Correlates of HIV-1 viral suppression in a cohort of HIV-positive drug users receiving antiretroviral therapy in Hanoi, Vietnam.

Injection drug users bear the burden of HIV in Vietnam and are a focus of national treatment programmes. To date, determinants of successful therapy in this population are unknown. Substance use and clinical correlates of viral suppression were studied in 100 HIV-1-infected drug users receiving antiretroviral therapy (ART) for at least six months in Hanoi, Vietnam. The mean age of the cohort was 29.9 + 4.9 years; all were men. A majority of patients (73%) achieved viral suppression (HIV-RNA <1000 copies/mL). Correlates of viral suppression include self-reported > or = 95% adherence (P < 0.01) and current use of trimethoprim/sulphamethoxazole (P < 0.01); current or ever diagnosed with tuberculosis was associated with viral non-suppression (P = 0.006). Tobacco use was prevalent (84%), and surprisingly 48% of patients reported active drug use; neither was associated with viral non-suppression. This is the first study to document successful ART treatment in a population of Vietnamese drug users; rates of viral suppression are comparable to other international populations. The 28% of patients without HIV-1 suppression highlight the need for adherence promotion, risk reduction programmes, and population-based surveillance strategies for assessing the emergence of HIV drug resistance in settings where access to viral load and drug resistance testing is limited.

Are temporary inferior vena cava filters really temporary?

BACKGROUND: Despite significant risk for venous thromboembolism, severely injured trauma patients often are not candidates for prophylaxis or treatment with anticoagulation. Long-term inferior vena cava (IVC) filters are associated with increased risk of postphlebitic syndrome. Retrievable IVC filters potentially offer a better solution, but only if the filter is removed; our hypothesis is that the most of them are not. METHODS: This retrospective study queried a level I trauma registry for IVC filter insertion from September 1997 through June 2004. RESULTS: One IVC filter was placed before the availability of retrievable filters in 2001. Since 2001, 27 filters have been placed, indicating a change in practice patterns. Filters were placed for prophylaxis (n = 11) or for therapy in patients with pulmonary embolism or deep vein thrombosis (n = 17). Of 23 temporary filters, only 8 (35%) were removed. CONCLUSIONS: Surgeons must critically evaluate indications for IVC filter insertion, develop standard criteria for placement, and implement protocols to ensure timely removal of temporary IVC filters.

Efficacy of nelfinavir in patients switched from ritonavir/saquinavir combination antiretroviral therapy.

UNLABELLED: Based on available data and expert opinion, the IAS-USA treatment guidelines recommend "selective substitution" of the medication thought most likely to be causing a side effect for one that should have a different side effect profile. PURPOSE: This study evaluates the short-term virological efficacy of selective substitution with nelfinavir-nucleoside combination therapy in individuals with plasma viral RNA below 400 copies/mL. METHOD: This study involved a retrospective chart review at five large urban HIV Clinical practice settings and included 19 patients taking combination therapy including ritonavir with saquinavir. We performed selective substitution with a nelfinavir combination. Our main outcome measure was plasma HIV-1 RNA (Amplicor) obtained during the period between weeks 12 to 18. RESULTS: We identified 19 HIV-1-infected individuals with evidence of viral suppression as defined by a viral load below 400 copies/mL while taking dual nucleoside reverse transcriptase inhibitors with ritonavir/saquinavir. Reasons for switching included adverse effects (37%) or preference for nelfinavir due to the possibility of a better defined salvage regimen (63%). We defined a composite viral endpoint indicative of continued viral suppression using the first 12 to 18 weeks following the medication change. We found that 73% maintained undetectable viral loads (plasma HIV RNA below 400 copies/mL) during this period. CONCLUSION: These data suggest that any medication adjustment should be made cautiously, as there may be some potential risk in a substitution. Selective substitution of a medication that has undesirable side effects or other characteristics should be considered when the possible risks of the loss of viral suppression are outweighed by the potential benefits of that substitution.

Technical aspects of the percutaneous cervical and lumbar laser-disc-decompression and -nucleotomy.

