VHC) pós-transfusional, sobretudo, antes da implantação da triagem sorológica nos bancos de sangue, que no Brasil ocorreu em 1993. O objetivo do presente estudo foi determinar a prevalência de infecção e os genótipos do VHC circulantes nos pacientes com anemia falciforme, bem como avaliar a contribuição de outros fatores de risco para a aquisição do VHC e a possível associação do VHC com as manifestações clínicas da doença de base. Os pacientes com anemia falciforme atendidos no ambulatório multidisciplinar da HEMOBA foram convidados a participar do estudo, mediante assinatura do TCLE e resposta a um questionário clínico-epidemiológico individual. O diagnóstico laboratorial do VHC foi realizado através de ELISA de 4. geração para o anticorpo anti-VHC pela HEMOBA e a confirmação da infecção e genotipagem do RNA do VHC (VHC-RNA) nas amostras soropositivos para o anti-VHC através de técnicas de biologia molecular no LACEN-BA. Dados adicionais, tais como, histórico clínico e resultado de exames sorológicos e bioquímicos foram obtidos através da revisão de prontuários. Entre janeiro de 2009 e setembro de 2010, 585 pacientes com anemia falciforme foram incluídos no estudo. A média de idade foi de 21,1 ± DP 13,1 anos (1 - 65 anos). Trinta e sete pacientes com anemia falciforme apresentaram soropositividade para anti-VHC, que representa uma soroprevalência global de 6,4% (IC 95% 4,4 – 8,3 %). A soroprevalência foi associada com residência na Região Metropolitana de Salvador (RMS), período da primeira transfusão, número de transfusões e utilização de seringa não descartável (p<0,05), mas não foi encontrada associação com sexo, compartilhamento de utensílios domésticos ou uso de drogas. Entre os menores de 17 anos a soroprevalência foi de 1,5 % semelhante à prevalência na população em geral. A prevalência de infecção confirmada pela detecção do VHC RNA foi de 3,3 % (21/583) (IC 95% 2,1 – 5,1%). O genótipo 1 do VHC foi predominante, presente em 76,2%, seguido do genótipo 3, presente em 23,8% dos pacientes com anemia falciforme. O HTLV I/II foi encontrado em 2,6 % e a co-infecção com VHC chegou a 53,3%. Não foram encontrados casos de HIV. A infecção pelo VHC demonstrou associação significativa com manifestações clinicas da anemia falciforme como dactilite e osteonecrose. A anemia falciforme determina alterações em vários marcadores de avaliação do perfil hepático, entretanto, apenas elevações de TGP foram associadas com a infecção pelo VHC. Foi observado nesse estudo que o risco de infecção pelo VHC em pacientes com anemia falciforme foi reduzido desde a implantação da triagem sorológica, porém um risco residual ainda existe.
People affected by sickle cell anemia are considered at risk for post-transfusional hepatitis C virus (HCV) infection, especially prior to the implementation of serological screening tests in blood banks such as those that occurred in Brazil in 1993. The impact of this control measure and the possible interaction between hepatitis C and severity of sickle cell disease are unknown. We aim to determine the prevalence of infection and HCV genotypes circulating among patients with sickle cell anemia, to assess the contribution of other risk factors to the occurrence of new infections and to investigate the possible effect of HCV on the underlying disease severity. Sickle cell anemia outpatients who attended the multidisciplinary clinic from HEMOBA were invited to participate in the study, required to sign the informed consent waiver and answer an individual clinical-epidemiological questionnaire. HCV laboratory diagnosis was performed in HEMOBA using ELISA 4.generation to detect the anti-HCV antibody. Infections were confirmed and genotyped for the anti-HCV positive samples in LACEN-BA with molecular biology techniques. Additional data such as clinical history and examination results were obtained by reviewing patient’s charts. Between January 2009 and September 2010, 585 sickle cell anemia were included. The mean age was 21.1 ± 13.1 years (1-65 years). Thirty-seven sickle cell anemia showed seropositivity for anti-HCV, which represents an overall seroprevalence of 6.4% (95% CI 4.4 to 8.3%). The seroprevalence was associated with residence in the Metropolitan Region of Salvador (RMS), the time of first transfusion, number of transfusions and use of disposable syringe (p <0.05) but was not associated with sex, sharing domestic utensils or drug use. Among those younger than 17 years the prevalence was 1.5% similar to the prevalence in the general population. Blood transfusion was the only risk factor identified in this group. The prevalence of HCV infection confirmed by detection of HCV-RNA was 3.3% (21/583) (95% CI 2.1 to 5.1%). The HCV genotype 1 was predominant, it was present in 76.2%, followed by genotype 3, 23.8%. HTLV I / II was sickle cell anemia and HCV co-infection reached 53.3%. HIV infections were not reported in this study group. HCV infection showed a significant association with clinical manifestations of sickle cell disease and dactylitis and osteonecrosis. Sickle cell anemia causes alterations in several markers for assessing the hepatic profile, however only ALT was associated with HCV infection. Risk of HCV infection in sickle cell anemia was reduced after the implementation of serological screening, but residual risk remains.

El virus de la hepatitis C (VHC) causa una de las infecciones crónicas más importantes, afectando a una población estimada de 71 millones de personas. El tratamiento antiviral clásico con (peg)interferón-alfa y ribavirina (PR) provoca un deterioro en la calidad de vida relacionada con la salud (CVRS) de los pacientes con hepatitis C crónica (HCC). Recientemente, se han introducido antivirales de acción directa (AAD) que se han asociado a una mayor ratio de respuesta al tratamiento, una reducción de los efectos secundarios y un impacto mínimo relacionada con la CVRS. Sin embargo, las evidencias aún son escasas debido a que los ensayos clínicos investigando los AAD están en desarrollo. Para esta tesis doctoral, se han llevado a cabo dos estudios: (I) una revisión sistemática y un meta-análisis de ensayos clínicos randomizados (ECR) que han evaluado la CVRS y los factores de riesgo que podrían predecir su deterioro en pacientes en su deterioro con HCC tratados con AAD; (II) un estudio de cohorte naturalístico longitudinal con el fin de evaluar la CVRS y la incidencia de depresión durante el tratamiento antiviral, teniendo en cuenta posibles factores de riesgo para un deterioro en la CVRS y la aparición de depresión. Los resultados de la revisión sistemática sugieren que los nuevos regímenes antivirales tienen un impacto mínimo en la CVRS, e incluso pueden mejorar el componente de salud mental a 12 semanas de postratamiento (MD=2.88; 95%CI=2.24, 3.53). La co-administración de ribavirina a los AAD mostró deterioro en el componente mental (MD=-1.7; 95%CI=-2.5, -0.91). Cualquier combinación de AADs con PR empeoró la CVRS tanto en el componente mental como físico (MD= -0.13; 95%CI=-0.15, -0.11). A nivel basal, la CVRS fue menor en pacientes con VHC sin empleo, en aquellos con cirrosis, anemia, edad avanzada, o con antecedentes de depresión o ansiedad. Además, el género femenino, la edad avanzada, y los antecedentes de depresión pudieron predecir una menor CVRS durante AAD. Asimismo, los acontecimientos adversos y la no-respuesta al tratamiento con AAD y PR fueron factores de riesgo. En el segundo estudio, se observó una incidencia acumulada de depresión mayor en el 13.7% (95%CI: 5.7 - 26.3), y de cualquier trastorno depresivo en el 51% (95%CI: 36.6 - 65.2) durante la administración de AAD. El análisis de regresión logístico multivariado mostró la puntuación a nivel basal del PHQ-9 (p=0.002) como predictor para incidencia de depresión mayor, con una tendencia para historia familiar de depresión (p=0.079). Además, los pacientes con cirrhosis descompensada fue predictor para experimentar más dolor y disconfort durante el tratamiento (p=0.045). No se pudo descartar la presencia de cambios significativos de la media (DS) en puntuaciones del EQ-VAS durante el tratamiento antiviral con AAD (67.2±20.3), al final de tratamiento (71.3±19.6), o a las 12 semanas (76.1±18.7) comparado a nivel basal, después de controlar por otras variables. La presente investigación tiene algunas limitaciones. Pocos ECR en la literatura han replicado los resultados, o han estudiado la CVRS en grupos específicos, como por ejemplo con coinfección por VIH, con uso de sustancias u otros trastornos psiquiátricos. Por otro lado, el tamaño de la muestra, la inclusión de pacientes con enfermedad hepática avanzada y sin coinfección con VIH, y la no inclusión de un grupo control sin HCC, limitan la generalización de nuestros resultados. En conclusión, los resultados de la investigación apoyan que la calidad de vida puede mejorar después de un régimen antiviral exitoso. Es importante poder detectar pacientes con factores de riesgo, especialmente ellos con síntomas de depresión, antes de empezar cualquier tratamiento antiviral. En general, un enfoque multidisciplinar continúa siendo recomendable para mejorar la CVRS de los pacientes infectados por VHC.
Hepatitis C virus (HCV) affects physical and mental health in 71 million persons worldwide. Classic antiviral treatment with interferon and ribavirin (PR) causes considerable impairment on chronic hepatitis C (CHC) patients’ life quality. Recently, direct-acting antivirals (DAAs) have been introduced, which have been associated with high cure rates (over 95%), reduced side effects, and are suggested to have a minimal impact on health-related quality of life (HRQL). However, the amount of evidence is still limited, as trials on these new regimens are ongoing. In this doctoral thesis, two studies were conducted in order to assess HRQL in CHC patients treated with DAAs: (I) a systematic review and meta-analysis of RCT studies that have assessed HRQL and possible risk factors that may predict life quality impairment, in CHC patients treated with any type or combination of DAAs; (II) a longitudinal naturalistic cohort study assessing HRQL and incidence of depression during antiviral treatment, taking in account possible risk factors that may predict life quality impairment and depression. Findings from the systematic review suggest that the new antiviral regimens have a minimal impact on HRQL, and may even improve in terms of mental wellbeing at 12 weeks of post-treatment follow-up. With regard to DAAs alone, a slight improvement in patients’ mental life quality was observed (MD=2.88; 95%CI=2.24, 3.53). However, ribavirin co-administration with DAAs showed significant impairment on mental HRQL (MD=-1.7; 95%CI=-2.5, -0.91). Any combination of DAAs with PR seemed to impair significantly both mental and physical health quality (MD= -0.13; 95%CI=-0.15, -0.11). At baseline, HRQL was more impaired in CHC patients who are unemployed, have cirrhosis, anaemia, or history of depression, anxiety, fatigue, or insomnia, than those who do not. Furthermore, female gender, older age, and history of depression seemed to predict HRQL impairment during DAAs plus ribavirin treatment. Also, adverse events and treatment non-response at post-treatment were identified risk factors for DAAs plus ribavirin or PR. In the second study, the cumulative incidence of major depression was 13.7% (95%CI: 5.7 to 26.3), and of any depressive disorder, 51% (95%CI: 36.6 to 65.2) during DAA treatment. Multivariate logistic regression analysis showed that the PHQ-9 score at baseline was a predictive factor for incidence of major depression (p=0.002), with a tendency for family history of depression (p=0.079). Also, decompensated cirrhotic patients reported a impaired pain and discomfort (p=0.045) compared to those without (decompensated) cirrhosis during DAA treatment. We could not exclude the presence of significant mean (SD) changes in EQ-VAS scores during DAA treatment (67.2±20.3), nor at EOT (71.3±19.6), or 12 weeks after treatment cessation (76.1±18.7) related to baseline after controlling by age, gender, comorbidity, history of depression, or ribavirin co-administration. This research has some limitations. Few RCTs in the literature have replicated their findings, and of those studies, only few of them have studied HRQL in specific groups such as co-infection, substance use disorder, and other psychiatric comorbidities. Other limitations of the study include the relatively small sample size, and inclusion of patients with more advanced liver disease and without HIV co-infection, which are factors that limit the generalization of our results. In summary, the results from this dissertation support that HRQL may improve after successful treatment. It is important to detect those patients with risk factors, especially for those with baseline symptoms of depression, before starting antiviral treatment. Altogether, findings suggest the use of a holistic, multidisciplinary approach to manage both physical and mental health.

