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Total knee arthroplasty (TKA) is associated with increased risk of prolonged narcotic requirement compared to total hip arthroplasty (THA). This study aims to compare acute postoperative narcotic consumption between the 2 procedures and quantify amount of narcotics used by opioid prescribed.From October 2017 to August 2019, patients were surveyed at 4-week follow-up to determine amount and duration of opioids used and whether they continued to require narcotics. Among 1332 patients who self-identified as opioid naïve, 670 underwent THA and 662 underwent TKA. Descriptive analysis was performed based on data type.The total morphine equivalent dose (MED) used in the postoperative period was lower in THA than in TKA (143 ± 160 vs 259 ± 250 MED, P.001). The duration of use was shorter, total amount of pills consumed was lower, and refill rates were less in THA compared to TKA regardless of which opioid was prescribed. A smaller proportion of patients required narcotics at 4-week follow-up in THA compared to TKA. A postoperative prescription of 45 pills of any one type of narcotic was sufficient for nearly 90% of THA patients, and 60 pills of any one type of narcotic was appropriate for over 75% of TKA patients.THA is associated with less total narcotic consumption, shorter duration of use, less refills, and lower likelihood of requiring narcotics at 4-week follow-up. Percentiles of total narcotics consumed are provided to promote judicious postoperative prescribing patterns, and one could consider further reducing narcotics when utilizing our protocol, particularly for THA patients.This is a level III retrospective cohort study reviewing narcotic use in over 900 consecutive opioid-naïve patients undergoing total hip and knee arthroplasty.

Total knee arthroplasty (TKA) is associated with increased risk of prolonged narcotic requirement compared to unicompartmental knee arthroplasty (UKA). The purpose of the current study is to compare acute postoperative narcotic consumption between the 2 procedures and quantify narcotic consumption.From October 2017 to August 2019 patients were surveyed for four weeks to determine the amount and duration of opioids consumed and requirement for continued narcotics. Among 976 opioid naïve patients, 314 (32%) underwent UKA and 662 (68%) underwent TKA. Patients were analyzed according to specific narcotic prescribed. Total morphine equivalent dose (MED), number of pills, duration, refill percentage, and usage percentage for 4 weeks were calculated for each procedure.MED used in the postoperative period was lower in patients undergoing UKA than TKA (200 ± 195 vs 259 ± 250 MED, P = .002). Total number of pills consumed and duration of use was less in UKA compared to TKA regardless of which opioid was prescribed. A smaller proportion of patients required narcotics for 4 weeks after UKA (32% vs 43%, P.001), and fewer UKA patients required narcotic refills (14% vs 27%, P.001). Sixty pills of any 1 type of narcotic was sufficient for 90% of UKA patients and over 75% of TKA patients.UKA is associated with less narcotic consumption, shorter duration of use, less refills, and lower likelihood of narcotic requirement for 4 weeks. We report narcotic consumption patterns for both procedures to aid surgeons in judicious postoperative prescribing.This is a level III retrospective cohort study reviewing narcotic use in over 900 consecutive opioid naïve patients undergoing UKA or TKA.

Aims The purpose of this study was to use pharmacogenetics to determine the frequency of genetic variants in our total knee arthroplasty (TKA) patients that could affect postoperative pain medications. Pharmacogenetic testing evaluates patient DNA to determine if a drug is expected to have a normal clinical effect, heightened effect, or no effect at all on the patient. It also predicts whether patients are likely to experience side effects from medicine. We further sought to determine if changing the multimodal programme based on these results would improve pain control or reduce side effects. Methods In this pilot study, buccal samples were collected from 31 primary TKA patients. Pharmacogenetics testing examined genetic variants in genes OPRM1, CYP1A2, CYP2B6, CYP2C19, CYP3A4, CYP2C9, and CYP2D6. These genes affect the pharmacodynamics and pharmacokinetics of non-steroidal anti-inflammatory drugs and opioids. We examined the frequency of genetic variants to any of the medications we prescribed including celecoxib, hydrocodone, and tramadol. Patients were randomized to one of two groups: the control group received the standard postoperative pain regimen, and the study group received a customized regimen based on the pharmacogenetic results. For the first ten postoperative days, patients recorded pain scores, medication, and side effects. Results Genetic variants involving one or more medications in the multimodal pain protocol occurred in 13 of the 31 patients (42%). In total, eight patients (26%) had variants affecting more than one of the medications. For the 25 patients who recorded pain and medication logs, the mean pain levels and morphine equivalents (MEQs) consumed in the first ten days were higher in the control group than in the custom-guided group (p = 0.019 for pain and p = 0.655 for MEQ). Conclusion Overall, 42% of patients had a variant involving one of the pain medications prescribed in our perioperative pain program for TKA. Ongoing research will help determine if using these data to modify a patient’s medication will improve outcomes. Cite this article: Bone Joint J 2020;102-B(6 Supple A):73–78.

Background: A randomized, placebo-controlled phase III study (AB10015) previously demonstrated that orally administered masitinib (4.5 mg/kg/day) slowed rate of functional decline, with acceptable safety, in amyotrophic lateral sclerosis (ALS) patients having an ALS Functional Rating Scale-revised (ALSFRS-R) progression rate from disease onset to baseline of Methods: Survival status of all patients originally randomized in AB10015 was collected from participating investigational sites. Survival analysis (using the multivariate log-rank test and Cox proportional hazards model, with stratification factors as covariates) was performed on the intention-to-treat population and enriched subgroups, which were defined according to initial randomization, baseline ALSFRS-R progression rate and baseline disease severity. Results: A significant survival benefit of 25 months ( p = 0.037) and 47% reduced risk of death ( p = 0.025) was observed for patients receiving 4.5 mg/kg/day masitinib ( n = 45) versus placebo ( n = 62) in an enriched cohort with ⩾2 on each baseline ALSFRS-R individual component score (i.e. prior to any complete loss or severe impairment of functionality) and post-onset ALSFRS-R progression rate Conclusions: Analysis of long-term OS (75 months average follow-up from diagnosis) indicates that oral masitinib (4.5 mg/kg/day) could prolong survival by over 2 years as compared with placebo, provided that treatment starts prior to severe impairment of functionality. This trial was registered at www.ClinicalTrials.gov under identifier NCT02588677 (28 October 2015).

