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Ma R, Zhang Q, Zhao CS, Zhao R, Zhang Y, Zhang YS, Hai Y, Wei G, Pu Y, Hu LQ, Song Y, Zhang Y, Hu BY, Xin S. The consensus guideline of perioperative antiviral therapy for AIDS patients in China based on clinical practice. Front Med (Lausanne) 2023; 10:1267236. [PMID: 38126075 PMCID: PMC10731030 DOI: 10.3389/fmed.2023.1267236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/02/2023] [Indexed: 12/23/2023] Open
Abstract
The prevalence of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) has emerged as a major public health concern in China. When patients with HIV infection undergo surgical treatment, there are two main challenges. Firstly, medical staff face a high risk of HIV infection due to occupational exposure. Secondly, the patient's immune function is impaired, increasing the risk of opportunistic infections and postoperative complications. The surgical treatment of such patients is unique, and the risk of occupational exposure during the operation primarily depends upon the viral load of HIV/AIDS patients. Therefore, perioperative antiretroviral therapy is of paramount importance in order to standardize the perioperative antiretroviral therapy (ART) for HIV/AIDS patients. The Surgery Group of the Chinese Association of STD and AIDS Prevention and Control, in collaboration with the Treatment Association, and Surgery Group of the Chinese Medical Association of Tropical Diseases and Parasitology, has developed an expert consensus on perioperative antiretroviral therapy for HIV/AIDS patients. This consensus encompasses various aspects, including surgical risk assessment, selection of perioperative antiretroviral therapy regimens, prevention of opportunistic infections, and the crucial focus on rapid preoperative viral load reduction and immune function reconstruction for HIV/AIDS patients.
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Affiliation(s)
- Rui Ma
- Department of Orthopedics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qiang Zhang
- Department of Orthopedics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Chang song Zhao
- Department of Orthopedics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Rugang Zhao
- Department of Orthopedics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yao Zhang
- Department of Orthopedics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yao shen Zhang
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yong Hai
- Department of Orthopedics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Guo Wei
- Public Health and Clinical Center of Chengdu, Chengdu, China
| | - Yu Pu
- Public Health and Clinical Center of Chengdu, Chengdu, China
| | - Li qiang Hu
- Department of Otolaryngology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yanzheng Song
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Yu Zhang
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Bo yong Hu
- Guangzhou Eighth People’s Hospital, Guangzhou, China
| | - Shijie Xin
- The First Affiliated Hospital of China Medical University, Shenyang, China
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Laäs R, Clarke DL, Dufourq N, Smith MTD, Bruce JL, Naidoo M. The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa. World J Surg 2023; 47:2608-2616. [PMID: 37580602 PMCID: PMC10545630 DOI: 10.1007/s00268-023-07103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.
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Affiliation(s)
- Reza Laäs
- Department of Emergency Medicine, Nelson R Mandela, School of Medicine, University of KwaZulu-Natal, 719 Umbilo Rd, Umbilo, Berea, 4001, South Africa.
| | - Damian L Clarke
- Department of General Surgery and Trauma, Grey's Hospital, 201 Townbush Road, Pietermaritzburg, 3201, South Africa
| | - Nicholas Dufourq
- Department of Emergency Medicine, Nelson R Mandela, School of Medicine, University of KwaZulu-Natal, 719 Umbilo Rd, Umbilo, Berea, 4001, South Africa
- Department of Emergency Medicine, Harry Gwala Regional Hospital, 89 Selby Msimang Road, Pietermaritzburg, 3201, South Africa
| | - Michelle T D Smith
- Department of Anaesthetics and Critical Care, Grey's Hospital, 201 Townbush Road, Pietermaritzburg, 3201, South Africa
| | - John L Bruce
- Department of General Surgery and Trauma, Grey's Hospital, 201 Townbush Road, Pietermaritzburg, 3201, South Africa
| | - Mergan Naidoo
- Discipline of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Room 225F, George Campbell Building, King George V Avenue, Durban, South Africa
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3
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Bedada AG. The impact of HIV infection on surgical gastrointestinal diseases at the Princess Marina Hospital, Gaborone, Botswana: a cross-sectional study. Pan Afr Med J 2023; 46:72. [PMID: 38282770 PMCID: PMC10819848 DOI: 10.11604/pamj.2023.46.72.39140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 01/30/2024] Open
Abstract
Introduction various gastrointestinal diseases affect surgical patients. Literature on the burden and outcomes of surgical gastrointestinal diseases in a high HIV infection prevalence is scares. This study aimed to investigate this topic at the Princess Marina Hospital. Methods medical records of patients admitted with surgical gastrointestinal diseases to adult surgical wards were reviewed from August 2017 to July 2018. Demographics, date of admission and discharge, HIV status, CD4 count, and outcomes were analyzed. Results six-hundred and ninety-eight (698) patients with known HIV infection status and surgical gastrointestinal diseases were admitted. HIV+ patients contributed 274 (39.3%). Among HIV+, females contributed 147 (53.6%). Symptomatic gallbladder stone disease was significantly higher in HIV- patients, p=0.008; while anal cancers, p=0.001, anal warts, p=0.001, and perianal infections and fistulae, p=0.010 were significantly higher in HIV+ patients. Overall, surgical site infections were recorded in 15 (2.1%) and mortalities in 43 (6.2%). The mortality rate was higher in HIV+ than in HIV- patients, p=0.048. The total number of surgical procedures and median hospital stays among HIV- and HIV+ patients were not statistically significant, p=0.868 and p=0.249 respectively. The total number of complications, p=0.338, mortality, p=0.149, and median hospital stay, p=0.181, among HIV+ patients based on CD4 count, < 200 vs. > 200, were not significantly different. Conclusion symptomatic gallbladder stone diseases were significantly higher in HIV- patients; while anal cancer, anal warts, and perianal infections and perianal fistulae were significantly higher in HIV+ patients. HIV+ patients had a significantly higher mortality rate than HIV- patients, and this needs further investigation.
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Affiliation(s)
- Alemayehu Ginbo Bedada
- Department of Surgery, Faculty of Medicine, University of Botswana, Princess Marina Hospital, Gaborone, Botswana
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4
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Norimatsu Y, Ito K, Takemura N, Inagaki F, Mihara F, Tsukada K, Oka S, Kokudo N. Surgical management of appendicitis in patients with human immunodeficiency virus (HIV) positivity: a propensity score-matched analysis in a base hospital for HIV treatment in Japan. Surg Today 2023; 53:1013-1018. [PMID: 36808245 PMCID: PMC9940061 DOI: 10.1007/s00595-023-02661-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/28/2022] [Indexed: 02/23/2023]
Abstract
PURPOSE To investigate the impact of human immunodeficiency virus (HIV) infection on surgical outcomes after appendectomy. METHODS Data on patients who underwent appendectomy for acute appendicitis between 2010 and 2020 at our hospital were investigated retrospectively. The patients were classified into HIV-positive and HIV-negative groups using propensity score-matching (PSM) analysis, adjusting for the five reported risk factors for postoperative complications: age, sex, Blumberg's sign, C-reactive protein level, and white blood cell count. We compared the postoperative outcomes of the two groups. HIV infection parameters, including the number and proportion of CD4 + lymphocytes and the HIV-RNA levels were also compared before and after appendectomy in the HIV-positive patients. RESULTS Among 636 patients enrolled, 42 were HIV-positive and 594 were HIV-negative. Postoperative complications occurred in five HIV-positive patients and eight HIV-negative patients, with no significant difference in the incidence (p = 0.405) or severity of any complication (p = 0.655) between the groups. HIV infection was well-controlled preoperatively using antiretroviral therapy (83.3%). There was no deterioration in parameters and no changes in the postoperative treatment in any of the HIV-positive patients. CONCLUSION Advances in antiviral drugs have made appendectomy a safe and feasible procedure for HIV-positive patients, with similar postoperative complication risks to HIV-negative patients.
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Affiliation(s)
- Yu Norimatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan.
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Kunihisa Tsukada
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinichi Oka
- AIDS Clinical Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
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5
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Coccolini F, Improta M, Sartelli M, Rasa K, Sawyer R, Coimbra R, Chiarugi M, Litvin A, Hardcastle T, Forfori F, Vincent JL, Hecker A, Ten Broek R, Bonavina L, Chirica M, Boggi U, Pikoulis E, Di Saverio S, Montravers P, Augustin G, Tartaglia D, Cicuttin E, Cremonini C, Viaggi B, De Simone B, Malbrain M, Shelat VG, Fugazzola P, Ansaloni L, Isik A, Rubio I, Kamal I, Corradi F, Tarasconi A, Gitto S, Podda M, Pikoulis A, Leppaniemi A, Ceresoli M, Romeo O, Moore EE, Demetrashvili Z, Biffl WL, Wani I, Tolonen M, Duane T, Dhingra S, DeAngelis N, Tan E, Abu-Zidan F, Ordonez C, Cui Y, Labricciosa F, Perrone G, Di Marzo F, Peitzman A, Sakakushev B, Sugrue M, Boermeester M, Nunez RM, Gomes CA, Bala M, Kluger Y, Catena F. Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines. World J Emerg Surg 2021; 16:40. [PMID: 34372902 PMCID: PMC8352154 DOI: 10.1186/s13017-021-00380-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/18/2021] [Indexed: 02/08/2023] Open
Abstract
Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.
