A Mixed-Methods Exploration of the Needs of People Living with HIV (PLWH) Enrolled in Access to Care, a National HIV Linkage, Retention and Re-Engagement in Medical Care Program.

Competing needs pose barriers to engagement in HIV medical care. Mixed methods were used to explore and describe the needs of participants enrolled in Access to Care, a national HIV linkage, retention and re-engagement in care (LRC) program that served people living with HIV who knew their status but were not engaged in care. When asked to prioritize their most urgent needs, participants reported housing or shelter (31%), HIV medical services (24%), and employment (8%). When we assessed the HIV continuum of care by needs status, we found no significant differences in linkage, retention, or viral suppression between participants with and without basic needs. Qualitative interviews with program staff contextualized the barriers to HIV medical care faced by participants and explored the strategies used by LRC programs to address participant needs. Study findings will be of use to future programs and have implications for HIV policy, in particular the implementation of the National HIV/AIDS Strategy (2015-2020).

The Global Engagement in Care Convening: Recommended Actions to Improve Health Outcomes for People Living With HIV.

The National HIV AIDS Strategy (NHAS) calls for a more coordinated response to the HIV epidemic. The Global Engagement in Care Convening created a forum for domestic and international experts to identify best practices in HIV care. This manuscript summarizes the meeting discussions and recommendations from meeting notes and an audio recording of the meeting. Recommendations include: further standardization of performance goals and performance measures; additional research; a more robust system to support competing needs of clients receiving services; electronic information exchanges for HIV-related data; an expansion of the role of other health professionals to extend the capacity of physicians and other members of the care team; and revisions to current financing systems to increase reimbursement for and access to services that promote linkage to and retention in HIV care. The recommendations provide a unique example of "reverse technical assistance" and will inform U.S. program development, research, and policy.

Operative intervention for carotid restenosis is safe and effective.

Carotid stenting has been proposed as an alternative to reoperative carotid endarterectomy (rCEA) for recurrent carotid stenosis. The purpose of this study is to prove the safety, effectiveness and durability of reoperation in long term follow up of 18 years in a community hospital setting. From March 1988 to April 2005 80 patients, 46 men and 34 women (mean age: 64.1 years) underwent a total of 83 operations. Symptomatic recurrent stenosis (>70%) was the indication in 32, asymptomatic high-grade stenosis (>80%) in 49, intimal flap in one and fibromuscular dysplasia (F.M.D), in one. The initial operation was carotid endarterectomy with primary closure in 60 and prosthetic patch in 23. The mean recurrences were at 23.3 months in 33 with myointimal hyperplasia, 105.4 months in 29 with recurrent atherosclerosis, 61.4 months in 19 with both hyperplasia and atherosclerosis, 2 months in one with intimal flap and 8 months in one with F.M.D bands. Reoperation utilized primary closure (3), vein patch (14), prosthetic patch (55), Gore-Tex interposition grafts (7), vein interposition grafts (3) and intraoperative dilation (1). No perioperative strokes or deaths occurred. One patient died from cardiac complications following combined rCEA and coronary artery bypass grafting. Operative morbidity consisted of reversible nerve injury (5), irreversible recurrent laryngeal nerve injury (1) and hematoma requiring evacuation (3). During follow up (3-153 months; mean: 50.9) carotid occlusion resulted in mild ipsilateral stroke in one patient, and one non-hemispheric stroke. There were 26 late deaths due to all causes, one due to CVA. Eight patients required reoperation (mean 53.4 months). Seven of these were hypertensive. Kaplan-Meier analysis of long-term follow up shows relatively high stroke free rates; at 153 months (12.75 years) the hemispheric stroke free rate was 98.67% and the all-stroke free rate was 95.85%. The survival estimate following redo surgery was 69.97% at 5 years and 40.23% at 10 years. We found that individuals on statin therapy (p-value=0.0042), and those on combination of statin and aspirin (p-value=0.0320), had significantly increased interval between primary and secondary operation. Increased age was correlated to a decreased time to redo surgery (p-value=<0.0001). We conclude that reoperation for recurrent carotid stenosis using standard vascular techniques is safe, effective, durable and cost effective. It should continue to be the mainstay of treatment when secondary intervention is required. Statins have a salutary effect on durability of the procedure and should be used when indicated.

Axillobifemoral bypass: elective versus emergent operation.

Axillobifemoral bypass (AxBFB) is considered an inferior operation because of comparatively poor long-term results. One factor that has not been considered in the literature is whether or not the operation is performed electively or for acute ischemia (< 24 hours duration). This may be a more important predictor of poor results than previously recognized. During the last 10 years, we have performed 59 AxBFB. In Group A, 41 patients (mean age 71) underwent elective AxBFB and in Group B, 18 patients (mean age 65) had emergency AxBFB. Indications for surgery in Group A were limb-threatening ischemia (30), infected aortic graft (5), and severe claudication (6); in Group B, indications for surgery were acute limb ischemia (16), and aortoduodenal fistula (2). Primary patency (p < 0.002), limb salvage (p < 0.002), and survival (p < 0.03) were significantly better in Group A versus Group B. We conclude that an AxBFB performed electively provides satisfactory palliation of severe vascular disease in high-risk patients. The indications for operation and timing of the operation may explain the widely disparate clinical results reported in the literature.