Objectives: The recent introduction of direct-acting antiviral agents (DAAs) which can eliminate Hepatitis C virus (HCV) had revolutionized the treatment of HCV infections also in a complex clinical setting such as the patients with rheumatoid arthritis (RA). HCV elimination is also opportune due to the availability of more efficient immunosuppressive drugs, whose effect on the course of HCV infection is largely unknown. Methods: Consensus process was endorsed by the Italian Society of Rheumatology (SIR) and the Italian Society of Infectious and Tropical Diseases (SIMIT) to review the available evidence and produce practical, hospital-wide recommendations. The consensus panel consisted of 18 infectious diseases consultants, 20 rheumatologists and one clinical epidemiologist, who used the criteria of the Oxford Centre for Evidence-based Medicine to assess the quality of the evidence and the strength of their recommendations. Results: A core-set of statements about management of patients with RA and infection by HCV have been developed to help clinicians in their clinical practice. Conclusions: A screening for HCV should be performed in all RA patients and it is mandatory before starting an immunosuppressive therapy. Finally, a DAA treatment should be considered in all HCV-infected patients.Significance and Innovations HCV antibodies should be investigated at the time of diagnosis of RA and, in any case, before starting immunosuppressive therapy with disease-modifying antirheumatic drugs (DMARDs). HCV eradication with DAA should be attempted as soon as possible, depending on patient conditions allowing a continuous oral treatment lasting 8–12 weeks Conventional and biological DMARDs are allowed in patients with HCV infection, but they should be used cautiously in presence of advanced liver disease.

The Center for Health Design estimates that more than 30% of surgical site infections are caused by airborne pathogens. A device that creates a localized clean air field directly adjacent to and surrounding the incision site is meant to shield a surgical site from particulate in the operating room. The purpose of this study was to determine whether the routine use of this device would reduce the rate of infection following total hip arthroplasty (THA). The authors conducted a retrospective review of primary THA cases performed with and without the airflow device. Since July 2013, a total of 1093 primary THA cases were performed with the device at the authors' institution. The incidence of wound dehiscence and deep infection was compared with that of 1171 THA cases performed prior to July 2013 without the airflow device. There were no significant differences between the study groups regarding average patient age, sex, body mass index, or diagnosis. In the airflow group, there were 7 (0.64%) deep infections and 5 (0.46%) cases of wound dehiscence that required a return to the operating room for irrigation and wound revision. In the control group, there were 7 (0.60%) cases of deep infection and 4 (0.34%) wound revisions. The groups were not significantly different in the rates of infection ( P =1.0) or wound revision ( P =.75). Both groups had a very low incidence of infection and wound revision, with rates below 1%. Despite compelling bench data showing a dramatic reduction of particle load in the wound, the use of the airflow device did not reduce the clinical rate of infection over a large number of cases. [ Orthopedics . 2020;43(5):e425–e430.]

Purpose Electrochemotherapy (ECT) is a therapeutic approach based on the local application of electrical pulses that permeabilize cell membranes to enhance the uptake of low-permeant chemotherapeutic agents, thus increasing their cytotoxic effects. Materials and methods Twenty-one patients with SCC of the lower lip were treated according to the European Standard Operating Procedures of Electrochemotherapy. Bleomycin (15,000 IU/m2 body surface area) was administered intravenously over a 1-min period. Eight electrical pulses (amplitude, 1000 V/cm; duration, 100 μs) were generated and delivered at a repetition frequency of 5 kHz. Changes in tumor volume were used to assess treatment response. Results Objective response (OR), complete response (CR), and partial response (PR) rates of 100%, 71.4%, and 28.6% respectively were demonstrated following a single session of ECT. ECT was well tolerated, and no adverse events occurred. Conclusions Intravenous bleomycin-based ECT is a safe and effective therapy for SCC of the lower lip. ECT improves the quality-of-life of patients by preserving the function and the aesthetic appearance of the affected area. ECT provides a therapeutic option for elderly and frail patients who, due to their state of health, are not suitable for, or refuse surgical interventions.

Introduction Hereditary heart diseases are most often characterized by autosomal dominant inheritance and delayed cardiac expression. Predictive genetic testing (PGT) is offered to asymptomatic relatives to allow targeted medical care with early therapeutics in order to reduce the risk of complications. Purpose The aim of this study was to evaluate the psychological and socio-professional impact of predictive genetic testing in hereditary heart diseases through a prospective and retrospective study. Methods & results This multicentric French study involved 20 expert centers in hereditary heart diseases. We included 517 adult relatives (42.3 ± 16.7 years, 60.6% females) who performed PGT (prospective study: n = 264, retrospective study: n = 253). The opinion and experience were collected via auto-questionnaires, at various moments in the prospective study, with different items and validated scales (STAI and IES). In the prospective study, family history was characterized by cardiomyopathy (88.4%) and channelopathies (11.6%). The main motivations for performing the test were: “to remove doubt” (65.3%), “for children” (64.0%), “to benefit from medical supervision” (34.9%). A mutation was present in 39.4% of relatives. No regret was expressed after testing (only 2.3% regrets). The result did not lead to a socio-professional change or family relationship change in 60.7%. Among those who had a change, it was perceived as unfavorable for only 3%. The level of anxiety (STAI) increases before the test result and decreased to return to baseline. Subjects with depression history were more likely to develop anxiety at long-term after multivariate analyses (P = 0.004). Conclusions Our results show that contrary to a widespread opinion, the medical benefit was not the main motivation for predictive genetic testing. In most cases, no or marginal adverse psychological and socio-professional impact of genetic testing was observed when performed by a team expert in predictive testing.

