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.     

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 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.     

A randomized study of open-flap surgery of 32 intrabony defects with and without adjunct bovine bone mineral treatment

Background: Bovine bone mineral (BBM) is extensively used as a filler material in periodontal reconstructive surgery of intrabony defects. Data are mostly available on the combined use of BBM with other biomaterials. The aim of this study is to evaluate healing after open‐flap debridement (OF) of intrabony periodontal defects alone or with adjunct treatment with BBM. Methods: After initial treatment, 32 patients with 32 intrabony periodontal defects participated in the study. Full‐thickness flaps were raised and root surfaces and defects were debrided. Patients were then randomly assigned to treatment groups, either OF alone or combined with defect fill with BBM, and followed in a strict postoperative maintenance care program for 12 months. Results: At 12 months, a mean ± SE gingival recession of 1.1 ± 0.3 mm in OF and 0.9 ± 0.4 mm in BBM occurred. Probing depth reduction was 4.0 ± 0.5 mm in OF and 3.2 ± 0.7 mm in BBM. Gain in clinical attachment level was 2.8 ± 0.6 mm in OF and 2.3 ± 0.8 mm in BBM. Probing bone level was reduced by 2.7 ± 0.7 mm in OF and 1.8 ± 1.1 mm in BBM. None of the above parameters showed significant intergroup differences. In contrast, radiographic defect depth change was significantly greater in BBM (3.4 ± 2.3 mm) than in OF (1.9 ± 1.7 mm). Conclusions: Both treatments resulted in improved periodontal conditions. The adjunctive use of BBM in this study did not enhance the clinical result compared to OF alone.     

MR diffusion tensor imaging documented arcuate fasciculus lesion in a patient with normal repetition performance

Background: The pathophysiology of the syndrome of conduction aphasia has been thought to involve a disconnection between posterior and anterior language areas. The arcuate fasciculus has been one of the principal candidates for an anatomical link between Wernicke's and Broca's area, but direct evidence for its involvement in conduction aphasia has been difficult to obtain. Aims: The purpose of this study was to examine white matter tract integrity, using the novel magnetic resonance imaging technique of diffusion tensor imaging, in a patient with transcortical aphasia. Methods & Procedures: A case study of a 55-year-old, right-handed man with aphasia following a left hemisphere stroke is reported. The patient's language performance was assessed with the Boston Diagnostic Aphasia Examination twice: at 10 days and at 2 years after his stroke. An MR diffusion tensor imaging study was obtained approximately 2 years after his stroke using the 1.5 T Phillips Gyroscan NT system. White matter fibre tracts maps were reconstructed using the “FACT” algorithm. Outcomes and Results: Ten days after his stroke, the patient had a non-fluent aphasia with marked impairment of both auditory comprehension and spontaneous speech. However, repetition was relatively intact. By 2 years, when the MR diffusion tensor imaging study was performed, repetition was completely normal and the patient had only subtle deficits in areas of naming and auditory comprehension. The MR diffusion tensor imaging study revealed a lesion of the dominant hemisphere arcuate fasciculus. Conclusions: This study documents normal repetition performance in a patient who on subsequent MR diffusion tensor imaging was found to have a lesion involving the dominant hemisphere arcuate fasciculus lesion. This case adds to previously published cases of normal repetition performance despite a documented lesion of the arcuate fasciculus, and thus further challenges the traditional model of conduction aphasia invoking a critical role of this white matter tract. Our case also suggests that MR diffusion tensor imaging may be a potentially useful technique to evaluate regional involvement of specific white matter tract projections in patients with aphasia.