Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities.

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city's HIV/AIDS response.

The 'Expanded HIV care in opioid substitution treatment' (EHOST) cluster-randomized, stepped-wedge trial: A study protocol.

The public health response to HIV/AIDS has turned its focus onto optimizing health care system delivery to maximize case identification, access and sustained engagement in antiretroviral treatment (ART). Opioid Agonist Treatment (OAT) provides a critical opportunity for HIV testing and linkage to ART. The EHOST study is a cluster-randomized, stepped-wedge trial to evaluate a prescriber-focused intervention to increase HIV testing rates, and optimize ART engagement and retention outcomes among individuals engaged in OAT. The study will encompass all drug treatment clinics currently admitting patients for the treatment of opioid use disorder across the province of British Columbia, encompassing an estimated 90% of the OAT caseload. The trial will be executed over a 24-month period, with groups of clinics receiving the intervention in 6-month intervals. Evaluation of the proposed intervention's effectiveness will focus on three primary outcomes: (i) the HIV testing rate among those not known to be HIV positive; (ii) the rate of ART initiation among those not on ART; and (iii) the rate of ART continuation among those on ART. A difference-in-differences analytical framework will be applied to estimate the intervention's effect. This approach will assess site-specific changes in primary outcomes across clusters while adjusting for potential residual heterogeneity in patient case mix, volume, and quality of care across clinics. Statistical analysis of outcomes will be conducted entirely with linked population-level administrative health datasets. Facilitated by established collaborations between key stakeholders across the province, the EHOST intervention promises to optimize HIV testing and care within a marginalized and hard-to-reach population.

Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients.

OBJECTIVE: The goal of this report is to illustrate the use of radial artery grafts as bypass conduits in the management of complex intracranial aneurysms and to describe a new "pressure distension technique" to eliminate postoperative vasospasm, which was a common problem early in our experience. METHODS: This study included a series of 17 patients who were surgically treated between 1994 and January 2001 for complex intracranial aneurysms. Five patients were surgically treated without the pressure distension technique; for 12 patients, the technique was used to reduce postoperative vasospasm. Fourteen of the patients had anterior circulation aneurysms, and three had posterior circulation aneurysms. Five of the patients had undergone previous attempts at direct clipping or excision and reconstruction of the aneurysm in question, and embolization had been performed for one patient with a carotid-cavernous fistula. Thirteen patients underwent permanent revascularization combined with proximal occlusion, trapping, or clipping, and four patients underwent temporary revascularization for cerebral protection during anticipated prolonged occlusion of the parent vessel during aneurysm dissection. Surgical techniques are described, with particular reference to vessel collection and bypass techniques. RESULTS: The outcomes for this group of patients, considering the complexity of the aneurysms and their "inoperability," with respect to direct clipping, were satisfactory. The aneurysms were completely obliterated for all patients, and the grafts were patent for all except one patient on postoperative angiograms. There were two deaths, one attributable to systemic sepsis and the other attributable to cardiac arrest during a transbronchial biopsy. The postoperative Glasgow Outcome Scale scores were either better or the same for all other patients, compared with their preoperative scores. Three of the five patients treated before the institution of the pressure distension technique experienced vasospasm of the graft, with two of those patients requiring angioplasty. For one of those patients, angioplasty led to rupture of the graft. Vasospasm was not observed for any of the 12 patients for whom the pressure distension technique was used. We observed no morbidity related to radial artery collection. CONCLUSION: Revascularization techniques are occasionally necessary for the surgical treatment of complicated intracranial aneurysms. The merits of the use of the radial artery as a bypass conduit are discussed. Radial artery grafts should be considered as alternatives to saphenous vein and superficial temporal artery grafts. The problem of vasospasm of the artery has been solved with the pressure distention technique.

Giant ameloblastoma: report of an extreme case and a description of its treatment.

