Human immunodeficiency virus and the cardiac surgeon: a survey of attitudes

The decision to operate on carriers of the human immunodeficiency virus (HIV) who need an urgent cardiac operation is difficult. There is a lack of knowledge about the effect of the presence of HIV on operative risk, about the effect of cardiopulmonary bypass on the progression of HIV infection to acquired immunodeficiency syndrome (AIDS), and about the risk to the cardiac surgical team of operating on 1 or more HIV carriers. This lack of knowledge is exacerbated by the strict regulations surrounding testing. We polled the board-certified cardiac surgeons in the United States on their willingness to perform open cardiac procedures on HIV carriers and AIDS patients. Fifty-three percent of the surgeons responded. Two thirds of them will operate on HIV carriers who need an urgent cardiac operation but regard the presence of AIDS as a contraindication to cardiopulmonary bypass. This is presumably a medical judgment. Those who will not operate on HIV carriers are apparently motivated by fear rather than moral judgments concerning the patients. Virtually all surgeons want to be able to test "high-risk" patients, and a substantial majority would test all patients.     

HIV-1 infection and cardiothoracic surgery: the difference in attitudes between consultants and junior surgeons in the United Kingdom.

A postal survey was carried out inviting the opinions of consultant and trainee cardiothoracic surgeons on the subject of operating upon patients who are either HIV-1 antibody positive or suffer from full-blown AIDS. The questionnaire contained both cardiac and thoracic clinical situations, all of which under normal circumstances would be managed surgically with low operative mortality and long median survival. The overall response rate was 72.4%. A significantly greater number of consultants replied compared to juniors, 80% and 51.6%, respectively (P less than 0.001). In both groups, surgeons were more likely to operate upon a patient who was HIV-1 antibody positive than one who had AIDS. There were no significant differences in the replies of consultants and juniors to the clinical scenarios presented. However, a greater number of juniors admitted to modifying their surgical practice in the light of the increasing incidence of HIV-1 infection (P less than 0.001). Routine preoperative HIV antibody testing was advocated by 77.8% of consultants and 75% of juniors and this rose to 95.1% and 97%, respectively, if patients were in the traditionally high risk groups. Four consultants admitted that they were already performing routine preoperative HIV antibody screening. This survey emphasized the real concern amongst cardiothoracic surgeons, irrespective of their grade, about HIV-1 infection and the need for both education and clear policy guidelines to deal with this difficult issue.     

Attitudes of cardiothoracic surgeons in the UK to human immunodeficiency virus.

A survey was carried out into attitudes of cardiothoracic surgeons in the UK to human immunodeficiency virus type 1 (HIV-1) infection associated with clinical situations that would normally have been managed surgically with low operative mortality rates and long median survival times. The survey response rate was 72.4 per cent. In patients with acute valvular insufficiency or with continuing angina despite maximal medical therapy (unstable angina) who were HIV-1 antibody positive, 75.8 and 80.8 per cent, respectively, of surgeons would operate. If the patient had end-stage infection, acquired immune deficiency syndrome (AIDS), 29.7 per cent and 34.7 per cent, respectively, would consider surgical intervention. When asked to perform simple procedures such as open lung biopsy or pleurectomy on a patient with AIDS, more than half of surgeons would operate (52.2 and 65.6 per cent respectively). In patients with operable carcinoma of the lung and asymptomatic HIV-1 infection 52.3 per cent would operate. This fell to 15.0 per cent if the patient had a diagnosis of AIDS. The majority of surgeons (77.2 per cent) felt patients should have an HIV-1 antibody test before operation and this rose to 95.6 per cent if patients were in a high-risk group; 60.2 per cent of surgeons had changed their surgical practice to reduce the risks of blood-borne infection.     

