Treatment of hepatitis C virus infection in adults and children: updated Swedish consensus recommendations

Swedish recommendations for the treatment of hepatitis C virus (HCV) infection were updated at a recent expert meeting. Therapy for acute HCV infection should be initiated if spontaneous resolution does not occur within 12 weeks. The recommended standard-of-care therapy for chronic HCV genotype 1 infection is an HCV protease inhibitor in combination with peginterferon (peg-IFN) and ribavirin. Treatment is strongly recommended in patients with bridging fibrosis and cirrhosis, whereas in patients with less advanced fibrosis, deferring therapy may be preferential in light of likely therapeutic improvements in the near future. Patients with chronic genotype 2/3 infection should generally be treated with peg-IFN and ribavirin for 24 weeks. In patients with a very rapid viral response (i.e. HCV RNA below 1000 IU/ml on day 7), or favourable baseline characteristics and undetectable HCV RNA week 4, treatment can be shortened to 12-16 weeks, provided that no dose reductions are needed.     

Variables Associated with Stress Ulcer Prophylaxis Misuse: A Retrospective Analysis

Background

Stress ulcer prophylaxis (SUP) is commonly used in hospitals. Although its indications are better delineated for intensive care unit (ICU) patients, its use in non-ICU settings is somewhat arbitrary and based on judgment.

Objective

We attempted to assess the extent of SUP overuse in our hospital. We also carefully collected and analyzed several variables to detect associations governing this flawed behavior and its financial burden on the hospital’s budget.

Materials and Methods

We retrospectively analyzed charts of patients admitted to the medical floor of a tertiary referral university hospital over a 1 year period. All adult patients admitted to the medical ward who received at least one dose of SUP were included and reviewed for a multitude of variables in addition to the appropriateness of acid suppression therapy (AST).

Results

We included 320 charts and found that 92% of patients admitted during that period were not eligible for SUP. The total inappropriateness of SUP was noted to be 58% (p = 0.015). Increasing age and male gender were found to be significant variables in AST misuse (p = 0.045 and p = 0.010), much like duration of hospital stay (p = 0.008). Comorbidities was also found to be a defining variable for AST overuse (odds ratio [OR] = 3.27). Patients with two or more minor risk factors were also subjected more to SUP inappropriately (OR = 3.53), in addition to patients of certain specialties (Neurology, Infectious Diseases, etc.). Our calculated financial burden was more than $23,000 per year for the medical floor.

Conclusion

This retrospective study confirmed the growing suspicion that SUP misuse is evident on the medical floors. We also delineated several factors and variables associated with and affecting SUP overuse.     

Thrombosis is associated with inferior survival in multiple myeloma

Patients with multiple myeloma are at an increased risk of venous thromboembolism and arterial thrombosis. We assessed the impact of venous and arterial thrombosis on survival in a population-based study of 9,399 multiple myeloma patients diagnosed in Sweden from 1987 to 2005. We found multiple myeloma patients with venous thromboembolism to have a higher mortality at 1-, 5-, and 10-years of follow up compared with those without, with hazard ratios of 2.9 (95% confidence interval (CI) 2.4-3.5), 1.6 (95% CI: 1.5-1.8), and 1.6 (95% CI: 1.4-1.7), respectively. There was an increase in risk of death among multiple myeloma patients with arterial thrombosis, with hazard ratios of 3.4 (95% CI: 3.0-3.8), 2.2 (95% CI: 2.0-2.3), and 2.1 (95% CI: 1.9-2.1), respectively. In landmark analyses at six months, early arterial but not venous thromboembolism was associated with a higher risk of death. Thus, in contrast to prior smaller studies, we found the development of thrombosis to be associated with significantly poorer survival. The prevention of thrombosis in multiple myeloma is an important goal in the management of these patients.Key words: multiple myeloma, venous thromboembolism, survival, arterial thrombosis, thalidomide, lenalidomide, aspirin, low-molecular weight heparin, warfarin, prophylaxis     

Neuropsychological test performance before and after HIV-1 seroconversion: the Multicenter AIDS Cohort Study