The development of anti-IFNα antibodies is an occurrence described in chronic hepatitis C patients during treatment with Interferonα/PEG-Interferonα. However, its relevance, especially in difficult-to treat patients, has not been defined. Methods: We retrospectively measured the serum levels of anti-IFNα antibodies (baseline and week 12) and IFNα levels (week 12) by ELISA in 76 previous non-responders, and in 14 naive patients treated with Pegylated-IFNα and Ribavirin. A group of 57 healthy donors (HD) was also assessed as control. Positivity to anti-IFNα antibodies was established on the values of HD. Results: Baseline anti-IFNα antibodies were detected in 15.5% of patients and in 7% of HD, with significantly higher concentrations in patients than HD (181.5±389.9 vs 95.9±143.0 ng mL−1, p=0.0023). All positive patients were IFNα-experienced. At week 12, the prevalence of positivity increased to 22.3 and 28.5% in experienced and naïve patients, respectively, and the levels of anti-IFNα antibodies did not differ between the two groups (391±792.3 vs 384.7±662.6 ng mL−1, respectively). IFNα concentrations were significantly lower in antibody-positive patients than in antibody-negatives (988.2±1402 vs 3462±830.8 pg mL−1, p≤0.0001) and the levels of antibodies and IFNα were inversely correlated (r=-0.405, p=0.0001). The antibody-positive population clustered in null responders (67%) and 19/21 patients (90%) did not achieve SVR. Conclusions: The development of anti-IFNα antibodies is a non-negligible occurrence in patients treated with PEG-IFNα, is stable over time, and has a relevant clinical impact when associated with low levels of circulating PEG-IFNα. It should be considered in patients undergoing treatments including PEG-IFNα.

Hepatitis C is a fast growing infectious disease in Australia and is often associated with related psycho-social and mental health problems. The conventional treatment process for hepatitis C is challenging due to a number of reasons. This study explored social workers’ perceptions of the contribution of their role in hepatitis C treatment centres in relation to the treatment experience of patients. The roles that social workers fulfill, their contribution to the multidisciplinary team and towards a culturally competent service, were explored. Furthermore the knowledge, skills and values required for providing a competent service in a hepatitis C treatment setting was explored. The broad theoretical frameworks that inform social work practice were considered, especially the biopsycho-social model, the strengths perspective, the critically reflexive approach and communications theory. This qualitative study used a semi-structured interview method for data collection. Ten social workers in hepatitis C treatment clinics participated in the study. The findings highlight the needs of patients and how social worker participants described helping to address and meet these needs by employing their knowledge, skills and values through their social work roles and interventions in a team context in a multicultural and multi-faceted work environment. A major challenge that social workers described was to keep patients on treatment despite debilitating side effects that diminish patients' motivation to complete treatment. A shortcoming in the service was described to be the limited psychiatric support available at many treatment centres. The findings lead to a number of recommendations to improve social work services in hepatitis C treatment settings. More research was recommended in areas such as motivational techniques, psychiatric support, and effective group work strategies. The need for increased funding for social work positions in the hepatitis C field was also highlighted. It is anticipated that findings of this study can be applied to hepatitis C treatment in broader settings such as prisons, drug and alcohol settings and general practice. This research will contribute to literature in the field of hepatitis C treatment models and in the field of social work practice in hepatitis C contexts.

Le virus de l'hépatite C (VHC) est une menace majeure avec plus de 130 millions de personnes infectées chaque année. Il constitue la principale cause de cancer du foie. Le VHC est un virus transmis par le sang soit au cours de consommation de drogue par voie intraveineuse soit lors de transfusions sanguines. Il s'adapte à l'environnement de l'hôte grâce à un taux de mutation élevé qui amoindrit l’efficacité des traitements. Le virus se multiplie rapidement dans l'hôte et crée ainsi une population de virus génétiquement hétérogènes, appelée quasi-espèces, qui peut ainsi répondre aux pressions sélectives liées au traitement. Les traitement antiviraux existants sont des tri-thérapies contenant des peg-interféron, de la ribavirine et des inhibiteurs de la protéine (PI). Les inhibiteurs comme la telaprevir ou la bocéprévir ciblent la région NS3 du génome en bloquant le mécanisme de réplication. Cependant, en raison de la nature dynamique des quasi-espèces, les séquences cibles sont variables et les inhibiteurs conçus pour se lier à une région génomique particulière sont rendus inefficaces.Nous analysons ces populations virales en utilisant les techniques modernes de séquençage et le pyroséquencage profond qui permet l’analyse à grande échelle des données génétiques. La technique “Amplicon Sequencing” permet de cibler des régions particulières du génome viral, comme les régions NS3 ou NS5B qui participent au mécanisme de réplication et qui sont des cibles pour les thérapies antivirales. Par rapport au séquençage Sanger, notre pipeline NGS permet d’appréhender l’hétérogénéité de la population virale au sein d’un hôte. Pour analyser les données NGS, nous avons implémenté un pipeline d’analyse bioinformatique qui a été automatisé avec eHive.Nous étudions des échantillons de VHC de 40 patients traités par trithérapie. Deux sources de cellules virales sont utilisées pour le séquençage: les cellules du plasma et les cellules mononuclées du sang périphérique. L'objectif est de vérifier si une analyse des mutations de la région génomique NS3 peut aider à prédire le résultat du traitement. Nous constatons que des mutations de résistance aux antiviraux se trouvent à la fois chez les individus qui ont répondu et qui n’ont pas répondu au traitement. Nous avons donc recherché d'autres signatures génétiques de l'échec du traitement. Nous constatons que l'hétérogénéité génétique est plus faible chez les individus qui répondent de manière favorable au traitement. Notre conclusion est que l'hétérogénéité virale est un facteur indépendant pour prédire la réponse à un traitement, en plus de la présence de mutations spécifiques dans les régions ciblées par le traitement.Les techniques NGS permettent également d’étudier l'évolution virale au sein d'un seul hôte. En utilisant de multiples temps d'échantillonnage, nous pouvons mesurer les caractéristiques de l'évolution de la population virale. Pour trois patients avec des échantillons viraux couvrant une période de 13 ans, nous avons utilisé la technique “Amplicon Sequencing“ pour les régions NS3 et NS5B. Des infections mixtes comprenant de multiples génotypes sont retrouvées chez deux patients. Nous avons montré qu’il existe de la structure de populations et des lignées divergentes de VHC au sein de chaque patient. Au cours du traitement, l'hétérogénéité génétique et la taille efficace de la population dans la région NS5B augmente fortement après le début du traitement. Ces résultats mettent en évidence un processus de sélection diversifiante suite au traitement qui augmente l'hétérogénéité génétique virale. Nous mettons ainsi en évidence un processus dit de balayage sélectif doux qui est observé pour la première fois chez des patients infectées par des génotypes multiples du virus VHC.Notre analyse NGS montre que l'hétérogénéité génétique du VHC est liée à l'échec ou à la réussite du traitement et que son évolution permet de mieux comprendre la façon dont les virus s'adaptent au traitement
Hepatitis C virus (HCV) is a major threat to global health, with over 130 million annual infections. HCV is a blood borne virus transmitted primarily via intravenous drug use or hospital transfusions. It infects the liver cells and is the leading cause of liver cancer. It adapts to the host environment with a high mutation rate and can make efficient treatment very difficult. Due to poor replication proofreading, the virus multiplies rapidly in the host and creates a population of viruses which is genetically heterogeneous enough to escape selective pressures. This HCV population called quasispecies is found within and between infected hosts. Current antiviral treatment consists of a triple therapy of peg-Interferon, ribavirin and protein inhibitors (PI). PIs such as telaprevir, boceprevir target the NS3 region of the genome, blocking the replication mechanism. However due to the highly dynamic nature of the quasispecies, the target sequences are variable and PIs designed to bind to a particular genomic region are therefore rendered ineffective.We analyse viral populations of HCV using Next generation Sequencing (NGS) technologies and ultradeep pyrosequencing, which allow for rapid and large scale analysis of genetic data. Amplicon sequencing allows for targeting particular regions of the viral genome, such as the NS3 or NS5B which form a part of the replication mechanism and hence are targets for antiviral therapy. Compared to Sanger sequencing, our NGS pipeline ascertains viral population heterogeneity within a host. We implemented the bioinformatics workflow manually and in eHive as an automated pipeline.We study HCV samples from 40 patients treated with triple therapy. Two sources of the virus, plasma and peripheral blood mononuclear cells are used for sequencing. The main aim is to check if a baseline analysis of the NS3 genomic region can help to predict the outcome of the treatment. We find that antiviral resistance mutations are found in both responders and non-responders to the treatment. Since no correlation exists between observed mutations and failure of tri-therapy, we look for other genetic signatures of treatment failure. We find that genetic heterogeneity, calculated using Shannon’s entropy, is lower in responders. We conclude that the viral heterogeneity can be used as an independent factor to predict response to treatment, more than presence of specific mutations at baseline.NGS also enables large-scale studies of viral evolution within a single host. Using multiple sampling time points, we gain insights about viral evolutionary characteristics of HCV and responses to selective pressures during infection. For three patients with viral samples covering a period of 13 years, we perform amplicon sequencing on the NS3 and NS5B regions. Mixed infections comprising of multiple genotypes are found in two patients. We find considerable population structure and diverging HCV lineages within each patient. Over the course of treatment, genetic heterogeneity and effective population size in the NS5B regions increases sharply after treatment initiation compared to baseline. These results provide evidence of diversifying selection occurring post-treatment, acting on standing genetic variation resulting in high genetic heterogeneity. These are characteristics of a soft selective sweep, which is observed for the first time in chronic HCV patients infected with multiple genotypes.Our NGS analysis show that genetic heterogeneity in HCV is related to treatment failure and that its evolution provides insights about how viruses adapt to treatment

