The surgical management of anorectal diseases in AIDS and pre-AIDS patients

Benign Anorectal Disorder Management in Low-Resource Settings

There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the industrialized and western world. However, an interesting difference colorectal surgeons and gastroenterologists can face is the fact that many patients do not seek help or are not aware and have little opportunities to be helped. Latin America population is estimated to be around 8% of the world population, with Brazil having the largest percentage. Infectious diseases, which were previously under control or were steadily declining, have emerged. For example, we have seen resurgence of dengue, malaria, and syphilis in pregnancy, as well as other sexually transmitted diseases that can affect the anorectal region. In this article, we will address the most common benign anorectal disorders.

Surgical Procedures in Patients at Risk of Human Immunodeficiency Virus Infection

We have studied the outcome of 140 general surgical procedures in 112 patients known or suspected to be infected with human immunodeficiency virus (HIV) or hepatitis B virus. Forty patients had antibodies to HIV. A wide range of surgical procedures was performed, with an overall complication rate of 5.7%. Wound infection, wound haematoma and one unexplained pyrexia were the only complications seen. Some anorectal wounds in patients with HIV antibodies were noted to heal extremely slowly, but the aggressive anorectal sepsis reported by others was not seen. The postoperative course after general surgical procedures was unremarkable in patients with HIV antibodies, and in those suspected of HIV infection, but because anorectal wounds were found to heal slowly, we recommend that anorectal surgery be conservative in patients with HIV antibodies.

Persistent Ulceration of the Anal Margin in Homosexuals with Hiv Infection

A study of the outcome of surgical treatment of ulceration of the anal margin occurring in male homosexuals with HIV infection was undertaken. Ten patients with acquired immunodeficiency syndrome and three patients with symptomatic HIV infection were referred to the Department of Surgery with painful anal ulceration which had not responded to medical treatment. The medical treatments given prior to surgical referral included high dose oral acyclovir, intravenous foscarnet and broad spectrum antibiotics. Excision biopsy was performed in 12 patients and in 11 cases was followed by healing of the ulcers within 10 weeks. One patient died 2 weeks postoperatively from Pneumocystis carinii pneumonia without healing. The response to excision biopsy was unexpected but suggests that surgical excision may be beneficial for lesions which have failed to respond to aggressive medical treatment.

Clinical Profile of Surgical Diseases with Emergence of New Problems in HIV+ Individuals

North Karnataka is one of the regions with the high prevalence of HIV+ individuals. Bijapur is a district in North Karnataka with high prevalence as per fact sheets of NACO of March 2012. Better awareness, access to health care, and antiretroviral therapy have improved survival and increase in number of people living with HIV/AIDS (PLHA). Improved survival has increased their attendance to hospitals with variety of surgical problems, some known and some less known. The percentage of HIV+ individuals was 1.64 % among all admissions. Of these individuals, 13.65 % (272) had surgical problems. Abscesses were the commonest. Abscesses at uncommon sites also were encountered. Anorectal pathologies, tuberculosis, lymphadenopathy, appendicitis, etc. commonly seen in HIV+ individuals were seen. Drug-induced pancreatitis due to anti retroviral therapy was one of the common problems encountered. Uncommon conditions like ureteric calculi, external iliac artery thrombosis, diaphragmatic eventration, and few more were observed. Even though literature on AIDS/HIV is abundant, there is less information on surgical conditions encountered more so from this part of the subcontinent. Hence, it was decided to report the profile of the conditions encountered.

Progression From Perianal High-Grade Anal Intraepithelial Neoplasia to Anal Cancer in HIV-Positive Men Who Have Sex With Men

BACKGROUND

High-grade intraepithelial neoplasia is known to progress to invasive squamous-cell carcinoma of the anus. There are limited reports on the rate of progression from high-grade intraepithelial neoplasia to anal cancer in HIV-positive men who have sex with men.

OBJECTIVES

The purpose of this study was to describe in HIV-positive men who have sex with men with perianal high-grade intraepithelial neoplasia the rate of progression to anal cancer and the factors associated with that progression.

DESIGN

This was a prospective cohort study.

SETTINGS

The study was conducted at an outpatient clinic at a tertiary care center in Toronto.

PATIENTS

Thirty-eight patients with perianal high-grade anal intraepithelial neoplasia were identified among 550 HIV-positive men who have sex with men.

INTERVENTION

All of the patients had high-resolution anoscopy for symptoms, screening, or surveillance with follow-up monitoring/treatment.

MAIN OUTCOME MEASURES

We measured the incidence of anal cancer per 100 person-years of follow-up.

RESULTS

Seven (of 38) patients (18.4%) with perianal high-grade intraepithelial neoplasia developed anal cancer. The rate of progression was 6.9 (95% CI, 2.8-14.2) cases of anal cancer per 100 person-years of follow-up. A diagnosis of AIDS, previously treated anal cancer, and loss of integrity of the lesion were associated with progression. Anal bleeding was more than twice as common in patients who progressed to anal cancer.

LIMITATIONS

There was the potential for selection bias and patients were offered treatment, which may have affected incidence estimates.

CONCLUSIONS

HIV-positive men who have sex with men should be monitored for perianal high-grade intraepithelial neoplasia. Those with high-risk features for the development of anal cancer may need more aggressive therapy.

Project Gel a Randomized Rectal Microbicide Safety and Acceptability Study in Young Men and Transgender Women

OBJECTIVES

The purpose of Project Gel was to determine the safety and acceptability of rectal microbicides in young men who have sex with men (MSM) and transgender women (TGW) at risk of HIV infection.

METHODS

MSM and TGW aged 18-30 years were enrolled at three sites; Pittsburgh, PA; Boston, MA; and San Juan, PR. Stage 1A was a cross-sectional assessment of sexual health and behavior in MSM and TGW. A subset of participants from Stage 1A were then enrolled in Stage 1B, a 12-week evaluation of the safety and acceptability of a placebo rectal gel. This was followed by the final phase of the study (Stage 2) in which a subset of participants from Stage 1B were enrolled into a Phase 1 rectal safety and acceptability evaluation of tenofovir (TFV) 1% gel.

