Factors affecting outcomes after supermicrosurgical lymphovenous anastomosis in a defined patient population.

BACKGROUND: The optimal surgical treatment for lymphedema is still subject of intensive research. Therefore, it is vital to investigate what significance lymphovenous anastomosis (LVA) has in this context. OBJECTIVE: This study aims to determine the short- and long-term results as well as the most important factors that can improve outcomes after LVA. METHODS: This study includes a complete data set of 26 patients who received LVA for a therapy-resistant lymphedema. Patients were followed up for an average of 23 months. RESULTS: 50% of the patients reported a subjective improvement. Without conservative treatment after the operation the patients showed significant better results (100% vs. 40.9%, p = 0.030). The localization of lymphedema as well as the region of LVA had a significant influence. In patients with lymphedema affecting the entire leg, symptom improvement was significantly lower (35.3% vs. 77.8%, p = 0.039). Patients who received LVA in an upper limb show a significantly higher improvement in symptoms than patients who received LVA in a lower limb (100% vs. 30%, p = 0.021). CONCLUSIONS: We identified factors with a significant influence on the outcome of patients after receiving LVA. Patients with early-stage upper extremity lymphedema seem to benefit most from this procedure.

High rates of incident diabetes and prediabetes are evident in men with treated HIV followed for 11 years.

OBJECTIVE: To determine the long-term incidence of glucose disorders in treated HIV infection, associations with traditional and HIV-specific risk factors. METHODS: Observational cohort of 104 men with treated HIV infection and without diabetes, aged 43 ±â€Š8 years at baseline, with (mean ±â€ŠSD) 11.8 ±â€Š3.5 years follow-up. Ascertainment of glucose status by fasting glucose or, in a subset (n = 33), a 75 g oral glucose tolerance test by 10-12 years follow-up. A subset underwent sequential body composition measures (n = 58) to determine changes in total body and central abdominal adiposity. RESULTS: The cumulative incidence of glucose disorders was 48.1% (prediabetes 35.6%, diabetes 12.5%), with an incidence rate of 34.5/1000 years of patient follow-up (PYFU) (prediabetes: 24.3/1000 PYFU; diabetes: 10.2/1000 PYFU). Incident glucose disorders were independently associated with higher age (44.9 ±â€Š8.4 vs. 41.1 ±â€Š7.5 years, P = 0.027), baseline C-peptide (2.9 ±â€Š1.3 vs. 2.4 ±â€Š1.1 ng/ml, P = 0.019) and baseline 2-h glucose (135 ±â€Š41 vs. 95 ±â€Š25 mg/dl, P < 0.001). A prior AIDS-defining illness was independently associated with higher follow-up fasting glucose (108 ±â€Š38 vs. 94 ±â€Š16 mg/dl, P = 0.007). Abdominal fat gain over 2-4 years was associated with a 3.16-fold increased risk of incident glucose disorders (95% CI 1.30-7.68, P = 0.011). In a subgroup who underwent further oral glucose tolerance testing, 60% had a glucose disorder, the majority not detected by fasting glucose. CONCLUSION: Men with long-term treated HIV infection have high rates of incident glucose disorders associated with modest abdominal fat gain. Directed measures to prevent diabetes in this population are warranted.

Numerical simulations of river discharges, nutrient flux and nutrient dispersal in Jakarta Bay, Indonesia.

The present application of numerical modelling techniques provides an overview of river discharges, nutrient flux and nutrient dispersal in Jakarta Bay. A hydrological model simulated river discharges with a total of 90 to 377m(3)s(-1) entering Jakarta Bay. Daily total nitrogen and total phosphorus loads ranged from 40 to 174tons and 14 to 60tons, respectively. Flow model results indicate that nutrient gradients are subject to turbulent mixing by tides and advective transport through circulation driven by wind, barotropic and baroclinic pressure gradients. The bulk of nutrient loads originate from the Citarum and Cisadane rivers flowing through predominantly rural areas. Despite lower nutrient loads, river discharges from the urban area of Jakarta exhibit the highest impact of nutrient concentrations in the near shore area of Jakarta Bay and show that nutrient concentrations were not only regulated by nutrient loads but were strongly regulated by initial river concentrations and local flow characteristics.

Master Plan Jakarta, Indonesia: The Giant Seawall and the need for structural treatment of municipal waste water.