Hepatitis C virus (HCV) is considered to be the leading cause of hepatocellular carcinoma (HCC). During the last years, several highly efficacy regimens of direct-acting antivirals (DAAs) with excellent rates of success became available. However, therapeutic failure may occur in up to 10% of treated individuals. Our aim was to study the profile of NS5 coding region RASs in DAA-naive genotype 1 HCV infected patients, as well as to ascertain an association between treatment failure and the presence of baseline NS5 RASs. A comparison between LiPA and Sanger sequencing genotyping methods was also assessed. Plasma RNA from 81 DAA-naïve GT1 HCV infected patients was extracted, followed by an in-house nested RT-PCR of the NS5 coding region. PCR products were purified, leading to Sanger population sequencing on the 3130xl ABI Genetic Analyzer. Sequences were aligned using ChromasPro v1.7.6, and analyzed online in hcv.geno2pheno.org. NS5A RASs were present in 28,4% (23/81) of all GT1 infected patients. The most commonly detected NS5A RAS was Y93C/H with a prevalence of 9,9% (8/81) in all GT1 infected patients. NS5B RASs showed a prevalence of 14,8% (12/81) in all GT1 infected patients, and were only detected in GT1b, being mainly represented by C316N accounting for 40% (10/25). The combined Q30H+Y93H NS5A RASs, were detected at baseline in one HIV/HCV GT1a co-infected patient who later failed a treatment with sofosbuvir/ledipasvir (SOF/LDV) for 12 weeks. An isolated Y93H mutation was also detected at baseline in a relapsing GT1b mono-infected patient. Overall 38,3% (31/81) of all GT1 HCV infected patients presented NS5 RASs at baseline, in which 58% (18/31) were co-infected with HIV/HCV. The obtained data supports the usefulness of resistance testing prior to treatment initiation, as a statistical significant association was found between treatment failure and the baseline presence of specific NS5 RASs, namely Y93C/H (p = 0.04).

Background: In chronic hepatitis C virus (HCV) mono-infection and HIV/ HCV co-infection, the goal of antiviral treatment is a sustained virologic response (SVR). Some clinical benefits of SVR have been identified among HIV co-infected patients. However, endpoints beyond liver-related outcomes have not been well documented in co-infected patients who often have concurrent problems. We examined changes in health-related quality of life (HRQOL), health service use and substance over time among patients treated for HCV, in particular SVR-achievers and non-responders. Methods: HIV/ HCV co-infected patients with detectable HCV RNA were selected from the Canadian Co-infection Cohort and followed every six months. HRQOL was self-reported using the EuroQOL-5D visual analogue scale from 0 to 100 (worst to best health). Incidence rate ratios (IRR) for health service utilization and proportion of current users for substance use were determined. Linear and negative binomial regressions were used to model the effects of SVR on HRQOL and healthcare utilization respectively. Results:Of 1002 chronic HCV patients, 169 (17%) received treatment— 65 (38%) achieved SVR, 46 (27%) did not, 35 (21%) had ongoing treatment and 23 (14%) had unknown treatment response. EuroQOL scores improved in SVR-achievers after treatment (median (Q1, Q3): from 71 (60, 80) to 80 (70, 95.8)), but not in non-achievers (median (Q1, Q3): from 70 (48, 80) to 68 (50, 80)). Overall, SVR-achievers used fewer health services than non-achievers, particularly emergency visits and hospitalizations (IRR (95% CI): 0.36 (0.1, 1.0) and 0.17 (0.0, 0.5), respectively). One exception was walk-in clinic visits (IRR: 3.26 (95% CI: 1.3, 10.6)). Achieving SVR was associated with markedly decreased in-patient service use (IRR: 0.21 (95% CI: 0.07, 0.64). All Patients reduced tobacco smoking and illicit drug use behaviours, but alcohol consumption increased post-treatment among all patients (percentage reporting consumption: from 49% pre-treatment to 64% post-treatment in SVR-achievers; from 44% to 61% in non-achievers).Conclusions: HCV treatment and SVR can have a range of effects on HRQOL, healthcare use and substance use in HIV/ HCV co-infection. Longer follow-up is required to determine the duration of health benefits.
Contexte:Pour les patients infectés par le virus de l'hépatite C (VHC), l'objectif du traitement antiviral est d'atteindre une réponse virologique soutenue (RVS) qui procure des avantages en santé mesurables par rapport à la mono-infection en VHC. Cependant, l'existence de tels avantages pour les patients co-infectés par le VIH qui ont des problèmes de santé supplémentaires n'est pas claire. Nous avons examiné les changements de la qualité liée à la santé de la vie (QVLS), l'utilisation des services de santé et l'utilisation de substances au cours du temps chez les patients traités pour le VHC, en particulier les répondeurs et les non-répondeurs au traitement, dans la cohorte de co-infection VIH/VHC canadienne. Méthodes: Des patients co-infectés VIH/VHC avec ARN positif du VHC (avec ou sans traitement anti-VHC antérieur) ont été sélectionnés à partir de la Cohorte canadienne de coïnfection VIH-VCH et suivis aux six mois. Les patients se sont auto-évalués de 0 à 100 (du pire au meilleur état de santé) pour la QVLS en utilisant l'échelle visuelle analogique du questionnaire EuroQol-5D. Nous avons examiné les scores médians QVLS, les ratios des taux d'incidence des services de santé et la fréquence de consommation de drogues avant et après le traitement anti-VHC. Par ailleurs, nous avons utilisé la régression linéaire pour examiner l'effet de la RVS sur le changement en pourcentage de QVLS. Une régression binomiale négative a permis de modéliser la relation entre la RVS et la fréquence des services de santé utilisés. Résultats: À partir des 1002 patients VHC chroniques, 169 (17%) ont reçu un traitement - 65 (38%) ont atteint la RVS, 46 (27%) n'ont pas attient la RVS, 35 (21%) ont reçu un traitement continu et 23 (14%) avaient des résultats inconnus. Pour les répondeurs au traitement, les scores EuroQOL se sont améliorés après le traitement (médiane des scores: 71 à 80). Les non-répondeurs n'ont démontré aucune amélioration au cours du temps (scores médians: ≤ 70). Globalement, l'utilisation des services de santé était plus faible pour les répondeurs au traitement que pour les non-répondeurs., particulièrement pour les visites à l'urgence et les hospitalisations (ratios des taux d'incidence à six mois (post-traitement: 0,36 et 0,17, respectivement). À l'exception des visites aux cliniques sans rendez-vous (ratios des taux d'incidence à six mois post-traitement: 3,26). L'atteinte de la RVS a diminué de manière significative la fréquence des visites des patients hospitalisés. Les patients ont réduit leur consommation de tabac et les comportements de consommation de drogues illicites, mais la consommation d'alcool post-traitement a augmenté chez tous les patients (de 49% à 64% chez les répondeurs et de 44% à 61% chez les non-répondeurs). Conclusions: La RVS peut avoir des effets multidimensionnels sur la QVLS, l'utilisation des soins de santé et l'utilisation de substances. Un meilleur état de santé a été noté et moins de services de santé ont été utilisés par les répondeurs au traitement. L'augmentation de la consommation d'alcool après la RVS nécessite une investigation plus approfondie puisqu'elle pourrait contrecarrer les avantages du traitement anti-VHC. Un suivi plus long est nécessaire pour déterminer la durabilité des avantages pour la santé de la RVS dans la co-infection.