Human Immunodeficiency Virus Infection: Complications and Outcome of Orthopaedic Surgery

Orthopaedic surgeons practicing in areas with a high prevalence of human immunodeficiency virus (HIV) infection may expect that up to 7% of their patients who undergo emergent procedures and 1% to 3% of those who undergo elective surgery will be HIV-positive. Although basic science studies have demonstrated impairment of defenses to routine orthopaedic pathogens as well as to opportunistic organisms, clinical studies have shown that this impairment has not resulted in an increased incidence of postoperative infections or failure of wound healing in the asymptomatic HIV-positive patient. Even for the symptomatic patient, current medical management appears adequate to reduce the risk of early postoperative infection. The HIV-positive patient with a pros-thetic implant may be at increased risk for late hematogenous implant infection as host defenses diminish. Regular medical attention, prophylactic antibiotic therapy before dental work and invasive procedures, and early evaluation and treatment of possible infections are especially important in this setting. Decisions regarding elective surgery should be made on a risk-benefit basis. Because the risk of surgical complications increases with progression of the dis-ease, guidelines for elective surgery should include an assessment of the HIV-positive patient's immune status, including the CD4 lymphocyte count, history of opportunistic infection, serum albumin level, the presence of skin anergy, and the state of nutrition and general health.     

The influence of human immunodeficiency virus infection and intravenous drug abuse on complications of hemodialysis access surgery.

To examine the influence of human immunodeficiency virus (HIV) infection on complications in dialysis access surgery, a review was performed on patients undergoing hemodialysis at two major metropolitan medical centers over a 30-month period. One hundred eight patients underwent a total of 169 graft procedures; mean follow-up was 14 1/2 months. There were 18 (17%) patients who were HIV-positive who had no symptoms, 11 (10%) patients with acquired immunodeficiency syndrome (AIDS), and 79 (73%) patients who were HIV-negative. Twenty-three percent (25/108) of patients had a history of intravenous drug abuse (IVDA), most of whom also had either AIDS or asymptomatic HIV infection. Dialysis procedures included 44 autogenous reconstructions (26%), 117 polytetrafluoroethylene (PTFE) grafts (69%), and 8 (5%) procedures of unknown type. Arteriovenous fistula or graft thrombosis was a frequent complication. The overall 12-month graft patency rate was 41%, and patients with HIV infection or a history of IVDA did not have a significantly increased risk of thrombosis. Multivariate analysis showed that the use of PTFE as opposed to autogenous reconstruction was the only significant risk factor found for occlusion within the first 12 months after operation (p < 0.01). Twenty-five graft infections occurred, all in PTFE grafts. The PTFE graft infection rate was 43% in patients with AIDS, 36% in patients who were HIV-positive and who had no symptoms, and 15% in patients who were HIV-negative (p < 0.05). Patients with a history of IVDA had a 41% PTFE graft infection rate versus a 13% infection rate in patients who did not have a history of IVDA (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

HIV in der Gef??chirurgie

Surgeons have always been at risk of acquiring blood-borne infections during operative work. Hepatitis B and C transmission are described as well as HIV as a more recent type of blood-borne infection. Especially in the case of HIV, which is a chronic infection currently with a long life expectancy, the increasing number of people living with HIV/AIDS should also be kept in mind by vascular surgeons. For vascular surgery in HIV-positive patients, the same standards should be applied as in all other vascular surgery cases. Antiretroviral therapy in conjunction with vascular procedures (particularly drug interactions) will be discussed. Measures to prevent infection in the operating theatre and HIV postexposure prophylaxis will be presented.     

Survey of the knowledge, attitude and practice of Nigerian surgery trainees to HIV-infected persons and AIDS patients

Background  

The incidence of HIV infection and AIDS is rising in Nigeria. Surgeons are at risk of occupationally acquired infection as a result of intimate contact with the blood and body fluids of patients. This study set out to determine the knowledge, attitude and risk perception of Nigerian surgery residents to HIV infection and AIDS.     

Seroprevalence of HIV, HBV and HCV in orthopaedic patients at a tertiary hospital in Greece

Infections from hepatitis viruses and human immunodeficiency virus (HIV) as well represent a continuous risk factor to health care providers, in particular those working in surgical departments. The aim of this study was to define the prevalence of HIV, hepatitis B (HBV) and hepatitis C (HCV) viruses in patients admitted in an urban, tertiary orthopaedic department in Greece. We retrospectively studied 1,694 consecutive patients who underwent several orthopaedic procedures. All patients were tested for HIV, HBV and HCV infections. Sixty-six (3.9%) of the patients were seropositive for at least one of the studied viruses. Thirty (1.7%) were positive for HBV, 34 (2%) for HCV and 2 (0.1%) for HIV. The majority of the seropositive patients were women (53%), urban areas citizens (89.4%), and of Greek nationality (83.3%). Non-Greek nationality was the only significantly predictive factor for seropositivity (χ² = 590.2, P < 0.001). The majority of patients were not aware of their infection. A significant percentage of patients cared for at a Greek orthopaedic department were seropositive for blood-borne viruses. Non-Greek nationality is a risk factor. We believe that these data will increase awareness and will promote safer practices among health care providers in orthopaedic units.     