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Affiliation(s)
- Federico Coccolini
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Mario Improta
- grid.8982.b0000 0004 1762 5736Emergency Department, Pavia University Hospital, Pavia, Italy
| | | | - Kemal Rasa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Robert Sawyer
- grid.268187.20000 0001 0672 1122General Surgery Department, Western Michigan University, Kalamazoo, MI USA
| | - Raul Coimbra
- grid.488519.90000 0004 5946 0028Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
| | - Massimo Chiarugi
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Andrey Litvin
- grid.410686.d0000 0001 1018 9204Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Timothy Hardcastle
- Emergency and Trauma Surgery, Inkosi Albert Luthuli Central Hospital, Mayville, South Africa
| | - Francesco Forfori
- grid.144189.10000 0004 1756 8209Intensive Care Unit, Pisa University Hospital, Pisa, Italy
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Departement of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Andreas Hecker
- grid.411067.50000 0000 8584 9230Departementof General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Richard Ten Broek
- grid.10417.330000 0004 0444 9382General Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luigi Bonavina
- grid.416351.40000 0004 1789 6237General Surgery, San Donato Hospital, Milano, Italy
| | - Mircea Chirica
- grid.450307.5General Surgery, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Ugo Boggi
- grid.144189.10000 0004 1756 8209General Surgery, Pisa University Hospital, Pisa, Italy
| | - Emmanuil Pikoulis
- grid.5216.00000 0001 2155 08003rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Salomone Di Saverio
- grid.18887.3e0000000417581884General Surgery, Varese University Hospital, Varese, Italy
| | - Philippe Montravers
- grid.411119.d0000 0000 8588 831XDépartement d’Anesthésie-Réanimation, CHU Bichat Claude Bernard, Paris, France
| | - Goran Augustin
- grid.4808.40000 0001 0657 4636Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Dario Tartaglia
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Enrico Cicuttin
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Camilla Cremonini
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Bruno Viaggi
- grid.24704.350000 0004 1759 9494ICU Department, Careggi University Hospital, Firenze, Italy
| | - Belinda De Simone
- grid.418056.e0000 0004 1765 2558Department of Digestive, Metabolic and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy/Saint Germain en Laye, Saint Germain en Laye, France
| | - Manu Malbrain
- grid.8767.e0000 0001 2290 8069Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Vishal G. Shelat
- General and Emergency Surgery, Tan Tock Seng Hospital, Kuala Lumpur, Malaysia
| | - Paola Fugazzola
- grid.8982.b0000 0004 1762 5736General and Emergency Surgery, Pavia University Hospital, Pavia, Italy
| | - Luca Ansaloni
- grid.8982.b0000 0004 1762 5736General and Emergency Surgery, Pavia University Hospital, Pavia, Italy
| | - Arda Isik
- grid.411776.20000 0004 0454 921XGeneral Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ines Rubio
- grid.81821.320000 0000 8970 9163Department of General Surgery, La Paz University Hospital, Madrid, Spain
| | - Itani Kamal
- grid.38142.3c000000041936754XGeneral Surgery, VA Boston Health Care System, Boston University, Harvard Medical School, Boston, MA USA
| | - Francesco Corradi
- grid.144189.10000 0004 1756 8209Intensive Care Unit, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
| | - Stefano Gitto
- grid.8404.80000 0004 1757 2304Gastroenterology and Transplant Unit, Firenze University Hospital, Firenze, Italy
| | - Mauro Podda
- grid.7763.50000 0004 1755 3242General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Anastasia Pikoulis
- grid.5216.00000 0001 2155 0800Medical Department, National & Kapodistrian University of Athens, Athens, Greece
| | - Ari Leppaniemi
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Marco Ceresoli
- grid.18887.3e0000000417581884General Surgery, Monza University Hospital, Monza, Italy
| | - Oreste Romeo
- grid.268187.20000 0001 0672 1122Department of Surgery, Western Michigan University School of Medicine, Kalamazoo, MI USA
| | - Ernest E. Moore
- grid.239638.50000 0001 0369 638XTrauma Surgery, Denver Health, Denver, CL USA
| | - Zaza Demetrashvili
- grid.412274.60000 0004 0428 8304General Surgery, Tbilisi State Medical University, Tbilisi, Georgia
| | - Walter L. Biffl
- grid.415402.60000 0004 0449 3295Emergency and Trauma Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Imitiaz Wani
- General Surgery, Government Gousia Hospital, Srinagar, Kashmir India
| | - Matti Tolonen
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | | | - Sameer Dhingra
- National Institute of Pharmaceutical Education and Research, Hajipur (NIPER-H), Vaishali, Bihar India
| | - Nicola DeAngelis
- grid.50550.350000 0001 2175 4109General Surgery Department, Henry Mondor University Hospital, Paris, France
| | - Edward Tan
- grid.10417.330000 0004 0444 9382Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fikri Abu-Zidan
- General Surgery, UAE University Hospital, Sharjah, United Arab Emirates
| | - Carlos Ordonez
- grid.8271.c0000 0001 2295 7397Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Universidad del Valle, Cali, Colombia
| | - Yunfeng Cui
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Gennaro Perrone
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
| | | | - Andrew Peitzman
- grid.21925.3d0000 0004 1936 9000General Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Michael Sugrue
- General Surgery, Letterkenny Hospital, Letterkenny, Ireland
| | - Marja Boermeester
- grid.5650.60000000404654431Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | | | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Miklosh Bala
- grid.17788.310000 0001 2221 2926General Surgery, Hadassah Hospital, Jerusalem, Israel
| | - Yoram Kluger
- General Sugery, Ramabam Medical Centre, Tel Aviv, Israel
| | - Fausto Catena
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
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6
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Ljungqvist O, de Boer HD, Balfour A, Fawcett WJ, Lobo DN, Nelson G, Scott MJ, Wainwright TW, Demartines N. Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review. JAMA Surg 2021; 156:775-784. [PMID: 33881466 DOI: 10.1001/jamasurg.2021.0586] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion. Observations Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS. Conclusions and Relevance To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.
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Affiliation(s)
- Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Örebro University School of Health and Medical Sciences, Örebro, Sweden
| | - Hans D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
| | - Angie Balfour
- Surgical Services, NHS [National Health Service] Lothian, Edinburgh, United Kingdom
| | - William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
- MRC (Medical Research Council) Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham School of Life Sciences, Queen's Medical Centre, Nottingham, United Kingdom
| | - Gregg Nelson
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, United Kingdom
- Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Bournemouth, United Kingdom
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
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7
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Perioperative Antiretroviral Regimen for HIV/AIDS Patients Who Underwent Abdominal Surgery. World J Surg 2021; 44:1790-1797. [PMID: 32020326 DOI: 10.1007/s00268-020-05402-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND A short interruption of antiretroviral therapy (ART) and reduced oral bioavailability of antiretroviral medications could occur in perioperative human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients who undergo abdominal surgery. Therefore, we focused on the changes in HIV viral load and CD4+ T lymphocyte count in HIV/AIDS patients after surgery and explored whether the perioperative use of intravenous antiretroviral drugs is beneficial in lowering the viral load and increasing the safety of the surgery. METHODS We prospectively collected data from HIV/AIDS patients who underwent abdominal surgery at our institution from January 2019 and April 2019. According to the use of different antiretroviral medications during the perioperative period, the HIV/AIDS patients were divided into four groups: Group I: Patients continued their original antiretroviral medications; Group II: Patients received their original antiretroviral medications plus intravenous administration of the fusion inhibitor albuvirtide (ABT); Group III: Patients received ABT alone; and Group IV: Patients did not receive ART. The primary outcomes considered were the changes in HIV load and CD4+ T lymphocyte count and the postoperative complications in the four groups. RESULTS A total of 64 HIV/AIDS patients were enrolled, and their data were analyzed descriptively. There were no differences between group I and group II in terms of the changes in viral load. The viral load continued to decrease in group III within 30 days after surgery, especially from D7 to D30 (t = 2.179, p = 0.043). However, the viral load showed an upward trend after surgery in group IV. There were statistically significant differences between the two groups in the changes in viral load after surgery (p = 0.022). However, there were no statistically significant differences between group III and group IV in the postoperative changes in the CD4+ T lymphocyte count. Seven out of 64 patients had postoperative infective complications. The incidence of complications from high to low was as follows: group IV > group I > group III > group II (p < 0.05). CONCLUSIONS A short perioperative interruption of ART may have a small impact on viral load in HIV/AIDS patients on virologic suppression after abdominal surgery. For patients with a detectable viral load, an intravenous injection of ABT in the perioperative period can reduce the viral load quickly, lower the occurrence of postoperative complications, and increase operation safety for both the HIV/AIDS patient and the surgeons.
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8
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Runodada PM, Chihaka OB, Muguti GI. Surgical outcomes in HIV positive patients following major surgery at two tertiary institutions in Harare, Zimbabwe. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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9
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Ngulube A, Muguti GI, Muguti EG. Validation of POSSUM, P-POSSUM and the surgical risk scale in major general surgical operations in Harare: A prospective observational study. Ann Med Surg (Lond) 2019; 41:33-39. [PMID: 31016016 PMCID: PMC6475666 DOI: 10.1016/j.amsu.2019.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/20/2019] [Accepted: 03/24/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Raw mortality and morbidity, though commonly studied in surgical audit can nonetheless be misleading because of differences in preoperative and intraoperative findings of patients. There are some common scoring systems specifically designed to cater for case mix but these have not been tried locally. This study sought to validate these scoring systems and hopefully adopt them for our teaching hospitals. MATERIALS AND METHODS A prospective observational cohort study was conducted at two central hospitals in Harare Two hundred and two patients undergoing a variety of major general surgical operations were recruited into the study. Results of physiological and intraoperative parameters collected from the patients' records were scored according to POSSUM, P-POSSUM and SRS scores. Predicted mortality and morbidity rates of all these subjects were then compared to the observed rates. RESULTS One hundred and eighty one patients participated (123 males, 58 females). Using the POSSUM morbidity score, the observed versus expected (O: E) ratio of 0.88 showed no difference (p = 0.970). Using POSSUM, P-POSSUM and SRS mortality scores, O: E ratios of 0.74, 1.06 and 1.0 respectively were obtained, the differences were not significant (p = 0.650, p = 0.987 and 0.730). All three scores were comparable on the Receiver Operating Characteristic curve. The Physiological score independently predicted mortality (p < 0.00001). CONCLUSION POSSUM, P-POSSUM and SRS scores are comparable and suitable for estimating outcomes after major surgery in Harare. A larger study inclusive of low risk patients is needed to generalise these findings across Zimbabwean patients.