RESULTS

248 participants were enrolled into Stage 1A. Participants' average age was 23.3 years. The most common sexually transmitted infection (STIs) at baseline were Herpes simplex (HSV)-2 (16.1% by serology) and rectal Chlamydia trachomatis (CT) (10.1% by NAAT). 134 participants were enrolled into Stage 1B. During the 12 week period of follow-up 2 HIV, 5 rectal CT, and 5 rectal Neisseria gonorrhea infections were detected. The majority of adverse events (AEs) were infections (N = 56) or gastrointestinal (N = 46) and were mild (69.6%) or moderate (28.0%). Of the participants who completed Stage 1B, 24 were enrolled into Stage 2 and randomized (1:1) to receive TFV or placebo gel. All participants completed Stage 2. The majority of AEs were gastrointestinal (N = 10) and of mild (87.2%) or moderate (10.3%) severity.

CONCLUSIONS

In this study we were able to enroll a sexually active population of young MSM and TGW who were willing to use rectal microbicides. TFV gel was safe and acceptable and should be further developed as an alternative HIV prevention intervention for this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01283360.

Review of Hemorrhoid Disease: Presentation and Management

Symptomatic hemorrhoid disease is one of the most prevalent ailments associated with significant impact on quality of life. Management options for hemorrhoid disease are diverse, ranging from conservative measures to a variety of office and operating-room procedures. In this review, the authors will discuss the anatomy, pathophysiology, clinical presentation, and management of hemorrhoid disease.

A case of HIV ulcer

HIV-associated ulcers must be distinguished from idiopathic anal fissures in HIV-positive patients and from other sexually transmitted diseases that cause anogenital ulcers as the treatments differ.

Does HIV infection have an impact upon dental implant osseointegration? A systematic review

OBJECTIVE

A systematic review is made to determine whether human immunodeficiency virus (HIV) infection has an impact upon dental implant osseointegration.

STUDY DESIGN

A PubMed (MEDLINE) literature search was made of articles published up until 14 April 2014. The systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The quality of the studies included in the review was assessed using the Methodological Index for Nonrandomized Studies (MINORS) and levels of evidence (based on the University of Oxford's Center for Evidence Based Medicine criteria).

RESULTS

The combinations of search terms resulted in a list of 132 titles. Nine studies finally met the inclusion criteria and were selected for inclusion in the systematic review. A total of 173 dental implants were placed in 80 patients (135 implants in 56 HIV-positive subjects and 38 implants in 24 HIV-negative patients), and a single loss of dental implant osseointegration was recorded in an HIV-positive patient.

CONCLUSIONS

Our results suggest that dental implant placement in HIV-positive patients does not increase the dental implant failure rate. Prophylactic antibiotic treatment, the administration of highly active antiretroviral therapy, and control of the CD4+ T lymphocyte counts appear to be the main influencing factors in this respect. Given the few studies included in our systematic review, further prospective studies involving larger sample sizes and longer durations of follow-up are required in order to confirm the results obtained.

Gastrointestinal surgery and the acquired immune deficiency syndrome

Acquired immune-deficiency syndrome (AIDS) is becoming an increasing problem to the surgeon. The impact of HIV/AIDS on surgical practice include the undoubted risk to which the surgeon will expose him or herself, the atypical conditions that may be encountered and the outcome and long term benefit of the surgical treatment in view of disease progression. The two factors most associated with surgical outcome and poor wound healing were AIDS and poor performance status (ASA score). This article questions whether gastrointestinal surgical procedures can be safe and effective therapeutic measures in HIV/AIDS patients and if surgical outcome is worthy of the surgeon's ethical responsibility to treat. As HIV/AIDS patients are not a homogeneous group, with careful patient selection, emergency laparotomy for peritonitis confers worthwhile palliation. However, aggressive surgical intervention must be undertaken with caution and adequate peri-operative care is required. Symptomatic improvement of anorectal pathology may make delayed wound healing an acceptable complication. Alternatives to surgery can be contemplated for diagnosis, prophylaxis or palliation.

AIDS, Emergency Operations, and Infection Control

Acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV) may turn out to be the largest lethal epidemic of infection ever. The estimated global number of HIV-infected adults in 1993 was 13 million, with projections of up to 40 million by the year 2000. Human immunodeficiency virus infections and AIDS are relevant to surgeons with respect to the surgical management of AIDS patients in general, the treatment of the increasingly long list of surgical complications specific to AIDS patients in particular, and the risks of patient-to-surgeon and surgeon-to-patient HIV transmission. Because of migration of individuals and populations throughout the world, even surgeons practicing in relatively unaffected regions should be familiar with the potential surgical implications of AIDS. Ethical considerations arise, as well. Are surgeons obliged to operate on HIV-positive or AIDS patients? Some surgeons adhere strictly to the Hippocratic Oath, whereas others reserve the right to be selective on whom they operate, except in emergencies. Other common ethical considerations in the AIDS patient are similar to those arising in the terminal cancer case: whether to operate or not; whether to provide advanced support such as total parenteral nutrition or hemodialysis. Answers are not simple and require close collaboration between the surgeon, the AIDS specialist, and involved members of other specialties. Emergency operations become necessary to treat AIDS independent disease such as acute cholecystitis and appendicitis or AIDS-related life-threatening conditions such as gastrointestinal bleeding, obstruction, perforation, or ischemia complicating Kaposi's sarcoma, lymphoma, and cytomegalovirus or disseminated nontuberculous mycobacterial infections. Delays and errors in diagnosis are frequent. Poor nutritional state with weight loss, low serum albumin, and leukocyte count prevails in most patients requiring emergency operations and account for a high mortality. By applying solid judgment and selecting management appropriately, the surgeon has the ability to prolong life and to improve the quality of life for these unfortunate patients, and to do so with extremely minimal risk to himself and his team.

Results of surgical treatment on benign anal diseases in Korean HIV-positive patients

Perianal diseases are the most common reasons for surgery in HIV-positive patients. This study aimed to evaluate the outcomes of these surgical procedures in Korean patients, focusing on wound healing and postoperative complications. Retrospective analysis was performed on 72 HIV-positive patients who underwent surgery by a single surgeon for benign anal disease between 1998 and 2011. Of these, 68.1% (49/72) of patients received surgery for condyloma acuminata, 19.4% (14/72) for anal fistulas, 6.9% (5/72) for hemorrhoids, and 5.6% (4/72) for perianal abscesses. Patients with condyloma acuminata received surgical excision with electrical coagulation, and all wounds healed completely within 3 months, though 16.3% (8/49) of these patients experienced recurrence. Twelve of the 49 patients (24.5%) who were treated for condyloma acuminata underwent simultaneous operations for concomitant anal fistulas (n = 6), hemorrhoids (n = 4), and perianal abscesses (n = 2). Overall, 3 postoperative complications developed following a total of 94 procedures, and there was no significant increase in complication rate for patients with a low CD4+ T-cell count ( < 200/µL) compared to those with a higher count. The results demonstrate favorable results following perianal surgery in HIV-positive Korean patients.