HIV infection in South Africa, 1982-1988--a review

A review of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) in South Africa between 1982 -1988 is presented. One hundred and sixty-six cases of AIDS have been seen in South Africa so far, with a mortality rate of 59.2%. There has been a predicted and alarming increase in the number of cases of AIDS in the black population. A total of 1857 HIV antibody-positive sera have been tested by various laboratories in the RSA, but this figure excludes sera found to be positive in the mining industry. The HIV-positive and AIDS cases include members of all population groups. A number of surveillance studies are presented. These revealed that beyond the groups at high risk for HIV infection the prevalence of this infection is still very low. Of an estimated 710,000 blood donors tested, 244 were positive for HIV-1 antibodies. Although 1 case of HIV-2 infection was detected in South Africa, this does not constitute a problem at present. No evidence of infection with HIV-1 was detected in southern and central African sera taken between 1970 and 1974. In the absence of a vaccine and specific treatment a change of sexual behavior to one of safer sex practices through education is the only means we have of containing the spread of the epidemic.     

Attitudes and experiences of human immunodeficiency virus-positive patients to surgery and surgeons.

The issues regarding screening and identification of patients at risk for human immunodeficiency virus (HIV) infection before surgery continue to be discussed, and there is a need for information regarding attitudes of both surgeons and patients to this issue. A population of HIV-positive patients attending a genitourinary medicine clinic were given an anonymous questionnaire to review their experiences of attending for operation. Of 174 patients who replied, 52 had undergone a total of 65 procedures. In all but three of the operations, the HIV status was made known to the surgeon.     

Catheter-related bacteraemia in haemodialysis patients with HIV infection.

BACKGROUND: Tunnelled catheters are used for dialysis in over 25% of haemodialysis (HD) patients and are a major risk factor for bacteraemia. HIV-positive patients may be at particularly increased risk of catheter-related bacteraemia (CRB) due to their immunocompromised state. The present case-controlled study compared catheter-related bacteraemia with HIV-positive and HIV-negative haemodialysis patients. METHODS: Using a prospective computerized vascular access database, we identified 33 HIV-positive haemodialysis patients who had a tunneled dialysis catheter placed during a 6.5-year period. Their catheter outcomes were compared with those observed in 55 age-, sex- and access date-matched control haemodialysis patients. RESULTS: The two groups were similar in terms of age, sex, diabetes, hypertension and peripheral vascular disease, but the HIV patients were more likely to be black (94 vs 76%, P=0.03). CRB occurred in 52% of the HIV patients and 49% of the controls (P=0.83). The median infection-free catheter survival was similar in HIV-positive and negative patients (165 vs 119 days, P=0.12). Among patients with CRB, the likelihood of a Gram-negative infection was similar in both groups (18 vs 30%, P=0.37). However, polymicrobial CRB was more likely in HIV patients (41 vs 15%, P=0.049). HIV-positive patients were more likely to be hospitalized for treatment of CRB than HIV-negative patients (29 vs 7%, P=0.05). CONCLUSION: CRB is equally likely in HIV-positive and control haemodialysis patients. However, CRB is likely to be more severe in HIV-positive patients, as judged from the greater likelihood of polymicrobial infection and of hospitalization.     

Mid-Term Outcomes in HIV-Positive Patients After Primary Total Hip or Knee Arthroplasty

We hypothesized that infection rates following total joint arthroplasty (TJA) in those with the human immunodeficiency virus (HIV) without hemophilia or drug use would be similar to rates in HIV-negative patients. Records at an urban HIV referral hospital were searched for patients who underwent primary total hip and knee arthroplasty from 2003 to 2010. The primary outcome was revision for infection. 372 HIV-negative and 22 HIV-positive TJA patients met inclusion criteria. The HIV-positive group had more deep infections than the HIV-negative group (9.1% v 2.2%, P = 0.102). There were no infections in those with AIDS-defining CD4 counts. Those with HIV may have a higher risk of developing a deep infection. A low CD4 count is not an absolute contraindication to TJA in HIV positive patients.     