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Affiliation(s)
- Allan Ngulube
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Box A167, Avondale, Harare, Zimbabwe
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10
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Migaud P, Silverman M, Thistle P. HIV status and mortality of surgical inpatients in rural Zimbabwe: A retrospective chart review. South Afr J HIV Med 2019; 20:812. [PMID: 30863621 PMCID: PMC6407318 DOI: 10.4102/sajhivmed.v20i1.812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 09/13/2018] [Indexed: 12/14/2022] Open
Abstract
Background People living with HIV treated with antiretroviral therapy (ART) are now living longer and thus many are requiring surgical procedures. For healthcare resource planning, it would be helpful to better understand the prevalence of HIV in surgical patients, the types of surgery HIV-positive patients are undergoing and whether HIV status impacts mortality. Objective The goal of this study was to determine the prevalence of HIV in surgical inpatients and the extent of ART coverage, as well as to assess any differences between HIV-positive and HIV-negative patients in type of surgery undergone and in-hospital mortality at Karanda Mission Hospital, Mount Darwin, Zimbabwe. Method A 1-year retrospective chart review was undertaken to collect clinical and demographic data for adult (excluding maternity cases) and paediatric surgical inpatients including age, sex, type of surgery, HIV status, CD4+ counts and, if patient was HIV-positive, whether he or she was taking ART. Results and conclusion: Charts for 1510 surgical inpatient stays were reviewed. HIV prevalence among the adults was higher than that in the general population in Zimbabwe in 2016 (23.2% vs. 14.7%). There was no significant difference in inpatient mortality between the HIV-negative group and the HIV-positive group. Within the group of patients with malignancies, people living with HIV were significantly younger than uninfected patients (mean age 50.5 vs. 64.4 years; p < 0.01). There were correlations between HIV and certain malignancies. Thus, in addition to AIDS-defining illnesses, clinicians must be alert to squamous cell carcinoma and oesophageal, anal and penile cancers in HIV-positive patients.
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Affiliation(s)
- Pascal Migaud
- Department of Infectious Diseases and Gastroenterology, Vivantes Auguste-Viktoria-Klinikum, Germany
| | - Michael Silverman
- Department of Infectious Disease, Faculty of Medicine, Western University, Canada
| | - Paul Thistle
- Department of Obstetrics and Gynaecology, Karanda Mission Hospital, Zimbabwe.,Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Toronto, Canada
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11
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Surgical treatment of chronic ear disease in remote or resource-constrained environments. The Journal of Laryngology & Otology 2018; 133:49-58. [DOI: 10.1017/s0022215118002165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackgroundSurgery for chronic suppurative otitis media performed in low- and middle-income countries creates specific challenges. This paper describes the equipment and a variety of techniques that we find best suited to these conditions. These have been used over many years in remote areas of Nepal.Results and conclusionExtensive chronic suppurative otitis media is frequently encountered, with limited pre-operative investigation or treatment possible. Techniques learnt in better-resourced settings with good follow up need to be modified. The paper describes surgical methods suitable for resource-poor conditions, with rationales. These include methods of tympanoplasty for subtotal wet perforations, hearing reconstruction in wet ears and open cavities, large aural polyps, and canal wall down mastoidectomy with cavity obliteration. Various types of autologous ossiculoplasty are described in detail for use in the absence of prostheses. The following topics are discussed: decision-making for surgery on wet or best hearing ears, children, bilateral surgery, working with local anaesthesia, and obtaining adequate consent in this environment.
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12
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The Effect of Human-Immunodeficiency Virus Status on Outcomes in Penetrating Abdominal Trauma: An Interim Analysis. World J Surg 2018; 42:2412-2420. [PMID: 29387958 DOI: 10.1007/s00268-018-4502-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The purpose of this study was to determine whether the outcomes of hemodynamically stable patients undergoing exploratory laparotomy for penetrating abdominal trauma differed as a result of their HIV status. METHODS This was an observational, prospective study from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included. The mechanism of injury, the HIV status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days. RESULTS A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The two groups were comparable. Ten (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in the HIV negative group. The complication rate was 34% (n = 72). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, older age, and a lower RTS were significant risk factors for ICU admission. After 30 days, 12 patients (5.7%) were still in hospital. Twenty-four patients (11%) underwent a second laparotomy. The PATI score was the single independent predictor for complications, relaparotomy, and hospital stay longer than 30 days. CONCLUSIONS Preliminary results reveal that HIV status does not influence outcomes in patients with penetrating abdominal trauma.
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13
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Martin AN, Byiringiro JC, Petroze RT, Nkeshimana M, Byiringiro F, Calland JF. Assessing the impact of HIV status on injury outcomes: A multicenter study of trauma patients in Rwanda. Surgery 2018; 165:444-449. [PMID: 30327188 DOI: 10.1016/j.surg.2018.07.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 07/24/2018] [Accepted: 07/30/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is conflicting evidence regarding the impact of human immunodeficiency virus serostatus on trauma outcomes in low-resource settings. This study sought to evaluate the impact of human immunodeficiency virus serostatus on mortality outcomes for Rwandan patients presenting after trauma. METHODS This retrospective review of the University of Rwanda trauma registry captured all adult trauma patients with known human immunodeficiency virus status presenting between March 2011 and July 2015. Confirmed human immunodeficiency virus-positive cases were matched 1:2 with known human immunodeficiency virus-negative controls using a modified Kampala Trauma Score, sex, and district of residence or primary hospital. All-cause mortality was compared using multivariable logistic regression. RESULTS In total, 11,280 patients were recorded prospectively in the registry (169 human immunodeficiency virus positive; 334 human immunodeficiency virus negative matches). There was no difference in delay of hospital presentation or time until operation (P = .50 and P = .57, respectively). Less than 30% of all patients underwent operation during admission (n = 133), and the rate of operative intervention was independent of human immunodeficiency virus serostatus (P = .946). There was no association between development of any complication and human immunodeficiency virus status (P = .837). The overall mortality rate was 8.9% and 3.3% for human immunodeficiency virus-positive and human immunodeficiency virus-negative patients, respectively (P = .010). Human immunodeficiency virus positivity was associated with increased 30-day mortality when controlling for potential confounders (P = .016; odds ratio 3.60, 95% confidence interval: 1.27-10.2, C statistic 0.88). CONCLUSION Both human immunodeficiency virus and trauma pose substantial public health threats in sub-Saharan Africa. Known human immunodeficiency virus seropositivity in Rwandan trauma patients is associated with early mortality. Further investigation regarding testing, treatment, and outcomes in human immunodeficiency virus-positive trauma patients is warranted and provides an opportunity for leveraging human immunodeficiency virus global health efforts in trauma outcomes assessment.
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Affiliation(s)
- Allison N Martin
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Jean Claude Byiringiro
- Division of Clinical Education and Research, University Teaching Hospital of Kigali, Kigali, Rwanda; College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
| | - Robin T Petroze
- Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Menelas Nkeshimana
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Fidele Byiringiro
- Department of Surgery, University Teaching Hospital of Kigali, Rwanda
| | - James F Calland
- Department of Surgery, University of Virginia, Charlottesville, VA
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14
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Shanthamurthy D, Manesh A, Zacchaeus NG, Roy LR, Rupali P. Perioperative outcomes in human immunodeficiency virus-infected patients - the PRO HIV study. Int J STD AIDS 2018; 29:968-973. [PMID: 29669485 DOI: 10.1177/0956462418764485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It is estimated that a quarter of patients with HIV/AIDS undergo at least one surgical procedure in their life time. Surgical outcomes in these patients from developing countries are poorly characterized and surgeons are often concerned about poor surgical outcomes, especially when their CD4 cell counts are less than 200 cells/µl. This study evaluated the surgical outcomes of HIV-infected patients undergoing various surgical procedures over a six-year period in a large tertiary care hospital from South India. Two hundred and ninety-three patients underwent 374 surgical procedures during the study period. The median duration of HIV prior to surgery was 1.9 years (range 0-18.8 years). Two-thirds (58%) were on highly active antiretroviral therapy (HAART) at the time of surgery with the median duration of this treatment being 38 months (n = 194). About one-third (35%) of surgical procedures were performed as an emergency. Abdomino-pelvic surgeries were the most common (225, 60%). Adverse surgical outcome defined as death or post-operative infection was seen in 25 (6.6%). The post-operative infection rate was 5% (20/374). The most common of these was surgical site infection observed in nine (60%) followed by pneumonia in five patients (33%) and urinary tract infection in one patient. Day 30 mortality was 2% (n = 8) and a quarter of these were reported to be related to post-operative infectious complications. On multivariate analysis, only preoperative haemoglobin of less than 10 g/dl was significantly associated with a poor surgical outcome. HIV-related parameters such as CD4 cell counts, duration of HIV infection and HAART regimen did not seem to contribute towards an adverse surgical outcome.
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Affiliation(s)
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | | | - Lisa R Roy
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Priscilla Rupali
- Department of Infectious Diseases, Christian Medical College, Vellore, India
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15
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Green S, Kong VY, Laing GL, Bruce JL, Odendaal J, Sartorius B, Clarke DL. The effect of stage of HIV disease as determined by CD4 count on clinical outcomes of surgical sepsis in South Africa. Ann R Coll Surg Engl 2017; 99:459-463. [PMID: 28660809 DOI: 10.1308/rcsann.2017.0057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION This paper reviews the impact of the stage of human immunodeficiency virus (HIV) disease on the outcome of surgical sepsis. METHODS All adult emergency general surgical patients (aged >15 years) who fulfilled the criteria for sepsis or septic shock, with a documented surgical source of infection, and who were HIV positive were reviewed. RESULTS During the 5-year study period, a total of 675 patients with a documented surgical source of sepsis were managed by our service; 142 (21%) of these were HIV positive. Among the individuals who were HIV positive, the CD4 count was <200 cells/µl in 21 patients and ≥200 cells/µl in 121 patients. There was no difference between these two cohorts in terms of demography or spectrum of surgical conditions. The range of surgical procedures and complications was also similar in both groups. Nevertheless, patients with a CD count of <200 cells/µl had a significantly longer length of hospital stay than those in the cohort with ≥200 cells/µl. For HIV positive patients with a CD4 count of <200 cells/µl, the mortality rate was 66.7% (14/21) while the mortality rate for individuals with HIV and a CD4 count of ≥200 cells/µl was 2.5% (2/121). This difference was statistically significant (p<0.001). CONCLUSIONS The clinical presentation and spectrum of surgical sepsis disease in cases with stage 1 and stage 2 HIV is not markedly different. However, in patients with a CD4 count of <200 cells/µl, the length of hospital stay and mortality is significantly higher. Stage of HIV disease must be considered when stratifying patients' risk for surgery.