Introduction Hereditary heart diseases (cardiomyopathy & channelopathies) are most often characterized by autosomal dominant inheritance and delayed cardiac expression. The risk of complications of these diseases are sudden cardiac death and heart failure. Medical management allow to reduce significantly, but does not cancel, the risk of complications. If the causal mutation is known, couples with a pregnancy project may discuss the use of prenatal genetic diagnosis (PND) or preimplantation genetic diagnosis (PGD). The use of PND or PGD in these diseases is controversial and the medical, ethical and psychological issues are particularly complex. Purpose The aim of this study was (i) to collect at national level the procedures of PNDs and PGDs in the context of “isolated” hereditary heart disease; (ii) obtain the opinion of patients about this issue. Methods and Results The data collected with help of the French Biomedicine Agency show that 18 PND were carried out in France between 2009 and 2017 and 13 PGD between 2013 and 2017. So, number of PND and PGD for hereditary heart disease is rare in comparison of the relatively high prevalence of these diseases. The opinion of 20 patients (95% with cardiomyopathy), followed at Pitie-Salpetriere referral center for hereditary heart diseases, was prospectively collected via auto-questionnaires. Their answers show that few know the options (PND, PGD, gamete donation, adoption): only 25% are aware of all the alternatives. Despite this, 45% of patients mentioned that they did not want more information about these procreation options. Moreover, 45% consider the use of a PND to be fully acceptable or acceptable and 75% for the use of PGD, although they would not ask for themselves. Conclusions We report the first data about procreation procedures in France, and wishes of patients, in non-syndromic hereditary heart diseases. This may help to better manage these complex issues in clinical practice.

This article deals with the attempt to join HIV and geriatric care management in the 2017 edition of the Italian guidelines for the use of antiretrovirals and the diagnostic-clinical management of HIV-1 infected persons. The outlined recommendations are based on evidence from randomized clinical trials and observational studies published in peer-reviewed journals and/or presented at international scientific conferences in recent years. The principles of starting antiretroviral therapy in elderly patients and the viroimmunological goals are the same as in the general HIV population. However, there are some specificities to consider, related to the host as well as the therapy itself. HIV care in elderly patients must shift from a combined AntiRetroviral Therapy specific approach to a more comprehensive management, and from a disease-based model (list of co-morbidities) to a multi-morbidity and frailty standpoint. The implementation of a geriatric approach, based on the Comprehensive Geriatric Assessment, is essential and consists of a broader evaluation of health status. This multidimensional and multidisciplinary evaluation is focused on the development of a tailored intervention plan. Polypharmacy is a frequent condition in the older population and an independent risk factor for negative health-related outcomes. This can be overcome with a multidisciplinary and cooperative approach involving HIV specialists, geriatricians and primary care physicians. The inclusion of geriatric care becomes necessary due to the novel needs of an evolving patient population. It is important to underline that the HIV specialist will continue to lead multidimensional interventions and optimize quality of care for HIV-positive people.

OBJECTIVES: The long-term side effects of stavudine (d4T) led to recommendations in 2009 to phase out use of this drug. We aimed to describe temporal patterns of d4T use across Europe. METHODS: Patients taking combination antiretroviral therapy (cART) in EuroSIDA with follow-up after 1 January 2006 were included in the study. cART was defined as d4T-containing [d4T plus at least two other antiretrovirals (ARVs) from any class] or non-d4T-containing (at least three ARVs from any class, excluding d4T). Poisson regression was used to describe temporal changes in the prevalence of d4T use and factors associated with initiating d4T. RESULTS: A total of 5850 patients receiving cART on 1 January 2006 were included in the current analysis, rising to 7768 patients on January 1 2013. During this time, the prevalence of d4T use fell from 11.2% to 0.7%, with an overall decline of 19% per 6 months [95% confidence interval (CI) 19-20%]. d4T use declined fastest in Northern Europe [26% (95% CI 23-29%) per 6 months], and slowest in Eastern Europe [17% (95% CI 16-19%) per 6 months]. In multivariable Poisson regression models, new d4T initiations decreased by 14% per 6 months [adjusted incidence rate ratio (aIRR) 0.86; 95% CI 0.80-0.91]. Factors associated with initiating d4T were residence in Eastern Europe (aIRR 4.31; 95% CI 2.17-9.98) versus other European regions and HIV RNA > 400 copies/mL (aIRR 3.11; 95% CI 1.60-6.02) versus HIV RNA < 400 copies/mL. CONCLUSIONS: d4T use has declined sharply since 2006 to low levels in most regions; however, a low but persistent level of d4T use remains in Eastern Europe, where new d4T initiations post 2006 are also more common. The reasons for the regional differences may be multifactorial, but it is important to ensure that all clinicians treating HIV-positive patients are aware of the potential harmful effects associated with d4T.

Objectives Hepatitis B (HBV) infection, which is prevalent worldwide, is also frequently seen in patients with rheumatoid arthritis (RA). The Italian Society of Rheumatology (SIR) and the Italian Society of Infectious and Tropical Diseases (SIMIT) endorsed a national consensus process to review the available evidence on HBV management in RA patients and to produce practical, hospital-wide recommendations. Methods The consensus panel consisted of infectious disease consultants, rheumatologists and epidemiologists and used the criteria of the Oxford Center for Evidence-based Medicine to assess the quality of the evidence and the strength of their recommendations. Results A core-set of statements has been developed to help clinicians in the management of patients with RA and HBV infection. Vaccination and prophylaxis of RA patients treated with biological drugs have been also discussed. Conclusions HBV infection is not rare in clinical practice; a screening for HBV in all patients with early arthritis is not universally accepted, while it is considered mandatory before starting any immunosuppressive or hepatotoxic treatment. In fact, a specific risk, associated with the use of biologic treatments, exists for patients with HBV infection, although longitudinal studies of viral reactivation are generally reassuring. RA patients with HBV infection should be referred to the hepatologist and correctly classified into active or inactive carriers. Patients with active hepatitis B should undergo antiviral treatment before starting immunosuppressive treatments. Occult HBV carriers should be monitored or receive prophylaxis on the basis of the risk of reactivation associated with the administered treatment.