Ameloblastoma is an odontogenic tumor that usually occurs in the mandible. It is an aggressive but benign tumor of epithelial origin that is rarely metastatic. We report the case of a 53-year-old woman who had a massive ameloblastoma of the mandible. The tumor measured 15.2 x 11.4 x 12.0 cm. The patient had oral bleeding that required a transfusion. The workup included three-dimensional imaging, arteriography, and embolization to control bleeding. Surgical management entailed the resection of the entire left mandible and right symphysis, followed by reconstruction with a free fibular flap. To our knowledge, this is the largest reported ameloblastoma managed with three-dimensional imaging, radical resection, and free-flap reconstruction. This article also reviews aspects of the differential diagnosis, pathology, and management of jaw tumors.

Preferential use of the ipsilateral pedicle in TRAM flap breast reconstruction.

Breast reconstruction utilizing the ipsilateral transverse rectus abdominis musculocutaneous (TRAM) flap provides superior results when compared with contralaterally based reconstructions by preserving the medial inframammary fold and eliminating the perixiphoid bulge. Additionally, a longer pedicle can be obtained using the ipsilateral TRAM, thereby allowing greater mobility and flexibility during flap transposition. These findings are based on a retrospective review of 50 consecutive ipsilateral TRAM flap reconstructions in 38 patients. The mean patient age was 45.4 years and mean follow-up was 8.6 months. Thirty-two flaps were performed as immediate reconstructions and 18 flaps were delayed. No patient suffered total flap loss, whereas partial flap loss was observed in three flaps. One patient required suture removal to alleviate venous congestion of the flap. No patient developed a postoperative hernia, but 1 patient required removal of a polytetrafluoroethylene onlay patch following graft exposure. This technique achieves aesthetically pleasing results with acceptable morbidity, allows greater flap mobility without disruption of the medial inframammary fold or creation of a perixiphoid bulge, and is our method of choice for TRAM flap breast reconstruction.

Multiple neoplasms following craniospinal irradiation for medulloblastoma in a patient with nevoid basal cell carcinoma syndrome. Case report.

A 28-year-old man presented to the authors' hospital with multiple intracranial tumors. At 2 years of age, he had undergone resection of a medulloblastoma and received adjunctive craniospinal irradiation. Subsequently, he was diagnosed with nevoid basal cell carcinoma syndrome, Gorlin's syndrome. Since his first presentation, he has required surgery for multiple basal cell carcinomas, an osteochondroma of the rib, two meningiomas, a trigeminal schwannoma, and a pleomorphic liposarcoma, all of which arose within the radiation field. Despite this impressive list of benign and malignant neoplasms, the patient is relatively well and leads a normal life. The authors examine the relationships between Gorlin's syndrome and radiation therapy and the subsequent development of tumors.

Management and long-term outcome of adenoid cystic carcinoma with intracranial extension: a neurosurgical perspective.

Adenoid cystic carcinoma is a tumor of minor and major salivary glands that often invades the cranial base and intracranial cavity via local and perineural spread. In the past, the role of neurosurgeons in managing these tumors has been limited. The growth of interdisciplinary cranial base surgical approaches has now increased the involvement of neurosurgeons in the management of these tumors. We present a series of 16 patients with adenoid cystic carcinomas with cranial base and intracranial extension, the largest series reported in the neurosurgical literature. We have focused our approach on a neurosurgical perspective and made recommendations for the treatment of these tumors in relation to the following specific aspects of this disease. 1) The management of the carotid artery: In our experience, when the carotid artery is involved by tumor, a preliminary cerebral revascularization procedure with a cervical carotid to middle cerebral artery vein bypass graft should be performed before tumor resection. 2) The management of the cavernous sinus and orbit: Cavernous sinus tumor should be removed as fully as possible, but every effort should be made to preserve the IIIrd and IVth cranial nerves to achieve optimal functional and cosmetic results. The orbit should be exenterated when there is intraconal involvement; otherwise, intraorbital tumor can be removed with orbital preservation. 3) The use of palliative surgery: We have found that the use of palliative surgery can be considered even in patients whose extent of local disease precludes a surgical cure. The slow progression of the disease allows for long-term survival of many patients with advanced local disease and even of those with metastatic disease. 4) The long-term survival of these patients: In our series, six patients had no evidence of local disease and a mean survival of 72 months, one living patient had evidence of local disease and has survived 56 months, eight patients died of disease, with a mean survival of 137 months, and one patient died of complications after surviving for 63 months.