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Affiliation(s)
- S Green
- University of KwaZulu-Natal , Durban , South Africa
| | - V Y Kong
- University of KwaZulu-Natal , Durban , South Africa
| | - G L Laing
- University of KwaZulu-Natal , Durban , South Africa
| | - J L Bruce
- University of KwaZulu-Natal , Durban , South Africa
| | - J Odendaal
- University of KwaZulu-Natal , Durban , South Africa
| | - B Sartorius
- University of KwaZulu-Natal , Durban , South Africa
| | - D L Clarke
- University of KwaZulu-Natal , Durban , South Africa.,University of the Witwatersrand , Johannesburg , South Africa
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16
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Gojo MK, Prakaschandra R. Acute systemic inflammatory response after cardiac surgery in patients infected with human immunodeficiency virus using clinical and inflammatory markers. Afr Health Sci 2017; 17:719-728. [PMID: 29085399 PMCID: PMC5656216 DOI: 10.4314/ahs.v17i3.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Immediate post-cardiopulmonary bypass (CPB) immune responses and organ injuries in immune-compromised patients remain poorly documented. METHOD Sixty-one consecutive patients (30 HIV seropositive and 31 seronegative), undergoing elective cardiac valve(s) replacement were enrolled, from a single center hospital, after informed consent was obtained. C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) were used as biomarkers of acute inflammatory response. RESULTS The mean age was similar between the HIV seropositive and negative group. Pre-operatively, CRP (p=0.388) and ESR (p=0.817) were comparable. The CPB events and durations were significantly different between the two groups: duration (p=0.021), clamp aortic duration (p=0.026), bloodtransfusion (p=0.013), total urine output (p=0.035) and peak lactate (p=0.040). Post-operatively, there was significant increased biomarkers level in both groups, albeit not between the groups with a significant negative correlation between the mean change in CRP levels and mechanical ventilation (r=0.548, p=0.002) in the seropositive group (r=0.025, p=0.893). The correlation between pre-operative and post-operative difference in CRP and ICU stay was not significant in both groups. A significant drop (p=<0.001) in CD4 cells was documented post-operatively in the HIV seropositive group. CONCLUSION HIV positive patients' post-operative reactions to cardiac surgery supported by CPB are similar to those of HIV seronegative patients.
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Affiliation(s)
- Mawande Ke Gojo
- Port Elizabeth Hospital Complex, Department of Cardiothoracic Surgery, Buckingham Road, Port Elizabeth, South Africa.
| | - Rosaley Prakaschandra
- Durban University of Technology, Department of Biomedical and Clinical Technology; 41/43 ML Sultan Road, Durban, South Africa.
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17
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Shephard SN, Lengmang SJ, Anzaku SA, Mamven OV, Kirschner CV. Effect of HIV infection on outcomes after surgical repair of genital fistula. Int J Gynaecol Obstet 2017; 138:293-298. [PMID: 28602050 DOI: 10.1002/ijgo.12233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/11/2017] [Accepted: 06/07/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare outcomes following surgical repair of genital fistula among Nigerian women with or without HIV. METHODS A retrospective review was conducted of all genital fistula repair surgeries performed at Evangel Vesicovaginal Fistula Center in Jos, Nigeria, between January 1, 2004, and April 30, 2014. Patient characteristics, HIV status, genital fistula characteristics, and postoperative outcomes were assessed for between-group variance. The odds ratio (OR) and 95% confidence intervals (CIs) were the primary measures used for determining the association between HIV status and surgical outcomes. RESULTS Of the 3313 surgeries recorded, 201 (6.1%) were performed among patients with HIV infection. No statistically significant between-group differences were found for patient or fistula characteristics. By contrast, failed vesicovaginal failure (VVF) closure was significantly more common among women infected with HIV than among their HIV-negative counterparts (OR 0.629, 95% CI 0.443-0.894). No between-group differences in failure rates were found for ureterovaginal or rectovaginal fistulas. CONCLUSION Determining HIV status before surgery could aid prediction of outcomes among Nigerian women undergoing repair of VVF. Further studies are required to examine factors that might improve outcomes for women with HIV infection.
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Affiliation(s)
- Steven N Shephard
- Evangel Vesicovaginal Fistula Center, Bingham University Teaching Hospital, Jos, Nigeria.,Department of Obstetrics and Gynaecology, College of Medicine and Health Sciences, Bingham University, Jos Campus, Nigeria
| | - Sunday J Lengmang
- Evangel Vesicovaginal Fistula Center, Bingham University Teaching Hospital, Jos, Nigeria.,Department of Family Medicine, College of Medicine and Health Sciences, Bingham University, Jos Campus, Nigeria
| | - Stephen A Anzaku
- Department of Obstetrics and Gynaecology, College of Medicine and Health Sciences, Bingham University, Jos Campus, Nigeria
| | - Oluwatobi V Mamven
- Evangel Vesicovaginal Fistula Center, Bingham University Teaching Hospital, Jos, Nigeria.,Department of Family Medicine, College of Medicine and Health Sciences, Bingham University, Jos Campus, Nigeria
| | - Carolyn V Kirschner
- Evangel Vesicovaginal Fistula Center, Bingham University Teaching Hospital, Jos, Nigeria.,NorthShore University HealthSystem, Evanston, IL, USA
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18
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Moodley Y, Govender K. An HIV-positive status and short term perioperative mortality – a systematic review. S Afr J Infect Dis 2017. [DOI: 10.1080/23120053.2016.1192822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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19
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Cherewick ML, Cherewick SD, Kushner AL. Operative needs in HIV+ populations: An estimation for sub-Saharan Africa. Surgery 2016; 161:1436-1443. [PMID: 28043694 DOI: 10.1016/j.surg.2016.11.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/18/2016] [Accepted: 11/22/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND In 2015, it was estimated that approximately 36.7 million people were living with HIV globally and approximately 25.5 million of those people were living in sub-Saharan Africa. Limitations in the availability and access to adequate operative care require policy and planning to enhance operative capacity. METHODS Data estimating the total number of persons living with HIV by country, sex, and age group were obtained from the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2015. Using minimum proposed surgical rates per 100,000 for 4, defined, sub-Saharan regions of Africa, country-specific and regional estimates were calculated. The total need and unmet need for operative procedures were estimated. RESULTS A minimum of 1,539,138 operative procedures were needed in 2015 for the 25.5 million persons living with HIV in sub-Saharan Africa. In 2015, there was an unmet need of 908,513 operative cases in sub-Saharan Africa with the greatest unmet need in eastern sub-Saharan Africa (427,820) and western sub-Saharan Africa (325,026). Approximately 55.6% of the total need for operative cases is adult women, 38.4% are adult men, and 6.0% are among children under the age of 15. CONCLUSION A minimum of 1.5 million operative procedures annually are required to meet the needs of persons living with HIV in sub-Saharan Africa. The unmet need for operative care is greatest in eastern and western sub-Saharan Africa and will require investments in personnel, infrastructure, facilities, supplies, and equipment. We highlight the need for global planning and investment in resources to meet targets of operative capacity.
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Affiliation(s)
- Megan L Cherewick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | | | - Adam L Kushner
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Surgery, Columbia University, New York, NY
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Chew GWM, Teoh SCB, Agrawal R. Analysis and Outcomes of Cataract Surgery in Patients with Acquired Immunodeficiency Syndrome. Ocul Immunol Inflamm 2016; 25:535-539. [PMID: 27082491 DOI: 10.3109/09273948.2016.1158281] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To investigate the surgical outcomes, complications and postoperative progression in HIV patients undergoing cataract surgery in a teaching hospital. METHODS A retrospective cohort study of patients with HIV/AIDS who had cataract surgery from January 2000 until December 2011 at a tertiary referral multidisciplinary hospital in Singapore. RESULTS We identified 44 eyes from 29 patients. Preoperatively, 41.3% had no ophthalmic manifestations of HIV/AIDS, while 16 eyes had quiescent cytomegalovirus retinitis (CMVR). Postoperatively, 1 eye developed new CMVR, while 1 eye had reactivation of previous CMVR. Of eyes with new or previous CMVR, 1 eye developed rhegmatogenous retinal detachment (RD) postoperatively. Only 3 eyes had prolonged postoperative inflammation. There were no cases of endophthalmitis or cystoid macular edema. Postoperative improvement of at least two Snellen lines was achieved in 86.6% of eyes. CONCLUSIONS Cataract surgery in HIV patients is generally safe, regardless of CD4 count, but their general and ocular health should be optimized preoperatively.
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Affiliation(s)
- Grace W M Chew
- a National Healthcare Group Eye Institute Tan Tock Seng Hospital , Singapore
| | - Stephen C B Teoh
- a National Healthcare Group Eye Institute Tan Tock Seng Hospital , Singapore.,b Eagle Eye Centre , Mt Alvernia Hospital , Singapore
| | - Rupesh Agrawal
- a National Healthcare Group Eye Institute Tan Tock Seng Hospital , Singapore
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21
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Agarwal J, Ganjoo P, Hansda U, Sharma MU, Tandon MS, Singh D. Perioperative concerns in neurosurgical patients with human immunodeficiency virus infection. Asian J Neurosurg 2016; 11:103-8. [PMID: 27057214 PMCID: PMC4802929 DOI: 10.4103/1793-5482.145050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: The perioperative management of human immunodeficiency virus (HIV) infected patients undergoing neurosurgery is challenging due to the presence of HIV-related multi-system derangements, opportunistic infections and malignancies, history of substance abuse, and adverse effects of anti-retroviral therapy (ART), together with the inherent risks of neurosurgery. The possible adverse impact of HIV disease on the anesthetic outcome due to the associated co-morbidities, and conversely, the role of surgery and anesthesia in HIV disease progression due to their immunosuppressive effects, and also, the fear of HIV transmission among the attending medical personnel are the important perioperative concerns in such surgeries. Aim: To present our experience in the perioperative management of HIV-infected patients who underwent neurosurgery at our institute in the past 5 years and highlight the relevant perioperative issues. Materials and Methods: A retrospective analysis of the records of HIV-infected neurosurgical patients was undertaken to determine their HIV status and ART, anesthesia and surgery details, perioperative complications, and instances of postoperative worsening of HIV disease or its transmission, if any. Results: Seven HIV infected patients with variable severity of HIV infection and systemic disease underwent neurosurgery for different indications. Their perioperative management was modified in accordance with the co-morbidities and the type of neurosurgery. There was no obvious adverse impact of the HIV disease on the anesthetic outcome, no obvious clinical evidence of post-surgery worsening of the HIV disease, and no instance of HIV transmission in our patients. Conclusion: A goodunderstanding of the HIV disease and its perioperative implications during neurosurgery helps in better patient management and enables a safe outcome.