In order to take actions against the annual flooding in Jakarta, the construction of a Giant Seawall has been proposed in the Master Plan for National Capital Integrated Coastal Development. The seawall provides a combination of technical solutions against flooding, but these will heavily modify the mass transports in the near-coastal area of Jakarta Bay. This study presents numerical simulations of river flux of total nitrogen and N,N-diethyl-m-toluamide, a molecular tracer for municipal waste water for similar scenarios as described in the Master Plan. Model results demonstrate a strong accumulation of municipal wastes and nutrients in the planned reservoirs to extremely high levels which will result in drastic adverse eutrophication effects if the treatment of municipal waste water is not dealt with in the same priority as the construction of the Giant Seawall.

Pressure on oxygen levels of Jakarta Bay.

Jakarta Bay is subject to inputs of large amounts of dissolved inorganic nutrients and organic matter deriving from the Jakarta Metropolitan Area and its hinterland. As a consequence, inorganic and organic nutrient concentrations in the nearshore area are considerably increased. The hydrographic pattern inside the bay fosters phytoplankton bloom formation due to pronounced vertical density gradients. High Biomass Blooms (HBB) of phytoplankton are observed recurrently, representing an additional source for oxygen consuming degradable organic matter. An oxygen deficiency area of 20km(2) can be identified in the eastern part of Jakarta Bay where oxygen levels decrease to 60% saturation, equaling a noxiously low concentration of 4.0mg·dm(-3) O2. The absolute minimum detected was 51% O2 or 3.2mg·dm(-3) O2. The observed oxygen concentrations fail Indonesian quality standards for seawater.

Raltegravir and unboosted atazanavir dual therapy in virologically suppressed antiretroviral treatment-experienced HIV patients.

BACKGROUND: Because of the favourable safety and tolerability profiles of atazanavir (ATV) and raltegravir (RAL), attention has recently turned to the use of dual ATV plus RAL therapy as a nucleoside reverse transcriptase inhibitor-sparing treatment strategy in highly antiretroviral treatment (ART)-experienced HIV-infected patients. METHODS: A retrospective observational study was carried out to assess the maintenance of viral suppression and ART tolerability in 20 highly ART-experienced patients with viral suppression, who had been switched to RAL and unboosted ATV dual therapy, using data collected during standard-of-care visits. RESULTS: At 6, 12 and 18 months, viral load was maintained at <400 HIV RNA copies/ml, with only one participant recording a detectable viral load (150 copies/ml) at the 6-month time point. Stable CD4(+) T-cell counts were maintained throughout the study period. Five participants changed regimen during the 18-month follow-up, with the median time to switch being 9 months (range 2-12). In three cases, patients were changed from dual therapy because of adverse events while on the regimen. These included increased fatigue (two patients), persistently increased bilirubin (one patient) and gastrointestinal side effects (one patient). Two additional patients changed therapy: one patient added lamivudine and one ceased ATV to pre-empt a potential drug-drug interaction. All five patients who switched from ATV/RAL before 12 months follow-up maintained viral suppression, implying no disadvantage from switching to dual therapy. CONCLUSIONS: Dual therapy with ATV plus RAL maintained viral suppression in this small group of highly ART-experienced patients. Further investigation of this novel dual therapy regimen is warranted.

Low bone mineral density, renal dysfunction, and fracture risk in HIV infection: a cross-sectional study.

BACKGROUND: Reduced bone mineral density (BMD) is common in adults infected with human immunodeficiency virus (HIV). The role of proximal renal tubular dysfunction (PRTD) and alterations in bone metabolism in HIV-related low BMD are incompletely understood. METHODS: We quantified BMD (dual-energy x-ray absorptiometry), blood and urinary markers of bone metabolism and renal function, and risk factors for low BMD (hip or spine T score, -1 or less) in an ambulatory care setting. We determined factors associated with low BMD and calculated 10-year fracture risks using the World Health Organization FRAX equation. RESULTS: We studied 153 adults (98% men; median age, 48 years; median body mass index, 24.5; 67 [44%] were receiving tenofovir, 81 [53%] were receiving a boosted protease inhibitor [PI]). Sixty-five participants (42%) had low BMD, and 11 (7%) had PRTD. PI therapy was associated with low BMD in multivariable analysis (odds ratio, 2.69; 95% confidence interval, 1.09-6.63). Tenofovir use was associated with increased osteoblast and osteoclast activity (P< or = .002). The mean estimated 10-year risks were 1.2% for hip fracture and 5.4% for any major osteoporotic fracture. CONCLUSIONS: In this mostly male population, low BMD was significantly associated with PI therapy. Tenofovir recipients showed evidence of increased bone turnover. Measurement of BMD and estimation of fracture risk may be warranted in treated HIV-infected adults.