Significance of the human immunodeficiency virus infection in patients submitted to cardiac surgery.

BACKGROUND: To realize if cardiac surgery could interfere with the evolution of HIV infected patients to the acquired immunodeficiency syndrome (AIDS). METHODS: The study group consisted of 30 HIV positive patients (0.21%) among 14,785 who underwent cardiac surgery at the Heart Institute of University of Sao Paulo Medical School (Incor-FMUSP) from November 1988 to December 1994. Patients were followed up until they were discharged from hospital and a new contact was kept at the end of the first semester of 1995. RESULTS: All patients were asymptomatic at the time they were operated. Two patients progressed to death during hospitalization due to non-infectious complications and other three patients could not be traced. After all 25 patients had their progression evaluated. Six patients (24%) died within a period ranging from 1 to 46 months (average=17 months): 2 due to bacterial pneumonia and 04 due to AIDS-related complications. The average follow-up period for the 19 surviving patients was 33.6 months (ranging from 13 to 74 months), and only one of them (5.3%) saw the infection progress to AIDS. In summary, 5/25 (20%) saw HIV infection progress to AIDS within a maximum period of 74 months. CONCLUSIONS: Data available up to now show no conclusive evidence of acceleration of HIV into AIDS associated with cardiac surgery.     

Total knee arthroplasty in classic hemophilia

Thirteen semiconstrained total knee arthroplasties (TKA) were performed in nine men with classic hemophilia. The average age at surgery was 38 years, the average Factor VIII administration during hospitalization was 84.222 units, and the average hospitalization time was 33 days. Four patients (44%) died during the observation period, three from acquired immunodeficiency syndrome (AIDS) contracted through contaminated Factor VIII plasma concentrates and one from sudden cardiac arrest. One of the patients who died from AIDS had a positive test for human immunodeficiency virus (HIV) at surgery. He died three months after the arthroplasty. The remaining two patients contracted AIDS one year and four years after the arthroplasty. All but one patient were followed for at least one year, with an average follow-up period of 43 months. Using The Hospital for Special Surgery Knee Rating Scale, the overall result was excellent in nine knees and good in three knees. All patients were completely relieved of pain. TKA in hemophiliacs is an effective treatment for otherwise intractable chronic knee pain due to severe joint degeneration. However, caution should be taken in HIV-positive patients owing to the challenge of the patient's immune system and the risk of transmitting the virus to the hospital staff.     

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.     

Complications of laparoscopic cholecystectomy in HIV and AIDS patients

We retrospectively evaluated the results of laparoscopic cholecystectomy in patients infected with the human immunodeficiency virus (HIV) with and without acquired immunodeficiency syndrome (AIDS).One thousand one hundred twenty-seven consecutive patients underwent laparoscopic cholecystectomy by our surgical group. Eighteen of these patients were known to be infected with the HIV virus; 6 were asymptomatic and 12 had AIDS. We reviewed the medical records of all HIV-positive individuals with regard to morbidity, mortality, and postoperative outcome following laparoscopic cholecystectomy.In the six HIV-patients without AIDS, five (83%) had improvement of symptoms postoperatively. There was one minor complication (17%). In contrast, only one of the 12 patients with AIDS had postoperative improvement of symptoms and eight (66%) had complications after surgery. There were four deaths (33%) within 30 days of surgery in this group.Only a small percentage of AIDS patients benefit from laparoscopic cholecystectomy. There is a significantly morbidity and mortality following this procedure in this group. Strategies to improve outcome are presented.     

ABDOMINAL SURGERY IN HIV/AIDS PATIENTS: INDICATIONS,OPERATIVE MANAGEMENT,PATHOLOGY AND OUTCOME

Despite the increasing number of patients with the human immunodeficiency virus (HIV) infection. surgical experience with these patients remains limited. A retrospective review over a 9 year period (January 1985 to December 1993) was undertaken to determine the indications, operative management. pathologic findings and outcome of major abdominal surgery in these patients. A total of 51 procedures were performed in 45 patients; 30 patients had acquired immunodeficiency syndrome (AIDS) and IS patients had asymptomatic HIV infection. Indications included gastrointestinal bleeding. complicated pancreatic pseudocysts. cholelithiasis. bowel obstruction, immune disorders, acute abdomens. elective laparotomy. colostomy formation. menorrhagia and Caesarean section. Pathologic findings directly related to the HIV infection were found in 81% of the AIDS patients and 35% of the asymptomatic HIV infected patients (P<0.05). These included opportunistic infections. non-Hodgkin's lymphoma. Kaposi's sarcoma, immune disorders. lymphadenopathy and pancreatic pseudocysts. It was noted that AIDS patients had more complications than asymptomatic HIV infected patients with most complications related to chest problems and sepsis (61 vs 7%; P<0.01). Emergency operations carried a higher complication rate than elective operations though this was not significant. The hospital mortality was 12%. On follow up, 13 of the 25 AIDS patients had died with the median survival of 7 months, while three of the 14 asymptomatic HIV infected patients had died with the median survival of 40 months. Of the remaining patients, the 12 AIDS patients had a median postoperative follow up of 7 months and the 11 asymptomatic HIV infected patients had a median postoperative follow up of 29.5 months. Despite impaired immune function, surgical treatment of HIV infected patients with abdominal pathology can be practised with acceptable mortality and morbidity and be of major benefit to these patients.     