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Affiliation(s)
- Jyotsna Agarwal
- Department of Anaesthesiology and Intensive Care, GB Pant Hospital and Maulana Azad Medical College, New Delhi, India
| | - Pragati Ganjoo
- Department of Anaesthesiology and Intensive Care, GB Pant Hospital and Maulana Azad Medical College, New Delhi, India
| | - Upendra Hansda
- Department of Anaesthesiology and Intensive Care, GB Pant Hospital and Maulana Azad Medical College, New Delhi, India
| | - Megha U Sharma
- Department of Anaesthesiology and Intensive Care, GB Pant Hospital and Maulana Azad Medical College, New Delhi, India
| | - Monica S Tandon
- Department of Anaesthesiology and Intensive Care, GB Pant Hospital and Maulana Azad Medical College, New Delhi, India
| | - Daljit Singh
- Department of Neurosurgery, GB Pant Hospital and Maulana Azad Medical College, New Delhi, India
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Bowa K, Kawimbe B, Mugala D, Musowoya D, Makupe A, Njobvu M, Simutowe C. A Review of HIV and Surgery in Africa. Open AIDS J 2016; 10:16-23. [PMID: 27347268 PMCID: PMC4893540 DOI: 10.2174/1874613601610010016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 07/09/2015] [Accepted: 10/12/2015] [Indexed: 01/01/2023] Open
Abstract
HIV has a significant impact on surgery in Africa. Its’ influence has spanned a period of about 30 years. In the 1980s' Africa experienced a rise in the national prevalence of HIV spreading across East Africa through Southern Africa, and reaching peak prevalence in the Southern African region. These prevalence levels have affected four key areas of surgical practice; namely patient care, practice of surgery, surgical pathologies, the practitioner and more recently prevention. The surgical patient is more likely to be HIV positive in Africa, than elsewhere in the world. The patients are also more likely to have co infection with Hepatitis C or B and are unlikely to be aware of his or her HIV status. Surgical patients are also more likely to have impaired liver and renal function at the time of presentation. Therefore, HIV has affected the pattern of surgical pathologies, by influencing disease presentation, diagnosis, management and outcomes. It has also influenced the surgeon by increasing occupational risk and management of that risk. Recently in an ironic change of roles, surgery has impacted HIV prevention through the role of male circumcision as a significant tool in HIV prevention, which has traditionally focused on behavioural interventions. The story of surgery and HIV continues to unfold on the continent. Ultimately presenting a challenge which requires innovation, dedication and hard work in the already resource limited environments of Africa.
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Affiliation(s)
- K Bowa
- The Copperbelt University School of Medicine, P.O Box. 71191, Ndola, Kitwe, Zambia
| | - B Kawimbe
- The Copperbelt University School of Medicine, P.O Box. 71191, Ndola, Kitwe, Zambia
| | - D Mugala
- The Copperbelt University School of Medicine, P.O Box. 71191, Ndola, Kitwe, Zambia
| | - D Musowoya
- The Copperbelt University School of Medicine, P.O Box. 71191, Ndola, Kitwe, Zambia
| | - A Makupe
- The Copperbelt University School of Medicine, P.O Box. 71191, Ndola, Kitwe, Zambia
| | - M Njobvu
- The Copperbelt University School of Medicine, P.O Box. 71191, Ndola, Kitwe, Zambia
| | - C Simutowe
- The Copperbelt University School of Medicine, P.O Box. 71191, Ndola, Kitwe, Zambia
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CD4 Count is Still a Valid Indicator of Outcome in HIV-Infected Patients Undergoing Major Abdominal Surgery in the Era of Highly Active Antiretroviral Therapy. World J Surg 2016; 39:1692-9. [PMID: 25663010 DOI: 10.1007/s00268-015-2994-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients with HIV/AIDS on antiretroviral therapy (ART) live longer and now require surgery for indications similar to those described for the general population. They have been previously reported to carry higher mortality and complication rates, especially septic complications. The aim of this study was to compare the outcome of major abdominal surgery in three groups of patients with different CD4 counts. METHODS This is a prospective study comparing HIV-negative patients and two groups of HIV-infected patients on ART with different CD4 counts. The primary outcomes considered were mortality and complication rates after abdominal surgery. We emphasised on the value of CD4 as a predictor of outcome and the impact of the indication for surgery (septic versus non-septic). RESULTS We included 63 patients (21 per group). The majority of patients (71 %) were operated on as an emergency and the indications were similar in all groups. The overall and the septic complication rates were both higher in the group with a low CD4 count. This resulted in a significantly longer admission period but did not result in a higher mortality rate. The duration of ART and the World Health Organisation stage of the disease did not significantly influence surgical outcomes. CONCLUSIONS HIV-infected patients on ART can now safely undergo major abdominal surgery with encouraging results though still relatively poorer than those of HIV-negative subjects. CD4 count remains a significant predictor of outcome and patients with a low CD4 count, however, still require closer pre- and post-operative monitoring.
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Cronley K, Wenzke J, Hussan H, Vasquez AM, Hinton A, El-Dika S, Conwell DL, Krishna SG, Stanich PP. Diverticulitis in HIV-infected patients within the United States. HIV Med 2015; 17:216-21. [PMID: 26283564 DOI: 10.1111/hiv.12304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Diverticulitis in patients on immunosuppressant therapy has been associated with increased mortality, but there are no data for HIV-infected patients. Our aim was to compare the outcomes of hospitalizations for diverticulitis in patients with and without HIV infection. METHODS Cross-sectional study of hospitalizations in the United States accessed through the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project. Patients hospitalized for diverticulitis in 2007-2011 were included in the analysis. The primary outcomes of interest were mortality and surgical therapy rates. Patients from 2003 to 2011 were utilized to analyse trends in prevalence. RESULTS There were 2375 patients with HIV infection hospitalized for diverticulitis and 1 160 391 patients without HIV infection hospitalized for diverticulitis from 2007 to 2011. The patients with HIV infection were younger and more likely to be male and nonwhite (P < 0.001 for all). There were also differences in insurance types (P < 0.001) and hospitals [size (P = 0.008), type (P < 0.001) and location (P < 0.001)]. After multivariate analysis, patients with diverticulitis and HIV infection had a significantly increased in-hospital mortality rate [odds ratio (OR) 3.94 (95% confidence interval, CI, 1.52-10.20)] and a lower rate of surgical intervention [OR 0.74 (95% CI 0.57-0.95)]. From 2003 to 2011, there was a linear increasing trend in the prevalence of HIV infection among patients hospitalized for diverticulitis (P < 0.001). CONCLUSIONS HIV-infected patients with diverticulitis had increased mortality and received less surgical treatment in comparison to the general population. Diverticulitis in HIV-infected patients increased in prevalence over the study period.
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Affiliation(s)
- K Cronley
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - J Wenzke
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - H Hussan
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - A M Vasquez
- Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - A Hinton
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA.,Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - S El-Dika
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - D L Conwell
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - S G Krishna
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - P P Stanich
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
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van den Berg K, Murphy EL, Pretorius L, Louw VJ. The impact of HIV-associated anaemia on the incidence of red blood cell transfusion: implications for blood services in HIV-endemic countries. Transfus Apher Sci 2014; 51:10-8. [PMID: 25457008 DOI: 10.1016/j.transci.2014.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Cytopaenias, especially anaemia, are common in the HIV-infected population. The causes of HIV related cytopaenias are multi-factorial and often overlapping. In addition, many of the drugs used in the management of HIV-positive individuals are myelosuppresive and can both cause and exacerbate anaemia. Even though blood and blood products are still the cornerstone in the management of severe cytopaenias, how HIV may affect blood utilisation is not well understood. The impact of HIV/AIDS on blood collections has been well documented. As the threat posed by HIV on the safety of the blood supply became clearer, South Africa introduced progressively more stringent donor selection criteria, based on the HIV risk profile of the donor cohort from which the blood collected. The implementation of new testing technology in 2008 which significantly improved the safety of the blood supply enabled the removal of what was perceived by many as a racially based donor risk model. However, this new technology had a significant and sustained impact on the cost of blood and blood products in South Africa. In contrast, it would appear little is known of how HIV influences the utilisation of blood and blood products. Considering the high prevalence of HIV among hospitalised patients and the significant risk for anaemia among this group, there would be an expectation that the transfusion requirements of an HIV-infected patient would be higher than that of an HIV-negative patient. However, very little published data is available on this topic which emphasises the need for further large-scale studies to evaluate the impact of HIV/AIDS on the utilisation of blood and blood products and how the large-scale roll-out of ARV programs may in future play a role in determining the country's blood needs.