Hospital-based HIV/HSV-2 seroprevalence among male patients with anal disease in Korea: cross sectional study

BACKGROUND

This study aimed to identify the characteristics of HIV and herpes simplex virus (HSV)-2 seroprevalence in male patients with anal disease.

METHODS

HIV seroprevalence was estimated for different age groups of male patients with anal disease who were treated at Songdo colorectal hospital in Korea between 2001 and 2011. HIV seroprevalence of patients with anal disease was compared with that of patients with nonanal disease for each year from 2007 to 2011. HSV-2 antibody tests were conducted on 2,038 HIV-tested male patients with anal disease in 2009.

RESULTS

For 11 years from 2001, HIV seroprevalence differed significantly by age group (P < 0.001) and was highest in the group aged <20 years. From 2007 to 2011, HIV seroprevalence in patients with anal disease was 7.6/10,000-13.3/10,000 and that in patients with nonanal disease was 0-0.9/10,000. HSV-2 seroprevalence among patients with anal disease was 24.0%, and only one patient with HIV and HSV-2 was observed.

CONCLUSIONS

HIV seroprevalencein male patients with anal disease was significantly higher than that for other diseases. HSV-2 seroprevalence was similar to that in the general male population. Implementation of the current HIV surveillance system for male patients at colorectal hospitals is necessary to help prevent HIV transmission.

Factors predictive of 30-day postoperative mortality in HIV/AIDS patients in the era of highly active antiretroviral therapy

BACKGROUND

Factors that predict HIV (human immunodeficiency virus)/AIDS patient postoperative mortality have remained poorly defined.

OBJECTIVES

The primary objective of this study was to identify factors predictive of short-term, postoperative mortality in HIV/AIDS patients. The secondary objective of this study was to develop a scoring system that would predict short-term postoperative mortality in HIV/AIDS patients.

METHODS

We retrospectively reviewed all HIV/AIDS patients who underwent surgical procedures in British Columbia, Canada, between April 1995 and March 2002. The primary outcome evaluated was 30-day postoperative mortality. Demographic, clinical, and hospitalization-related data were obtained and utilized to predict outcomes using a logistic regression model.

RESULTS

A total of 2305 procedures were carried out on 1322 patients during the study period. Admissions were classified as urgent/emergent for 1311 procedures (57%) and the overall 30-day postoperative mortality was 9.5% (126 deaths). Urgent/emergent admission, older age, prior surgery, a CD4 cell count of ≤ 50 cells/mm, a hemoglobin level ≤ 120 g/L, and a white blood cell count >11 g/L within 90 days before the surgical procedure was predictive of an increased 30-day postoperative mortality in a multivariate model. Using these variables, we formulated the HIV Surgical Mortality Score (HSMS) to obtain the median-estimated probability of postoperative death.

CONCLUSIONS

For accurate preoperative mortality risk stratification for HIV/AIDS patients, we have found that several clinical and laboratory variables must be evaluated. If appropriately validated, our proposed HSMS could be utilized to estimate the probability of short-term postoperative death among HIV/AIDS patients.

Anal fissure

Anal fissure is one of the most common anorectal problems. Anal fissure is largely associated with high anal sphincter pressures and most treatment options are based on reducing anal pressures. Conservative management, using increased fiber and warm baths, results in healing of approximately half of all anal fissures. In fissures that fail conservative care, various pharmacologic and surgical options offer satisfactory cure rates. Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure. This review outlines the key points in the presentation, pathophysiology, and management of anal fissure.

Estimation of HIV Seroprevalence in Colorectal Hospitals by Questionnaire Survey in Korea, 2002-2007

Objectives

The incidence of anal disease is higher among persons with human immunodeficiency virus (HIV) infection than among the general population. We surveyed the status of seroprevalence in colorectal hospitals in Korea.

Methods

The survey was conducted in colorectal hospitals in Korea from November to December 2008. The questionnaire was comprised of six topics about the status of HIV testing in colorectal hospitals. We gathered the data by website (http://hivqa.nih.go.kr/risk) or fax.

Results

Among 774 colorectal hospitals contacted, 109 (14%) hospitals participated in the survey. Among these, 48 hospitals (44%) performed HIV tests in their own hospitals and 11 (23%) took HIV testing by rapid method. The main reason for recommending an HIV test was surgical operation (54%) followed by endoscope (11%) and health checkup (9%). The annual number of HIV tests increased from 58,647 (at 21 hospitals) in 2002 to 246,709 (at 58 hospitals) in 2007. HIV seroprevalence was >3.0 per 10,000 individuals during 2002–2005, decreased to 2.2 per 10,000 individuals in 2006 and rose to 2.8 per 10,000 individuals in 2007.

Conclusions

HIV seroprevalence of colorectal hospitals was more than twice that of general hospitals in Korea. HIV surveillance systems based on colorectal hospitals for HIV/AIDS transmission prevention by early HIV diagnosis are needed.

Hemorrhoids

Hemorrhoid disease is the most common reason patients seek evaluation by a colon and rectal surgeon. The majority of hemorrhoids can be managed nonoperatively with medical management or office-based procedures. The authors review the anatomy, pathophysiology, presentation, and management of hemorrhoids.

CD4 count is predictive of outcome in HIV-positive patients undergoing abdominal operations

BACKGROUND

The impact of immune status and surgical outcome in patients with HIV and acquired immunodeficiency syndrome (AIDS) remains unknown.

METHODS

Clinical variables of HIV/AIDS patients undergoing abdominal surgery were examined for their impact on outcome.

RESULTS

Major abdominal procedures were performed in 77 patients with a diagnosis of HIV/AIDS (55 males, mean age 41.1 years, mean CD4 count 210 mg/dL). A majority of operations (53%) were performed on an urgent basis. Patients undergoing urgent procedures had lower CD4 counts (129 ± 121 vs 303 ± 324, P = .002). The mean CD4 count was lower for patients with complications (146 ± 156 vs 288 ± 319, P = .013) and for those who died (112 ± 113 vs 251 ± 283, P = .026). On multivariate analysis, CD4 count was independently associated with an increased risk for complication, and urgent operation was associated with an increased risk for mortality.