The anatomic relationship between major neurological and vascular structures in the neck places any patient undergoing cervical spine surgery at risk of complications during the surgical exposure for degenerative, traumatic and oncologic pathologies. A knowledge of anatomy and careful technique during dissection are essential to prevent and treat injures if they occur. In this paper we describe the neuro-vascular structures at risk for the most usual anterior and posterior approaches and provide strategies for prevention and treatment of these injuries.

Introduction The zygomaticomaxillary complex is very vulnerable to injury because of its intrinsically prominent convexity. There are 2 different surgical approaches for the therapy of these fractures: closed reduction and open reduction. In the open reduction 2 or 3 fixation points with related incisions are usually necessary in dislocated fractures: osteosynthesis must be performed starting from zygomaticofrontal suture when dislocated at this site, followed by zygomatic body fixation on the anterior sinus wall, anterior orbital floor margin fixation, and finally orbital floor reconstruction in case of eye globe dislocation with diplopia. Aim This study evaluated the combination of the transconjunctival (TC) approach without canthotomy in association with the transoral maxillary approach and lateral rim skin incision (SI) without canthotomy for frontozygomatic dislocated fractures to achieve proper reduction and stabilization without any aesthetic decay in young patients. A less invasive and more aesthetic technique is shown for treating dislocated zygomaticomaxillary complex fractures with 2 or 3 fixation points and platelet-rich fibrin (PRF) use to promote tissue healing. Materials and methods Ten patients (mean age: 32) were referred for dislocated zygomaticomaxillary complex fracture. Five patients were treated by TC approach without canthotomy in association with the transoral maxillary approach and, when needed, eyebrow SI without canthotomy for frontozygomatic dislocated fractures (group 1). Five more patients were treated by traditional subciliar incision at lower eyelid and vertical lateral incision at lateral margin of the orbit (group 2). Autologous PRF for orbital floor reconstruction was used. The follow-up period was 6 months long. Follow-up radiographs (TC) and photos were routinely used to evaluate the adequacy of reduction and lower eyelid right position or retraction. Results All cases were successful; there were no problems at surgery and postoperative time. During the 6-month follow-up, all 5 patients of group 1 showed satisfactory facial symmetry, no noticeable scarring, no ectropion or lower eyelid significant droop, and no functional impairment. Mean difference for lower eyelid droop between the 2 groups of patients was 1.4 mm at T1 and 1.2 mm at T2. Discussion Aesthetic result is a priority in the treatment planning of orbitozygomatic fractures because of the fundamental role of the eye and lid area in the aesthetic of the face. In our experience best aesthetic results were achieved through a latero cantal horizontal SI combined to a vertical periosteal incision at the frontozygomatic rim without canthotomy, thus performing a different double-layer incision. In the patients with large orbital floor dislocation, reconstructive titanium mesh was covered by autologous PRF membranes, which can improve the vascularization of the surgical site, by promoting neoangiogenesis. Conclusions In young patients these techniques are indicated because of the need of better aesthetic results that can be achieved by preventing postoperative functional impairment with lower eyelid droop and unnatural aesthetic asymmetry of the 2 lower lids. This more conservative technique resulted in better aesthetic results, avoiding most common complications.

Despite several scientific and technological advances, there is no single neuroprotective treatment that can reverse the brain damage after acute ischemic stroke (AIS). Neuroactive steroids are cholesterol-derived hormones that have the ability to modulate the normal and pathologic nervous system employing genomic and nongenomic mechanisms. In this work, we first investigated if AIS affects the plasma concentration of 5 neuroactive steroids (cortisol, estradiol, progesterone, testosterone, and 3α-androstenediol glucuronide). Second, we studied if levels of circulating steroids associate with neurological, cognitive, and functional outcome in a cohort of 60- to 90 year-old male and female patients with AIS. For this purpose, we recruited patients who were hospitalized at the Emergency Room of the Central Military Hospital within the first 24 h after stroke onset. We designed 2 experimental groups, each one composed of 30 control subjects and 30 AIS patients, both males and females. The assessment of neurological deficit was performed with the NIHSS and the tests used for the functional and cognitive status were: (1) modified Rankin Scale; (2) Photo test, and (3) abbreviated Pfeiffer's mental status questionnaire. We observed a significant difference in plasma concentration of cortisol and estradiol between both experimental groups. In the AIS group, higher levels of these neuroactive steroids were associated with more pronounced neurological, cognitive and functional deficits in women compared to men. We propose that in elderly patients, high levels of circulating neuroactive steroids like cortisol and estradiol could potentiate AIS-mediated neuropathology in the ischemic and penumbra areas. Fil: Casas, Sebastian. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor ; Argentina Fil: Gonzalez Deniselle, Maria Claudia. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; Argentina Fil: Gargiulo Monachelli, Gisella Mariana. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; Argentina Fil: Pérez, Andrés Felipe. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor ; Argentina Fil: Tourreilles, Martin. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor ; Argentina Fil: Mattiazzi, Marcelo. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor ; Argentina Fil: Ojeda, Cristian. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor ; Argentina Fil: Lotero Polesel, Daniel. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor ; Argentina Fil: de Nicola, Alejandro Federico. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor ; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Publishing outlets in the field of early childhood vary widely in terms of emphasis on theory, practice, and research as they relate to the care and education of the very young; these outlets also have different readerships (i.e., primarily for teachers, the teachers of their teachers, or the fellow scholars/researchers). Included in the mixture of publications in the early childhood field are two broad categories: (1) professional magazines that are intended primarily for an audience of practitioners and (2) journals that are intended primarily for college students, teacher education faculty, and researchers. This article begins with a discussion of the extrinsic and intrinsic benefits of publishing for the early childhood professional as well as some of the impediments to scholarship in the field. It then surveys 24 different publishing outlets in early childhood education and provides descriptive data on each magazine or journal. Next, it explains the anonymous peer review process that is used to evaluate journal articles. The article concludes with practical advice to authors seeking to publish in the early childhood field.