博士
國立臺灣大學
臨床醫學研究所
103
Chronic hepatitis C virus (HCV) infection, the leading cause of cirrhosis, hepatic decompensation and hepatocellular carcinoma (HCC), affects approximately 3% of the individuals worldwide. Peginterferon (PEG-IFN) plus ribavirin (RBV) therapy (PR) is one of the current standard of care (SOC) regimens for chronic hepatitis C (CHC), especially is the Asia-Pacific region, with the overall sustained virologic response (SVR) rates of about 50% in HCV genotype 1 (HCV-1) Western patients who receive 48 weeks of treatment. Many pretreatment factors, including age, gender, body mass index (BMI), insulin resistance, hepatic steatosis/fibrosis, ethnicity, and viral load, are associated with SVR. Furthermore, previous studies showed that the viral decline at week 4 and 12 of PR therapy is highly predictive of SVR. However, whether other pretreatment and on-treatment factors, including the single nucleotide polymorphisms (SNPs) near the interleukin 28B (IL28B) gene (rs8099917 and rs12979860) and the week 8 viral decline could further help decide the optimal treatment duration deserve further studies. In this thesis, we therefore investigated the personalized therapy for HCV-1 Taiwanese patients based on treatment duration and early virokinetics. In addition, the role of IL28B in predicting SVR in HCV-1 patients who receive combination therapy was also examined. Aim 1: Peginterferon and ribavirin combination therapy for chronic HCV-1 Asian patients Combination therapy with PR has been one of the current SOC regimens to treat chronic HCV-1 patients. However, previous studies showed that Asian HCV-1 patients with 24 weeks of combination therapy could achieve comparable SVR rates to Western HCV-1 patients with 48 weeks of treatment. In this part, we aimed to evaluate if 48 weeks of PR therapy further improve the overall SVR rate than 24 weeks of PR therapy in Asian chronic HCV-1 patients. We enrolled 308 HCV-1 Asian patients and randomly assigned them to receive either 24 or 48 weeks of combination therapy. The overall SVR rate in patients with 48 weeks of therapy was superior to that in patients with 24 weeks of therapy (76% vs. 56%, p < 0.001). Patients with low baseline viral load (< 800,000 IU/mL) and rapid virologic response (RVR) could achieve a high SVR rate even by truncated duration of therapy. Patients with high viral load (≥ 800,000 IU/mL) or without RVR should receive 48-week therapy to secure the high SVR rate. We concluded that Asian HCV-1 patients had better treatment responses to Western HCV-1 patients by the combination therapy, and the early virokinetics were important to decide the optimal treatment duration. Aim 2: Peginterferon and ribavirin combination therapy for chronic HCV-1 patients with slow viral response PEG-IFN and RBV for 72 weeks has been shown to improve sustained virologic response (SVR) in hepatitis C genotype 1 (HCV-1) slow viral responders. Treatment-naïve Asian HCV-1 patients who failed to achieve RVR were randomly assigned to receive 48 (n = 168) or 72 (n = 167) weeks of PR therapy. On-treatment virologic responses at week 8 and 12 of therapy were evaluated for SVR. The SVR rate in patients with 72 weeks of treatment was higher than that in those with 48 weeks of treatment (65% vs. 52%, p = 0.03). Patients who achieved undetectable HCV RNA at week 8 could receive 48 weeks of treatment without compromising the SVR rate. In contrast, patients who achieved undetectable HCV RNA at week 12 should receive 72 weeks of therapy to secure the SVR rate. We concluded that extending the treatment duration to 72 weeks could benefit HCV-1 Asian patients with slow viral response, and on-treatment viral kinetics at week 8 and 12 of PR therapy were key determinants for the optimal treatment duration. Aim 3: The role of IL28B genotype in identifying RVR-positive chronic HCV-1 patients who could receive a truncated duration of peginterferon and ribavirin therapy IL28B single nucleotide polymorphisms (SNP) and viral factors can predict SVR in HCV-1 patients receiving 48 weeks of PR therapy. Whether these factors would identify patients who benefit from shorter duration of therapy remain unclear. A total of 662 HCV-1 patients receiving 24 or 48 weeks of combination therapy were enrolled. Baseline demographic data, HCV viral load, IL28B genotype (rs8099917), duration of therapy, and RVR were evaluated to predict SVR. The SVR rates were further stratified and compared by the independent factors. The IL28B rs8099917 TT genotype, low baseline viral load (HCV RNA ≤ 600,000 IU/mL), RVR and 48-week therapy independently predicted SVR. In RVR patients with IL28B rs8099917 TT genotype, the SVR rate of 24-week therapy was comparable to 48-week therapy (95% vs. 99%) at low baseline viral load, but was inferior to 48-week therapy (70% vs. 97%) at high baseline viral load. We concluded that HCV-1 patients simultaneously bearing IL28B rs8099917 TT genotype, low baseline viral load and rapid virologic response may receive a shorter duration of combination therapy. Aim 4: The role of IL28B in determining optimal PR treatment duration for RVR-negative chronic HCV-1 patients Viral decline at weeks 8 and 12 of PR therapy is an important on-treatment factor for chronic HCV-1 patients who fail to achieve an RVR. Whether IL28B genotype could further identify these patients who benefit from 48 or 72 weeks of PR therapy remains unclear. IL28B and on-treatment virologic responses at week 8 and 12 of PR therapy were evaluated for SVR in 289 compliant patients who received ≥ 80% of drug dosages and treatment duration, and had the end of follow-up viral response. The stratified SVR rates for independent factors were compared by treatment duration. In week-8 viral response (Wk-8R, undetectable HCV RNA at week-8 treatment) patients, the SVR rates of 72-week and 48-week treatment were similar (75-88%), regardless of IL28B genotype or cirrhosis. In non Wk-8R patients who achieved cEVR, the SVR rate of 72-week treatment was higher than that of 48-week treatment for non-cirrhotic patients, regardless of IL28B genotype (91-100% vs. 13-44%). We concluded that although IL28B genotype could predict SVR, it played a minor role when on-treatment viral responses are taken into consideration. On-treatment viral responses at week 8 and 12 were the key determinants to decide the optimal treatment duration in HCV-1 patients without RVR.

碩士
中山醫學院
免疫學研究所
89
Hepatitis C virus (HCV) infection has been found to be strikingly associated with autoimmune diseases, autoimmunity and chronic hepatitis. The aim of the present study was to investigate the frequency and the significance of antibodies to dihydrolipoamide dehydrogenase (E3), dihydrolipoamide acetyltransferase (E2), SS-A/Ro (60KD), SS-A/Ro (52 kD), SS-B/La, topoisomerase II, anticardiolipin (aCL), dsDNA, ssDNA, nuclear antibodies (ANA), rheumatoid factor (RF), neutrophil cytoplasmic antibody(ANCA), PR3 (proteinase 3), and MPO (myelo-peroxidase) in 516 patients with HCV infection by indirect immunofluoresence assay, particle latex agglutination test, enzyme linked immunosorbent assay (ELISA), and immunoblotting.Anti-E3 antibody, ANCA and RF were found in 53.3 %, 55.6% and 56%, respectively, of patients with HCV infection. ANA were found in 15.8%, anti-ssDNA antibodies in 15.6%, anti-dsDNA antibodies in 8.5%, ACL in 5%, anti-SSB/La in 4.1%, anti-SSA/Ro (60 kD) antibodies in 3.9%, anti-E2 antibodies in 3.3% and anti-SSA/Ro (52 kD) in 1.2 %, anti-Topo II in 0%, anti-PR3 in 55.6%, anti-MPO in 4.8%, anti-actin in 0%. Anti-E3 antibodies were found more frequently in patients with HCV infection (53.3%) than in patients with primary biliary cirrhosis (27%) (P<0.01).Anti-E3 antibodies and ANCA were present in a high prevalence in patients with HCV infection. These data suggest that E3 and ANCA were associated with the immune response of HCV infection.

碩士
國立成功大學
生物學系
84
To investigate the presence of quasi species of hepatitis C virus (HCV) in indi-vidual hepatitis C patient and the possibility of intrafamilial transmission of HCV, we analyzed sequence variability of hypervariable region 1 (HVR1) of HCV in8 chronic hepatitis C patients, who belong to 4 families or spouses. The reversetranscriptional polymerase chain reaction (RT-PCR) was applied to amplify HCVHVR1 in serum of each patient. The PCR products were then cloned into pCR-ScriptSK(+) plasmids and sequenced using dideoxy nucleotide chain termination method.DNA sequences and deduced amino acid sequences of each clone of HCV HVR1 were compared within each patient, among spouses and among non-familial members. Va- riability between any 2 clones of sequence was represented by phylogenetic dis-tance. The results revealed that mean variabilities of HCV HVR1 nucleotide se-quences of 8 patients (i.e. patient A, B, E, F, G, H, I, J belonging to 4 fami-lies) were 0.0589, 0.0055, 0.1122, 0.3198, 0.0427, 0.0962, 0.0125, 0.1904, res-pectively. Mean variabilities of deduced amino acid sequences of same region were 0.1406, 0.0160, 0.3120, 0.6940, 0.0768, 0.1628, 0.0187, 0.5859, respec-tively. Except patient F, all patient showed very low variability. Yet quasi species are indeed present. Variability among spouses in family I, II, and III is significantly lower than that of non-spouses. Variability among spouse in family IV showed the opposite result suggesting the different source of HCV in-fection for patient I and J in this family. Both variability and phylogenetic tree analyses suggest the possibility of intrafamilial transmission of HCV in- fection.