Early free-flap debulking: avoiding the second donor site.

The advantages of this technique in large, shallow defects are: 1. The flap can be monitored clinically during the critical postoperative period. 2. The aesthetic result is much better than that of the bulky myocutaneous flap. 3. No second donor site for the split-thickness skin graft is required.

Vascular interventions for impotence: lessons learned.

PURPOSE: The purpose of this study was to analyze the results of vascular interventions for impotence in men with this complaint. METHODS: Between September 1983 and March 1993, 1094 men with the chief complaint of impotence (average age 54.5 years) were screened by use of penile plethysmography and penile brachial indexes: 635 were considered to have normal flow, and 459 were considered to have abnormal arterial flow, 12.2% of whom were found to have aortoiliac disease. Based on negative neural screening results, absence of erectile responses on increasing doses of intracavernously injected papaverine or prostaglandin E1 (ICI), surgical candidates for microvascular procedures were referred for dynamic infusion cavernosography (DICC) and pudendal arteriography. Operations for men discovered to have aortoiliac disease were based on conventional indications including aneurysm size or limb ischemia. None of the subjects had diabetes. Only those patients without diabetes and those not requiring blood pressure medications were selected for microvascular procedures. We report our experience and surgical outcomes at average follow-ups of 33 to 48 months. Four types of operations were performed on 67 men (age 18 to 79 years). These included 17 aortoiliac reconstructions, 11 dorsal penile artery bypasses, 12 dorsal vein arterializations, and 27 venous interruptions. Follow-up data were obtained by direct examination and noninvasive Doppler examinations; repeat arteriography (4 of 11); repeat DICC after venous ablation procedures (18 of 27) and postoperative ICI response. Mail questionnaires completed postoperative surveillance. RESULTS: Among 17 men undergoing aortoiliac intervention for aneurysms in eight and occlusive disease in nine, 58% functioned spontaneously after operation and 18% used ICI or vacuum constrictor devices at an average follow-up time of 38 months. Among 11 men with dorsal penile artery bypasses, 27% functioned spontaneously and 45% used ICI at an average follow-up time of 34.5 months. Among 12 men with dorsal vein arterialization, 33% functioned spontaneously, and 47% used ICI at an average follow-up time of 48 months. Among 27 with venous interruption, 33% functioned spontaneously and 44% used ICI. In seven of eight aneurysms of 4.5 to 6.0 cm in size, impotence workup led to discovery; probable embolic mechanisms existed in three. Venous interruption efficacy correlated with postoperative DICC results when flow to maintain erection was 40 ml or less. Apart from two cases of glans hyperemia, no surgical complications occurred in the microvascular procedures. There was one episode of bleeding caused by DICC after aortic reconstruction. There were no deaths. CONCLUSIONS: With prospective screening criteria, 6% to 7% of impotent men became candidates for vascular intervention. Including those functioning with ICI or vacuum constriction devices, about 70% of these men were functional after operation. Men undergoing aortoiliac reconstruction has a significantly higher rate (58%) of spontaneous function as compared with those undergoing microvascular procedures.

Ischemic tolerance of canine jejunal flaps.

Reconstruction of the upper aerodigestive tract with free jejunal flaps is now an accepted alternative to more conventional techniques. Success rates for microsurgical transfer approach 100 percent; however, complications following this technique are reported despite technical success, ischemia being implicated as an important etiologic factor. A histologic analysis of canine jejunum subjected to progressively increasing normothermic ischemic periods was undertaken. One hundred canine jejunal flaps were randomly assigned ischemia times between 0 and 12 hours and evaluated 48 hours after reperfusion. Results indicate that (1) isolation of a segment of jejunum on a single pedicle results in no light microscopic changes, (2) histologic changes are evident after 30 minutes of warm ischemia, but gross changes are not evident until greater than 2 hours of ischemia, (3) histologic changes that occur with ischemic insults are progressive and cumulative, (4) mucosal ulcerations are evident at 3 hours, (5) partial-thickness muscle necrosis occurs in all segments at 4 hours, (6) 5 hours of ischemia results in spotty full-thickness necrosis of the bowel wall in 80 percent of the flaps, and (7) by 6 hours, full-thickness myonecrosis is present in all segments. Ischemic periods greater than 6 hours result in increasing histologic disarray.