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.     

Control of transmission of HIV and other bloodborne pathogens in biomechanical cadaveric testing

The Bioengineering Center at Wayne State University uses universal blood and body fluid precautions when handling human cadavers in bio-mechanical testing. Our infection control protocol largely follows the precautions outlined by the Centers for Disease Control (CDC). In addition, we screen each cadaver for the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV) before accepting a cadaver for biomechanical tests. This paper discusses acquired immunodeficiency syndrome (AIDS) and infection control guidelines by addressing the following: (a) what is AIDS? (b) How infectious is the HIV virus, which causes AIDS? (c) What precautions should be taken in cadaveric testing to safeguard against HIV and other bloodborne pathogens? The infection control procedures presented in this paper can be adapted to whole-body cadaveric testing or to the testing of tissue specimens.     

Clinical outcome of HIV positive patients with moderate to severe burns

Human immunodeficiency virus (HIV) infection is a world wide and growing problem. Little is found in the literature concerning the treatment and outcome of patients suffering from HIV infection who are treated for burns. The aim of this study was to assess whether the outcome of HIV positive patients suffering from burn wounds differed from those who do not have HIV infection. Thirty three patients formed the HIV positive study group. HIV negative controls were matched for age, degree of burns, sex and inhalation injury. The mean age of the patients was 31.6 years and the mean total body surface burn was 26.4%. There was no significant difference in the outcome of the two groups in terms of mortality or treatment parameters measured. Two patients had stigmata of AIDS (tuberculosis) and both died. One patient, with a CD4 count of 228, developed severe necrotizing fasciitis. In keeping with other studies looking at the outcome of HIV positive patients in an Intensive Care Unit setting, we concluded that a HIV positive patient, who suffers from a burn wound and has no stigmata of AIDS, should be treated similarly to a HIV negative patient.     

Surgery in HIV-positive and AIDS patients: indications and outcome

We have reviewed the indications for and outcome of surgery in 147 patients who were seropositive for human immunodeficiency virus (HIV), 100 of whom have developed acquired immunodeficiency syndrome (AIDS). There were 256 operations; the commonest indications were anorectal conditions (34%), central venous access (21%), lymph node and soft tissue biopsy (15%) and an important minority underwent laparotomy (4%). Complications occurred in 20% of operations and repeat procedures were required in 35 patients. Both were of equal frequency in the HIV and AIDS populations. Most operations were therefore minor, and achieved satisfactory results with an acceptable morbidity. The possibility of HIV-related infection or malignancy affected the diagnostic and therapeutic approach, particularly in those considered for anorectal surgery or laparotomy. With increasing numbers of HIV-infected patients, knowledge of the types of surgery required and the likely outcome is important to enable provision of a safe and effective surgical service.     

Survival of human immunodeficiency virus-infected patients on maintenance dialysis

It has recently been reported that patients on maintenance dialysis with the acquired immune deficiency syndrome (AIDS) survive only 1 to 3 months. We studied all patients on maintenance dialysis at the Baumritter Kidney Center who were known to be infected with the human immunodeficiency virus (HIV). Five patients met the criteria for AIDS; another ten had anti-HIV antibodies but no opportunistic infections. The AIDS patients survived 8 to 18 months, and two are still alive. Mean survival in the AIDS group was 13.2 +/- 1.9 months, while the HIV(+) non-AIDS group survived 15.7 +/- 3.0 months. While these data are not statistically different, the survival curve in the AIDS group predicted a shorter survival than for the HIV(+) patients without AIDS. In fact, the survival of our dialyzed AIDS patients was similar to that reported for AIDS patients in general. Our experience suggests that dialysis may have no adverse effect on survival in AIDS. We conclude that dialysis patients with AIDS may survive 8 to 12 months or more and that the approach to such patients should be individualized.     

Human Immunodeficiency Disease: How Should It Affect Surgical Decision Making?