People with hepatitis C (HCV) face stigma and discrimination because of the association of this disease with injecting drug use (IDU). Research has found that many instances of HCV-related discrimination occur in the health care sector. Health care workers' beliefs about their HCV positive clients are likely to influence how they relate to clients and their treatment delivery. This research assessed the implicit and explicit attitudes of both health care workers and their HCV positive injecting drug using (HCV+) clients toward each other and then established whether these affect the treatment experiences of health care workers and clients. The sample consisted of 60 health care workers (doctors and nurses), 120 HCV+ and 120 HCV- clients, recruited from the same treatment facility. Participants were given a series of attitude and treatment experiences measures to complete. Data illustrate that while health care workers' and HCV+ clients' explicit attitudes towards each other were positive, clients with HCV still rated their health care workers less highly and reported less satisfaction with their treatment than HCV- clients. Analyses also indicated that more conservative health care workers displayed greater prejudice toward their HCV+ clients because they believe that injecting drug use is controllable. This prejudice toward IDUs on the part of health care workers was associated with worry about the behaviour of IDU clients and this worry in turn predicted differences in treatment experiences reported by HCV+ and HCV- clients. These data support the contention that health care worker concerns, particularly those related to injecting drug use, underlie discriminatory treatment of people with HCV. Finally the research also addressed the impact of health care worker contact with HCV+ clients on their attitudes towards this group. Analysis revealed that while health care workers who have had more contact with people with HCV show more positive explicit attitudes, they also show less favourable implicit attitudes toward IDUs. This may reflect the difficulties and stresses associated in caring for IDUs and may provide insight into the hidden costs involved for health care workers working with a population that may be challenging and at times difficult to manage.

博士
高雄醫學大學
醫學研究所
99
Viral hepatitis infection and its related chronic viral hepatitis, liver cirrhosis, and hepatocellular carcinoma remain a tremendous concern of public health in Taiwan at present. The prevalence of hepatitis B virus (HBV) infection and its leading liver diseases will be decreased and diminished in the foreseeable future post the era of our nation-wide launch of HBV vaccination in 1984. However, the multi-directional issues of hepatitis C virus (HCV) infection have come up progressively for the past 1-2 decades. It is well known that 70-80% of the individuals will become a chronic state after an acute HCV infection. Moreover, 20-30% of the chronic HCV infection (CHC) patients will progress to liver cirrhosis after an estimated period of 20-30 years, and a proportion of them will face the threaten of hepatocellular carcinoma. The prevalence of HCV infection in general populations was reported to be &lt;5% in our country. Nonetheless, the prevalence of HCV infection in some townships of southern Taiwan reached as high as 30-40%. Therefore, there is a pressing need to clarify the associated covariates between HCV infection and its related disorders. HCV per se is both hepatotropic and lymphotropic. Replication of HCV in diseased extrahepatic organs and tissues may have cytopathic effects. It, therefore, may either trigger latent autoimmunity or induce an autoimmune disease de novo. Molecular mimicry, unfolded protein response and/or immunological dysregulation may contribute to possible pathogenetic mechanisms. Therefore, in addition to established liver injury, there are multiple examples of extrahepatic metabolic disorders attributed to HCV infection, such as type 2 diabetes mellitus (T2DM), thyroiditis, glomerulopathy, mixed cryoglobulinemia, and other immunological abnormalities. Previous reports or studies concerning metabolic abnormalities of CHC were scattered and not fully integrated. Moreover, there were only few studies addressing these issues in the past decade in Taiwan, an endemic country of viral hepatitis. The aims of my serial studies initially focused on the metabolic manifestations of CHC, e.g. proteinuria and its related renal disorders, T2DM and metabolic syndrome to elucidate the characteristics of metabolic abnormalities and their clinical relevants from the aspect of epidemiological view. Native related database has thus been established with collaborative works from my distinguished colleagues. Secondly, related studies have been conducting to investigate the interaction between glucose abnormalities and CHC, particularly in the aspects of molecular biology, virology and clinical therapeutics. I also tried to clarify the mutual roles of insulin resistance and CHC with respect to the prediction of treatment efficacy, how treatment response affects insulin resistance and the role of pancreatic beta cell function in the interesting suite. Recently, the studies regarding cytokines prevail worldwide. With the help and kind instruction from my colleagues and tutors, I conducted several translational studies aiming to elucidate the specific roles of the newcomers in a clinical setting. It will be helpful to clarify the host viral interaction and possible pathogenetic mechanisms of this topic.

Among the estimated 210,000 Australians living with the hepatitis C virus, over 80% will go on to live with chronic hepatitis C and its debilitating effects. Patients with chronic hepatitis C who have active inflammatory changes on liver biopsy may undergo combination therapy with interferon and ribavirin. Adverse effects of combination therapy can be variable in their nature, intensity and severity. They may be mild, reversible, moderate, or serious and life threatening. For some patients the adverse effects are so severe that it places enormous stress on partner relationships. Through a phenomenological approach using purposive sampling and semi-structured interviews of five patients and their partners, this study aimed to explore the issues surrounding chronic hepatitis C, combination therapy and personal relationships. The purpose of the study was to enhance understanding of the experiences of people living with the illness and undergoing treatment. The complexities that hepatitis C and treatment brings into the personal lives of people have led me to this study because there is a need to understand their impact on the personal relationships of patients and their partners. Through deeper understanding of their experiences, nurses can move beyond the medical oriented approach to treatment towards a holistic approach. The findings from this study revealed that chronic hepatitis C and combination therapy had an enormous impact on the lives of the patients, their partners and families. Both had significant physiological effects that impacted on quality of life, however, the social and psychological consequences of living with a highly stigmatised disease with an unknown course and outcome cannot be underestimated. The participants’ narratives provided a rich description of their experiences and offered insight into the life world of people living with chronic hepatitis C and combination therapy, and their partners. The themes that emerged from the study were: experiencing illness and treatment; keeping a secret; sharing the experience; and enduring struggle. Nurses play a significant role in educating patients with chronic hepatitis C, advocating for them and helping them to achieve a reasonable state of well being. Nurses also have the important role of providing partners with information and support that will assist them as caregivers. The results of this study lend support to the effectiveness of providing equitable services to persons diagnosed with chronic hepatitis C. However, additional research is needed to explore gender, socioeconomic, sexual-orientation, transmission, cultural and religious differences within this group to better address their needs.
Master of Nursing (Honours)

碩士
長庚科技大學
護理系碩士在職專班
105
Background: The hepatitis C virus could cause liver cirrhosis and cancer. There is currently no vaccine for prevention. Fortunately a good antiviral treatment is available, which mainly relies on using the pegylated interferon plus ribavirin. Treatment processes often produce the discomfort symptoms of oral ulcers. When the side effects of whole body appear, patients often neglect to carry out the oral hygiene behaviors. In addition, oral hygiene is always neglected by nursing staff, which would increase oral discomfort and induce oral inflammation. It may influence patient's appetite and immunity at this time. Furthermore, patients may give up their treatment. Therefore, providing oral care is an important task for nursing professional, which could mainly reduce oral ulcers, increase oral comfort and complete treatment rate. However, the systematic review showed that using oral care program in hepatitis C patients during antiviral therapy was limited. Aims: To explore the effectiveness of oral care program for hepatitis C patients receiving antiviral treatment, including changed of the concepts of oral health, oral health behaviors and oral health status. Methods: This study was designed as one group of quasi-experimental pretest-posttest. We implemented face-to-face interviews with structured questionnaires, including demographics, oral health behaviors and oral health status. The period of oral care intervention was three months for each patient. We collected patients' oral health behaviors, oral health status and plaque index between pretest and posttest. The instruments included dental plaque indicator and oral care materials. SPSS software for windows version 22 was applied in this study. Both descriptive and inferential statistics were used, including percentage, mean, standard deviation, McNemar test and generalized estimating equation. Results: Of the total 34 participants, who met the inclusion criteria, from the outpatient clinics in southern Taiwan. The mean age was 50 (SD=11, range=21-76), women accounted for 55.9%. The finding indicated that oral care program for participants in frequency of brushing teeth (p<.001), using dental floss or interdental brushes (p<.001) and comfort in oral cavity (p<.001) were significantly improved. The generalized estimating equation showed the score of oral health had significantly improved in the first (β= -1.559, p<.001), the second (β= -2.074, p<.001) and the third month (β= -2.251, p<.001). The plaque index (PI) also indicated significantly improved in the first (β= -1.732, p<.001), the second (β= -2.120, p<.001) and the third month (β= -2.490, p<.001). Conclusions: The result of this study showed that oral care program can reduce oral discomfort, improve oral health behaviors and oral health status during patients receiving antiviral treatment. Additionally, this is a simple and low cost program, which can be performed at home easily, and could enhance their quality of oral health. This finding can provide as a reference for clinician. It is recommended that oral care should be included in the routine of antiviral treatment in the future.

