Exploring Individual and Contextual Factors Associated With Sexual Risk and Substance Use Among Underserved GBQMSM and Transgender and Nonbinary Persons in South Central Appalachia

Gay, bisexual, queer, and other men who have sex with men (GBQMSM) and transgender and nonbinary persons are at elevated risk for HIV, sexually transmitted infections (STIs), and hepatitis C (HCV); in Appalachia, these communities experience more disease burden. However, little is known about the factors influencing risk. Sixteen semistructured in-depth interviews were conducted examining factors influencing prevention and care. Data were analyzed using constant comparison methodology. Fifteen themes emerged within four domains: social environment (e.g., microaggressions across gender, sexual orientation, and racial identities), substance use (e.g., high prevalence, use as coping mechanism), sexual health (e.g., misinformation and denial of risk for HIV and STIs), and access to health care (e.g., cost and transportation barriers, lack of local respectful care). Findings highlighted salient barriers and assets influencing prevention and care and suggest that multilevel interventions are needed to improve access to and use of HIV, STI, and HCV prevention and care services.

From Billroth to PCV: a century of gastric surgery

The development of gastric surgery is one of the most fascinating chapters in surgical history. The first operations on the stomach were done during the second half of the nineteenth century; at first they were minor procedures but then gradually became more daring, major procedures-albeit with considerable mortality. The work of Theodor Billroth and his pupils ushered in the era of major resectional therapy, first for cancer and later also for ulcer disease. Complications due to the lack of understanding gastric physiology plagued the early days of ulcer surgery, and a variety of modifications tried to remedy these problems. Although the role of the vagus was known through Pavlov's studies, its practical application had to wait until well into the twentieth century. For several decades, resection and vagotomy, separately or combined, were practiced until more sophisticated types of vagotomy began to dominate and replace resection in the surgical treatment of ulcer disease. Resection remained the treatment for cancer. We thus see over a period of 100 years, owing to the increased understanding of physiologic factors, a gradual shift from major resections toward smaller, better directed procedures. The pioneering work of Billroth and his generation, however, must not be forgotten.

Injuries of the retroperitoneal portions of the colon and rectum

Experience with 66 penetrating injuries of the retroperitoneal colon and rectum is reviewed. These injuries usually affect the intraperitoneal anterior and the retroperitoneal posterior walls. The bare areas of the colon have to be inspected when only one intraperitoneal hole is found or whenever the wound is in the flank or back. There is an increasing tendency toward primary suture rather than exteriorization unless there are multiple severe intra-abdominal injuries, gross contamination, or poor general condition of the patient. Rectal injuries require careful repair, diverting colostomy, irrigation of the excluded rectum and presacral drainage. For suspected bowel injuries, antibiotics should be started preoperatively.

[The management of traumatic hemothorax (author's transl)]

We reviewed 395 patients with isolated hemo- or hemopneumothorax from stab or bullet wounds. Of these, 45 were in shock on admission. All patients were initially treated by closed thoracostomy and infusions or transfusions. Of the 45 patients in shock, 24 responded to this treatment and remained stable. The other 21, after an initial response, showed a renewed drop in blood pressure and rise in pulse rate and had to be explored. All were found to be bleeding from either a systemic artery or a major lung laceration extending into the hilus. All other patients were continued on tube drainage, supplemented, if necessary, by needle aspiration and instillation of fibrinolytic enzymes until the lung was fully expanded, thus avoiding empyemas and the need for decortications. We found the clinical course after initial tube thoracostomy to be a reliable indicator for thoracotomy or for continued non-operative management, thus avoiding unnecessary thoracotomies.

Systematic approach to traumatic hemothorax

We reviewed 395 patients with isolated hemo- or hemopneumothorax from penetrating injuries. All patients were treated with immediate insertion of a chest tube and drainage of various amounts of blood up to 1,500 ml. Forty-five patients (11 percent) were in hemorrhagic shock on admission to the hospital emergency room, and all were resuscitated with volume replacement. Twenty-one patients (5.3 percent) whose blood pressure decreased again were found on exploration to have lacerated internal mammary or intercostal arteries or major lung lacerations extending into the hilus. All other patients were treated aggressively with chest tubes, aspiration of residual blood and fibrinolytic enzymes until the lung was fully expanded. We conclude that the clinical course of patients with hemothorax after insertion of a chest tube should determine whether exploration is necessary or whether nonoperative treatment should continue.

Comparison of stapled and hand-sutured gastrectomies

We reviewed 585 Billroth II gastrectomies to compare the results of stapled and hand-sutured cases. In 385 patients who had the duodenal stump handled by conventional methods, 18 (4.7%) leaked, compared with four (2.5%) leaks in 160 patients who had the duodenal stump stapled. In 474 hand-sutured anastomoses, there were 12 complications (leaks, hemorrhage, or obstruction), whereas there were no complications in 71 stapled anastomoses. We conclude that stapling provides an expedient way of performing gastrectomies that is at least as safe if not safer than conventional hand suture.

Newer concepts in the management of penetrating abdominal trauma

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Wounds of the abdomen: radiographic diagnosis of intraperitoneal penetration

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