CONCLUSION

Patients with HIV/AIDS who had lower CD4 counts were more likely to require an urgent operation and experience a complication with increased mortality.

A prospective evaluation of lower extremity ulcers in a Zimbabwean population

Aetiological factors and their frequencies, causes, level and impact of immunosuppression on outcome of lower extremity ulcers were prospectively recorded. A total of 100 patients were evaluated. Consent for HIV testing was given by 68 patients and 31 (46%) of these were HIV infected. Thirty patients were diabetic. CD 4+ T-lymphocyte count was assessed in 41 patients. Eleven were HIV infected with a mean CD 4+ count of 229 +/- 137 cells/microl. Six had non insulin-dependent diabetes mellitus (NIDDM) with a mean CD 4+ count 430 +/- 308 cells/microl. Five had both HIV infection and NIDDM with a mean CD 4+ count of 299 +/- 120 cells/microl. All three groups differed from the normal 707 +/- 285 cells/microl found in 17 non HIV-infected non diabetic patients (P < 0. 05). The main aetiologies were bacterial infection, arterial disease, trauma and neuropathy. Ulcer healing and limb salvage were noted in 71%. Mortality was 10%; seven in HIV-infected and three in non HIV-infected non diabetic patients (P = 0. 06). Amputation rate was 9%. Persisting ulcers were noted in 8% and 2% were lost to follow-up. Our evaluation shows that wound aetiologies in Zimbabwe differ from those in the West. Immunosuppression because of HIV infection and NIDDM was noted in more than half of the patients. HIV infection may increase mortality in this group of patients.

Current concepts in anal fissures

INTRODUCTION

Anal fissure is a common and distressing problem the true incidence of which is probably higher than recorded. There is a progressive understanding of the etiopathogenesis of this entity and the changing trend in its management approach. This is a systematic review of available published literature looking at current management options in anal fissures.

METHODS

A MEDLINE-based search of the relevant literature from 1970 to 2004 was performed on the current concepts in etiopathogenesis and management of anal fissure.

RESULTS

The current opinion is a drift toward conservative measures as the first- and second-line approaches rather than surgery for treatment of anal fissure. Simple and readily available measures with less complication, good patient compliance, and satisfaction requiring no hospitalization should first be considered.

CONCLUSIONS

Most anal fissures heal with medical therapy, but their limitations include side effects, poor compliance, and recurrence of the fissure. A cautious surgical approach is required to treat those who do not respond to medical therapy.

Inguinal Lymph Node Biopsy in Patients Infected with the Human Immunodeficiency Virus Is Safe

BACKGROUND AND PURPOSE

The incidence of postoperative complications in human immunodeficiency virus (HIV)-infected patients remains controversial. Published data suggest that these patients are at higher risk for postoperative surgical site infections (SSIs) than are uninfected patients if the site is contaminated. To determine the incidence of postoperative SSI in HIV-infected patients undergoing aseptic surgery at uncontaminated sites, we performed a prospective case series analysis. We hypothesized that the rate of postoperative SSI would be low for this aseptic procedure, irrespective of CD4(+) lymphocyte counts. Additionally, we monitored the rates of other complications, namely, hematoma, dorsal vein thrombosis, epididymitis, lymphocele, and suture extrusion.

METHODS

From May 1, 2000, through January 31, 2006, we performed 137 sterile inguinal lymph node biopsies in 44 HIV-infected patients as part of a funded study evaluating the role of peripheral lymphatic tissue in the pathophysiology of HIV infection. Postoperatively, we followed all patients for a minimum of 30 days.

RESULTS

Postoperatively, we noted one instance each (0.7%) of infection, dorsal vein thrombosis with epididymitis (0.7%), and lymphocele and two cases each (1.4%) of hematoma and suture extrusion. The CD4(+) count at the time of biopsy did not correlate with postoperative complications.

CONCLUSIONS

Inguinal lymph node biopsy in HIV-infected patients is safe, irrespective of CD4(+) lymphocyte count.

Aneurysmal Subarachnoid Hemorrhage in a Patient With Human Immunodeficiency Virus Type 1 Infection-Case Report-

A 54-year-old human immunodeficiency virus type 1 (HIV-1)-infected homosexual Japanese male was found to have collapsed in his bathroom and was brought to our facility with diminished level of consciousness. Computed tomography showed subarachnoid hemorrhage (SAH). He was severely dehydrated with unstable general status that deterred us from performing emergent surgery. Cerebral angiography performed on the 18th hospital day revealed bilateral distal anterior cerebral artery aneurysms. Clipping of these aneurysms was performed on the 30th hospital day and no postoperative complications were experienced. The scalp wound showed no delayed healing, whereas the tracheostomy wound showed repeated wound dehiscence and delayed healing. Postoperative highly active antiretroviral therapy with antibiotic treatment gradually improved his general and immunological conditions. The patient was finally discharged as independent with mild muscle weakness in the bilateral lower extremities. HIV-1 infection should not be the guiding factor in the decision to aggressively treat concomitant aneurysmal disease. Clipping of cerebral aneurysms with full craniotomy or endovascular obliteration should be considered even in HIV-1-infected patients with SAH.

Acquired rectal fistula in human immunodeficiency virus-positive children: a causal or casual relationship?

Acquired rectal fistula in human immunodeficiency virus (HIV)-positive children is a new and worrisome entity. The aim of this paper is to highlight the relationship between HIV infection and acquired rectal fistula (RF) in children in order to create awareness among clinicians who attend to children. Over a 1-year period, 11 girls aged 4 weeks-11 months (median 5 months) with acquired RF were managed at our institution. Ten were HIV-positive by enzyme-linked immunosorbent assay and confirmed by Western blot test. One child defaulted before the test. All the mothers and three fathers of the 10 children were seropositive for HIV. Bronchopneumonia, otitis media, oral thrush, diarrhoea, and lymphadenopathy were common associations. Treatment was essentially conservative because the result of surgical intervention was disappointing. Two of the infants and one of the fathers are now dead from full-blown acquired immunodeficiency syndrome. Acquired RF seems to be a sign of HIV infection in children. It will be necessary to screen any child presenting with acquired RF for HIV infection.