To achieve optimal results during percutaneous cervical and lumbar laser-disc-decompression, technical aspects have to be taken into consideration for this minimally invasive operation. The selection of the laser system is thus most significant. A Neodym-YAG-Laser is applied with a wavelength of 1064 nm which, compared to vaporization, has the prerequisites for shrinking from the experimental viewpoint. Selection of parameters for the application of energy depends on size and position of the cervical and lumbar discs. A needle with a mandrin having an outer cross section of up to 2 mm is used to puncture the disc. An ultrasharp needle tip is important. The approach depends on the section of the vertebral column involved. The insertion of the needle in the cervical discs is from the right side ventral and dorsolateral in thoracic and lumbar regions. In difficult cases of spondylophytes the insertion is helped by the so-called punctual laserosteotomy through the spondylophytes, which does not require any additional equipment at the operating table. The C-bow is sufficient for X-ray equipment and has to be adjusted according to the disc position. This minimal invasive procedure shows a technical failure rate of only 1.5/1000 in 2535 percutaneous laser disc decompressions and nucleotomies. There are two malfunctions of the laser machine and one of the X-ray technique. The PLDN using Nd-YAG 1064 nm is a technically perfect method with a very high standard of safety.

Evaluation of simplified protease inhibitor dosing regimens for the treatment of HIV infection.

Complicated dosing regimens can unfavorably affect patient adherence and drug efficacy. In an effort to increase adherence while maximizing the benefits of the protease inhibitor (PI) component of HAART, the efficacy and safety of less frequent PI dosing regimens have recently been under scrutiny. Limiting the number of drugs required in antiretroviral therapy regimens may also minimize toxicity and drug-drug interactions. This article reviews the current movement toward twice-daily regimens and examines the efficacy and safety data available on twice-daily dosing of amprenavir, indinavir, nelfinavir, saquinavir soft-gel capsules, and ritonavir. Future trends in dosing are also discussed.

Complications of non-endoscopic percutaneous laser disc decompression and nucleotomy with the neodymium: YAG laser 1064 nm.

In this review, we discuss how nonendoscopic percutaneous laser disc decompression (PLDD) and nucleotomy, using the YAG laser 1064, now has reinforced itself as a minimally invasive procedure in discogenic, vertebral pain syndromes, created by bulging, protrusions, and contained and uncontained extrusions in all areas of the spine. The rate of complication is an important criterion of the application of this new method. 3377 patients were treated with this method in the period of November 11, 1989 to April 30, 2002. While 356 patients' cervical spine was operated on, a further 38 patients had their thoracic spine operated on. Six weeks later, a prospective, consecutive control followed with an uninterrupted recording. Subsequently, all complications that occurred in this time frame were recorded. A comparison was carried out between the complication rate as covered by the literature of other intradiscal percutaneous methods and open disc surgery. Using the Nd-YAG laser 1064 nm, PLDD is generally evaluated with a complication rate of 0.5%. In the cervical spine area, the complication rate was 1.0%. No significant complications followed the thoracic intervention. In comparison to figures suggested by the relevant literature regarding possible complications with other procedures, this particular procedure is relative risk-free. In conjunction with the satisfying results regarding pain and paralysis removal, the extraordinarily low complication density of Nd-YAG PLDD culminates in the recommendation that the procedure should be applied to patients who are between unsuccessful conservative therapy and other operative methods.

Alcohol use among HIV-infected persons in care: results of a multi-site survey.

OBJECTIVE: We sought to determine the prevalence of any alcohol use and hazardous alcohol consumption among HIV-infected individuals engaged in care and to identify factors associated with hazardous alcohol use. METHODS: During 2003, 951 patients were interviewed at 14 HIV primary care sites in the USA. Hazardous drinking was defined as >14 drinks/week or >or=5 drinks/occasion for men and >7 drinks/week or >or=4 drinks/occasion for women. Moderate alcohol use was consumption at less than hazardous levels. We used logistic regression to identify factors associated with any alcohol use and hazardous alcohol use. RESULTS: Forty per cent of the sample reported any alcohol use in the 4 weeks prior to the interview; 11% reported hazardous use. In multivariate regression, male sex [adjusted odds ratio (AOR) 1.52 (95% confidence interval, CI, 1.07-2.16)], a college education (compared toor=500 cells/microL [AOR 2.65 (1.23-5.69)] and illicit drug use [AOR 2.67 (1.48-4.82)] were associated with increased odds of hazardous alcohol use (compared to moderate and none). CONCLUSIONS: Alcohol use is prevalent among HIV-infected individuals and is associated with a variety of socioeconomic and demographic characteristics. Screening for alcohol use should be routine practice in HIV primary care settings.