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Affiliation(s)
- Karin van den Berg
- South African National Blood Service, Port Elizabeth, South Africa; Division Clinical Haematology, Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa.
| | - Edward L Murphy
- University of California, San Francisco, United States; Blood Systems Research Institute, San Francisco, United States
| | - Lelanie Pretorius
- Division Clinical Haematology, Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa; Ampath Laboratories, Bloemfontein, South Africa
| | - Vernon J Louw
- Division Clinical Haematology, Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa
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Affiliation(s)
- Sven Young
- Department of Orthopedic Surgery Haukeland University Hospital 5021 Bergen Norway
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Haac BE, Charles AG, Matoga M, LaCourse SM, Nonsa D, Hosseinipour M. HIV testing and epidemiology in a hospital-based surgical cohort in Malawi. World J Surg 2014; 37:2122-8. [PMID: 23652356 DOI: 10.1007/s00268-013-2096-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite the high prevalence of HIV in adults (11 %) in Malawi, testing among surgical patients is not routine. We examined the feasibility of universal opt-out HIV testing and counseling (HTC) on the surgical wards of Kamuzu Central Hospital in Lilongwe, Malawi, and sought to further delineate the role of HIV in surgical presentation and outcome. METHODS We reviewed HTC and surgical admission records from May to October 2011 and compared these data to data collected prospectively on patients admitted from November 2011 through April 2012, after universal HTC implementation. RESULTS Prior to universal HTC, 270 of the 2,606 (10.4 %) surgical admissions were tested; 13 % were HIV-infected. After universal HTC implementation, HTC counselors reviewed 1,961 of the 2,488 admissions (79 %): 310 (16 %) had known status (157 seropositive, 153 seronegative) and 1,651 had unknown status (81 %). Among those with unknown status, 97 % (1,598, of 64 % of all admissions) accepted testing, of whom 9 % were found to be HIV-infected. Patients with longer lengths of stay (LOS) (mean = 11 vs. 5 days, p < 0.01) and those who underwent surgical intervention (odds ratio [OR] 2.5; confidence interval [CI] 2.0-3.1) were more likely to have a known status on discharge. HIV was more prevalence in patients with infection and genital/anal warts or ulcers and lower in trauma patients. HIV-positive patients received less surgical intervention (OR 0.69; CI 0.52-0.90), but there was no association between HIV status and length of stay or mortality. CONCLUSIONS Universal opt-out HTC on the surgical wards was well accepted and increased the proportion of patients tested. High HIV prevalence in this setting merits implementation of universal HTC.
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Affiliation(s)
- Bryce E Haac
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Nagoba B, Patil Dawale C, Raju R, Wadher B, Chidrawar S, Selkar S, Suryawanshi N. Citric acid treatment of post operative wound infections in HIV/AIDS patients. J Tissue Viability 2013; 23:24-8. [PMID: 24411100 DOI: 10.1016/j.jtv.2013.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 12/06/2013] [Accepted: 12/17/2013] [Indexed: 01/27/2023]
Abstract
The normal cellular immunity is required for normal wound healing. The HIV infection affects wound healing adversely. Wound infections in HIV/AIDS patients are difficult to manage because of compromised immunity. The result is delayed wound healing and increased susceptibility to wound infection. Here we report two cases of HIV positive patients who had developed the post operative wound gape, not responding to the conventional treatment, treated simply by local application of three percent citric acid ointment.
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Affiliation(s)
| | | | | | - Bharat Wadher
- Medical Microbiology Research Lab, P.G. Dept. of Microbiology, R.T.M. Nagpur University, Nagpur, India
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Kendig CE, McCulloch DJ, Rosenberg NE, Samuel JC, Mabedi C, Shores CG, Hosseinipour MC, Matoga M, Charles AG. Prevalence of HIV and Disease Outcomes on the Medical and Surgical Wards at Kamuzu Central Hospital, Lilongwe, Malawi. Trop Med Health 2013; 41:163-70. [PMID: 24505214 PMCID: PMC3883455 DOI: 10.2149/tmh.2013-12] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 07/01/2013] [Indexed: 12/03/2022] Open
Abstract
Introduction: The World Health Organization (WHO) recommends HIV Counseling and Testing (HCT) in a range of clinical settings. We describe the characteristics of patients diagnosed with HIV on the medical and surgical wards at a tertiary care hospital in Malawi. Methods: Under the universal opt-out HCT protocol we characterized the number of new HIV/AIDS infections and associated clinical features among hospitalized surgical and medical patients diagnosed during the course of admission. Results: All 2985 and 3959 medical and surgical patients, respectively, admitted between April 2012 and January 2013 were screened for HCT. 62% and 89% of medical and surgical patients, respectively, had an unknown status on admission and qualified for testing. Of the patients with an unknown status, a new HIV diagnosis was made in 20% and 7% of medical and surgical patients, respectively. Of the newly diagnosed patients with a CD4 count recorded, 91% and 67% of medical and surgical patients, respectively, had a count less than 350, qualifying for ART by Malawi ART guidelines. Newly HIV-diagnosed medical and surgical patients had an inpatient mortality of 20% and 2%, respectively. Discussion: While newly diagnosed HIV-positive medical patients had high inpatient mortality and higher rates of WHO stage 3 or 4 conditions, surgical patients presented with less advanced HIV, though still meeting ART initiation guidelines. The medical inpatient wards are an obvious choice for implementing voluntary counseling and testing (VCT), but surgical patients present with less advanced disease and starting treatment in this group could result in more years of life gained.
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Affiliation(s)
| | | | | | - Jonathan C Samuel
- University of North Carolina Chapel Hill, Department of Surgery, Division of Trauma and Critical Care Surgery
| | | | - Carol G Shores
- University of North Carolina Chapel Hill, Department of Otolaryngology/Head & Neck Surgery
| | - Mina C Hosseinipour
- UNC Project, Lilongwe, Malawi ; University of North Carolina Chapel Hill, Department of Medicine, Division of Infectious Diseases
| | - Mitch Matoga
- UNC Project, Lilongwe, Malawi ; Kamuzu Central Hospital, Department of Medicine
| | - Anthony G Charles
- University of North Carolina Chapel Hill, Department of Surgery, Division of Trauma and Critical Care Surgery
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Dias SS, Andreozzi V, Martins RO. Analysis of HIV/AIDS DRG in Portugal: a hierarchical finite mixture model. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2013; 14:715-723. [PMID: 22864565 DOI: 10.1007/s10198-012-0416-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 07/16/2012] [Indexed: 06/01/2023]
Abstract
Inpatient length of stay (LOS) is an important measure of hospital activity, but its empirical distribution is often positively skewed, representing a challenge for statistical analysis. Taking this feature into account, we seek to identify factors that are associated with HIV/AIDS through a hierarchical finite mixture model. A mixture of normal components is applied to adult HIV/AIDS diagnosis-related group data (DRG) from 2008. The model accounts for the demographic and clinical characteristics of the patients, as well the inherent correlation of patients clustered within hospitals. In the present research, a normal mixture distribution was fitted to the logarithm of LOS and it was found that a model with two-components had the best fit, resulting in two subgroups of LOS: a short-stay subgroup and a long-stay subgroup. Associated risk factors for both groups were identified as well as some statistical differences in the hospitals. Our findings provide important information for policy makers in terms of discharge planning and the efficient management of LOS. The presence of "atypical" hospitals also suggests that hospitals should not be viewed or treated as homogenous bodies.
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Affiliation(s)
- Sara Simões Dias
- Departamento Universitário de Saúde Pública, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo dos Mártires da Pátria 130, 1169-056, Lisbon, Portugal.
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Okumu G, Makobore P, Kaggwa S, Kambugu A, Galukande M. Effect of emergency major abdominal surgery on CD4 cell count among HIV positive patients in a sub-Saharan Africa tertiary hospital--a prospective study. BMC Surg 2013; 13:4. [PMID: 23442732 PMCID: PMC3599316 DOI: 10.1186/1471-2482-13-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 02/20/2013] [Indexed: 11/24/2022] Open
Abstract
Background Surgery plays a key role in HIV palliative care, specifically in the diagnosis and treatment of HIV related and non-related conditions. Yet major surgery depresses the immune system. Whereas the surgical consequences of HIV infection are well described, there is a paucity of published data, in resource-limited settings, on the effects of major surgery on the immune system. The purpose of this study was to determine the effect of major abdominal surgery on CD4 count in HIV positive and HIV negative patients after emergency major surgery. Methods A prospective cohort study was done for patients who underwent emergency major abdominal surgery. Their peri-operative CD4 counts were done for both HIV- and HIV + patients. Median CD4s were used in analysis. Mann Whitney test of significance was used for continuous data and Fisher’ exact test used for categorical data. IRB approval was obtained. Results A total of 101 patients were recruited, 25 HIV positive and 76 HIV negative. The median CD4 cell reduction was higher in the HIV negative group (−68 cells) than HIV positive group (−29 cells) (p = 0.480). There was a general increase in the median CD4 change by 72 cells for the HIV positives and 95 cells for the HIV negatives (p = 0.44). CD4 change rose in both the HIV positive and negative groups by 27 cells for the HIV positives and 28 cells for the HIV negatives (p = 0.94). Relative Risk was 0.96, {CI 0.60 – 1.53}. Conclusion Major emergency abdominal surgery had no significant effect on CD4 cell count among HIV positive patients.
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Affiliation(s)
- Gabriel Okumu
- Department of Surgery, College of Health Sciences, Makerere University, Kampala, Uganda
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Comparison of in-hospital morbidity and mortality in HIV-infected and uninfected children after surgery. Pediatr Surg Int 2012; 28:1007-14. [PMID: 22922947 DOI: 10.1007/s00383-012-3163-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2012] [Indexed: 12/31/2022]
Abstract
PURPOSE Increasingly HIV-infected children can be expected to require surgery. The aim of this study was to compare the outcome of HIV-infected and HIV-unexposed children undergoing surgery. PATIENTS AND METHODS A prospective study of children less than or equal to 60 months admitted to a tertiary pediatric surgical service from July 2004 to July 2008. Children underwent age-definitive HIV testing and were followed up postoperatively for complications, length of stay and mortality. RESULTS Three hundred and twenty-seven children were enrolled: 82 (23 %) HIV-infected and 245 (67 %) were HIV-unexposed. Eighty-four (26 %) children were malnourished, which was higher in the HIV-infected group [41 (50.0 %) vs. 43 (17.5 %), relative risk (RR) 2.9; 95 % confidence interval (CI) 2.0-4.1; p < 0.0001]. Three hundred and twenty-eight surgical procedures were performed. A similar number of major [28 (34.2 %) vs. 64 (26.1 %); p = 0.2] and emergency procedures [37 (45.1 %) vs. 95 (38.8 %); p = 0.34] were performed in each group. HIV-infected children had a higher rate of contamination at surgery [40 (48.7 %) vs. 49 (20 %); RR 2.43 (CI 1.7-3.4); p < 0.0001]. There were more complications in the HIV-infected group [34 (41.5 %) vs. 14 (5.7 %); RR 7.3 (CI 4.1-12.8); p < 0.0001]. The most common complications were surgical site complications 30 (55 %), followed by postoperative infections, 19 (34 %). Infections with drug-resistant organisms occurred more commonly in HIV-infected children [11/19 (58 %) vs. 2/13 (15 %); RR 3.8 (CI 1.3-14.2); p = 0.02]. The median length of hospital stay was longer in the HIV-infected group [4 (IQR 2-14) vs. 2 (IQR 1-4) days; p = 0.0001]. There was a higher mortality amongst the HIV-infected group [6 (7.3 %) vs. 0 (0 %); p < 0.0001]. CONCLUSION HIV-infected children have a higher rate of postoperative complications and mortality compared with HIV-unexposed children.
