Recollections of James Neel.

In his long and influential career Neel contributed to almost all aspects of genetic epidemiology from mutation to ethical and philosophical issues. His research spanned North America, Japan, Africa, and Latin America in a fascinating equipoise among clinical, biochemical, epidemiological, and molecular studies that have stimulated hundreds of researchers who enjoyed the controversies he generated as much as the insights he provided. Without exception, we treasure recollections of a high-principled and warm-hearted colleague whose field studies were a model for their generation.

Modeling the HIV/AIDS epidemic in the English-speaking Caribbean.

The study reported here examines the past and potential future impact of HIV/AIDS in 19 nations of the primarily English-speaking Caribbean. The authors use DemProj, a demographic projection model, to explore two different HIV scenarios. In the low scenario adult HIV prevalence stabilizes at 2% in the year 2000, and in the high scenario adult HIV prevalence stabilizes at 5%. By the year 2010, annual AIDS incidence exceeds 11,000 cases in the low scenario and 28,000 in the high scenario. In both scenarios, 70% of the cases are in young adults 20-45 years old and 12% are in children 0-15. Age-specific mortality is more than doubled in the 20-40 age range in the low scenario, and more than quadrupled in the high scenario. The impact on death rates is also severe among children 0-10. In assessing the economic impact, the authors estimate that the total annual costs of the epidemic will approach US$ 500 million (in constant 1989 US$) or 2% of GDP in the low scenario, and will exceed US$ 1,200 million or 5% of GDP in the high scenario.

AIDS costs in Trinidad and Tobago.

PIP: In 1983, there were only eight registered cases of AIDS in Trinidad and Tobago, all among male homosexuals and bisexuals. By the beginning of 1992, however, Trinidad and Tobago was ranked 17th worldwide among 164 countries for which AIDS-case data had been collected in terms of the number of reported cases of AIDS per 100,000 population. Moreover, by 1992, of the 175 new cases reported for which risk factors could be established, 77.1% were from among the heterosexual population, with 10.3% of cases with known risk factors being in the pediatric category. 143 people had died of AIDS in the country by the end of November 1993. IV drug use has not been much of a problem in Trinidad and Tobago. The prospective costs of HIV and AIDS depend upon the course taken by the epidemic over the next few years, but it has already, in terms of the human capital approach, made an impact upon national GDP. The authors developed projections of AIDS incidence for Trinidad and Tobago through the year 2020 based upon assumptions of plausible patterns of HIV prevalence. The AIDS Projection Model and DemProj, a demographic projection model used mainly to generate estimates of the age distribution of AIDS incidence, were employed. Even the most conservative of projections suggests that the number of cases will rise by a factor of 4-5 by the year 2000. It is hoped that a better appreciation of the full costs of AIDS will help in the development of policies designed to contain the spread of the disease and ensure that the level of societal investment necessary is undertaken to save upon prospective private and social costs. Sections describe unfolding scenarios, estimates of social monetary costs, hospitalization costs, foregone earnings, and prevention programs.^ieng

Imported cholera in a 31-year-old Peruvian female.

We present the case of a 31-year-old Peruvian female with severe dehydration due to diarrhea and vomiting. The patient was one of a number of travelers arriving in Los Angeles on an international flight from Argentina and Peru. Because of the travel history and clinical presentation, cholera was suspected and ultimately confirmed by stool culture. The patient's clinical course is outlined, and discussion of the relevant epidemiology and clinical management of cholera is provided. Physicians should suspect cholera when treating patients with severe gastroenteritis. The short incubation period, rapid onset of dehydration and shock, and high case fatality rate of untreated cholera require a consideration of cholera in patients with diarrhea and recent travel to areas where cholera is prevalent.

Expanding the horizons in treatment of severe peripheral vascular disease using microsurgical techniques.

The use of microvascular tissue transfer as an adjunct to arterial reconstruction has begun to have a positive impact on limb salvage in patients with advanced arteriosclerosis and nonhealing ischemic wounds. However, many patients with severe peripheral vascular insufficiency not amenable to conventional arterial reconstructive procedures eventually require limb amputation. We have treated 12 patients with advanced peripheral vascular disease and nonhealing ischemic wounds by three different methods. These included distal bypass alone, distal bypass done in conjunction with free-tissue transfer, and free-tissue transfer alone. All bypass grafts were done to vessels at or below the ankle using a reversed saphenous vein. In each case, the distal anastomosis was performed, using the operating microscope and standard microvascular technique. Mean follow-up for these patients is 18 months. Distal bypass alone resulted in limb salvage in three of five patients. In the combined bypass and free-flap group, three of five patients had salvage of their threatened extremity at a 1-year follow-up. Two patients with ischemic ulcers, rest pain, and unsuitable distal vessels for bypass were treated with free-tissue transfer alone. This resulted in healed wounds, limb salvage, and complete resolution of the rest pain symptoms in both patients. When advanced ischemia is complicated by large areas of tissue loss, combined bypass and microvascular free-issue transfer, performed in stages or simultaneously, is safe and can often result in limb salvage. In the rare instance of a completely obliterated distal runoff bed, free-tissue transfer alone may provide not only a healed wound, but also a means of "indirect" revascularization of the extremity and limb salvage.

Extensive and complex defects of the scalp, middle third of the face, and palate: the role of microsurgical reconstruction.

Twenty-one patients with gigantic defects of the scalp and middle third of the face and palate following excision of neglected or recurrent tumors, burns, and infections have undergone microsurgical reconstruction. Wide resection of the middle third of the face, orbit, and palate requires "complex" three-dimensional volume reconstruction, whereas extensive defects of the scalp and skull (exceeding 80 cm2) require coverage of the larger surface area soft-tissue defect and the exposed brain and dura. The latissimus dorsi free-muscle flap and split-thickness skin graft have become our methods of choice for extensive scalp and skull defects. The latissimus dorsi musculocutaneous free flap is preferable for reconstruction of complex palatal and external skin and orbital defects of the middle third of the face. Microsurgical free-tissue transfer reliably frees the oncologic surgeon from the constraints imposed by conventional reconstructive techniques and may therefore allow improved curative or at least palliative resection of these extensive tumors.