The impact of illicit drug use and substance abuse treatment on adherence to HAART.

High levels of adherence to highly active antiretroviral therapy (HAART) are essential for virologic suppression and longer survival in patients with HIV. We examined the effects of substance abuse treatment, current versus former substance use, and hazardous/binge drinking on adherence to HAART. During 2003, 659 HIV patients on HAART in primary care were interviewed. Adherence was defined as > or =95% adherence to all antiretroviral medications. Current substance users used illicit drugs and/or hazardous/binge drinking within the past six months, while former users had not used substances for at least six months. Logistic regression analyses of adherence to HAART included demographic, clinical and substance abuse variables. Sixty-seven percent of the sample reported 95% adherence or greater. However, current users (60%) were significantly less likely to be adherent than former (68%) or never users (77%). In multivariate analysis, former users in substance abuse treatment were as adherent to HAART as never users (Adjusted Odds Ratio (AOR)=0.82; p>0.5). In contrast, former users who had not received recent substance abuse treatment were significantly less adherent than never users (AOR=0.61; p=0.05). Current substance users were significantly less adherent than never users, regardless of substance abuse treatment (p<0.01). Substance abuse treatment interacts with current versus former drug use status to affect adherence to HAART. Substance abuse treatment may improve HAART adherence for former substance users.

[Transoropharyngeal approach to C 1 and C 2]. / Der transoropharyngeale Zugang zu C 1 und C 2.

In rare cases of diseases or traumatic lesions of C1 and C2 it is possible to prefer the short way with the transoropharyngeal approach. The operative procedure is described. Specialities are explained in three cases. A metallic osteosynthesis in case of odontoid fracture is seldom indicated.

[Experimental and clinical aspects of the living articular cartilage transplantation and half-joint transplantation (author's transl)]. / Experimentelle und klinische Aspekte der vitalen Gelenkknorpel- und Halbgelenktransplantation.

The articular cartilage transplantation and the half-joint transplantation necessitate the assessment of specific biological-transplantation questions as to the structure and function of the hyaline cartilage. Compared with other organ transplantations biometric and biomechanical factors have to be taken into consideration additionally. Up to now contradictory results were obtained in the animal experiment. On principle a survival of grafted non-preserved parts of cartilage seems to be possible. In clinical practice therapeutic trials for autogenous reimplantation of articular cartilage, autogenous joint surface partial transplantations and half-joint transplantations are justified. Allogenous half-joint transplantations may also be possible in exceptional cases.

[The problem of infection in alloplastichip-replacement (author's transl)]. / Zum Infektionsproblem beim alloplastischen Hüftgelenkersatz.

The total hip protheses implanted (THP) in two different operation periods (156 THP till September 174, 577 THP from October 1974 till December 1976) is evaluated under the aspect of infection and the influence on the rate of infection by different factors is emphasized. The rate of infection could be decreased from 7.1 per cent to 2.4 per cent adaquate measures.

Electrical stimulation of the callus formation by means of bipolar rectangular pulse sequences.

The clinical application of the electrical stimulation, lasting several weeks, for the callus formation is reported in 11 patients. Bipolar rectangular pulse sequences were used for the stimulation at a frequency of 1 Hz and a current intensity of +/-20mu amp. The electrical stimulation was successfully employed after distraction osteotomies with a KDA-apparatus in shortening of the leg provoked by different causes or in the treatment of pseudarthroses. The realignment of the newly formed callus and the osseous consolidation are stimulated and speeded up by the bipolar rectangular pulse sequences as it is also shown in the light of the roentgenograms of a case.

