Confronting structural violence in sex work: lessons from a community-led HIV prevention project in Mysore, India.

Evidence from community-led HIV prevention projects suggests that structural interventions may result in reduced rates of HIV and STIs. The complex relationship between empowerment and confronting stigma, discrimination and physical abuse necessitates further investigation into the impact that such interventions have on the personal risks for sex workers. This article aims to describe lived experiences of members from a sex worker's collective in Mysore, India and how they have confronted structural violence. The narratives highlight experiences of violence and the development and implementation of strategies that have altered the social, physical, and emotional environment for sex workers. Building an enabling environment was key to reducing personal risks inherent to sex work, emphasizing the importance of community-led structural interventions for sex workers in India.

Acute occlusion of the abdominal aorta.

BACKGROUND: Acute aortic occlusion most commonly results from aortic saddle embolus or thrombosis of an atherosclerotic abdominal aorta. The purpose of this study was to review the experience at a university hospital to better define the diagnosis and management of this uncommon process. METHODS: A retrospective chart review was performed from patients admitted to Emory University Hospital with acute occlusion of the abdominal aorta from 1985 through 1997. RESULTS: Thirty-three patients were identified. In group EMB (n = 16), occlusion was due to saddle embolus. In group IST (n = 17), occlusion was attributed to in situ thrombosis of a severely diseased aorta. Operative procedures performed included transfemoral embolectomy (15), aorto-bifemoral bypass (9), axillobifemoral bypass (5), fasciotomy (3), and thrombolysis (1). The in-hospital mortality rate was 21% (31% EMB, 12% IST), and morbidity was significant and included mesenteric ischemia (6%), bleeding complications (9%), subsequent amputation (12%), renal failure (15%), recurrent embolization or thrombosis (21%), and cardiac complications (42%). CONCLUSIONS: Acute aortic occlusion has tremendous morbidity and mortality even with optimal surgical care.

The surgical anatomy and technique of the thoracoabdominal incision.

The thoracoabdominal incision provides excellent exposure of the thoracic, abdominal, and retroperitoneal compartments and can be safely performed in the vast majority of cases. To be more specific, the advantage of the left thoracoabdominal incision is excellent exposure of the lower esophagus, the gastroesophageal junction, the gastric cardia and stomach in toto, the left hemidiaphragm, the distal pancreas and spleen, the left kidney and adrenal gland, and the aorta. The advantage of the right thoracoabdominal incision is excellent exposure of the upper esophagus, the liver, the hepatic triad and inferior vena cava, the proximal pancreas, the right hemidiaphragm, the right kidney, and the adrenal gland. Several possible disadvantages should also be taken into consideration when contemplating this procedure. Morbidity and mortality may be increased with the opening of the two cavities. The surgeon must possess good detailed anatomic technique for opening and closure. This procedure is not advisable for children; it should be used only for good technical indications. Some of the more commonly encountered anatomic complications to be avoided include (1) splenic injury, occurring most often during division and resection of the diaphragm; (2) phrenic nerve injury, with subsequent diaphragmatic dysfunction; (3) ureteric injury during retroperitoneal dissection; (4) left first lumbar vein injury (located in the posterior aspect of the left renal vein) during left kidney mobilization; and (5) pain in the early postoperative period, which can occur secondary to transection of the cartilaginous costal arch. This may be minimized by secure fixation using No. 1 Prolene. Patients occasionally complain of a clicking sensation owing to nonunion of the costal cartilage.

Hepatic arterioportal fistula.

Hepatic arterioportal fistula (HAPF) is uncommon, arising largely from either a ruptured hepatic artery aneurysm or from penetrating trauma. It is being encountered increasingly, secondary to rising numbers of percutaneous transhepatic procedures. We will describe five cases of HAPF seen at Emory University Hospital over the last 5 years and conclude with a review of the current status of treatment of this condition. HAPF occurred secondary to ruptured hepatic artery aneurysm in two patients, operative injury in two patients, and after trauma in one patient. The predominant clinical manifestation in these patients were complications of portal hypertension, most commonly gastrointestinal bleeding. Angiography remains the definitive diagnostic procedure and it was used to accurately diagnose HAPF in all cases. However, duplex ultrasonography is rapidly becoming a useful screening tool and was the initial imaging modality in the most recent case. Several factors determine the therapeutic approach including the location of the HAPF and associated comorbidity. Due to the development of portal hypertension even asymptomatic fistulas should be treated. In general, surgery is the procedure of choice for extrahepatic fistula, while embolization is optimal for intrahepatic fistulas. Embolization is also useful for patients in whom associated comorbidity prohibits surgical treatment. The goal of surgery is to interrupt the fistula, to maintain hepatic arterial flow, and to close the defect in the portal vein.

Retroperitoneal hematoma following femoral arterial catheterization: a serious and often fatal complication.

Retroperitoneal hematoma (RPH) following cardiac catheterization is an infrequent (0.15% incidence) but morbid complication. During a 13-month study period, 11 patients with a significant RPH requiring operative intervention were identified. The mean transfusion requirement was 8.7 units, with two deaths as a consequence of their RPH. Adjunctive cardiac procedures included percutaneous transluminal coronary angioplasty (five), stent placement (one), and thrombolysis (two). Two patients had RPH following aortography. Suspicion of RPH was most frequently prompted by a falling hematocrit (73%), with hypovolemic shock (systolic blood pressure < 90) in 64%. Lower quadrant or flank pain occurred in four patients. Lower extremity pain occurred in five patients due to femoral nerve compression. Of six patients with a preoperative femoral nerve palsy, complete resolution occurred in four cases. RPH following femoral arterial puncture is a cause of significant morbidity, particularly in the anticoagulated patient. Postcatheterization anticoagulation and high arterial puncture were the principal risk factors (p < 0.001). Early recognition is essential and should be prompted by a falling hematocrit, lower abdominal pain, or neurological changes in the lower extremity. There should be a low threshold for performing abdominopelvic CT scans in such patients. Management of RPH must be individualized: 1) patients with neurological deficits in the ipsilateral extremity require urgent decompression of the hematoma, 2) anticoagulation should be stopped or minimized, 3) hematoma progression by serial CT necessitates surgical evacuation and repair of the arterial puncture site.