Long-term follow-up of bypasses to the brachial artery across the shoulder joint.

BACKGROUND: Most atherosclerotic lesions in the subclavian artery are successfully treated with carotid to subclavian bypass. The need to bypass to the brachial artery (BA) is rare. We reviewed our experience with this bypass. METHODS: Over a 10-year period, we have performed 13 bypasses to the BA originating from an artery proximal to the shoulder joint. In this retrospective study, the demographic and clinical risk factors were evaluated. Long-term results were analyzed. RESULTS: Thirteen operations were performed in 10 patients, aged 47 to 80 years. The operations were carried out for acute severe ischemia in 1 limb, effort discomfort in 9, and rest pain in 3 limbs. Donor arteries were axillary (7), carotid (4), and subclavian (2). All bypasses were to the BA proximal to the elbow joints. Life-table analysis showed 100% patency in the first 3 years and 88% at 7 years. There were 2 deaths in follow-up. Average preoperative brachial to brachial index was 0.59 and postoperative index was 1.1. In patients with bilateral occlusions, mean preoperative brachial artery pressure was 62 mm Hg, which improved to 142 mm Hg postoperatively. There were no neurological complications and no 30-day mortality. CONCLUSIONS: Bypass across the shoulder joint to the BA using expanded polytetrafluoroethylene (ePTFE) or vein is a safe operation with excellent long-term patency. The carotid artery can be used as a donor vessel without complications. Hypertension and female gender appear to be risk factors for extensive disease in proximal upper extremity arteries.

Vascular operations in nonagenarians.

This is a retrospective study describing our experience with vascular surgical procedures performed in patients 90 years of age or older. Thirty-four procedures, including major and minor vascular reconstruction and amputation, were performed in 20 patients. The 30-day mortality rate was 6% for planned surgical procedures. The 24-month survival rate was 82% for elective major revascularizations and limb salvage was 80% in these patients. We believe that vascular reconstruction can be carried out with acceptable morbidity and mortality when the operations are planned and the patients have been chosen carefully.

Improvement in suction catheter efficiency and safety in arterial operations.

The Blood Shield is a new device which has been developed to attach easily to the tip of a conventional suction catheter. Two experiments were performed to determine if the Blood Shield could limit the degree of splash which occurs during vascular graft flushing and whether it could increase the efficiency of a standard suction tip in collecting shed blood for autotransfusion. The results of the experiments indicate that the Blood Shield, when added to a conventional suction catheter, diminishes the amount of spray which may occur during anastomotic flushing. Secondly, it more effectively collects blood from a flushed anastomosis or arteriotomy in comparison with a suction catheter alone.

Aortoiliac bypass in a renal transplant patient using a new technique.

There are only 18 patients described in the English literature who had a preexisting renal transplant and underwent aortic surgery for aortoiliac occlusive disease. We describe an additional patient who was treated with a new technique using a Sundt shunt and a GraftAssist. This technique provides antegrade flow and minimal ischemic time and avoids exploration of arteries not involved in the anastomosis.

Routine completion study during carotid endarterectomy is not necessary.

The results of many studies have suggested the need for a completion study during carotid endarterectomy (CE). This paper describes our experience not routinely using completion studies. We retrospectively reviewed the charts of 417 patients who underwent 455 CEs. Demographic features, risk factors, ipsilateral neurologic events during the first 30 days, and mortality data were identified. There were 14 neurologic events and 4 deaths. No technical defects were found in 13 patients; 1 patient did not have exploratory surgery after an occlusion. Long-term follow-up shows 10 of the 14 arteries are open. Two patients were lost to follow-up, 1 patient died, and 1 artery was not explored. We conclude that CE may be carried out without routinely using a completion study, with an acceptable postoperative neurologic complication rate. Careful technique is mandatory.

A new technique to correct vascular steal secondary to hemodialysis grafts.

Three patients are described who developed symptomatic steal distal to hemodialysis grafts, documented by angiodynography. Intraoperatively, the graft was plicated to increasing depths while using angiodynography over the radial and ulnar artery. When the flow became antegrade, the plication was stopped, resulting in salvageable grafts. Using the technique, all three patients had long use of the graft after the steal was corrected.

The impact of angiodynography on infrainguinal bypass graft surveillance.

