Reconstruction of parasacral hernia with acellular human dermis graft.

Parasacral hernias are defects through the pelvic floor which occur as the result of sacral resection. These defects are often large, and are frequently the result of treatment for sacral malignancies. This report documents the case of a 71-year-old woman who underwent radical coccygectomy and partial sacrectomy for a chordoma and subsequently presented 1 year later with a large parasacral hernia. The defect was repaired using an acellular human dermis graft with a gluteus maximus muscle-advancement flap overlay. This article summarizes the current literature of this challenging clinical problem, and examines the use of acellular human dermis in the repair of complex hernias.

Human immunodeficiency virus infection in rural areas and small cities of the southeast: contributions of migration and behavior.

The design of education and prevention strategies to stem the spread of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) in rural areas depends on having accurate patterns of risk behavior and transmission in local areas. Interviews were conducted with people in rural areas and small cities in Delaware, Florida, Georgia and South Carolina who were at least 18 years old and infected with HIV in order to describe demographic characteristics, migration patterns and risk behaviors. Interviews were conducted with 608 people. Most respondents were male (66 percent), black (63 percent of men, 85 percent of women) and had been infected through sexual contact (67 percent of men, 66 percent of women). Most (65 percent) had lived away from a rural area or small city for at least one month; of those, 71 percent had moved from an urban area. Twenty-seven percent of respondents indicated they had been infected locally. People with a history of injection drug use were less likely to have been infected locally than those who had no history of injection drug use (6 percent vs. 26 percent among men, 3 percent vs. 40 percent among women, P < 0.001). Further understanding of the role of socioeconomic factors in HIV transmission in rural areas and small cities is needed. Programs designed to prevent HIV acquisition among people living in rural areas and small cities in the Southeast should focus on sexual behavior.

Differences in participation in experimental drug trials among persons with AIDS.

To measure participation in experimental drug trials among persons with acquired immunodeficiency syndrome (AIDS), we interviewed 4,604 persons at least 18 years of age who were reported to have AIDS to 11 state and city health departments in the United States. Ten percent reported that they were currently in a trial. Current enrollment differed significantly (p < 0.05) by race/ethnicity (blacks, 5%; whites, 14%; Hispanics, 15%), gender (women, 7%; men, 11%), exposure mode (injection drug use, 5%, men who have sex with men, 14%), annual household income (< $10,000, 8%, > or = $10,000, 14%), education (< 12 years, 6%; > or = 12 years, 12%), health care (no regular care, 1%, public care, 8%; private care, 17%), and time since AIDS diagnosis (< or = 6 months, 9%; > 6 months, 12%). Adjusting for all factors and time since AIDS diagnosis, blacks (adjusted odds ratio [AOR] = 0.35, 95% confidence interval [CI] 0.26, 0.47), persons with less than 12 years of education (AOR = 0.71, CI 0.53, 0.96), and those without regular health care (AOR = 0.24, CI 0.10, 0.61) remained less likely to be in a trial. Blacks, those with less than 12 years of education, and persons without regular health care were less likely than other persons with AIDS to be currently enrolled in AIDS trials. To increase enrollment of these persons, researchers must address barriers to participation for these groups.

HIV testing patterns: where, why, and when were persons with AIDS tested for HIV?

OBJECTIVE: To describe the location of, primary reason for, and time between the first positive HIV test and AIDS diagnosis in a sample of persons with newly diagnosed AIDS. DESIGN: Interviews supplementing information routinely collected through AIDS case reporting. SETTING: Eleven US states and cities. PATIENTS: Persons with AIDS (2441) diagnosed between January 1990 and December 1992. MAIN OUTCOME MEASURES: Location of first positive HIV test, primary reason for testing, and time interval between first positive HIV test and AIDS diagnosis. RESULTS: Overall, persons were tested late in their course of HIV infection: 36% were tested for HIV within 2 months and 51% within 1 year of their AIDS diagnosis. Sixty-five per cent were HIV-tested in acute health-care settings: 33% in hospitals, 28% in physicians' offices, and 4% in emergency departments. Testing during hospitalization was most common among injecting drug users (43%) and persons infected through heterosexual contact (50%). Persons primarily sought HIV testing because of illness (58%); other reasons included being in a known risk group (13%) and having had a known HIV-infected sex partner (8%). Testing because of being in a known risk group was least common among persons infected through heterosexual contact (1%). Among persons in these exposure categories, testing differed by race/ethnicity. CONCLUSION: Most persons with AIDS were tested relatively late in their course of HIV infection, in acute health-care settings, and because of illness. Not knowing one's serostatus precludes early medical intervention and may increase transmission.

The types of drugs used by HIV-infected injection drug users in a multistate surveillance project: implications for intervention.

OBJECTIVES: This study sought to describe the drugs used by drug injectors infected with human immunodeficiency virus (HIV) and to determine factors associated with the primary injection drug used. METHODS: A cross-section of persons 18 years of age or older reported with HIV or acquired immunodeficiency syndrome (AIDS) to local health departments in 11 US states and cities was surveyed. RESULTS: Of 4162 persons interviewed, 1147 (28%) reported ever having injected drugs. Of these 1147 injectors, 72% primarily injected a drug other than heroin. However, the types of drugs injected varied notably by place of residence. Heroin was the most commonly injected drug in Detroit (94%) and Connecticut (48%); cocaine was the most common in South Carolina (64%), Atlanta (56%), Delaware (55%), Denver (46%), and Arizona (44%); speedball was most common in Florida (46%); and amphetamines were most common in Washington (56%). Other determinants of the type of drug primarily injected were often similar by region of residence, except for heroin use. Polysubstance abuse was common; 75% injected more than one type of drug, and 85% reported noninjected drug use. CONCLUSIONS: Preventing the further spread of HIV will require more drug abuse treatment programs that go beyond methadone, address polysubstance abuse, and adapt to local correlates of the primary drug used.