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Factors predictive of 30-day postoperative mortality in HIV/AIDS patients in the era of highly active antiretroviral therapy. Ann Surg 2012; 256:170-6. [PMID: 22580943 DOI: 10.1097/sla.0b013e318255896b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Young S, Beniyasi FJ, Munthali B, Banza L. Infection of the fracture hematoma from skeletal traction in an asymptomatic HIV-positive patient. Acta Orthop 2012; 83:423-5. [PMID: 22880713 PMCID: PMC3427636 DOI: 10.3109/17453674.2012.704564] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 05/06/2012] [Indexed: 01/31/2023] Open
Affiliation(s)
- Sven Young
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi, Norway.
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Karpelowsky J, Millar AJW. Surgical implications of human immunodeficiency virus infections. Semin Pediatr Surg 2012; 21:125-35. [PMID: 22475118 DOI: 10.1053/j.sempedsurg.2012.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pediatric HIV (human immunodeficiency virus) is a pandemic predominantly in sub-Saharan Africa. Approximately 2.2 million children aged less than 15 years are infected with HIV, representing almost 95% of the total number of children globally infected with HIV. Therefore, increasing numbers of HIVi or -exposed but uninfected children can be expected to require a surgical procedure to assist in the diagnosis of an HIV/acquired immune deficiency syndrome-related complication, to address a life-threatening complication of the disease, or for routine surgery encountered in HIV-unexposed children. HIVi children may present with both conditions unique to HIV infection and surgical conditions routine in pediatric surgical practice. HIV exposure confers an increased risk of complications and mortality for all children after surgery, whether they are HIV infected or not. This risk of complications is higher in the HIVi group of patients. These findings seem to be independent of whether patients undergo an elective or emergency procedure, but the risk of an adverse outcome is higher for a major procedure. Surgical implications of HIV infection are comprehensively reviewed in this article.
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Effect of CD4+ T-lymphocyte count on hospital outcome of elective general thoracic surgery patients with human immunodeficiency virus. Gen Thorac Cardiovasc Surg 2011; 59:743-7. [PMID: 22083692 DOI: 10.1007/s11748-011-0808-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 03/21/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE Traditionally, the chief surgical indicator for human immunodeficiency virus (HIV)-infected patients was the CD4-positive T-lymphocyte count; however, there is no current consensus. Reports published after 2006 indicated that HIV-infected patients had a higher incidence of postoperative pneumonia and higher 12-month mortality rates. In addition, CD4 counts had no relation to the in-hospital outcome. Therefore, we retrospectively examined all of the previous patients who underwent operations in our department on the basis of these findings. METHODS Regardless of the initiation of highly active anti-retroviral therapy (HAART), we retrospectively reviewed 10 general thoracic surgeries performed in our department according to the CD4 cell count, HIV-ribonucleic acid (RNA) viral load, time of HAART initiation, operating time, amount of blood, postoperative course, and period of observation. RESULTS There was no incidence of postoperative pneumonia or wound infection. There were also no complications during the perioperative period. One patient died 7 months after surgery. CONCLUSION Our retrospective study demonstrates that the indicator for elective general thoracic surgery is not the CD4-positive T-lymphocyte count and that the initiation of HAART may reduce the 12-month mortality rates. In HIV-positive patients, regardless of the CD4-positive T-lymphocyte count, surgeons can operate in the same manner as they would with HIV-negative patients.
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CD4 count is predictive of outcome in HIV-positive patients undergoing abdominal operations. Am J Surg 2011; 200:694-9; discussion 699-700. [PMID: 21146004 DOI: 10.1016/j.amjsurg.2010.07.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 07/26/2010] [Accepted: 07/26/2010] [Indexed: 11/20/2022]
Abstract
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.
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Abalo A, Patassi A, James YE, Walla A, Sangare A, Dossim A. Risk factors for surgical wound infection in HIV-positive patients undergoing surgery for orthopaedic trauma. J Orthop Surg (Hong Kong) 2010; 18:224-7. [PMID: 20808017 DOI: 10.1177/230949901001800218] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To identify risk factors associated with surgical wound infection in patients infected with human immunodeficiency virus (HIV) undergoing surgery for orthopaedic trauma. METHODS Records of 29 male and 7 female HIV-positive patients aged 18 to 47 years who underwent surgery for orthopaedic trauma were reviewed. Data on HIV-specific variables (HIV clinical classification, CD4+ lymphocyte count) and highly active antiretroviral therapy were retrieved, as were data on wound class, fracture type, surgery type, surgical wound infections, and outcomes. Possible risk factors associated with surgical wound infection were analysed. RESULTS The median follow-up period was 27 (range, 19-41) months. Of the 36 patients, 14 (39%) developed surgical wound infections (4 were deep and 10 superficial). 89% and 67% of them were in HIV clinical category B and in CD4+ T-lymphocyte category 3, respectively. 12 of these infections resolved after debridement and prolonged antibiotic treatment, and 2 developed chronic osteomyelitis. Four of the patients had non-union. Surgical wound infections were associated with HIV clinical category B (p<0.001), CD4+ T-lymphocyte category of more than or equal to 2 (p=0.041), and contaminated wounds (p=0.003). CONCLUSION Identification of risk factors may help minimise morbidity in HIV-positive patients.
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Affiliation(s)
- Anani Abalo
- Department of Orthopaedics, Tokoin Teaching Hospital, Lome, Togo.
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Morrison CA, Wyatt MM, Carrick MM. Effects of Human Immunodeficiency Virus Status on Trauma Outcomes: A Review of the National Trauma Database. Surg Infect (Larchmt) 2010; 11:41-7. [DOI: 10.1089/sur.2008.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- C. Anne Morrison
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew M. Wyatt
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew M. Carrick
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Dias SS, Andreozzi V, Martins MO, Torgal J. Predictors of mortality in HIV-associated hospitalizations in Portugal: a hierarchical survival model. BMC Health Serv Res 2009; 9:125. [PMID: 19627574 PMCID: PMC2725041 DOI: 10.1186/1472-6963-9-125] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 07/23/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The beneficial effects of highly active antiretroviral therapy, increasing survival and the prevention of AIDS defining illness development are well established. However, the annual Portuguese hospital mortality is still higher than expected. It is crucial to understand the hospitalization behaviour to better allocate resources. This study investigates the predictors of mortality in HIV associated hospitalizations in Portugal through a hierarchical survival model. METHODS The study population consists of 12,078 adult discharges from patients with HIV infection diagnosis attended at Portuguese hospitals from 2005-2007 that were registered on the diagnosis-related groups' database.We used discharge and hospital level variables to develop a hierarchical model. The discharge level variables were: age, gender, type of admission, type of diagnoses-related group, related HIV complication, the region of the patient's residence, the number of diagnoses and procedures, the Euclidean distance from hospital to the centroid of the patient's ward, and if patient lived in the hospital's catchment area. The hospital characteristics include size and hospital classification according to the National Health System. Kaplan-Meier plots were used to examine differences in survival curves. Cox proportional hazard models with frailty were applied to identify independent predictors of hospital mortality and to calculate hazard ratios (HR). RESULTS The Cox proportional model with frailty showed that male gender, older patient, great number of diagnoses and pneumonia increased the hazard of HIV related hospital mortality. On the other hand tuberculosis was associated with a reduced risk of death. Central hospital discharge also presents less risk of mortality.The frailty variance was small but statistically significant, indicating hazard ratio heterogeneity among hospitals that varied between 0.67 and 1.34, and resulted in two hospitals with HR different from the average risk. CONCLUSION The frailty model suggests that there are unmeasured factors affecting mortality in HIV associated hospitalizations. Consequently, for healthcare policy purposes, hospitals should not all be treated in an equal manner.
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Affiliation(s)
- Sara S Dias
- Higher Institute of Statistics and Information Management, New University of Lisbon, Lisbon, Portugal.
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Madiba TE, Muckart DJJ, Thomson SR. Human immunodeficiency disease: how should it affect surgical decision making? World J Surg 2009; 33:899-909. [PMID: 19280251 DOI: 10.1007/s00268-009-9969-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- T E Madiba
- Department of Surgery, University of KwaZulu-Natal, Private Bag 7 Congella, 4013 Durban, South Africa.