The objective of this study is to compare neuropsychological test performance before and after HIV-1 seroconversion in order to identify possible acute changes in psychomotor speed, memory, attention, and concentration secondary to seroconversion. The study utilized mixed effects models to examine longitudinal neuropsychological test data. We conducted a nested cohort study of 362 male HIV-1 seroconverters enrolled in the Multicenter AIDS Cohort Study. We used linear mixed models with random subject effects to compare repeated neuropsychological test outcomes from 5 years before seroconversion to 2 years after seroconversion on the Trail Making Test (parts A and B), Symbol-Digit Test, Grooved Pegboard (dominant and non-dominant hands), Stroop Color-Interference Test, Rey Auditory Verbal Learning Test, and the CalCAP Reaction Time Test. We found no significant changes in the time-dependent score after seroconversion for the majority of neuropsychological tests used in the Multicenter AIDS Cohort Study. There was a significant change in time trend after seroconversion on part B of the Trail Making Test (p?=?0.042), but the difference only represented a 2 % decrease in performance. We found the following characteristics to be associated with worse neuropsychological test performance: lower education levels, history of depression, older age, and no previous neurocognitive testing (p?<?.05). Our results suggest that despite a 50 % decrease in CD4 cell count immediately following infection, HIV-1 does not appear to have a measurable effect on psychomotor or complex cognitive processing for up to 2 years following infection, using this set of neurocognitive measures.     

Family structure,socioeconomic position and utilization of oral health services among Nigerian senior secondary school pupils

Objective: To test the relationship between socioeconomic position (SEP), family composition, number of siblings, and birth position in the family, and the utilization of oral health services by senior secondary school pupils in Ile‐Ife, Nigeria. Methods: A cross‐sectional study design included senior secondary school pupils in the Central Local Government Area of Ile‐Ife during 2007/2008. Sample size calculation was performed and 1,200 pupils were invited to participate. A multistage, stratified sampling technique was used. Data collection included a self‐administered questionnaire. Data were analyzed using logistic regression. Results: The response rate was 76 percent (n = 1043). The mean age was 15.8 (standard deviation = 1.9) and 49 percent were males. Only 22.5 percent of pupils had ever visited a dentist in their lives. Results from multivariate analyses showed that pupils attending free schools, those paying 1 to 10,000 naira (equivalent to US$ 63.31) and 10,000 to 19,000 naira (equivalent to US$ 120.29) were respectively 1.93, 1.87, and 2.74 times less likely to have attended a dentist in the past than pupils in more expensive schools. Pupils living with single mothers or without a parent were unlikely to have visited the dentist. Number of siblings and birth position in the family were not associated with utilization of oral health services. Conclusions: Adolescents from families with a low SEP growing up without their parents may need extra incentives to visit dentist.     

Treatment with mesenchymal stromal cells is a risk factor for pneumonia-related death after allogeneic hematopoietic stem cell transplantation

We performed a retrospective cohort study to find out whether the use of reduced‐intensity conditioning (RIC) might reduce the risk of early death from pneumonia. Pneumonia‐associated deaths were evaluated in 691 hematopoietic stem cell transplantation (HSCT) patients. The majority had a hematological malignancy (n = 504) and an HLA‐matched donor (n = 584). RIC was given to 336 patients and myeloablative conditioning (MAC) to 355. Data concerning radiology, culture and autopsy results were evaluated together with risk factors for death related to pneumonia within or after 100 d after HSCT (early and overall pneumonia). In 60 patients, pneumonia contributed to death (early n = 17). The cumulative incidence of early pneumonia‐related death was 2.8% and 2.1% in MAC and RIC patients, respectively. The cumulative incidence of overall pneumonia‐related death was 8.2% and 10.5%, respectively. In 40 patients, (67%) an etiology could be established, with 19 patients having proven or probable mold infection. In the multivariate analyses, acute graft‐versus‐host disease (GVHD) grades II–IV, cytomegalovirus (CMV) infection and having received mesenchymal stromal cells (MSCs) were factors associated with overall pneumonia‐related death. Bacteremia and a previous HSCT were associated with early pneumonia‐related death. RIC did not reduce the incidence of early death associated with pneumonia. Acute GVHD II–IV, CMV infection and MSC treatment were factors associated with pneumonia‐related death. Mold infection was the most common contributor to pneumonia‐related death in HSCT patients.     