Risk behaviors of persons with heterosexually acquired HIV infection in the United States: results of a multistate surveillance project.

To describe past risk behaviors among persons with heterosexually acquired human immunodeficiency virus (HIV) infection, we interviewed 497 persons > or = 18 years of age with heterosexually acquired HIV infection reported to 11 state and city health departments in the United States. Thirty-nine percent of persons reported using noninjection drugs in the past 5 years; noninjection drug use was highest among men whose sex partners injected drugs (53%). Sixteen percent of all persons used crack, and 17% were classified as potential alcoholics; among men, 29% were classified as potential alcoholics. Of the 49% of men who reported paying a woman for sex, 86% did so multiple times. Most persons had multiple sex partners in the past 5 years; however, 35% of the women had only one sex partner. Thirty-four percent of the women and 50% of the men had been treated for a sexually transmitted disease in the past 10 years. Seventy-four percent of the women and 68% of the men had never used condoms in the 5 years before they knew they were HIV positive. Among these people with heterosexually acquired HIV, noninjection drug use was common, many men have paid someone for sex, and many women have not had multiple sex partners. These findings have important implications for the types of prevention programs that can most successfully lessen the spread of HIV among heterosexuals.

Survival prognosis of HIV-infected patients.

Previous studies of survival after a diagnosis of acquired immunodeficiency syndrome (AIDS) have reported variation in temporal trends in association with age, gender, race, mode of transmission, lymphadenopathy, antiretroviral therapy, and presence of specific opportunistic infections at diagnosis. We used a logistic regression model to assess the effect of these factors while controlling for other potential predictors of time from initial CD4 cell count to death in 839 HIV-infected patients at a public hospital in Atlanta, Georgia. Our study found that a CD4 level of < 200 cells/microliters [odds ratio (OR) = 1.71; 95% confidence interval (CI) of 1.58, 1.85] and the presence of an AIDS-indicating condition (initial diagnosis OR = 2.50 and CI of 1.93, 3.24; diagnosis of a second AIDS condition OR = 3.02 and CI of 2.08, 4.40) are independently predictive of survival in HIV-infected persons. Furthermore, specific clinical manifestations of AIDS vary in their contribution to progression from diagnosis of AIDS to death. Therefore, changes in survival of AIDS patients must take into account changes over time in the relative frequency of specific AIDS-indicating diagnoses.

Disseminated Mycobacterium avium complex infection: clinical identification and epidemiologic trends.

To evaluate the incidence of disseminated Mycobacterium avium complex infection (DMAC) and to define the association between signs and symptoms and development of DMAC in patients with human immunodeficiency virus (HIV) infection, all cases of DMAC at Grady Memorial Hospital Infectious Disease Clinic (Atlanta) between 1985 and 1990 were reviewed, and a prospective study of the association of symptoms with DMAC was done. Between 1985 and 1990, DMAC occurred in 16% of patients with AIDS. Incidence increased from 5.7% in 1985-1988 to 23.3% in 1989-1990 (P less than .001). Median time from AIDS diagnosis to diagnosis of DMAC increased from 4.5 months in 1985-1988 to 8 months in 1989-1990 (P less than .02). In the prospective study, DMAC was seen only in persons with a CD4+ count less than 100 cells/mm3 and was associated with fever (P less than .03), anemia (P less than .001), weight loss (P less than .01), diarrhea (P less than .01), and elevated alkaline phosphatase (P less than .01). It is recommended that all such HIV-infected persons have mycobacterial blood cultures done.

Survival of patients with acquired immune deficiency syndrome and disseminated Mycobacterium avium complex infection with and without antimycobacterial chemotherapy.

The contribution of disseminated Mycobacterium avium complex (DMAC) infection to the morbidity and mortality of patients with acquired immune deficiency syndrome (AIDS) is unclear. Previous studies that suggested the decreased survival of patients with AIDS and DMAC had incomplete information on patient immunologic status and follow-up. We studied patients with AIDS and DMAC and compared their survival with that of AIDS patients without DMAC but with other comparable risk factors for survival. Case and control subjects were similar in terms of CD4 cell count, prior AIDS status, history of antiretroviral therapy, history of Pneumocystis carinii prophylaxis, and year of diagnosis. A group of 39 patients with untreated DMAC had significantly shorter survival, mean of 5.6 +/- 1.1 months (median 4 months), than 39 matched patients with AIDS but without DMAC, mean 10.8 +/- 1.3 months (median 11 months, p less than 0.0001). The survival of 16 additional patients with DMAC who received antimycobacterial therapy, mean of 9.5 +/- 1.4 months (median 8 months), was not significantly shorter than that of an additional 16 matched control subjects, mean 11.7 +/- 1.9 months (median 11 months, p = 0.58). Patients with treated DMAC survived significantly longer than those with untreated DMAC (p less than 0.01). We conclude that untreated DMAC significantly shortens survival. Moreover, these results indicate that patients with DMAC who receive antimycobacterial therapy do not experience the shortened survival seen in untreated DMAC.