碩士
國立臺灣大學
分子醫學研究所
83
Individuals infected by hepatitis C virus often evolve into chronic hepatitis C, and liver cirrhosis or hepatocellular carcinoma may develop later.Currently, the only approved treatment of chronic hepatitis C is the recombinant α interferon Unfortunately, the outcome of the treatment is poor. An interferon sensitivity determining region(ISDR) in the NS5A region is claimed to be correlate with the treatment outcome. A recent important advance in the treatment of chronic hepatitis C is that the combination of interferon α and ribavirin lead to a much better result. The mechanisms of how ribavirin works and how these two drugs cooperate are still unknown. To understand how combination therapy take effect, we examinedHCV NS5B region, whose product is a RNA dependent RNS polymerase and is a possible candidate as the target site of ribavirin, from the pre- treatment serum of 5 responders and 5 non-responders. Serum samples at the end of 24-week therapy and at the end of 6 months after treatment cessation from these non responders are also examined by RT-PCR and direct sequencing.Using the same methods, pre treatment serums of 11 responders and 7 non- responders of the combination therapy were analyzedto check the mutations in the ISDR of the NS5A region.We found that the occurence of mutations in the NS5B region tended to be more frequent in the pre-treatment samples from nonresponders; and the mutation rate of amino acids 2470, 2843,2955 are significantly different among responders and nonresponders. How these mutations affect the effectness of the therapy needs more information to Also, there were no significant differences in the numbers of mutation in ISDR between responders and nonresponders. This suggest the antiviral activity of the combination therapy is partly different from the interferon mono-therapy.