Background  The ever-increasing prevalence of human immunodeficiency virus (HIV) infection and the continued improvement in clinical management has increased the likelihood of surgery being performed on patients with this infection. The aim of the review was to assess current literature on the influence of HIV status on surgical decision-making. Methods  A literature review was performed using MEDLINE articles addressing “human immunodeficiency virus,” “HIV,” “acquired immunodeficiency syndrome,” “AIDS,” “HIV and surgery.” We also manually searched relevant surgical journals and completed the bibliographic compilation by collecting cross references from published papers. Results  Results of surgery between noninfected and HIV-infected individuals and between HIV-infected and acquired immunodeficiency syndrome (AIDS) patients are variable in terms of morbidity, mortality, and hospital stay. The risk of major surgery is not unlike that for other immunocompromised or malnourished patients. The multiple co-morbidities associated with HIV infection and the availability of highly active antiretroviral therapy must be considered when assessing and optimizing the patient for surgery. The clinical stage of the patient’s disease should be evaluated with a focus on the overall organ system function. For patients with advanced HIV disease, palliative surgery offers relief of acute problems with improvement in the quality of life. When indicated, diagnostic surgery assists with further decision-making in the medical management of these patients and hence should not be withheld. Conclusion  HIV infection should not be considered a significant independent factor for major surgical procedures. Appropriate surgery should be offered as in normal surgical patients without fear of an unfavorable outcome.     

Management of empyema thoracis at Lusaka, Zambia.

Of the 39 consecutive patients with empyema thoracis managed by one of the five general surgical units at Lusaka, Zambia, 26 suffered from human immunodeficiency virus (HIV) infection and 19 were diagnosed as suffering from pulmonary tuberculosis within 3 years of developing empyema thoracis. Thirty patients were between 16 and 40 years of age; of these, 22 suffered from acquired immune deficiency syndrome (AIDS) and all 19 patients with pulmonary tuberculosis belonged to this age group. Of the four patients with empyema thoracis in the age group of 0-5 years, two were suffering from AIDS. The majority of cases of empyema thoracis associated with AIDS present insidiously and, because of late presentation, rib resection is necessary. After surgery these patients were managed at home with the help of a home care team, thus reducing the burden on hospital resources. The morbidity and mortality rates in these patients are higher than in those in whom empyema thoracis is not associated with AIDS.     

广西壮族自治区横县HIV/AIDS患者早期抗逆转录病毒疗效评估

目的分析人类免疫缺陷病毒感染者/获得性免疫综合征患者（HIV/AIDS）早期抗逆转录病毒治疗（ART）的疗效,为早期ART提供依据。 方法对2013年1月至12月广西横县的HIV/AIDS患者疗效进行观察并随访1年,观察早期治疗组及延迟治疗组发生死亡或患AIDS、失访、停药、维持治疗情况、病毒抑制、免疫学恢复情况及药物不良反应。 结果共入组288例患者,其中早期治疗组52例,延迟治疗组236例。早期治疗组死亡或患AIDS者2例（3.8%）,失访2例（3.8%）,停药9例（17.3%）,维持治疗40例（76.9%）。延迟治疗组死亡或患AIDS者68例（28.8%）,失访13例（5.5%）,停药24例（10.2%）,维持治疗173例（74.0%）。早期治疗组死亡或患AIDS率显著低于延迟组（χ²= 14.438、P = 0.000）。两组失访率（χ²= 0.238、P = 0.625）、停药率（χ²= 2.140、P = 0.143）和维持治疗率（χ²= 0.290、P = 0.590）差异均无统计学意义。延迟治疗组CD4⁺T细胞计数增幅为144.00（13.00～228.00）/μl,早期治疗组增幅为131.00（72.00～195.00）/μl,两组增幅差异无统计学意义（Z =-0.026、P = 0.980）。早期组病毒完全抑制患者38例（95.0%）,延迟组161例（93.1%）,两组差异无统计学意义（χ² = 0.198、P = 0.656）。两组患者发生各级药物不良反应差异无统计学意义（1级：χ² = 1.297、P = 0.255,2级：χ² = 2.122、P = 0.145,3级：χ² = 0.394、P = 0.530,4级：χ² = 1.426、P = 0.232,5级：χ² = 0.000、P = 1.000）。 结论早期ART可显著降低死亡和AIDS相关疾病的发生率,且安全性良好。     

Acute appendicitis in patients with AIDS/HIV infection.