The pericapsular osteotomy of the os ilium in the treatment of flat acetabula.

The operative correction of the pathological flat acetabulum in congenital dislocation of the hip, myelodysplasia and cerebral palsy can be performed with pelvic osteotomies and acetabuloplasties. In the light of our own experiences gained with different methods we prefer the pericapsular osteotomy of the ilium according to Pemberton since 1971. After the evaluation of the results the advantages of the method compared with other procedures are presented in the light of the improvements of correction and the rate of complication.

[Feasibility and limitations of reconstructive interventions in rheumatoid arthritis and Bekhterew's disease]. / Möglichkeiten und Grenzen wiederherstellender Eingriffe bei Rheumatoid-Arthritis und Morbus Bechterew.

Among the reconstructive interventions in rheumatoid arthritis preponderate the arthroplasties, among them again the resection arthroplasties in contrast to the alloarthroplasties. The resection arthroplasties are most frequently performed on the forefoot and on the hand joint and the cubital joint. The artificial joint substitute is possible nearly on every joint. As to the hip joint the problems are already satisfactorily solved, not yet, however, on the knee joint. In Bechterew's disease the indication to the alloarthroplasty is to be rendered depending less on pain than on function. In severe kyphoses the columnotomy is to be taken into consideration.

[Treatment of hip joint fractures and their sequelae (author's transl)]. / Zur Belhandlung von Hüftgelenksfrakturen und deren Folgen.

Present state and own experience in surgical treatment of different fractures of the acetabulum are reported. Primary insufficient treatment of those cases and delayed treatment impair the results considerably.

[Results of total endoprosthetic treatment of dysplasia coxarthrosis with additional autologous acetabuloplasty of the roof of the acetabulum]. / Ergebnisse der totalendoprothetischen Versorgung von Dysplasiekoxarthrosen mit zusätzlicher autogener Pfannendachplastik.

With reference to the different operative treatments of dysplasia coxarthroses with a total hip endoprosthesis, 43 operations on the hip joint performed from 1975 to 1979 with a filling up to the acetabular roof defect with an autogenous bone graft had a clinical and roentgenological follow-up. The results were evaluated by means of a standardised procedure, and it was demonstrated with the help of clear successes that also anatomopathologically complicated cases can be provided with a suitable total endoprosthesis.

A biophysical explanation for Nd:YAG percutaneous laser disc decompression success.

OBJECTIVE: To use pre- and postoperative CT density measurements to demonstrate changes achieved by Nd:YAG laser (1,064 nm) in protruded or extruded discs. BACKGROUND DATA: Nonendoscopic percutaneous laser disc decompression and nucleotomy (PLDN) with the Nd:YAG laser is an established minimal invasive treatment of discogenic pain syndromes in patients with bulging, protruded, or extruded intravertebral discs. Extremely high success rates involving improvement in the flow of cerebrospinal fluid in the dural sac and enhanced venous flow by MRI myelography are 80% lumbar, 86.5% cervical, and 98% thoracic spine. However, verification of reduced intradisc and intraspinal pressure by imaging procedures is difficult. METHODS: Twenty-one patients, four women and 17 men, with an average age of 43.67 (range, 24-59) were selected. The patients showed lumbar radicular pain syndromes with monosegmental disc protrusion or extrusion, and monoradicular clinical symptoms. Measurements were performed preoperatively and on postoperative day 1. RESULTS: The preoperative density measurements averaged 83.43, in agreement with the Houndsfield units (HU) described in the literature. Postoperatively, the reduction down to 66.33 HU had a statistical significance of p = 0.001 verified in the t test. Standardizing the measurements prior to laser irradiation to 100% produced an average 20% postoperative density reduction. CONCLUSION: PLDN with the Nd:YAG laser (1,064 nm) markedly reduces the postoperative density in protrusion and extrusion of intravertebral discs. The excellent therapeutic results achieved with this method in discogenic pain syndromes can be verified by imaging procedures.