Cardiac surgery in human immunodeficiency virus (HIV) carriers

Intravenous drug addicts have always been at risk for acquiring infective endocarditis. In the United States in recent years, as many as 50% of addicts have become infected also with the human immunodeficiency virus (HIV). Since testing became available in late 1984, we have knowingly performed open cardiac surgery for endocarditis 11 times in HIV-positive patients. In 7, signs of infection were still presented at the time of surgery. Four died within 2 months of continued or recurrent sepsis. The others are alive, although 1 has returned to IV drug abuse. Open heart surgery was performed 4 times in patients whose endocarditis had been cured by antibiotics but who were left with destroyed valves and severe congestive cardiac failure. All these patients left hospital alive and well. One has since died of AIDS. Ten addicts with endocarditis coming to surgery in the pre-AIDS era had similar valvular pathology but only 2 with uncontrolled infection. All were cured by the combination of antibiotics and surgery. Conclusions: in HIV-positive patients with endocarditis, continued sepsis despite appropriate antibiotic therapy signals a potentially very serious prognosis which may be due to an already seriously impaired immune state. By contrast, in the absence of uncontrolled infection, HIV-positive patients appear to have a normal response to open cardiac surgery. Data on the risk to the patient of progressing to AIDS and the risk to the surgical team of acquiring HIV infection are unknown. Testing is vital for answering these questions.     

Rate of and risk factors for acute inpatient mortality after orthopaedic surgery

BACKGROUND: Orthopaedic surgeons operate on a diverse group of patients, and many of these patients have concomitant medical problems. The purpose of this study was to identify the rate of mortality and to evaluate the risk factors associated with mortality after orthopaedic surgery. METHODS: Data from the National Hospital Discharge Survey, a nationwide sample of hospital admissions, were obtained for the years 1995 through 1997. The study was limited to hospital admissions. Univariate and multivariate analyses were performed. RESULTS: The 43,215 inpatient orthopaedic operations that we evaluated were associated with a mortality rate of 0.92%. Seventy-seven percent of all deaths occurred after procedures performed for patients who were more than seventy years old, and 50% of all deaths occurred after operations performed for the treatment of hip fractures. The independent preoperative medical risk factors for death included chronic renal failure, congestive heart failure, metastasis to bone, atrial fibrillation, chronic obstructive pulmonary disease, and osteomyelitis. The risk factors of diabetes, coronary artery disease, peripheral vascular disease, septic arthritis, and rheumatoid arthritis did not achieve significance. Among orthopaedic subspecialty categories, operations for tumors, trauma, and infection were associated with elevated mortality rates. In a predictive model, five critical risk factors were identified as most helpful in identifying patients at risk for death: chronic renal failure, congestive heart failure, chronic obstructive pulmonary disease, hip fracture, and an age of greater than seventy years. The mortality rate was 0.25% for patients with no critical risk factors. A linear increase in mortality was seen with increasing numbers of critical risk factors (p < 0.005). CONCLUSION: Death is rare after orthopaedic operations. In the United States, the rate of acute mortality after inpatient orthopaedic surgical procedures is approximately 1% for all patients, 3.1% for patients with a hip fracture, and 0.5% for patients without a hip fracture. These data will aid orthopaedic surgeons in predicting operative mortality for their patients.     

Prevalence and correlates of HIV among men who have sex with men in Tijuana,Mexico

Introduction

Men who have sex with men (MSM) in developing countries such as Mexico have received relatively little research attention. In Tijuana, Mexico, a border city experiencing a dynamic HIV epidemic, data on MSM are over a decade old. Our aims were to estimate the prevalence and examine correlates of HIV infection among MSM in this city.

Methods

We conducted a cross-sectional study of 191 MSM recruited through respondent-driven sampling (RDS) in 2012. Biological males over the age of 18 who resided in Tijuana and reported sex with a male in the past year were included. Participants underwent interviewer-administered surveys and rapid tests for HIV and syphilis with confirmation.