HIV infection reduces skin graft survival in burn injuries: a prospective study

Impaired survival of skin grafts has been noted in human immunodeficiency virus (HIV) infected patients, but the reason is not known. Alterations in inflammatory response, which might be recorded as an imbalance in cytokine production, have been implicated. The aim of this study was to determine the impact of HIV infection in patients with burn injuries by comparison of split skin graft survival, T lymphocyte count and cytokine levels in HIV-infected and non HIV-infected patients in relation to healthy and HIV-infected nonburnt volunteers.Fifty-four patients with deep dermal burns were included. Fifteen patients' were HIV-infected. Thirteen healthy and 15 HIV-infected, volunteers were recruited as controls. The burnt surface area was traced on a transparent plastic sheet and converted to area. Graft survival on day of discharge/regraft for non HIV-infected patients was 69%, and in HIV-infected 22%, (p<0.05). The median length of hospital stay for early excision among non HIV-infected patients was 21 (12-53) days and for HIV-infected, 41 days (p<0.05). Serum protein levels in HIV-infected patients were elevated compared to non HIV-infected patients (p<0.05). CD4+ lymphocytes were depressed in HIV-infected volunteers and HIV-infected burn patients compared to healthy volunteers (p<0.05). CD8+ lymphocytes were elevated in HIV-infected volunteers compared to non HIV-infected burn patients. Pro-inflammatory cytokine levels of Interleukin-2 (IL-2), Interleukin-6 (IL-6), Interferon-gama (IFN-gamma) and tumour necrosis factor alpha (TNF-alpha) were depressed in HIV-infected volunteers compared to healthy volunteers and non HIV-infected burn patients. The pro-inflammatory cytokine IFN-gamma did not increase after burn injury in HIV-infected burns patients as did IL-2, IL-6 and TNF-alpha (p<0.05). Anti-inflammatory cytokine levels of IL-4 were elevated in HIV-infected volunteers compared to healthy volunteers and burn patients (p<0.05).

CONCLUSION

Graft survival after split skin grafting of burn wounds in HIV-infected patients is impaired and hospital stay is prolonged. HIV infection result in immune dysregulation, which might be related to impaired skin graft survival.

Management options for symptomatic hemorrhoids

Hemorrhoids remain one of the most common colorectal complaints. They are defined as a pathologic engorgement of the submucosal vascular plexus. Although they are often asymptomatic, hemorrhoids may cause bleeding, prolapse and, less commonly, pain. This review gives an update on various treatment options for symptomatic hemorrhoids, which include conservative treatments, office interventions, and surgical procedures, depending on the individual constellation of symptoms. Objective findings and expectations are also addressed. Recent advances (eg, stapled hemorrhoidectomy and use of alternate energy sources) are emphasized, and treatment under special circumstances (HIV, pregnancy, inflammatory bowel disease, and liver disease) is outlined.

Septic complications after treatment of haemorrhoids

BACKGROUND

Recent reports of serious sepsis following stapled haemorrhoidectomy have raised concerns about the appropriate treatment of haemorrhoidal disease.

METHODS

A Medline search was undertaken for reports of sepsis following the commonly practised conservative and surgical treatments of haemorrhoids.

RESULTS

Published accounts of significant septic complications after injection sclerotherapy, rubber-band ligation, cryotherapy, open and closed haemorrhoidectomy, and stapled haemorrhoidectomy are discussed. This is supplemented by the authors' own experiences of stapled haemorrhoidectomy.

CONCLUSION

Septic complications following both conservative and surgical treatment of haemorrhoids are rare but may be catastrophic. Immunological compromise poses an additional risk for many treatment modalities. The technique of stapled haemorrhoidectomy should be learned diligently to avoid septic complications.

Anal condyloma and HIV-associated anal disease

Although there are a large variety of anal diagnoses associated with the HIV population, anal condyloma and anal ulcerations make up the vast majority. A large percentage of individuals having multiple concurrent pathologies should also be noted. Thus, this article concentrates on anal condyloma, anal ulceration and HIV, making note of other significant issues.

Rubber band ligation for hemorrhoidal disease can be safely performed in select HIV-positive patients

PURPOSE

Many surgeons have abandoned the use of rubber band ligation for the treatment of hemorrhoids in patients infected with human immunodeficiency virus because of the belief that this procedure could lead to disastrous outcomes. This study was designed to evaluate the safety and efficacy of rubber band ligation in otherwise healthy human immunodeficiency virus-positive patients.

METHODS

A retrospective chart review of healthy human immunodeficiency virus-positive patients who underwent rubber band ligation for symptomatic hemorrhoids between April 1993 and May 2000 was conducted.

RESULTS

The study group comprised 11 patients. All patients were male, with a median age of 48 (range, 32-64) years. Mean T-cell helper count was 450 (range, 200-1,000) cells/microl. A median of 2 (range, 1-4) rubber band ligations were performed per patient. The median length of follow-up was seven (range, 1-28) months. There were no deaths or complications in any study group patient. Eight patients (73 percent) had excellent results, with complete resolution of symptoms. Two patients (18 percent) had initial improvement but subsequently had hemorrhoidectomy because of recurrent symptoms. Only one patient (9 percent) had no benefit from rubber band ligation and underwent hemorrhoidectomy.

CONCLUSION

These data suggest that asymptomatic human immunodeficiency virus-positive patients can be treated safely and effectively with rubber band ligation for symptomatic hemorrhoids.

A comparison of biomechanical properties of excised mature scars from HIV patients and non-HIV controls

BACKGROUND

Patients with human immunodeficiency virus (HIV) infection have been found to have impaired wound healing. This study aimed to determine whether the healed wounds from these patients have an impaired intrinsic strength.

METHODS

The healed wounds of patients with HIV infection who were undergoing a subsequent surgical procedure were excised and examined immediately by tensionometry. A non-HIV group with wounds of the same range of maturity were used as controls.

RESULTS

The wounds of 11 patients with HIV were compared with those of 11 controls. There was no significant difference between the groups' preoperative hemoglobin or albumin; however, the white cell count was lower in the HIV group (P = 0.005). When examined biomechanically, wounds of the HIV group had a lower resilience (P = 0.0138), toughness (P = 0.0138), and maximum extension (P = 0.0235) compared with the control group.