We have followed 64 lower extremity in situ grafts and 56 selected vein or prosthetic grafts with serial angiodynography since 1988 (Quantum Color-flow Duplex) and ankle/brachial indices (ABI). Each graft can be scanned in 20 minutes. Scan results affected clinical decision making in 26 cases. There were ten graft stenoses, 10 distal stenoses, 5 large arteriovenous fistulas (AFV), and one limb with a stenosis and AFV. Four other limbs had incompressible vessels and normal angiodynograms. There were no false positives. Twenty-eight graft revisions were performed in 24 patients. Seven stenoses detected by angiodynogram were not accompanied by changes in ABI. Cumulative patency of revised grafts were 61% at 3 years. The detection of graft or distal arterial stenoses by color flow changes is accurate and rapid. Scanning is recommended for all lower extremity bypass grafts. ABI alone is not sufficient. Scanning helps in planning the surgical incision and may obviate arteriography in selected cases.

Cross-over bypass to axillary vein in haemodialysis patients.

Two patients are described in whom cross-over bypass to axillary vein was performed to salvage brachio-basilic grafts. Both patients had massively swollen arms because of subclavian vein thrombosis and functioning grafts. Their grafts were used for prolonged periods after the corrective operation.

Use of spiral vein graft to bypass occluded subclavian vein.

A patient presented with massive swelling of left arm secondary to left radio-cephalic fistula and ipsilateral subclavian vein occlusion. This was successfully treated with a spiral vein graft interposed between axillary vein and internal jugular vein.

Effects of vasopressin on cardiac output and its distribution in the subhuman primate.

The effects of vasopressin, when administered as intravenous bolus injections and infusions, on cardiac output and the distribution of blood flow to the splanchnic vascular beds were studied in six anesthetized rhesus monkeys. Vasopressin as bolus injections caused dose-dependent decreases in superior mesenteric arterial blood flow. However, small reductions in cardiac output were observed only at the highest doses concomitant with increases in systemic arterial pressure. When vasopressin was infused at the highest dose (5 X 10(-2) units kg-1 min-1) for 10 minutes, cardiac output was unaffected; but sustained reductions in superior mesenteric arterial blood flow and increases in arterial pressure and total peripheral resistance were observed. Infusions of vasopressin (5 X 10(-3) units kg-1 min-1) caused significant and sustained reductions in superior mesenteric arterial blood flow and increases in arterial pressure but no measurable effects on cardiac output or total peripheral resistance. However, there was a significant redistribution of blood flow away from the stomach, small and large intestines, spleen, and pancreas toward the liver (hepatic artery), with no statistically significant change in renal blood flow. On the assumption that comparable responses exist among primates, these data support the clinical use of vasopressin to control gastrointestinal hemorrhage and to offer a probably ideal dose and route of administration.

Hemodynamics of an anastomotic arteriovenous fistula.

Various vascular surgical techniques have been employed to increase both graft patency and limb survival when the prognosis for limb salvage in arteriosclerotic patients is especially poor due to a diseased outflow tract. Ibrahim et al described the creation of an anastomotic arteriovenous fistula in distal tibial bypasses as the reconstructive procedure of choice in severely ischemic extremities unsalvageable by more conventional methods. This study presents the hemodynamics of an anastomotic arteriovenous fistula under such circumstances. Four adult mongrel dogs were anesthesized, and a femoral artery and vein were exposed from the groin to the knee. The femoral artery was ligated in midthigh, and the ligated segment was than bypassed using an umbilical vein graft. The distal anastomosis included an arteriovenous fistula. Flow was measured electromagnetically, and pressure was measured with intravascular catheters attached to strain gauges. The creation of an anastomotic arteriovenous fistula rapidly leads to a reversal of flow in the distal artery, distal arterial hypotension, and distal venous hypertension. Its clinical use in contraindicated as a result of our experimental observations.

Preoperative cardiac screening before peripheral vascular operations.

Myocardial infarction continues to be a major cause of morbidity and mortality after peripheral vascular operations. In this study, radionuclide angiography (RNA) of the heart was used to delineate the cardiac risk. In 78 patients, there were 53 abnormal RNA studies. Twenty-seven patients with abnormal RNA underwent coronary angiography. Six aortocoronary bypasses were performed prior to or in conjunction with the vascular operation without complications. Ninety major operations were carried out in these 78 patients. There was no myocardial infarction in patients with normal RNA. There were two postoperative fatal myocardial infarctions in patients with abnormal RNA giving a procedure mortality of 2.2 per cent. In 11 patients, the proposed operation was changed. Thirteen patients with abnormal RNA had no cardiac symptoms. Three patients in this subgroup underwent aortocoronary bypass. It was concluded that RNA can effectively identify the cardiac risk in patients undergoing peripheral vascular operations. Routine coronary angiography may be unnecessary as patients with normal RNA have minimal risk of myocardial infarction.

The Hemasite-incorporated graft. Operative technique and early results.

A new device (the Hemasite-incorporated graft), has been available to provide access for hemodialysis. Herein, we have described the technique to insert the device and reviewed our early experience. Sixteen Hemasite-incorporated grafts were inserted in 11 patients over a 16 month period. Cumulative functional patency at the end of 1 year was 70 percent. The major complication rate was 0.15 per dialysis month. Patient comfort was considerably increased compared with what was achieved with other grafts. The need for temporary blood access methods is also decreased. More patients may be able to receive hemodialysis at home.