Background and purpose: Sporadic amyotrophic lateral sclerosis (sALS) is a disease with a focal clinical onset and contiguous spread. We examined patterns of disease spread following symptoms onset in sALS and whether the pattern of spread predicted survival. Methods: Review of medical records (2003–2009) at London Ontario and Buenos Aires clinic cohorts retrieved 318 patients with sporadic sALS. According to patient self-report, we determined eight spread patterns: rostro-caudal, caudo-rostral, crossed, circular, superior interposed, middle interposed, inferior interposed and isolated. The variables studied were as follows: age, gender, sALS phenotypes, time from onset to diagnosis and time and direction of the spreading to the first region. Survival from symptoms onset was analysed by Kaplan–Meier, Tarone-Ware and Cox proportional hazards methods. Results: The direction of first spread was horizontal in 33%, rostral to caudal in 32% and caudal to rostral in 21%, whereas spread to remote regions was observed in 14% of patients. Survival curves and 3- and 5-year survival rates favoured patients with an isolated and caudo-rostral pattern of spread compared to patients progressing to distant regions without involvement in the intervening region, or superior and inferior interposed patterns (Tarone-Ware P = 0.001, v 2 = 0.002 and v 2 = 0.006, respectively). Factors affecting survival were gender, time to diagnosis, flail arm phenotype and age at diagnosis. Conclusions: We have provided evidence that not all spread in ALS is contiguous and that the nature of symptom progression influences survival. Patients with sALS with interposed patterns had a worse prognosis, whereas patients with caudo-rostral pattern fared better than the rest.

Background The orthopedic literature documents that obesity can place patients at increased risk for complications. This is the first study to document the increased risk of infection in obese patients after direct anterior approach (DAA) primary total hip arthroplasty (THA). Methods We retrospectively evaluated 1621 consecutive primary THAs performed with a DAA. Patients were stratified by body mass index 2 (group 1) or ≥35 kg/m 2 (group 2). Rates of postoperative infection requiring revision, superficial wound dehiscence, return to the operating room, and total wound complications were compared. There were 1417 cases in group 1 and 204 in group 2. Results Five cases in each group had a deep infection, resulting in a significantly higher rate in group 2 (0.35% vs 2.5%, P = .0044, relative risk = 7.1). Superficial wound dehiscence was diagnosed in 13 (0.92%) THA in group 1 and 4 (1.96%) in group 2 ( P = .256). The all-cause reoperation rate was 0.92% and 3.43% in each group, respectively ( P = .008). The total rate of all studied complications was 1.27% compared to 4.41% ( P = .0040, relative risk = 3.5). Conclusion This is the first study to report on significantly increased rates of postoperative infection requiring revision in patients with body mass index ≥35 kg/m 2 after anterior approach hip arthroplasty. We believe it is the combination of immune dysfunction and proximity of the anterior incision to the inguinal crease and genitalia with overlying abdominal pannus that contributes to this risk. Further studies comparing other surgical approaches in obese patients are needed to determine if this complication is truly attributable to the DAA alone.

In this paper, a DC/DC power converter devoted to electrical motor drive in motorbike racing application is designed and simulated in MATLAB Simulink environment, along with its control logic strategy. In particular, we conceived, developed and simulated a thermal control strategy, to be implemented as the logic core of the power converter, which dynamically and automatically fits the electric power fed to motor, depending on its actual temperature. As a result, motor burnout during the race is avoided, improving the power train reliability without affecting the racing performance. Simulation results, in which the whole power train system was modeled in Simulink, confirmed the proposed algorithm effectiveness.

A major breakthrough in the molecular genetics of hypertrophic cardiomyopathy (HCM) has made genetic testing now available in clinical practice, raising new questions about its implications, potential benefits, and the organisation of the procedure. The aim of this work was (1) to discuss the different questions related to genetic testing in HCM, and propose guidelines for the different situations, (2) to report our preliminary experience with a specific procedure.The main questions asked by patients and relatives concern presymptomatic diagnosis and prenatal counselling/diagnosis, while clinicians sometimes discuss diagnostic and prognostic testing. To take into account the complex medical and psychological implications of this new approach, we developed a specific, multidisciplinary, and multiple step procedure, including a cardiologist, a geneticist, and a psychologist. Seventy subjects were examined, including (1) 29 adults for presymptomatic diagnosis (of whom 10 left the procedure after the first visit and 19 continued, among whom six had a mutation and two experienced negative psychological impact, observed during follow up), (2) nine couples of parents for presymptomatic diagnosis in their children (the procedure was stopped after the first visit in eight and continued in one), (3) 22 couples for prenatal counselling (no prenatal genetic testing was asked for after the first visit), and (4) 10 subjects for diagnostic testing. We decided to perform no prognostic testing.Our preliminary experience confirms the complexity of the situation and suggests the necessity for a specific procedure to ensure good practice in genetic testing of HCM.

Full article available online at Healio.com/Orthopedics The goal of this study was to evaluate patient satisfaction with the use of a mobile compression device after anterior total hip arthroplasty. Two hundred forty-seven patients used the mobile compression device for 10 days after surgery with recom- mended adjunctive 325 mg aspirin therapy. The device has a rechargeable battery pack that weighs 1.65 lb and is attached to compression sleeves worn over the calves of both lower extremities. It delivers sequential compression to the sleeves at a pressure of 50 mm Hg for about 10 seconds at a cycle of 1/min and is synchro- nized to the patient's venous blood flow pulses. A questionnaire was administered to all patients at 1-month follow-up to gauge patient perception of the device. There were 14 questions about comfort, noise, cost, pain, skin breakdown, rash, and falls related to the device. Overall, 234 of 247 (94.7%) patients stated that they would use the device again. The most common complaint from patients was that the mo- bile compression device was cumbersome (63.6%). Twenty-five patients (10.1%) reported having a fall while using the device, although no fall-related injuries were documented. Therefore, the authors recommend counseling patients about fall risk and reminding them to use caution while moving about with the device. Despite the limitations described in this study, the data confirmed that patients who used the device had an overall positive response to the system and would choose to use the device again rather than using chemical agents for deep venous thrombosis prophylaxis.