CONCLUSIONS

The wounds of patients with HIV infection when measured biomechanically are weaker than those of normal non-HIV controls.

Predictors of operative outcome in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome

BACKGROUND

Plasma viral load has recently been associated with clinical outcome in patients with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). We hypothetized that, in addition to CD4 lymphocytes, plasma HIV-1 RNA counts are predictive of postoperative outcome.

METHODS

HIV-infected and AIDS patients admitted to a major teaching hospital requiring invasive or surgical procedures were retrospectively analyzed for postoperative outcome. Preoperative and postoperative immune cell counts including plasma HIV-1 RNA counts were recorded. Chi-square analysis, Fisher's exact test, and multivariate regression were performed with statistical significance P </=0.05.

RESULTS

Fifty-five consecutive patients between 14 and 62 years of age were admitted in a 1-year period and underwent 64 diagnostic and therapeutic procedures. Fourteen (22%) postoperative infections and 18 (28%) complications other than infection, with an overall mortality of 11%, were documented. Total preoperative white blood cell count ([WBC] P <0.01), preoperative percent lymphocyte count (P <0.01), absolute postoperative CD4 lymphocyte count (P <0.01), and postoperative plasma viral load (P <0.0001) are associated with mortality. Multivariate regression indicated that postoperative percent CD4 lymphocyte count is an independent predictor of both postoperative infection and other complications (P <0.05, R = 0.848, power = 0.9911), while the decrement in percent CD4 lymphocyte count is an independent predictor of postoperative complications other than infection (P <0.05, R = 0.596, power = 0.7838).

CONCLUSIONS

In accordance with the medical literature for clinical outcome in HIV-infected and AIDS patients, both immune cell counts and HIV-1 RNA counts were found to associate with postoperative mortality. However, the postoperative and decrement in percent CD4 lymphocyte proved to be the independent predictors of postoperative complications.

Management of idiopathic ulcer of the anal canal by excision in HIV-positive patients

PURPOSE

The aim of this article is to show our results from the surgical treatment of idiopathic anal ulcers.

METHODS

We present 33 patients with acquired immunodeficiency syndrome and idiopathic perianal ulcers. They presented with anal pain that failed to improve with medical treatment. Evaluation under anesthesia typically showed an irregular ulcer in the anal canal and an intersphincteric abscess. Surgical treatment consisted of an incision around the ulcer, its excision including margins but not its base, and abscess drainage.

RESULTS

All patients experienced significant immediate postoperative pain relief. Biopsies of the ulcer showed chronic inflammation, and no specific agents appeared in cultures.

CONCLUSIONS

These lesions seem to have the same cryptogenic origin as perianal abscesses, and we recommend surgical treatment to provide symptom relief.

Prospective study of healing time after hemorrhoidectomy: influence of HIV infection, acquired immunodeficiency syndrome, and anal wound infection

PURPOSE

Hemorrhoids and rectal diseases are very frequent in HIV-positive patients, especially in those with homosexual habits. This study was designed to compare posthemorrhoidectomy healing time in such patients, and evaluate the role of various factors related to their HIV-positive status.

METHODS

The study involved a prospective series of 48 male patients (32 HIV-seropositive and 16 with acquired immunodeficiency syndrome) who underwent hemorrhoidectomy between 1992 and 1996; 20 age-matched and gender-matched seronegative patients were retrospectively identified as controls. Healing times, postoperative complications, and wound infections were recorded, and the delaying effect of CD4+, Karnofsky Index scores, and HIV-ribonucleic acid were evaluated. Between-group differences were analyzed using Cox's model, Student's t-test, chi-squared test, and Fisher's exact probability test. P values of <0.05 were considered statistically significant.

RESULTS

Cox's model revealed that HIV positivity and the presence of acquired immunodeficiency syndrome significantly delayed wound healing, which also correlated with the presence of infection. The healing rate in HIV-positive patients was 66 percent after 14 weeks and 100 percent after 32 weeks; the corresponding figures for patients with acquired immunodeficiency syndrome were 0 and 50 percent. All of the controls were healed after 14 weeks (P < 0.01 vs. both the patients with acquired immunodeficiency syndrome and HIV+ patients). Centers for Disease Control and Prevention HIV-positive status (including CD4+ counts) and the performance status proved to be of prognostic value.

CONCLUSIONS

Our data suggest that the indications for hemorrhoidectomy in patients with acquired immunodeficiency syndrome need to be considered extremely carefully because of the high incidence of delayed wound healing.

Perianal diseases in HIV-positive patients compared with a seronegative population

PURPOSE

The aim of this report was to present our cases showing the prevalence and cause of perianal diseases in human immunodeficiency virus-positive patients.

METHODS

We compared 1,860 human immunodeficiency virus-positive patients to 1,350 human immunodeficiency virus-negative outpatients with perianal diseases, examined from January 1989 to December 1996, and the results obtained with the treatment methods for seropositive patients. Among them, 88.7 percent were males, mostly in the age range from 30 to 50 years old.

RESULTS

Condylomas, ulcers, hemorrhoids, fistulas, fissures, abscesses, and tumors were the most frequently diagnosed diseases. Two or more anal diseases occurred in 16.7 percent of patients. Among the human immunodeficiency virus-negative patients we noticed the same incidence of gender, and most were in the age range of 40 to 60 years old. Hemorrhoids, fistulas, skin tags, and fissures were diagnosed.

CONCLUSIONS

From statistical analysis we may conclude that human immunodeficiency virus-positive patients have more condylomas, ulcers, tumors, fistulas, and abscesses than human immunodeficiency virus-negative patients, who have more hemorrhoids. Incidence of fissures was similar in the two groups.

Anal warts, sexually transmitted diseases, and anorectal conditions associated with human immunodeficiency virus

Sexually transmitted diseases (STDs) are the cause of many different anorectal symptoms and complaints. Patients often present concerned that they have hemorrhoids. It is very important for primary care providers to be aware of the prevalance of anorectal STDs, common presentations, and management options. This article specifically addresses anal warts, gonorrhea, chlamydia, syphilis, herpes, and anorectal manifestations associated with HIV.