Results

A total of 33 MSM tested positive for HIV, yielding an RDS-adjusted estimated 20% prevalence. Of those who tested positive, 89% were previously unaware of their HIV status. An estimated 36% (95% CI: 26.4–46.5) had been tested for HIV in the past year, and 30% (95% CI: 19.0–40.0) were estimated to have ever used methamphetamine. Independent correlates of being infected with HIV were methamphetamine use (odds ratio [OR]=2.24, p=0.045, 95% CI: 1.02, 4.92) and active syphilis infection (OR=4.33, p=0.01, 95% CI: 1.42, 13.19).

Conclusions

Our data indicate that MSM are a key sub-population in Tijuana at higher risk for HIV. Tijuana would also appear to have the highest proportion among upper-middle-income countries of HIV-positive MSM who are unknowingly infected. More HIV prevention research on MSM is urgently needed in Tijuana.     

Risk of human immunodeficiency virus in surgeons, anesthesiologists, and medical students.

We postulated that three factors determined the occupational risk of infection from the human immunodeficiency virus (HIV) for surgeons, anesthesiologists, and medical students: first, the risk of needlestick exposure per year (range for surgeons 3.8-6.2, weighted average 4.2; range for anesthesiologists 0.86-2.5, weighted average 1.3; range for third-year medical students 0-5, best estimate 5); second, the risk of seroconversion from a needlestick exposure (0.42%-0.50%); and third, prevalence of HIV in the population served (0.32%-23.6%, depending on geographic location). Thus, the calculated range for occupational risk of HIV infection for a surgeon over a 30-yr period (assuming no change in HIV prevalence or benefit from protective measures) was 0.17%-13.9%; for an anesthesiologist, 0.05%-4.50%. The corresponding range of occupational risk for a medical student during the third year was 0.007%-0.59%. The range of risk is large because the variation in prevalence of HIV infection from one area to another is great. The authors validated the methodology first by using an equation, with estimates from the literature for factors in the equation, to calculate the risk of infection for hepatitis B and then by comparing the results with known rates of infection in the prevaccine era. Calculated occupational risk of hepatitis B infection for anesthesiologists was in the lower range of actual prevalence of infection (calculated range 2.32%-20.6%; known range 6%-26%). Calculated risk versus prevalence for surgeons was fairly close (7.31%-53.4% versus 24.4%).(ABSTRACT TRUNCATED AT 250 WORDS)     

安全有效的HIV治疗与预防性疫苗的设计、开发和成功应用

普遍认为引起肆虐全球的HIV/AIDS大流行的病原体HIV是不可治愈并且是致命的。自从 20多年前发现并分离出病毒后,全世界在生产预防性和治疗性疫苗的努力至今都是失败的。作者在尼日利亚设计开发了HIV疫苗,并且已经应用这些疫苗分别对知情同意的HIV感染者和正常人进行了试验。在许多病例中,治疗性疫苗不仅在HIV感染的症状上产生了快速的改善,而且许多患者持续的抗 HIV抗体血清转阴。在那些并发HBV和 /或HCV感染的HIV患者中,治疗性疫苗产生了持续的抗HBsAg和抗HCV抗体转阴。使用这些疫苗至今没有观察到显著的不良反应,也没有引起可检测的标志性抗 HIV抗体产生。推测这种疫苗可诱导针对HIV、HBV和HCV感染细胞有效的选择性的细胞介导的细胞毒性免疫应答。     

Eye protection for the surgeon

The surgeon today is obliged to operate on an increasing number of patients who are classed as high risk. A study is presented which examines the extent of potential corneal contamination with blood or tissue fluids, during common orthopaedic operations. In all, 65% of goggles worn by surgeons during the study were contaminated. The greatest risk was associated with operations around the hip joint, which are among the commonest orthopaedic procedures. Increased contamination was associated with the use of power tools and irrigation. The contamination rate of the protective flaps at the side of the goggles was relatively low (5%) suggesting that ordinary spectacles, which are more convenient and comfortable than the standard issue goggles, would provide adequate protection during routine use.     

Cauda equina and lumbar nerve root compression in patients with AIDS

Five patients known to be HIV (human immunodeficiency virus)-positive--that is, susceptible to AIDS--presented with symptoms initially thought to be indicative of lumbar disc lesions. Signs of nerve root or cauda equina compression were found in all five patients. Lumbar radiculography and, in one patient, computerised tomography produced no evidence of compressive pathology. We recommend that orthopaedic surgeons exercise caution in diagnosing nerve root compression in patients who may be HIV-positive.