Shotgun injuries to the maxillofacial region may have minor or, more often, devastating consequences. The most important factor in determining the extent of injury is the distance of the victim from the muzzle of the gun: usually, the longer the distance, the less severe the damage. Here is reported a case of shotgun injury sustained from a distance of approximately 10 m in which the deeper penetration of a single lead pellet led to significant involvement of the temporomandibular joint.

With the aim of evaluating if Shirodkar cerclage is appropriate for patients at high risk of cervical incompetence, we performed a retrospective analysis of the results obtained with this procedure performed over an 8-year period by a single surgeon in 65 women in whom previous cerclage(s) had proved unsuccessful. The women were divided into three groups according to indication for cerclage as follows: (I) 31 women considered at high risk of cervical incompetence based on their obstetric history or altered cervical conditions, 16 of whom had had two or three cerclages without success, (II) 9 women with prolapse of the amniotic sac who required emergency Wurm-Hefner cerclage, and (III) 25 women with a history of conservative operations on the uterus who underwent a prophylactic Shirodkar cerclage (experimental management). The pregnancy outcome was not known in 7 cases. A full-term pregnancy (≥37 weeks of gestation) was achieved in 44 women, and premature delivery (34–36 weeks) occurred in 7 and v...

The majority of today's Internet-based services are generally not concerned about the level of quality of service (QoS) presented to their users. For many such services, however, the QoS perceived by users is becoming a critical success factor. The main QoS attributes include those related to the service availability and timeliness. Ensuring them is essential to many services. In our opinion, this has to be achieved not only by providing services with appropriate access bandwidth, or through QoS awareness of the network communication protocols used, but also by means of a differentiation of the usage of system resources by server processes. We focus on Internet-based multimedia data delivery services (e.g., services provided by Web, FTP and video-on-demand servers). These services are run by processes whose activity is typically dominated by network communication; we call them communication-bound processes. We present the design and implementation of an operating system extension for quality-of-service differentiation among classes of communication-bound processes. The system allows to define classes of services with different quality attributes concerning the network data delivery performance. The proposed architecture provides server application developers with an object-based communication library (similar to the standard TCP/IP socket library), that supports different classes of service. Implementation issues and optimization strategies are also discussed. Quantitative measures aimed at evaluating the effectiveness of the proposed architecture are provided.

Abnormal anterior-posterior and rotational motion secondary to anterior cruciate ligament (ACL) insufficiency is typically described in terms of dynamic laxity. An original description of the abnormal tibiofemoral relationship in the setting of ACL insufficiency has highlighted the presence of a fixed anterior tibial subluxation in this population of failed ACL reconstruction (ACLR); however, no study has quantified the degree of tibial subluxation in both the medial and lateral compartments.To measure and compare the amount of anterior tibial subluxation among various states of ACL competency, including (1) intact ACL, (2) acute ACL disruption, and (3) failed ACLR (ie, patients requiring revision ACLR). We hypothesized that anterior tibial displacement would be greater in the lateral compartment and in cases of failed ACLR compared with intact and acute ACL injured states.Cross-sectional study; Level of evidence, 3.Using sagittal magnetic resonance imaging (MRI) and a standardized measurement technique, we determined the amount of anterior tibial subluxation relative to a constant posterior condylar reference point. Measurements were performed in both the medial and the lateral compartments and were compared with 1-way analysis of variance. The presence of meniscal tears along with meniscal volume loss and chondral damage was correlated with the amount of subluxation in each group.Compared with the intact ACL state, the medial tibial plateau was positioned more anteriorly relative to the femur in both acute ACL injured knees (mean 1.0 mm) and those that failed ACLR (mean 1.8 mm) (P = .072). In the lateral compartment, there was 0.8 mm of mean anterior tibial displacement after acute ACL injury and 3.9 mm of mean anterior subluxation in patients who failed ACLR (P.001). Mean anterior displacement of the lateral plateau in patients who failed ACLR was almost 5 times greater than the amount observed in patients with acute ACL injuries. There was no correlation between meniscal/chondral injury and the amount of subluxation.Patients who require revision ACLR have an abnormal tibiofemoral relationship noted on MRI that is most pronounced in the lateral compartment and should be taken into account during revision surgery. These observations may explain the suboptimal clinical results seen in some patients who undergo revision ACLR.

Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.

Parallel resonant converter (PRC) behaves as a constant current (CC) source when operated at its resonant frequency; however, its output current slightly depends on output load changes. In practical applications - e.g. in LED drivers - a precisely regulated output value should be requested, also over a wide load range. To fix this shortcoming, in this paper we present a PRC-CC with variable switching frequency control implemented on microcontroller (µc), to regulate output current against load variations. Optimal design considerations are introduced to allow the adoption of such kind of control strategy, without losing the CC circuit behavior and zero voltage switching (ZVS) transitions. A 100 W, 2 A PRC-CC prototype was realized. Experimental results demonstrate the CC behavior of the controller, as well as the effective output current regulation.

Sporadic amyotrophic lateral sclerosis (sALS) is considered a multifactorial disease with genetic and environmental factors causing motor neuron degeneration. To describe the epidemiological and occupational characteristics of patients with sALS who attended the Ramos Mejía Hospital at Buenos Aires, Argentina. We analyzed the medical records of sALS patients diagnosed between 2001 and 2008. All occupations were coded according to the International Standard Classification of Occupation (ISCO). La esclerosis lateral amiotrófica esporádica (ELAe) es considerada una enfermedad multifactorial. Se describen las características epidemiológicas y laborales de un grupo de pacientes con ELA que fueron evaluados en el Hospital Ramos Mejía de Buenos Aires, Argentina. Se analizaron los registros médicos de pacientes con ELAe diagnosticados entre 2001 y 2008. Las ocupaciones fueron codificadas de acuerdo a la Clasificación Internacional de Ocupaciones (ISCO). Fil: Bettini, Mariela. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; Argentina Fil: Gargiulo Monachelli, Gisella Mariana. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; Argentina Fil: Rodriguez, Gabriel. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; Argentina Fil: Rey, Raúl C.. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; Argentina Fil: Martinez Peralta, Liliana A.. Universidad de Buenos Aires. Facultad de Medicina. Departamento de Microbiología; Argentina Fil: Sica, Roberto Ernesto Pedro. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

A novel active bypass approach for shaded photovoltaic panels embedded in a string is presented, which benefits from the low voltage drop across a bipolar transistor operated in saturation, whose activation is automatically handled by a circuit comprising a pair of MOS transistors only. The functioning principle of the proposed system is carefully discussed, and the improvement in comparison to the traditional diode-based scheme is clarified.