人類免疫缺陷病毒 (HIV) 是人獲得性免疫缺陷綜合征 (愛滋病，AIDS) 的致病原，2010年全球有180萬人死於愛滋病，HIV/AIDS已成為全球健康的嚴重挑戰。人類免疫缺陷病毒與乙型肝炎病毒 (HBV) ，丙型肝炎病毒 (HCV) 的合併感染非常普遍，已演變成具有嚴重臨床後果的新健康問題。儘管對於人類免疫缺陷病毒的研究已有很大的進展，但由於受研究模型的限制，人體免疫系統對人類免疫缺陷病毒感染的應答，特別是對乙型肝炎病毒，丙型肝炎病毒與人類免疫缺陷病毒合併感染的免疫應答，仍值得進一步的闡明。
在本研究中，我們首先對深圳人類免疫缺陷病毒，乙型肝炎病毒，丙型肝炎病毒合併感染的流行情況進行研究。共選取914份人類免疫缺陷病毒感染者的血漿，經過對乙型肝炎病毒表面抗原 (HBsAg) 和抗丙型肝炎病毒抗體 (anti-HCV) 的檢測，發現10.9% (100/914) 的被檢測者是人類免疫缺陷病毒/乙型肝炎病毒合併感染，14.6% (133/914) 為人類免疫缺陷病毒/丙型肝炎病毒合併感染，3.7% (34/914) 為人類免疫缺陷病毒/乙型肝炎病毒/丙型肝炎病毒三重感染。多元邏輯回歸分析證明人類免疫缺陷病毒傳染的危險行為與合併感染顯著相關聯。大多數的人類免疫缺陷病毒/乙型肝炎病毒合併感染者都是通過性接觸感染人類免疫缺陷病毒，包括異性傳播與同性傳播 (95/100, 95%); 大多數的人類免疫缺陷病毒/丙型肝炎病毒合併感染者是靜脈注射吸毒者 (89/133, 66.9%); 人類免疫缺陷病毒/乙型肝炎病毒/丙型肝炎病毒三重感染者中，大多數是靜脈注射吸毒者 (28/34, 82.4%)。靜脈注射吸毒人群中，大部分是男性 (108/122, 88.5%)，約半數人的年齡介乎27至32歲 (56/122, 45.9%) 。有接近一半的經過血液和血液製品傳播人類免疫缺陷病毒的人是人類免疫缺陷病毒/丙型肝炎病毒合併感染者 (10/23, 43.5%) 。性別與人類免疫缺陷病毒感染的危險行為有顯著關係，大部份的靜脈注射吸毒者是男性。
進一步，我們利用酶聯免疫吸附測定法 (ELISA) 檢測深圳愛滋病陽性樣本血漿中白細胞介素27 (IL-27) 的濃度。結果顯示，對比健康參照者，人類免疫缺陷病毒單獨感染者，人類免疫缺陷病毒/乙型肝炎病毒合併感染者，人類免疫缺陷病毒/丙型肝炎病毒合併感染者的血漿IL-27濃度顯著升高。隨後我們進一步發現，人類免疫缺陷病毒單獨感染組，人類免疫缺陷病毒/乙型肝炎病毒，人類免疫缺陷病毒/乙型肝炎病毒/丙型肝炎病毒合併感染組之間的血漿IL-27濃度沒有顯著差異，而人類免疫缺陷病毒/丙型肝炎病毒合併感染組與人類免疫缺陷病毒/乙型肝炎病毒/丙型肝炎病毒三重感染組的血漿IL-27濃度差異顯著。我們還發現人類免疫缺陷病毒單獨感染組中，血漿IL-27濃度與CD4⁺ T 淋巴細胞數量顯著正相關 (r = 0.177, P = 0.034)。
我們進一步分析了人類免疫缺陷病毒和丙型肝炎病毒的病毒載量對血漿IL-27濃度的影響，發現HIV單獨感染組中人類免疫缺陷病毒載量與血漿IL-27濃度沒有顯著相關 (r = - 0.063, P = 0.679)，而人類免疫缺陷病毒/丙型肝炎病毒合併感染組中，人類免疫缺陷病毒載量與血漿IL-27濃度顯著正相關 (r = 0.362, P = 0.049)。人類免疫缺陷病毒/丙型肝炎病毒合併感染組中，人類免疫缺陷病毒載量與丙型肝炎病毒載量缺少顯著線性關聯 (r = - 0.072, P = 0.704)，而人類免疫缺陷病毒/丙型肝炎病毒合併感染組可根據人類免疫缺陷病毒與丙型肝炎病毒的病毒載量再細分成血漿IL-27濃度差異顯著的三組 (P = 0.014) ， 丙型肝炎病毒載量與血漿IL-27濃度缺少顯著關聯 (r = - 0.119, P = 0.530) 。
我們利用TaqMan®等位基因分型技術測定深圳男同性戀人群中IL-27 p28基因的單核苷酸多態性 (SNP)。結果顯示，人類免疫缺陷病毒感染組IL-27 p28 -964A/G 和4603G/A的基因型與健康男同性戀參照組的基因型沒有顯著差異， IL-27 p28 -964A/G 和4603G/A的等位基因比率也沒有顯著差異。結果也顯示，IL-27 p28 2905T/G的TG基因型可減少2.77倍的人類免疫缺陷病毒感染風險，等位基因G可減少2.72倍的人類免疫缺陷病毒感染風險。連鎖不平衡在IL-27 p28 -964A/G 和2905T/G 中存在 (
綜上所述， 在本研究中，我們首次調查了深圳人類免疫缺陷病毒，乙型肝炎病毒，丙型肝炎病毒合併感染的流行情況，並分析了合併感染的風險因素。 發現人類免疫缺陷病毒單獨感染者，人類免疫缺陷病毒/乙型肝炎病毒合併感染者， 及人類免疫缺陷病毒/丙型肝炎病毒合併感染者的血漿IL-27濃度比健康參照組顯著地升高；人類免疫缺陷病毒單獨感染組中，血漿IL-27濃度與CD4⁺ T淋巴細胞數量顯著正相關。人類免疫缺陷病毒/丙型肝炎病毒合併感染組中，人類免疫缺陷病毒載量與血漿IL-27濃度顯著正相關 (r = 0.362, P = 0.049)。分析深圳男同性戀人群IL-27 p28基因的單核苷酸多態性，發現IL-27 p28 2905T/G 與人類免疫缺陷病毒感染相關，GGG單型可降低男同性戀人群人類免疫缺陷病毒感染的風險。
Human Immunodeficiency Virus (HIV) is the causative agent of Acquired Immunodeficiency Syndrome (AIDS); HIV/AIDS caused 1.8 million deaths world-widely in 2010 and became a major global health challenge. HIV co-infections with Hepatitis B virus (HBV), Hepatitis C virus (HCV) are common and have emerged into new health problems with severe clinical consequences. Since the discovery of HIV, massive progress in understanding of the pathogen has been achieved. Due to the restriction of research model, how human immune system responds to HIV infection, particularly, to HBV or HCV co-infections is still worthy further elucidation.
A cohort study was first conducted in Shenzhen regarding the seroprevalence of HBV, HCV infections among HIV-infected population. Totally 914 HIV positive individuals were recruited in the study and tested for HBsAg and anti-HCV antibodies. The results showed a 10.9% (100/914) HIV/HBV co-infection rate, 14.6% (133/914) HIV/HCV co-infection prevalence and 3.7% (34/914) HIV/HBV/HCV triple-infection prevalence. Multivariate logistic regression revealed that HIV transmission risk behavior was significantly associated with HIV, HBV, HCV co-infections. Most HIV/HBV co-infection cases got HIV through sexual contact including heterosexual and homosexual behaviors (95/100, 95%); while most HIV/HCV co-infection subjects were injection drug users (IDUs) (89/133, 66.9%). In the case of HIV/HBV/HCV triple-infection, IDUs accounted for a large ratio (28/34, 82.4%). Among IDUs, most of them were male (108/122, 88.5%) and nearly half were aged 27 to 32 years old (56/122, 45.9%). Near half people who got HIV through blood and blood products were HIV/HCV co-infected (10/23, 43.5%). Gender has a significant correlation with HIV risk behavior and most IDUs were male.
Next, we applied ELISA to test HIV positive clinical samples and proved that plasma interleukin-27 (IL-27) level was significantly elevated in HIV mono-infected, HIV/HBV co-infected and HIV/HCV co-infected subjects when compared with healthy controls. Later, we further revealed that plasma IL-27 titer was not significantly varied among HIV, HBV and HCV co-infections except between HIV/HCV co-infections and HIV/HBV/HCV triple-infections. We also observed a significant positive correlation between CD4⁺ T cell counts and plasma IL-27 titer within HIV mono-infected group (r = 0.177, P = 0.034).
We further analyzed the impact HIV and HCV viral loads on plasma IL-27 titer. We found there was no significant correlation between HIV viral load and IL-27 titer among HIV mono-infected individuals (r = - 0.063, P = 0.679); while a significant positive correlation was observed between HIV viral load and IL-27 titer in HIV/HCV co-infected individuals (r = 0.362, P = 0.049). In the case of HIV/HCV co-infection, there was no significant linear correlation between HIV and HCV viral loads (r = - 0.072, P = 0.704) but exist obvious subdivision of samples in terms of HIV and HCV viral loads with significant IL-27 titer variance (P = 0.014). No correlation was observed between HCV viral load and IL-27 titer (r = - 0.119, P = 0.530).
IL-27 p28 polymorphisms were genotyped with TaqMan® Allelic Discrimination Assay in Chinese men who have sex with men (MSM) population in Shenzhen and the results revealed that proportions of IL-27 p28 -964A/G and 4603G/A genotypes were not significantly different from the healthy controls; IL-27 p28 -964A/G and 4603G/A allele frequencies were similar between HIV positive MSM group and healthy control MSM group. Results also showed that for IL-27 p28 2905T/G polymorphism, TG genotype has a 2.77-fold decreased risk of HIV susceptibility and subjects with G allele has a 2.72-fold decreased risk of HIV susceptibility. Linkage disequilibrium (LD) coefficients were observed between IL-27 p28 -964A/G and 2905T/G (
In conclusion, the seroprevalences of HBV and HCV infection among HIV positive population in Shenzhen were surveyed and risk factors associated with co-infections were analyzed. Plasma IL-27 titer was significantly elevated in HIV mono-infected, HIV/HBV co-infected and HIV/HCV co-infected individuals. IL-27 level was correlated with CD4⁺ T cell counts within HIV mono-infected people. A significant positive correlation was found between HIV viral load and IL-27 titer in HIV/HCV co-infected individuals (r = 0.362, P = 0.049). IL-27 p28 2905T/G was associated with individual susceptibility to HIV infection and haplotype GGG showed a protective role in restricting HIV infection in MSM population.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
He, Lai.
"October 2012."
Thesis (Ph.D.)--Chinese University of Hong Kong, 2013.
Includes bibliographical references (leaves 135-155).
Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web.
Abstract also in Chinese.
Abstract (English) --- p.iii
Abstract (Chinese) --- p.vi
Acknowledgements --- p.ix
Contents --- p.x
List of Tables --- p.xv
List of Figures --- p.xvi
Abbreviations --- p.xvii
Chapter Chapter 1 --- Introduction --- p.1
Chapter 1.1 --- Human Immunodeficiency Virus --- p.1
Chapter 1.1.1 --- HIV virology --- p.1
Chapter 1.1.1.1 --- HIV structure and genome organization --- p.1
Chapter 1.1.1.2 --- HIV life cycle --- p.3
Chapter 1.1.1.3 --- HIV genotypes --- p.5
Chapter 1.1.2 --- HIV epidemiology --- p.6
Chapter 1.1.2.1 --- Global HIV epidemiology --- p.6
Chapter 1.1.2.2 --- HIV epidemiology in China --- p.9
Chapter 1.1.3 --- HIV pathogenesis --- p.13
Chapter 1.1.3.1 --- Natural history of HIV infection --- p.13
Chapter 1.1.3.2 --- HIV transmission --- p.15
Chapter 1.1.3.3 --- HIV tropism --- p.17
Chapter 1.1.4 --- Immune responses to HIV infection --- p.19
Chapter 1.1.4.1 --- Innate immune response --- p.19
Chapter 1.1.4.2 --- Adaptive immune response --- p.21
Chapter 1.1.5 --- Diagnosis --- p.24
Chapter 1.1.6 --- HIV prevention --- p.25
Chapter 1.1.7 --- Anti-HIV therapy --- p.25
Chapter 1.1.8 --- Hepatitis B virus, Hepatitis C virus infection --- p.26
Chapter 1.1.8.1 --- HBV infection natural history, diagnosis, disease progression and epidemiology --- p.26
Chapter 1.1.8.2 --- HCV infection natural history, diagnosis, disease progression and epidemiology --- p.30
Chapter 1.1.9 --- HIV, HBV, HCV co-infections --- p.32
Chapter 1.2 --- Interleukin-27 --- p.36
Chapter 1.2.1 --- Biology of IL-27 --- p.36
Chapter 1.2.2 --- IL-27 on immune system --- p.37
Chapter 1.2.3 --- IL-27 anti-tumor properties --- p.38
Chapter 1.2.4 --- IL-27 antiviral features --- p.40
Chapter 1.2.5 --- IL-27 with hepatitis --- p.41
Chapter 1.3 --- Single-nucleotide polymorphisms (SNPs) --- p.42
Chapter 1.3.1 --- Types of SNPs --- p.43
Chapter 1.3.2 --- Functions of SNPs --- p.43
Chapter 1.4 --- Objectives of the study --- p.45
Chapter Chapter 2 --- Seroprevalence of HBV, HCV infection among HIV positive individuals in Shenzhen --- p.52
Chapter 2.1 --- Introduction --- p.52
Chapter 2.2 --- Materials and methods --- p.54
Chapter 2.2.1 --- Study participants --- p.54
Chapter 2.2.2 --- Measure of HBV, HCV seroprevalence --- p.55
Chapter 2.2.3 --- Statistical analysis --- p.60
Chapter 2.3 --- Results --- p.61
Chapter 2.3.1 --- HIV infection in Shenzhen --- p.61
Chapter 2.3.2 --- Seroprevalence of HBV, HCV infection among HIV positive individuals in Shenzhen --- p.61
Chapter 2.4 --- Discussion --- p.65
Chapter 2.4.1 --- HIV infection in Shenzhen --- p.65
Chapter 2.4.2 --- HIV, HBV, HCV co-infections in Shenzhen --- p.68
Chapter 2.4.3 --- Limitations of the study --- p.71
Chapter Chapter 3 --- Upregulation of Interleukin-27 titer in HIV infected persons --- p.78
Chapter 3.1 --- Introduction --- p.78
Chapter 3.2 --- Materials and methods --- p.80
Chapter 3.2.1 --- Study participants --- p.80
Chapter 3.2.2 --- Measure of HIV, HBV, HCV infection --- p.80
Chapter 3.2.3 --- Detection of IL-27 in plasma --- p.81
Chapter 3.2.4 --- CD4 counting --- p.84
Chapter 3.2.5 --- Statistical analysis --- p.84
Chapter 3.3 --- Results --- p.84
Chapter 3.3.1 --- Demographics of study participants --- p.84
Chapter 3.3.2 --- Upregulation of IL-27 levels in HIV infected persons --- p.85
Chapter 3.3.3 --- Correlation of plasma IL-27 titer with CD4⁺ T cell count --- p.86
Chapter 3.4 --- Discussion --- p.86
Chapter Chapter 4 --- Impact of HIV, HCV viral loads on Interleukin-27 titer among Antiretroviral Therapy- Naïve HIV positive Chinese --- p.95
Chapter 4.1 --- Introduction --- p.95
Chapter 4.2 --- Materials and methods --- p.96
Chapter 4.2.1 --- Study participants --- p.97
Chapter 4.2.2 --- HIV, HBV and HCV Serological assays --- p.97
Chapter 4.2.3 --- CD4 counting --- p.97
Chapter 4.2.4 --- Detection of plasma IL-27 --- p.98
Chapter 4.2.5 --- Quantification of HIV, HCV viral loads --- p.98
Chapter 4.2.6 --- Statistical analysis --- p.102
Chapter 4.3 --- Results --- p.102
Chapter 4.3.1 --- Demographics of study participants --- p.102
Chapter 4.3.2 --- Plasma IL-27 was elevated in HIV-positive persons --- p.103
Chapter 4.3.3 --- Correlation of IL-27 titer and CD4⁺ T cell count --- p.103
Chapter 4.3.4 --- Correlation of HIV viral load and IL-27 titer --- p.104
Chapter 4.3.5 --- Correlation of HCV viral load and IL-27 titer --- p.104
Chapter 4.4 --- Discussion --- p.105
Chapter Chapter 5 --- Association of Interleukin-27 polymorphisms with the susceptibility to HIV infection in a Chinese men who have sex with men population --- p.116
Chapter 5.1 --- Introduction --- p.116
Chapter 5.2 --- Materials and methods --- p.118
Chapter 5.2.1 --- Study participants --- p.118
Chapter 5.2.2 --- HIV screening --- p.118
Chapter 5.2.3 --- Genomic DNA extraction --- p.119
Chapter 5.2.4 --- IL-27 p28 -964A/G, 2905T/G and 4603G/A genotyping --- p.120
Chapter 5.2.5 --- Statistical analysis --- p.121
Chapter 5.3 --- Results --- p.122
Chapter 5.3.1 --- Demographics of study participants --- p.122
Chapter 5.3.2 --- IL-27 genotypes and allele frequencies in HIV MSM and healthy MSM controls --- p.122
Chapter 5.3.3 --- LD analysis and haplotype analysis --- p.123
Chapter 5.4 --- Discussion --- p.124
Chapter Chapter 6 --- Summary and perspectives --- p.130
Chapter 6.1 --- Summary --- p.130
Chapter 6.2 --- Perspectives --- p.132
Bibliography --- p.135