Emergency free flap reconstruction of a facial gunshot wound.

An emergency free rectus abdominis myocutaneous flap was used to reconstruct a massive facial gunshot wound with associated cranial communication immediately after the primary debridement. The bony defect was reconstructed with split calvarial and rib grafts, plates, and screws. The free flap provided adequate coverage of the bony reconstruction and separation of the cranial and sinus cavities.

Prediction of vascular complications following free tissue transfer.

Thirty-five consecutive free tissue transfers were evaluated prospectively. A prediction of postoperative vascular complications was made at the time of wound closure. Two vascular complications occurred, each predicted intraoperatively. Conversely, the 33 flaps that did not develop vascular complications were correctly identified intraoperatively. Intraoperative findings that correlated with postoperative vascular complications were clinically recognizable changes in flap perfusion.

Reverse forearm flap based on an "exteriorized" pedicle.

Soft tissue coverage after multiple digital amputations was achieved with a reverse forearm flap based on an "exteriorized" vascular pedicle. The length of exposed radial artery pedicle was calculated to permit full range of motion of the involved digits before flap division and inset. No complications of the exposed vascular pedicle were noted.

Primary and secondary critical ischemia times of myocutaneous flaps.

The primary critical ischemia time of the latissimus dorsi myocutaneous flap model was determined in the pig. Latissimus dorsi flaps were subjected to a primary ischemic insult of 2 hours (mimicking the ischemic event of free-tissue transfer). Following 12 hours of normal flow, the flaps were subjected to a second ischemic insult ranging from 0 to 12 hours. The secondary critical ischemia time (11.3 hours) was found to be statistically comparable to the primary critical ischemia time (9.1 hours). Questions are raised concerning the mechanism of action of this phenomenon and its clinical relevance.

An anastomotic device for microvascular surgery: evolution.

A new anastomotic device is demonstrated that is suitable in microvascular surgery for repairing severed blood vessels and inserting vein grafts. Initial pilot studies indicate a 100% patency rate for vessel anastomosis, and a one-year study produced a 96% success rate. However, histological examination revealed notable vessel deterioration with a rigid device. Therefore, an absorbable anastomotic coupler was developed that demonstrates a high patency rate (92%) in both arteries and veins, with substantial absorption of the device by 70 days. Healing at the anastomotic site was qualitatively similar to that obtained with a sutured anastomosis; there was endothelialization by 14 days and absorption of the device by 70 days.

An absorbable anastomotic device for microvascular surgery: experimental studies.

A new absorbable anastomotic device is presented. Over 200 anastomoses were done in the rabbit's carotid artery and posterior facial vein with an overall patency rate of 96 percent. Follow-up extended to 1 year in certain series. Its advantages over other devices include a consistently high patency rate, complete absorption by 70 days, lack of intraluminal foreign body, and simple instrumentation. Its principle advantage over suture anastomosis is a shortened insertion time (5 minutes). However, it does require additional vessel length for eversion and a skilled assistant. It can accommodate only limited vessel size discrepancies and has no capability for end-to-side anastomoses.

An absorbable anastomotic device for microvascular surgery: clinical applications.

An absorbable anastomotic device that can be inserted in less than 4 minutes for vessels with a 1.3- to 2.5-mm diameter was utilized in 20 clinical cases. Only one documented thrombosis occurred, and it was successfully revised. In 11 of 20 cases, tissue survival was totally dependent on the coupled anastomosis. Subsequent follow-up offers evidence of maintained patency. It would appear that anastomotic devices are a useful adjunct for the experienced microsurgeon skilled in suture techniques.

Microsurgical techniques in experimental lymphedema of the rabbit ear.

One of the main obstacles to the study of changes occurring in lymphedema and the effects of various therapeutic modalities has been the lack of a reproducible inexpensive experimental model. We believe that the rabbit ear model satisfies this requirement permitting both evaluation of changes which lead to development of lymphedema as well as evaluation of the efficacy of microsurgical techniques.