The impact of human immunodeficiency virus (HIV) on outcome and practice in trauma: past, present and future

Postoperative CD4 counts predict anastomotic leaks in patients with penetrating abdominal trauma

INTRODUCTION

The influence of trauma- and surgical stress-induced decrease of CD4 count on anastomotic leaks after penetrating abdominal trauma has to date not been investigated. A prospective study was performed to explore the effect of CD4 count 24 h after surgery on the anastomotic leak rate and to identify risk factors for anastomotic leaks.

METHODS

This was a prospective study including 98 patients with small or large bowel resection and subsequent anastomosis due to penetrating abdominal trauma. Univariate analysis identified risk factors for the development of anastomotic leak and also investigated the predictive value of the CD4 count for this complication.

RESULTS

Of the 98 patients 23 patients (23%) were HIV-infected. The overall leak rate was 13%. Univariate analysis including all potential risk factors with p-values<0.05 identified six factors leading to a significantly higher rate of anastomotic complications: postoperative CD4 count<250 cells/μl, postoperative albumin <30 g/L, penetrating abdominal trauma index≥25, gunshot wound as mechanism of injury, blood transfusion requirement >6units and delayed anastomosis after damage control surgery. Survival rates were analysed with the χ² test and did not show a significantly higher mortality rate in patients with low CD4 count. The negative impact of trauma and subsequent surgery on the cell mediated immunity was demonstrated by the fact that 55 (73%) of the HIV-negative patients had a CD4 count less than 500 cells/μl 24 h postoperatively. HIV-infection had no significant influence on the leak rate, however all HIV infected patients that developed an anastomotic leak died.

CONCLUSION

A low post-operative CD4 count is a predictor for anastomotic leaks irrespective of HIV-serostatus. Low postoperative serum albumin, high injury severity, gunshot wound as mechanism of injury, blood transfusion requirement >6 units and delayed anastomosis were further risk factors for anastomotic complications. Postoperative CD4 count and serum albumin should be considered in the decision making process of performing an anastomosis or diverting stoma for patients after "clip and drop" of the bowel as part of damage control surgery.

A prospective look at the burden of sharps injuries and splashes among trauma health care workers in developing countries: true picture or tip of iceberg

OBJECTIVES

Health care workers (HCWs) face constant risk of exposure to cuts and splashes as occupational hazard. Hence, a prospective observational study was conducted to observe the exposure of HCWs to various sharp injuries and splashes during health care and to work up a baseline injury rate among HCWs for future comparison in trauma care set ups.

METHODS

A 2 year and 5 month study was conducted among the voluntarily reported exposed HCWs of the APEX trauma centre. Such reported cases were actively followed for 6 months after testing for viral markers and counselled. The outcomes of such exposed HCWs and rate of seroconversion was noted. To form a future reference point, the injury rate in trauma care HCWs based on certain defined parameters along with the rate of under reporting were also analysed in this study.

RESULTS

In our study, doctors were found to have the highest exposure (129, 36.2%), followed by nurses (52, 14.6%) and hospital waste disposal staff (27, 7.6%). Of the source patients, a high number of them were HBV positive (11, 3.1%), followed by HIV positive patients (8, 2.2%). No seroconversion was seen in any of the exposed HCWs. Injuries by sharps (303, 85.1%) outnumber those due to splashes (53, 14.9%) which were much higher in those working in pressing situations. Underreporting was common, being maximally prevalent in hospital waste disposal staff (182, 51.1%).

CONCLUSIONS

High rates of exposure to sharp injuries and splashes among HCWs call for proper safety protocols. Proper methods to prevent it, encouraging voluntary reporting and an active surveillance team are the need of the hour.

HIV seroprevalence and its effect on outcome of moderate to severe burn injuries: A Ugandan experience

BACKGROUND

HIV infection in a patient with burn injuries complicates the care of both the patient and the treating burn team. This study was conducted to establish the prevalence of HIV among burn patients in our setting and to compare the outcome of these patients who are HIV positive with those who are HIV negative.

METHODS

This was a prospective cohort study involving burn injury patients admitted to Mulago Hospital between November 2005 and February 2006. Patients were stratified into HIV positive (exposed) group and HIV-negative (unexposed) group. Data was collected using a pre-tested coded questionnaire and analyzed using SPSS statistical computer software version 11.5.

RESULTS

Of the 130 patients included in the study, 17 (13.1%) patients tested HIV positive and this formed the study (exposed) group. The remaining 113 patients (86.9%) formed the control (unexposed) group. In the HIV positive group, females outnumbered males by a ratio of 1.4:1 and the mean age was 28.4 ± 21.5 years (range 3 months-34 years). 64.7% of HIV positive patients reported to have risk factors for HIV infection. Of these, multiple sexual partners [Odds Ratio 8.44, 95% C.I. (3.87-143.23), P = 0.011] and alcoholism [Odds Ratio 8.34, 95% C.I. (5.76-17.82), P = 0.002] were found to be independently and significantly associated with increased risk to HIV infection. The mean CD4 count for HIV positive and HIV negative patients were 394 ± 328 cells/μL and 912 ± 234 cells/μL respectively which is statistically significant (P = 0.001). There was no difference in the bacteria cultured from the wounds of HIV positive and negative patients (P = 0.322). Patients with clinical signs of sepsis had lower CD4+ counts compared to patients without sepsis (P < 0.001). ). Skin grafting was carried out in 35.3% of HIV negative patients and 29.4% of HIV positive patients with no significant difference in skin graft take and the degree of healed burn on discharge was the same (P = 0.324). There was no significant difference in hospital stay between HIV positive and negative patients (P = 0.674). The overall mortality rate was 11.5%. Using multivariate logistic regression analysis, mortality rate was found to be independently and significantly related to the age of the patient, HIV positive with stigmata of AIDS, CD4 count, inhalation injury, %TBSA and severity of burn (p-value < 0.001).

CONCLUSION

HIV infection is prevalent among burn injury patients in our setting and thus presents an occupational hazard to health care workers who care for these patients. All burn health care workers in this region need to practice universal precautions in order to reduce the risk of exposure to HIV infection and post-exposure prophylaxis should be emphasized. The outcome of burn injury in HIV infected patients is dependent upon multiple variables such as age of the patient, inhalation injury and %TBSA and not the HIV status alone.

The dead continue to teach the living: examining the role of computed tomography and magnetic resonance imaging in the setting of postmortem examinations

High-resolution imaging methods are used more frequently in the setting of postmortem investigation. Used for some time in forensics, computed tomography (CT) and magnetic resonance imaging (MRI) are now being evaluated as complementary or even as alternative means of postmortem examination. We review briefly the history of autopsy and the reasons for the gradual decrease in autopsy rates. An overview of advantages and limitations of modern imaging autopsy techniques is then presented, which includes a discussion of the potential role of imaging autopsy in medical and surgical education. Potential future applications of this technology in postmortem analysis, which includes the incorporation of ultrasound technology, are then discussed.