A straightforward non-invasive method is proposed to accurately evaluate the shunt resistance of an elementary cell of a photovoltaic module connected in an installed string without the need of preliminary knowledge of the intrinsic diode parameters. The approach relies on the measurement of the current-voltage characteristic of the whole string after intentionally shading the selected cell. Calibrated PSPICE simulations are employed to both illustrate and test the method. As a case study, the shunt resistances of several cells belonging to a series array of 10 commercial modules are determined.

A monitoring circuit for individual photovoltaic (PV) panels in grid-connected systems is proposed, which exhibits a number of features devised to simplify and reduce cost of diagnostics and maintenance of the PV plant. In particular, the system is provided with an effective energy harvesting supply stage, which eliminates the requirement for external supply or batteries; furthermore, no cables are needed for data transfer due to the adoption of a rugged wireless connectivity.

Donor site complications of the radial forearm are a significant cause of post-operative morbidity. 15 patients had radial forearm free tissue donor sites treated with split skin grafts and a negative pressure dressing. All grafts showed 100% take at 5 days. The advantages of this technique include rapid healing at an unfavourable graft recipient site, increased graft take and decreased donor site complications. This method is ideally suited for the management of large defects. The dressing can be quickly and easily applied and there have been no significant complications.

A total of 124 patients with lower respiratory tract (44) or urinary tract infections (80) were enrolled in an open, multicenter study to evaluate the efficacy and tolerability of sulbactam/ampicillin, administered at the dosage of 3 g/die by intramuscular route. Pretreatment pathogens from patients with lower respiratory tract infections included: Streptococcus alpha-haemolyticus in 8 cases, Streptococcus beta-haemolyticus in 2 cases, Staphylococcus albus in 7 cases, Haemophilus influenzae in 7 cases, Staphylococcus aureus in 6 cases, Klebsiella oxytoca in 5 cases, Staphylococcus epidermidis in 3 cases, Streptococcus pneumoniae in 3 cases, Escherichia coli in 2 cases; in one subject (2.75%), no microorganisms were isolated. In vitro, 36 isolates (84%) were sensitive to SA and 7 (16%) were resistant. At the end of therapy, all the causative pathogens sensitive to sulbactam/ampicillin were eliminated. In patients with urinary tract infections, pretreatment pathogens were: E. coli in 40 cases, S. albus in 16 cases, Proteus mirabilis in 8 cases, Enterobacter agglomerans in 6 cases, Proteus vulgaris in 3 cases, Streptococcus faecalis in 3 cases, Streptococcus liquefaciens in 2 cases, Pseudomonas aeruginosa in 2 cases. In vitro, 64 isolates (80%) were sensitive to sulbactam/ampicillin and 16 (20%) were resistant. At the end of therapy, 63 out of the 64 pathogens sensitive to sulbactam/ampicillin were eliminated; in one case the therapy was interrupted due to adverse effect. Clinical efficacy: in subjects with lower respiratory tract infections, sulbactam/ampicillin cured 32 patients (72.72%) and ameliorated the clinical status of 8 patients (18.18%); efficacy rate: 90.9%).(ABSTRACT TRUNCATED AT 250 WORDS)

Hereditary heart diseases are typically characterized by autosomal dominant inheritance and delayed cardiac expression. Predictive genetic testing is offered to asymptomatic relatives to allow targeted medical care with early therapeutics in order to reduce the risk of complications (sudden death, heart failure). Psychological and sociological issues related to predictive testing are however complex and have been poorly studied. Predictive genetic testing is performed in our multidisciplinary out-patient clinic dedicated to cardiogenetics since 1999. To evaluate our practices regarding predictive genetic testing for hereditary heart diseases and study the behavior of relatives after pre-test consultation (information phase), especially regarding a waiting period that was offered before blood sampling. We retrospectively studied records from 304 consecutive relatives seen in our department and have requested predictive genetic testing. Underlying diseases in the families were HCM (60%), DCM (17%), ARVC (15%), LQT (5%), Brugada syndrome (2%) and other (1%). A total of 21 different genes were analyzed and most frequent ones were MYBPC3 (97), MYH7 (77), LMNA (37), PKP2 (29) and TNNT2 (16). There were 260 adults and 44 minors. At the time of the first consultation, the average age was 37 years, and 83% of the relatives previously had a cardiac checkup (echocardiography for 71%). After first multidisciplinary consultation, 22 relatives (8%) dropped out of procedure (did not performed blood sampling) and 11 relatives (3%) performed blood sampling but did not come back to know their results. Blood sample was delayed for 70% of relatives and immediate for 30%. A mutation was present in 36% of relatives (leading to careful follow-up and cascade screening in offspring) and absent in 64% (they were reassured and discharged from clinic). We observed a high level of genetic uptake after initial consultation but a minority of relatives decided to stop or delay the procedure. These results suggest the benefit of a waiting period before blood sampling and illustrate the importance of a multidisciplinary team in this setting.