Treatment of Acute Achilles Tendon Rupture in Scandinavia Does Not Adhere to Evidence-based Guidelines: A Cross-sectional Questionnaire-based Study of 138 Departments

The best treatment of acute Achilles tendon rupture has been discussed for decades. During the past half decade, evidence has increased in favor of nonoperative treatment and dynamic and weightbearing rehabilitation. We hypothesized that the treatment strategies would show great variation and that adherence to evidence-based recommendations would not be as good as desired. The purpose of the present study was to investigate how acute Achilles tendon rupture is treated in Scandinavia. A questionnaire was distributed to all orthopedic departments treating acute Achilles tendon ruptures in Denmark, Sweden, Norway, and Finland. The questionnaire was returned by 138 of 148 departments (response rate 93%). Two-way tables with Fisher’s exact test were used for statistical analysis. In Denmark, Norway, Sweden, and Finland, 19 of 23 (83%), 44 of 48 (92%), 26 of 40 (65%), and 8 of 27 (30%) departments recommended surgical treatment (p < .001). Dynamic rehabilitation was used significantly less often in Denmark (5 of 23 [22%]), Norway (17 of 45 [38%]), and Sweden (11 of 40 [28%]) than in Finland (15 of 26 [58%]; p = .015). A significant difference was found among the countries in the educational level of the performing surgeons (p < .001). Surgical treatment was the treatment of choice in Danish, Norwegian, and Swedish hospitals regardless of the increasing evidence favoring nonoperative treatment. Although increasing evidence has favored dynamic rehabilitation, it has gained limited use across Scandinavia. Weightbearing was used in most hospitals. Surgery was performed by junior surgeons in most hospitals across Scandinavia. Treatment algorithms showed considerable variation and often did not adhere to the clinical evidence.     

Alternative techniques in trochanteric hip fracture surgery: Clinical and biomechanical studies on the Medoff sliding plate and the Twin hook

In allowing compression along the femoral shaft (uniaxial dynamization) and optional compression along the femoral neck (biaxial dynamization), the Medoff sliding plate (MSP) represents a new principle in the fixation of trochanteric hip fractures. The Twin hook with 2 apical hooks was designed as an alternative to the lag screw. In 3 prospective consecutive case series and 1 prospective randomized study together comprising 342 trochanteric fractures, these alternative techniques were investigated. 3 postoperative fixation failures occurred in the unstable intertrochanteric fractures treated with biaxial dynamization with the MSP (n=194), and 5 in those treated with the sliding hip screw (n=62) (p=0.04). A mean femoral shortening of 15 mm with the MSP and 11 mm with the sliding hip screw was found (p=0.03). More medialization of the femoral shaft occurred with the sliding hip screw (26%) than with the MSP (12%) in patients with marked femoral shortening (p=0.03). 3 postoperative fixation failures occurred in subtrochanteric fractures treated with uniaxial dynamization (n=29) and 2 in those treated with biaxial dynamization (n=19). Medialization of the femoral shaft occurred in 9 of the 19 biaxially dynamized fractures. The Twin hook was used in 50 patients and appeared to provide similar fixation stability as the lag screw. Biomechanical tests confirmed improved stress transmission over the fracture area with the MSP compared to the sliding hip screw in intertrochanteric fractures, and similar fixation stability with the MSP and the Intramedullary Hip Screw in subtrochanteric fractures. In axial and torsional loading, the Twin hook demonstrated gradually increasing resistance to migration. With the lag screw, the peak load was higher, but after migration with failure of the support by the threads, the loads were similar. Biaxial dynamization with the MSP appears to control fracture impaction effectively and minimizes the rate of postoperative fixation failure in intertrochanteric fractures. In subtrochanteric fractures, uniaxial dynamization prevents medialization of the femoral shaft and is therefore preferred to biaxial dynamization. The Twin hook appears to provide adequate fixation stability, and with potential for simplified intraoperative handling and reduced dissection, the Twin hook may pose advantages compared to the lag screw.