Surgery in patients with HIV infection: indications and outcome

We reviewed the records of 12 patients with HIV infection (one stage I, three stage II, two stage III, six stage IV) who received 15 surgical procedures under general or lumbar/epidural anesthesia. We discussed surgical indications, their poor wound healing and precautions for preventing the risk of transmission of HIV to health care workers. Six emergency and nine elective operations were performed. Postoperative complications developed after three emergency and three elective operations. Ten patients showed delay of wound healing which was not directly correlated with the CD4+ cell count. No operative deaths occurred. In any stage of HIV infection, not only palliative but also curative operations can be performed as long as HIV infection, opportunistic infections and HIV-related neoplasms can be controlled. Late stage wound healing is poor, but the wound will heal without keloid formation, although it takes two to three times longer than usual. For operating on patients with HIV infection precautions for preventing needle sticks, sharp injuries and blood exposure should be learned and used by health care workers. As a result, surgical staff members will be able to perform operations safely on HIV-infected patients to improve both quality of life and the prognosis of their disease.

Does HIV status influence the anatomy of anal fistulas?

PURPOSE

Although anorectal disease is common in human immunodeficiency virus-positive patients, little is known about the type and anatomic distribution of anal fistulas in this patient group. The aim of this study was to compare anatomic characteristics of anal fistulas in human immunodeficiency virus-positive patients with those in human immunodeficiency virus-negative patients by use of a retrospective chart review.

METHODS

The charts of 146 male patients younger than 50 years with an anal fistula were reviewed. Incomplete fistulas referred to those tracts arising from an internal opening into either a blind sinus or an undrained abscess cavity.

RESULTS

There were 60 human immunodeficiency virus-positive patients and 86 human immunodeficiency virus-negative patients. Mean age of the human immunodeficiency virus-positive patient group was 37 years vs. 40 years for the human immunodeficiency virus-negative patient group. Thirty-one human immunodeficiency virus-positive patients (52 percent) were classified as having AIDS, and the remaining 29 patients (48 percent) were asymptomatic. Mean T helper cell count in the human immunodeficiency virus-positive patient group was 277 cells per microliter. Fistulous tracts were intersphincteric (n = 56), transsphincteric (n = 41), suprasphincteric (n = 2), and incomplete (n = 47). Incomplete fistulas were identified in 33 (55 percent) human immunodeficiency virus-positive patients vs. 14 (16 percent) human immunodeficiency virus-negative patients (P < 0.001). Of the 47 incomplete fistulas, 37 (79 percent) were found in association with an abscess cavity. All ten patients with an incomplete fistula into a blind sinus were human immunodeficiency virus-positive. The incidence of an incomplete fistula without an abscess was significantly higher in the human immunodeficiency virus-positive patient group (17 percent) compared with the human immunodeficiency virus-negative patient group (0 percent; P < 0.001).

CONCLUSIONS

Anal fistulas in HIV-positive patients arise from the dentate line in similar locations to human immunodeficiency virus negative patients. However, human immunodeficiency virus-positive patients were more likely to have incomplete anal fistulas than human immunodeficiency virus-negative patients. Furthermore, human immunodeficiency virus-positive patients are predisposed to incomplete fistulas leading into a blind sinus.

Anorectal disease in HIV-infected patients

PURPOSE

Anorectal diseases are common in human immunodeficiency virus-infected individuals. The aim of this prospective study was to assess the cause and clinical presentation of anorectal disease in this human immunodeficiency virus-infected population.

METHODS

A registry of all human immunodeficiency virus-seropositive patients with anorectal complaints who were referred to and followed up in the colorectal surgery clinic at a county hospital was maintained, with all data collected prospectively. All patients underwent examination under anesthesia with random cultures and biopsies, along with specific sampling of any suspicious lesions.

RESULTS

Data from 180 consecutive human immunodeficiency virus-seropositive patients with anorectal symptoms were analyzed. Mean age of the population was 34 years, with a male-to-female ratio of 14:1. This group comprised homosexual and bisexual males (55 percent), injection-drug users (15 percent), heterosexuals (12 percent), and others (18 percent). The average lag time from diagnosis of human immunodeficiency virus to anorectal symptoms was 48 months. The average CD4 lymphocyte count was 160 cells/mm3. The most common symptom was anorectal pain (57 percent), followed by lumps or warts (28 percent), rectal bleeding (12 percent), discharge (11 percent), and pruritus (6 percent), with 24 percent of patients having multiple complaints. Anal condyloma was the most prevalent pathology observed (43 percent), of which 10 percent was associated with anal intraepithelial neoplasia. Wide-based anal ulcers were the most frequent noncondylomatous lesions, occurring in 32 percent of patients, with the majority (91 percent) presenting with the chief complaint of anorectal pain. Some of these ulcers were associated with viral infections: herpes simplex virus (12 percent) and cytomegalovirus (7 percent). However, most ulcers were idiopathic, with negative cultures and biopsies. Other lesions encountered included fistulas (14 percent), abscesses (12 percent), hemorrhoids (6 percent), and malignancy, with two cases of Kaposi's sarcoma, one case of non-Hodgkin's lymphoma, and one case of squamous-cell carcinoma. More than one anorectal condition was identified in 16 percent of the patients.

CONCLUSIONS

Human immunodeficiency virus infection is associated with a wide spectrum of anorectal disease, of which the most common lesions are anal condylomata and painful ulcers. The majority of these anal ulcers gave negative culture and biopsy results. In addition, there seems to be a high incidence of anorectal neoplasia in this patient population.

Perianal manifestations of human immunodeficiency virus infection: experience with 260 patients

PURPOSE

Individuals infected with the human immunodeficiency virus often have disorders affecting the anorectum. These disorders may be complex and difficult to treat. We reported our early experience with 40 human immunodeficiency virus-positive patients with perianal disorders in 1990. We now present our series of 260 consecutive human immunodeficiency virus-positive patients with perianal disorders who underwent evaluation between 1989 and 1996 to examine the distribution of disorders, their treatments, and outcomes.

METHOD

Patients were identified at initial presentation and followed prospectively.