Stimulation of the subthalamic nucleus is an effective treatment for advanced Parkinson disease (PD) and is currently performed after a mean disease duration of 14 years, when severe motor complications have resulted in marked loss of quality of life. We examined whether surgery at an early stage would maintain quality of life as well as improve motor function.Twenty patients with PD of short duration (time elapsed since first symptom +/- SD: 6.8 +/- 1.0 years) with mild to moderate motor signs (Unified Parkinson's Disease Rating Scale III "off" medication: 29 +/- 12) who responded well to levodopa treatment were included in pairs, matched for age, duration and severity of disease, and impairment in socioprofessional functioning. Patients were prospectively randomized to undergo bilateral subthalamic nucleus stimulation (n = 10) or receive optimized medical treatment (n = 10). Parkinsonian motor scores, quality of life, cognition, and psychiatric morbidity were assessed at inclusion and at 6, 12, and 18 months after randomization.Quality of life was improved by 24% in surgical and 0% in nonsurgical patients (p0.05). After 18 months, the severity of parkinsonian motor signs "off" medication, levodopa-induced motor complications, and daily levodopa dose were reduced by 69%, 83%, and 57% in operated patients and increased by 29%, 15%, and 12% in the group with medical treatment only (p0.001). Adverse events were mild or transient, and overall psychiatric morbidity and anxiety improved in the surgical group.Subthalamic nucleus stimulation should be considered a therapeutic option early in the course of Parkinson disease.

Background and purpose Previous studies have suggested that elevated progesterone levels are associated with a slower disease course in amyotrophic lateral sclerosis (ALS). Given that the effects of progesterone are mediated in part by the classical progesterone receptor (PR), the expression and cellular localization of the A and B isoforms (PR-A and PR-B, respectively) of the PR in control (neuropathologically normal) and ALS-affected spinal cord (SC) were examined. Methods Semi-quantitative RT-PCR, immunohistochemistry and immunofluorescence analyses of the cervical and lumbar SC of post-mortem ALS patients (n = 19) and control subjects (n = 10) were performed. Primers and antibodies used allowed the detection of both PR-A and PR-B isoforms together (PR-A+B) or PR-B isoform alone. Results Lumbar PR-A+B and cervical PR-B mRNA expression were significantly higher in ALS than controls. In both ALS and controls, PR-A+B immunoreactivity (IR) was occasionally detected in motor neurons. In contrast, PR-A+B IR was prominent in axonal processes and vessels. This was more evident in nerve roots and large arteries in ALS compared with controls. Colocalization of PR-A+B with markers of neurons, axonal processes and vascular endothelium was also observed. Conclusions Evidence that both PR-A and PR-B isoforms are expressed in the human SC is provided, with some regional variation in isoform expression between ALS and controls. The IR was more prominent in nerve roots and large arteries in ALS, suggesting a potential role in the degenerative process. Fil: Gargiulo Monachelli, Gisella Mariana. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental (i); Argentina. Western University; Reino Unido Fil: Campos Melo, Danae. Western University; Reino Unido Fil: Droppelmann, Cristian A.. Western University; Reino Unido Fil: Keller, Brian A.. Western University; Reino Unido Fil: Leystra Lantz, Cheryl. Western University; Reino Unido Fil: de Nicola, Alejandro Federico. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental (i); Argentina Fil: Gonzalez Deniselle, Maria Claudia. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental (i); Argentina Fil: Volkening, Kathryn. Western University; Reino Unido Fil: Strong, Michael J.. Western University; Reino Unido

Background Mesangial lupus nephritis (MLN) is thought to follow a benign course although there are studies that show otherwise(1,2). Objectives Our aim was to describe the clinical progression in patients with MLN. Methods retrospective, multicentric study in patients with systemic lupus erythematosus and MLN (ISN/RPS 2003) on the first renal biopsy and at least 12 months of post-biopsy follow-up. Demographic, clinical and laboratory characteristics were reviewed. Treatment response was rated based on the EULAR/ ACR criteria(3). Patients were divided into two groups: responders (R)[complete (CR) and partial (PR)] and non-responders(NR):[NR, chronic renal failure(CRF), histology transformation(HT)]. Favorable long term outcome was considered if the patient remained at CR or PR at the last evaluation. Unfavorable was defined as transformation to a proliferative or a membranous type or CRF at any time. The Mann-Whitney test was used to compare numerical variables, Fisher’s exact test to compare ratios. Results Twenty-seven patients (23 females) were assessed. Mean age at the time of first biopsy: 28.2±9 years old. Median time from SLE diagnosis to first biopsy: 1 year (range=0-6). Median time from onset of signs of nephropathy and first biopsy: 2 months (range=0-15). The presentations were: proteinuria > 0.5g/24hr: 19 patients (7 nephrotic-range), 13 hematuria, and 1 impaired renal function requiring dialysis. After the first biopsy 27 patients received corticosteroid therapy (0.5-1mg/kg/day) and 7 received another immunosuppressant for non-renal reasons. At 12 months of follow-up, 20 R(10 RC,10 PR) and 6 NR (4 NR, 1CRF,1HT). We had a missing data. The demographic data and immunology laboratory were similar between R and NR. Responders had a significantly lower level of 24-hour urine protein excretion(g/24hs) at 6 (0,06 vs 0,8)p=0,03 and 12 months (0,2 vs 3,2) p=0.03. Creatinine levels not differ between groups. In the R group 65% of patients received hydroxychloroquine and 15% immunosuppressant vs 100% and 50% respectively in NR group. At the five year follow-up 21 patients were evaluated (6 not reach 5 years of follow up);11 had been re-biopsied: renal flare 8, NR 3. Median time between 1st and 2nd biopsy: 25 months (11-52). Histology results: 1 Class II, 2 Class III, 5 Class IV, 3 Class V. Ten patients continued in remission at 5 years (7 CR, 3PR) and 11were NR (10 HT, 1CRF). The outcome remained favourable in 10/21(47,6%) and unfavourable 11/21(52,3%) patients, including 10 patients who transformed and one with CRF. There were no deaths. Conclusions Our group of patients had a high rate of progression to more serious classes of nephritis (47.6%) after five years of follow up. A higher degree of proteinuria was the only data that shown correlation with histology progression. Serologic markers of lupus activity were not different among R and NR group. References References Lupus(2003)12:665-671, RheumatolInt(2012)32:2459-2464, Lupus(2009)18,257-263. Disclosure of Interest : None Declared

Twenty-four patients with HCV and NonBNonC chronic hepatitis—4 with HIV coinfection—were treated with r-IFN alpha for at least six months. In this period 62.5% of patients show a normalization of ALT but not a sustained remission. Non-responders have histologically more severe and long-lasting chronic hepatitis.