Nine patients known to have acquired immunodeficiency syndrome (AIDS) and/or human immunodeficiency virus (HIV) infection and operated on for acute appendicitis are presented. Six of the nine patients did not have an elevation in the white blood cell count preoperatively. Two patients underwent diagnostic laparoscopy prior to exploration. In four cases, a perforated appendix was removed. Seven patients had persistent postoperative fever, while all nine had a significant lack of leukocytosis after surgery. Other than the absence of a preoperative increase in white blood cell count, the presenting characteristics of this group were similar to those expected in immunocompetent patients. However, concern for a possible opportunistic infection etiology and a desire to avoid operating on these patients resulted in an undue delay prior to exploration. The use of diagnostic laparoscopy aided in earlier and more accurate diagnosis. Despite persistent postoperative fever, appendectomy was performed in patients with AIDS/HIV infection without significant increase in morbidity and mortality.     

HIV/AIDS and the risk of deep vein thrombosis: a study of 45 patients with lower extremity involvement.

Many aspects of acquired immunodeficiency syndrome (AIDS) have been described in detail in the literature. However, there have been very few articles on the phenomenon of deep vein thrombosis (DVT) in the lower extremities of human immunodeficiency virus (HIV)/AIDS patients. The objective of this communication is to record the incidence of DVT in HIV/AIDS patients and the risks for development of embolic events and to emphasize the need for prevention and for the vigorous treatment of this complication. We conducted a retrospective review of HIV/AIDS-infected patients with DVT admitted to Mount Sinai School of Medicine/Cabrini Hospital in New York during the last 5 years. Analysis includes demographic data; risk factors for HIV/AIDS infection; associated medical problems; recent surgery; and laboratory findings including CD4 counts, platelet counts, prothrombin times, partial thromboplastin times, and plasma albumin levels; and image studies. From January 1995 to January 2000 4752 HIV/AIDS-infected patients were admitted. Of those admitted to the hospital 45 (0.95%) were found to have DVT. There were 36 males and nine females (mean age 43 years). Of the 45 patients 38 had infectious complications and 13 developed a malignancy. The distribution of the thromboses were the femoral vein in 23 patients, the popliteal vein in 20 patients, and the iliofemoral system in 2 patients. Twelve patients had recurrent DVT and three patients developed a pulmonary embolism. HIV/AIDS infection is a considerable risk for development of DVT in the lower extremity. Statistically DVT in HIV/AIDS is approximately 10 times greater than in the general population. Emphasis upon prevention and vigorous treatment of DVT is recommended.     

人类免疫缺陷病毒/获得性免疫缺陷综合征患者骨科手术部位感染的影响因素

目的研究人类免疫缺陷病毒（HIV）/获得性免疫缺陷综合征（AIDS）患者骨科手术后发生手术部位感染（SSI）的危险因素以及预防策略。 方法回顾性分析2010年1月至2018年1月于首都医科大学附属北京地坛医院住院行骨科手术的HIV/AIDS患者共79例，根据是否发生手术部位感染将其分为手术切口感染组（21例）和非感染组（58例）。分析两组患者SSI发生率，筛选SSI影响因素，并经Logistic回归分析确定独立危险因素。 结果79例行骨科手术的HIV/AIDS患者中发生SSI者共21例（26.58%），其中13例为切口浅部感染，5例为深部感染，3例为腔隙感染。感染组和非感染组患者年龄基础疾病（糖尿病）、合并疾病（结核）、术前HIV RNA载量、术后1周红细胞沉降率（ESR）、术后1周C-反应蛋白（CRP）、手术时程、住院时间、腰部及下肢手术部位、BMI指数、CD4⁺ T计数、CD8⁺ T计数、CD4⁺/CD8⁺ T、白细胞（WBC）和血红蛋白（HGB）差异均有统计学意义（P均< 0.05）。将临床中及以往文献报道的SSI相关因素均纳入多因素Logistic回归分析，结果显示：年龄、ALB、BMI、CD4⁺ T计数、HGB、WBC、合并疾病（结核）、手术类型、手术部位、手术时程、切口类型、麻醉类型和术中出血量均为HIV/AIDS患者骨科相关手术部位感染的独立危险因素（P均< 0.05）。 结论行骨科手术的HIV/AIDS患者为SSI高危人群，应针对其危险因素采取有效措施干预，积极治疗基础疾病，纠正贫血、低蛋白血症，合理围手术期用药包括高效联合抗反转录病毒治疗（HAART）进行免疫重建、应用抗菌药物以预防性抗感染治疗；尽量控制术中出血量，减少手术时间，术中严格执行无菌操作，尽可能降低手术切口感染。     

Renal involvement in patients infected with HIV: experience at San Francisco General Hospital