RESULTS

Two-hundred forty-nine (96 percent) of 260 patients were male, with an average age of 34.9 (range, 19-58) years. Average duration of human immunodeficiency virus positivity was 5 years, 5 months, with a maximum of 11 years, 5 months. Median CD4 count was 175 (range, 2-1,100) cells/mm3. Only 89 (34 percent) patients satisfied the criteria of the Centers for Disease Control and Prevention's for acquired immunodeficiency syndrome at presentation. The most frequent major presenting symptoms were anorectal pain (55 percent), a mass (19 percent), and blood in the stool (16 percent). Risk factors included homosexuality (75 percent) and a prior history of sexually transmitted disease (45 percent). Forty different perianal disorders were identified, which were categorized as benign noninfectious (18), infectious (14), neoplastic (6), and septic (2). The most common disorders were condyloma (42 percent), fistula (34 percent), fissure (32 percent), and abscess (25 percent). Neoplasms were present in 19 patients (7 percent). One hundred seventy-one patients (66 percent) had more than one disorder, with an average of 2.9 disorders among these patients. Four hundred eighty-five procedures were performed on 178 patients (2.7/patient), with no mortalities and a 2 percent complication rate. Thirty-one patients (12 percent) died during the course of follow-up, but anorectal disease was the cause of death in only two patients.

CONCLUSIONS

Perianal manifestations of human immunodeficiency virus infection are common, often multiple, and varied. Patients with perianal disorders seek treatment throughout the course of the human immunodeficiency virus infection, and a perianal condition may be this disease's initial manifestation. Although recurrence is common and healing delayed, improved overall management of human immunodeficiency virus infection and a healthier human immunodeficiency virus-positive patient population have improved the outcome of surgical intervention in human immunodeficiency virus-infected patients with perianal disorders.

Healing after anal fistulotomy: comparative study between HIV+ and HIV- patients

PURPOSE

The aim of this work was to compare wound-healing after anal fistulotomy in human immunodeficiency virus (HIV)+ and HIV- patients and to recognize healing parameters in HIV+ patients.

METHODS

Sixty patients were treated with fistulotomy for intersphincteric anal fistula. For each patient, we evaluated white blood cell count values, T CD4 counts, Centers for Disease Control and Prevention classification, and healing duration. There were 31 HIV+ patients (7 A2; 1 A3; 7 C1; 6 C2; 10 C3).

RESULTS

Seven C3 patients had incomplete healing. Statistically, there was no difference in the healing duration in HIV+ A2, C1, C2, and HIV-negative patients. C3 patients who did heal took longer than other HIV+ patients. T CD4 counts were similar to healed and not healed C3 patients, although healed C3 values of white blood cell counts were higher than not healed C3 values (4,450 and 2,380/mm3).

CONCLUSION

After anal fistulotomy, HIV+ C3 patients either had retarded healing or no healing at all. Therefore, we feel that surgery should be done only in emergency cases of anorectal diseases or in patients with more than 3,000 white blood cells/mm3.

Anorectal surgery in patients infected with human immunodeficiency virus: factors associated with delayed wound healing

OBJECTIVE

A review of all anorectal operations in patients infected with human immunodeficiency virus (HIV) was performed to assess the incidence, variety, and clinical course of anorectal disease in these patients and to identify factors influencing wound healing.

SUMMARY BACKGROUND DATA

Anorectal disease is the most common indication for surgical intervention in patients infected with HIV. The cause and management of HIV-related anorectal conditions, which differ significantly from non-HIV-related diseases, are not clear. There also is considerable variation in the reported results of surgical procedures, including wound healing. St. Vincent's Hospital, Sydney, is situated in an area with the highest concentration of individuals infected with HIV in Australia.

METHODS

The medical records of all identified patients infected with HIV who had an anorectal operation at St. Vincent's General Hospital between January 1, 1988, and January 31, 1995, were reviewed retrospectively. Logistic regression, Mann-Whitney U test, and Fisher's exact tests were used for analysis.

RESULTS

One thousand five hundred two patients with acquired immune deficiency syndrome (AIDS), equivalent to 26.8% of all known patients with AIDS in Australia at this time, were admitted to this hospital during the 7-year period. One hundred one patients infected with HIV underwent 161 anorectal operations. All patients were male homosexuals (98 patients, 97%) or bisexuals (3 patients, 3%), with intravenous drug use an additional risk factor in 5 patients (5%). Thirty-seven percent of patients had more than one operation. Seventy-two percent of patients were Centers for Disease Control (CDC) group 4 (AIDS) at operation, 27% were group 2, 1% was group 3, and none were group 1. Accurate information about wound healing was available for 74% of first operations, and univariate and multivariate logistic analyses of these showed that when the CD4+ T-lymphocyte count was <50 cells/ microL, healing was significantly retarded (p = 0.016). The Centers for Disease Control group, patient age, and serum albumin were not significant predictors of wound healing. The interval between HIV diagnosis and operation was not associated with impaired wound healing, but recognition of AIDS more than 1 year before operation was associated with significantly better wound healing compared with those in whom AIDS developed within the year before operation (p = 0.025). In the patients for whom accurate wound healing information was available, only 40% had healed their wounds by 3 months after operation. Wound healing was worst for patients with chronic fissures, only 16% of whom had healed their wounds at 3 months. The wound healing rate was worse for repeat operations than for first operations. Ten percent of patients had anorectal malignancies, none of which were diagnosed clinically before or during operation.

CONCLUSIONS

Wound healing is a significant problem after anorectal operations in patients infected with HIV, especially when the CD4 count is <50/microL. Although there seems to be little or no benefit from more invasive operations in some cases, thorough examination with adequate biopsies is required in all cases. The best management of anorectal disease in patients infected with HIV still is unclear.

Anorectal diseases

A proper understanding of the disease of the anorectum in the HIV-positive population mandates a familiarity with the ongoing advances in antiviral chemotherapy, mechanisms of oncogenesis, and effect of HIV infection on wound dynamics. As the prognosis for HIV-infected patients improves, therapies must reflect the expected increased survival of these patients.

Complicated anorectal sepsis

These complex anorectal conditions are difficult to diagnose because clinical features overlap. In general, an aggressive approach is reserved for hidradenitis suppurativa and necrotizing infections. Patients with Crohn's disease, hematologic disorders, or AIDS are often treated more conservatively, but the correct timing and degree of aggressiveness of surgical intervention may considerably improve the overall outcome. The increasing incidence of AIDS and the frequency with which infected patients present to surgical clinics make it imperative that all surgeons have a working knowledge of the conditions associated with this syndrome. Expertise is required not only to diagnose and treat these conditions but also to protect oneself and others from being inadvertently infected with the HIV. A high index of suspicion and constant vigilance permit the successful resolution of many of these challenging problems.