碩士
國立臺灣大學
護理學研究所
104
Chronic hepatitis B and C are common in Taiwan and also the leading cause of liver cirrhosis, hepatocellular carcinoma and liver failure. Although effective therapies have recently emerged for the disease, not all patients receive treatment and the outcome is not always successful. As the majority of patients have to live with a long-term condition, the role of self-care which focuses on indivisual-centered is increasingly critical for them to manage disease, prevent disease progression and have better quality of life. Self-efficacy is believed to have a great impact on self-care behavior. In addition to manage physical change of chronic illness, patients living with hepatitis also cope with perception of stigma due to infectious and fatal of the disease. However, no study regarding hepatitis-related stigma or self-care efficacy has been carried out in Taiwan. The current study attempted to explore the current status of hepatitis-related stigma and self-care efficacy and their association factors in a group of chronic hepatitis B or C. The purposes of this study were to: (1)explore the status of hepatitis-related stigma among chronic hepatitis patients; (2) explore the relationships among demographic and disease-related, liver disease symptoms, personality factors and hepatitis-related stigma; (3) explore the status of self-care efficacy among chronic hepatitis patients; and(4) understand the demographic and disease-related, liver disease symptoms, personality and hepatitis-related stigma factors associated with self-care efficacy and explore significant explanatory factors. We conducted a cross-sectional, structured questionnaire survey with purposive sampling to recruit eligible participants from outpatient settings in six sites, including three gastroenterology departments of two medical centers and a free hepatitis screening activity held in July 2015 in northern Taiwan, one metropolitan hospital and two public health centers in southern Taiwan. The inclusion criteria were chronic hepatitis B or C patients and who still receiving standard antiviral therapy or suffering from liver cirrhosis or liver cancer were excluded. Research materials included demographic and disease-related information, liver disease symptoms and distress assessed with the Liver Disease Symptom Index 2.0, personality assessed by the Type D scale-14 Taiwanese version-revised, hepatitis-related stigma assessed with the Stigma Scale of Chronic Hepatitis Patients, self-care efficacy measured with the Self-care Efficacy Scale of chronic hepatitis patients. Data were analyzed by descriptive statistics and logistic regression methods. A total of 207 patients in this study and average age was 56.4. The results indicated that: (1) The overall mean scores of hepatitis-related stigma favored a lower perception, however, the degree of nondisclosure and negative self-estimation were relative high; (2) The factors of transfusion etiology, liver disease symptoms (include symptom severity and symptom distress) and type D personality (include negative affection and social inhibition) were associated with stigma degree; (3) The overall mean score of self-care efficacy was around the high-level, but the degree of health-care efficacy (include exercise, diet, regular lifestyle and self-monitor symptoms) was relative low; (4) The factors of marital status, smoking history,liver disease symptoms (include symptom severity and symptom distress), type D personality (include negative affection and social inhibition) and hepatitis-related stigma were associated with self-care efficacy degree. After adjusted association factors with multiple logistic regression, marital status, smoking history, symptom severity and hepatitis-related stigma were significant determinants of self-care efficacy. In conclusion and suggestion: (1) the perception of hepatitis-related stigma centralize on the level of nondisclosure and negative self-estimation. The care for chronic hepatitis could focus on promotion of positive experience and image of disease, listening and assist patients to cope with symptom distresses with education and psychological consultation. And screening of type D personality among patients to reinforce education and give mental support for them could help to reduce negative impact of physical and mental health by stigma; (2) The level of confidence with health-care needs to be enhanced by reinforcing its benefits; (3) In addition to improve disease symptoms by encouraging patients to accept treatment, help patients to reduce perception of hepatitis-related stigma are beneficial to enhance self-care efficacy and self-care ability. (4) Although type D personality not significantly explained the study outcome variables after adjusting other factors, nearly 30 percent of patients had this personality and associated with psychological variables such as stigma and self-care efficacy in the current study. As type D personality is suggested to impair health behavior and health outcomes with specific disease, more studies need to be carried out in this particular group. This study provides valuable information about hepatitis-related stigma and self-care efficacy and it is helpful in clinical care, education and future research in nursing. Key words：Chronic hepatitis, Stigma, Self-care, Self-efficacy, Personality, Symptom.

碩士
國立臺灣海洋大學
食品科學系
92
Abstract Taurine is an essential amino acid for cats, and found in the tissues of most animal species. Its physiological functions include bile acid conjugation, detoxification, osmoregulation, antioxidation, preventing lipid peroxidation, cell membrane stabilization, neuromodulation and calcium flux regulator, etc. So, we prompted to study the effect of taurine on the liver function of hepatitis B or C patients. In experiment, the 24 patients with hepatitis B or C and 2 to 5 times over normal activities of alanine transaminase (ALT) or aspartate transaminase (AST) were selected and divided into two groups, taurine group and control group. Each group had 12 patients. In taurine group, patients took 6 g taurine each day divided into 3 times , for three months, and then stop treatment for 1 month. The daily intake（6 g taurine） was divided into three parts and given to patients of taurine group after meal. In control group, patients took placebo without taurine. The blood samples of all patients were collected and analyzed for the biological characters – white blood cells (WBC), red blood cells (RBC), hemoglobin (Hb), platelet, ALT, AST, cholesterol, triglyceride (TG) and thiobarbituric acid reactive substances (TBARS) values. It was found that the blood characters (WBC, RBC, Hb, Platelet) were not significantly different (p>0.05). However, the biochemical indicators （ALT, AST, cholesterol, TG values）of blood serum in the taurine group were all decreased, Among them, ALT showed significantly different (p<0.05) after taking taurine for 2 and 3 months. The levels of TBARS in the serum of taurine group were significantly decreased (p<0.05), but the control group was not. According to the results of experiment, it indicated that taurine plays an important role in the properties of antioxidation, and has some improvements on the liver function of hepatitis B or C patients. Furthermore, antioxidation effect of taurine was still found on the chronic hepatitis patients once they stop taking dietary taurine.

碩士
國立臺灣大學
臨床醫學研究所
100
Background Chronic hepatitis C (CHC) is a major cause of chronic liver disease both domestically and on a global scale. Pegylated interferon (Peg-IFN) in combination with ribavirin constitutes the current standard of care for CHC in most Asian countries. More than 60% of Asian CHC patients achieved sustained virologic response with combination therapy. Ribavirin-related hemolytic anemia is a common side effect of combination therapy and often leads to dose reduction or treatment discontinuation. Ribavirin dose reduction may compromise treatment responses. Noteworthy that recent studies revealed CHC patients with treatment-induced anemia achieved better virologic responses than those without. The association of treatment-induced anemia with virologic responses needs further investigation. Aim of the study The aim of this study was to evaluate the association between treatment-induced anemia and treatment outcomes in CHC patients. Factors predictive of virologic responses and treatment-induced anemia respectively will be analyzed as well. Methods We retrospectively enrolled naive HCV genotype 1 CHC patients who received Peg-IFN and ribavirin therapy. The treatment duration of enrolled patients was at least 4 weeks. The baseline demographics and patient characteristics were recorded, as well as on-treatment hemoglobin changes and ribavirin dosage. The virologic responses were evaluated. Genetic polymorphisms in the IL28B gene (rs8099917) and ITPA gene (rs1127354) were determined. Statistical analyses were performed to analyze factors predictive of treatment-induced anemia and treatment outcomes. Results A total of 313 patients were enrolled. All patients finished treatment except three who lost to follow-up before treatment completed. On-treatment virologic responses were determined for all patients in an intent-to-treat fashion. Sustained virologic response (SVR) was determined for 295 patients who finished posttreatment follow-up. The overall rapid virologic response (RVR) and SVR rates were 63% and 72%, respectively; the relapse rate was 23%. One hundred patients (32%) had hemoglobin decline >3 g/dL from baseline at week 4 of treatment. Thirty-eight patients (12%) had hemoglobin level <10 g/dL at week 4. The factors predictive of RVR included male gender (OR 2.11; P =0.006), baseline platelet count >180 ×103/μL (OR 1.96; P =0.021), baseline viral load <800,000 IU/mL (OR 4.35; P <0.001), rs8099917 genotype TT (OR 4.31; P <0.001), and rs1127354 genotype CC (OR 2.23; P =0.005). The predicting factors of SVR were male gender and achievement of RVR. Patient categories at risk of hemoglobin decline >3 g/dL at week 4 were age >55 years (OR 2.70; P =0.001), baseline hemoglobin >16 g/dL (OR 4.07; P <0.001), and rs1127354 genotype CC (OR 15.85; P <0.001). Age >55 years (OR 2.55; P =0.042), baseline hemoglobin <14 g/dL (OR 5.88; P <0.001), estimated glomerular filtration rate <60 ml/min/1.73m2 (OR 2.71; P =0.037), and rs1127354 genotype CC (OR 28.10; P =0.002) were predicting factors of hemoglobin level <10 g/dL at week 4. The magnitude of hemoglobin decline at week 4 was correlated with RVR rate. Conclusion For chronic hepatitis C patients receiving PegIFN plus ribavirin therapy, factors predictive of treatment-induced anemia are ITPA genetic polymorphism, baseline hemoglobin level, age, and renal function. ITPA genetic polymorphism is an independent factor of RVR. Treatment-induced anemia is also associated with treatment responses.