A spectrum of renal abnormalities has been described in patients infected with the human immunodeficiency virus (HIV) with or without signs of the acquired immunodeficiency syndrome (AIDS). In particular, attention has been focused on a nephropathy characterized clinically by nephrotic proteinuria and rapidly advancing renal insufficiency, and histologically by focal and segmental glomerulosclerosis (FSGS). To evaluate the relationship between HIV infection and structural renal disease, we reviewed all consultations between January 1982 and March 1988 to the Division of Nephrology at San Francisco General Hospital (SFGH), a municipal hospital treating approximately one-third of AIDS cases in San Francisco. Seventy-three consultation requests were received during this period regarding patients with AIDS (48), AIDS-Related Complex (23), or asymptomatic HIV infection (2). Of these, 27 gave evidence of structural renal disease (Group I): 14 had chronic renal insufficiency, in 10 of whom nephrotic proteinuria was also present. However, progression of renal insufficiency to end-stage renal disease (ESRD) in this group did not follow the rapid course described for HIV-associated nephropathy. Renal tissue was examined in 11 Group I patients and showed FSGS in four and a variety of acute and chronic glomerular and tubulointerstitial changes in the others. In 46 Group II patients, consultation was requested for acute renal failure or fluid, electrolyte, and acid-base disturbances. We also reviewed 91 consecutive autopsies performed in patients dying with AIDS at SFGH between 1981 and 1986.(ABSTRACT TRUNCATED AT 250 WORDS)     

AIDS-related cardiac tamponade: is surgical drainage justified?

In order to evaluate the usefulness of surgical drainage in the treatment of patients with acquired immunodeficiency syndrome (AIDS)-related cardiac tamponade, we reviewed our experience with subxiphoid pericardiostomy on 5 consequent such patients. One patient died in the immediate postoperative period and the remaining 4 died within 21 weeks after the operation. Similar results have been reported by other authors who found that surgical drainage has no diagnostic or therapeutic benefit over pericardiocentesis in this particular group of patients. Based on our limited experience and the data of the literature, we feel that surgical drainage cannot be justified as the primary method of treatment of AIDS-related cardiac tamponade.     

Major salivary gland lymphoepithelial lesions and the acquired immunodeficiency syndrome

Presently, there is no consensus regarding the most appropriate diagnostic and therapeutic approach to patients with human immunodeficiency virus (HIV)-associated lymphoepithelial lesions of the major salivary glands. A retrospective review of 60 consecutive patients with lymphoepithelial lesions is presented. Thirty-eight cases were associated with HIV infection. Lesions associated with HIV infection were usually bilateral, multiple, cystic, and associated with lymphadenopathy. In contrast, in those cases without HIV infection, the lesions tended to be solitary and solid. In the HIV-infected group, treatment included surgery, radiotherapy, zidovudine (AZT), and/or cyst aspiration. All therapeutic regimens, other than aspiration alone, were found to be effective. Eighteen of the patients with HIV infection developed the acquired immunodeficiency syndrome (AIDS) during the study period. Surgical treatment is probably not necessary in the majority of HIV-associated cases. Depending upon individual circumstances, treatment with AZT or low-dose radiotherapy is recommended. A diagnostic and therapeutic algorithm is presented as a guide to the management of future cases.     

Intracavitary repair of ventricular aneurysm and regional dyskinesia.

Myocardial damage after infarction is a common sequela in patients with coronary occlusive disease. The extent of injury varies and may be localized or diffuse. Since March 1989, the authors have used a new surgical repair technique that employs an intracavitary patch of Dacron fabric or glutaraldehyde-treated pericardium to exclude the hypokinetic or fibrotic myocardial segment. An elliptical configuration preserves the contour and volume of the ventricular cavity. After securing the patch, the ventriculotomy is closed with a simple continuous suture. Through July 31, 1991, 136 patients underwent repair using this technique. Of these patients, 100 (group I) had neither sustained an acute myocardial infarction (within 30 days before surgery) nor had undergone previous cardiac surgery, whereas 36 (group II) had sustained an acute myocardial infarction or had undergone previous cardiac surgery. In group I, four (4%) died within 30 days of surgery, and seven died later, resulting in a 6-month survival of 90.5% and a 1-year survival of 85.3%. In group II, 11 (30.6%) died within 30 days of surgery, and three died later. Functional class improved after repair in 95.7% of patients in group I and all patients in group II. In both groups, ejection fraction improved significantly (p less than 0.0001, group I; p less than 0.0001, group II). By eliminating the need for epicardial buttresses to repair the ventriculotomy, myocardial revascularization has been possible in most patients. This method of intraventricular repair is also appropriate for patients with calcified aneurysms, acquired ventricular septal defects, and acute ventricular rupture.