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Karpelowsky JS, Leva E, Kelley B, Numanoglu A, Rode H, Millar AJW. Outcomes of human immunodeficiency virus-infected and -exposed children undergoing surgery--a prospective study. J Pediatr Surg 2009; 44:681-7. [PMID: 19361626 DOI: 10.1016/j.jpedsurg.2008.08.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 08/30/2008] [Accepted: 08/31/2008] [Indexed: 10/20/2022]
Abstract
AIM Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) is a worldwide pandemic. Mother-to-child transmission programs should theoretically minimize vertical transfer of the virus, but with variable effectiveness of implementation a significant number of children become infected and may present for emergency, diagnostic, and elective surgery. The aim of this study was to prospectively document the clinical presentation, the spectrum of pathology, and surgical outcomes of patients presenting to our hospital. This formed part of a pilot study of a collaborative international working group studying HIV infection in children, which included the Buzzi Children's Hospital Milan, Italy; the University of San Diego, California, USA; and the Red Cross War Memorial Children's Hospital and University of Cape Town, School of Adolescent and Child Health, Cape Town, South Africa. METHOD Clinical data from all children admitted to the surgical service of the Red Cross War Memorial Children's Hospital between July 2004 and December 2006 with either a history of HIV exposure (born to an HIV-infected mother) or confirmation of HIV infection by ELISA or polymerase chain reaction was collected. The clinical course was documented prospectively for the duration of admission and subsequent follow-up as recorded in case records review. The spectrum of pathology, surgical intervention, outcome, complications, World Health Organization stage of AIDS, and type of antiretroviral therapy were all noted. Comparative outcomes and subgroup analysis were not done in this part of the study. RESULTS One hundred and thirteen patients were included in the study over the 30-month period. The average age was 24 months (1 day to 11 years). Seventy-nine (70%) of the 113 patients were infected and 34 (30%) were exposed, 9 of whom subsequently tested negative. Of the infected group, 53 (67%) patients were on antiretroviral therapy. The extent of disease in the infected group of patients according to the 2006 World Health Organization criteria was as follows: stage 1, 4 (5%); stage 2, 12 (15%); stage 3, 51 (65%); and stage 4, 12 (15%). All patients had nutritional assessments and were plotted on growth curves. Sixty-two (54%) were found to be malnourished and 41 (36%) of the children were found to have comorbid disease processes. Eighteen patients (16%) were treated with antibiotics or conservative therapy alone. The remaining 95 patients (84%) underwent an average of 1.6 procedures (range, 1-35), 59 (52%) in an elective manner and 36 (31%) as an emergency. When assessing the relationship of HIV to the presenting disease state, 58 (73.4%) had HIV-related diseases and 52 (46%) presented with sepsis. A total of 29 (25%) patients had surgical complications of which 6 (20%) were not considered to be HIV related. Nine (31%) had, in retrospect, incorrect management of the presenting disease, leaving 14 (48%) who potentially had HIV-related complications of poor wound healing and sepsis. A total of 100 (88%) were discharged alive, 6 (5.3%) died, and 7 (6 %) were lost to follow-up. Long-term follow-up of 50 patients for an average of 8 months revealed one further mortality. CONCLUSION Human immunodeficiency virus-positive and -exposed patients present a unique challenge in management which is complicated by concomitant disease and poor nutrition. These patients require an expanded differential diagnosis. We believe that, although on the surface there may be a higher complication rate, this needs to be confirmed in an expanded comparative cohort study, which is underway and that patients should still receive the benefit of full surgical intervention.
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HIV seropositivity predicts longer duration of stay and rehospitalization among nonbacteremic febrile injection drug users with skin and soft tissue infections. J Acquir Immune Defic Syndr 2009; 49:398-405. [PMID: 19186352 DOI: 10.1097/qai.0b013e318183ac84] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Skin/soft tissue infections (SSTIs) are the leading cause of hospital admissions among injection drug users (IDUs). METHODS We performed a retrospective investigation to determine the epidemiology of SSTIs (ie, cellulitis and/or abscesses) in febrile IDUs, with a focus on bacteriology and potential predictors of increased health care utilization measured by longer length of stay and rehospitalization. Subjects were drawn from a cohort of febrile IDUs presenting to an inner-city emergency department from 1998 to 2004. RESULTS Of the 295 febrile IDUs with SSTIs, specific discharge diagnoses were cellulitis only (n = 143, 48.5%), abscesses only (n = 113, 38.3%), and both (n = 39, 13.2%). Documented HIV infection rate was 28%. Of note, 10 subjects were newly diagnosed with HIV infection during their visits. Staphylococcus aureus was the leading pathogen, and increasing rates of methicillin-resistant S. aureus emerged over time (before 2001: 4%, 2001-2004: 56%, P < 0.01). HIV seropositivity predicted rehospitalization within 90 days [adjusted hazard ratios and 95% confidence intervals: 2.90 (1.20 to 7.02)]. HIV seropositivity also predicted increased length of stay in those who were nonbacteremic [adjusted hazard ratios and 95% confidence intervals: 1.49 (1.11 to 2.01)]. CONCLUSIONS Among febrile IDUs with SSTIs, a strong association between HIV seropositivity and health care resource utilization was found. Accordingly, attention to HIV serostatus should be considered in clinical disposition decisions for this vulnerable high-risk population.
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Abstract
BACKGROUND Our goal was to analyze whether the presence of human immunodeficiency virus (HIV) infection effects outcome after trauma. METHODS We performed a retrospective review of trauma patients from 2000 to 2005 comparing HIV-positive patients with HIV-negative patients. RESULTS A group of 54 HIV-positive patients were compared with 200 HIV- negative patients who were equally matched for demographics, mechanism, and injury severity. The groups had similar comorbidities except for more coagulopathy (0% vs. 3.7%, p = 0.04) and renal failure (0.5% vs. 9.3%, [p = 0.002]) in the HIV-positive group. The HIV-negative group had 9% overall complications versus 22.2% for the HIV-positive group (p = 0.02). There were more respiratory (0.5% vs. 5.6% [p = 0.03]) and renal (0% vs. 5.6% [p = 0.009]) complications in the HIV-positive group. No differences were found between the groups regarding ventilator, intensive care unit, hospital lengths of stay, or mortality. In the HIV-positive group, 34 had known CD4 counts which averaged 474.6 cells/muL +/- 457.4 cells/muL. There were eight who had a CD4 count less than 200 cells/muL of whom two had complications, and one had an infectious complication. These were not statistically different from those who had CD4 counts >/=200 cells/muL. Regression analysis did not demonstrate any difference in overall complications (p = 0.37) or infections (p = 0.38) regardless of the CD4 count. CONCLUSION Although HIV-infected patients suffer more complications than their noninfected counterparts, HIV does not alter the outcomes for trauma patient. HIV status should not influence management decisions for these patients regardless of the patient's CD4 count.
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Chidzonga MM, Mahomva L. Recurrent noma (cancrum oris) in human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV and AIDS): report of a case. J Oral Maxillofac Surg 2008; 66:1726-30. [PMID: 18634964 DOI: 10.1016/j.joms.2007.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Accepted: 08/22/2007] [Indexed: 10/21/2022]
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Chidzonga MM, Mahomva L. Noma (cancrum oris) in human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV and AIDS): clinical experience in Zimbabwe. J Oral Maxillofac Surg 2008; 66:475-85. [PMID: 18280380 DOI: 10.1016/j.joms.2007.09.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Revised: 06/12/2007] [Accepted: 09/05/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE This retrospective study describes the clinical features and management of noma (cancrum oris) in patients with HIV and AIDS. PATIENTS AND METHODS Records of 48 consecutive patients with noma (cancrum oris) seen between July 2002 and November 2006 were reviewed for age, gender, clinical features, and management. Other reports on noma in HIV and AIDS in Zimbabwe were also reviewed. RESULTS There were 48 patients included; 35.4% (n = 17) were males, of which 64.7% (n = 11) were children (16 years and younger) and 35.3% (n = 6) were adults; 64.6% (n = 31) were females, out of which 87.1% (n = 27) were children and 12.9% (n = 4) were adults. The average age was 14.2 years (range, 3 to 30 years) for males and 9.2 years (range, 1 to 36 years) for females. The average age for the entire group was 11 years (range, 1 to 36 years). All patients were HIV-positive by the ELISA method. Only 13 patients had CD4 cell and CD8 cell count obtained, ranging from 10 to 594 cells/microL with a CD4/CD8 ratio ranging from 0.02 to 0.45. Only 5 patients had microbiologic investigations conducted, isolating Staphylococcus aureus, Klebsiella species, group D Streptococcus, and group B hemolytic Streptococcus. Isolated cheek defect (37.5%) was most common, followed by the type I and type IV defect (25% each). Administration of antibiotics, nutritional support, wound debridement, and sequestrectomy were conducted before definitive reconstructive surgery. Facial reconstruction was performed using distant and local advancement flaps. No bony reconstruction was performed. Satisfactory results were achieved with minimal infection and flap breakdown. Follow-up was difficult; patients were lost to follow-up within 6 to 12 months after surgery. CONCLUSION Noma cases are on the increase in line with the current HIV and AIDS epidemic. Female children appear to be more commonly affected than their male counterparts. Reconstructive surgery is possible in patients with low CD4/CD8 ratios because of HIV infection.
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Abstract
Aging, immune disease and transplantation are discussed
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Affiliation(s)
- C Graeb
- Department of Surgery, University of Munich at Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - K-W Jauch
- Department of Surgery, University of Munich at Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
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Davies CG, Khan MN, Ghauri ASK, Ranaboldo CJ. Blood and body fluid splashes during surgery--the need for eye protection and masks. Ann R Coll Surg Engl 2007; 89:770-2. [PMID: 17999818 PMCID: PMC2173168 DOI: 10.1308/003588407x209301] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION While most surgeons make an effort to avoid needlestick injury, some can pay little attention to reduce the potential route of infection occurring when body fluids splash into the eye. It has been shown that transmission of HIV, hepatitis B or C can occur across any mucous membrane. This study aims to quantify how frequently body fluids splash the mask and lens of wrap around protective glasses thus potentially exposing the surgeon to infection. PATIENTS AND METHODS A prospective study was carried out by a single surgeon on all cases performed over a 1-year period. Protective mask and glasses were examined before and after operations. RESULTS A total of 384 operations were performed with 174 (45%) showing blood or body fluid splash on the lens. A high incidence of splashes was found in vascular surgical procedures (79%). All amputations showed splash on the protective lens. Interestingly, 50% of laparoscopic cases resulted in blood or body fluid splash on the protective lens. CONCLUSIONS This study has shown a high incidence (45%) of blood and body fluid splashes found on protective glasses and masks. There was a very high incidence (79%) during vascular surgical procedures. With the prevalence of HIV and hepatitis increasing, it seems prudent to protect oneself against possible routes of transmission.
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Affiliation(s)
- C G Davies
- Department of Surgery, Salisbury District Hospital, Salisbury, UK.
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Clarke DL, Thomson SR, Bissetty T, Madiba TE, Buccimazza I, Anderson F. A single surgical unit's experience with abdominal tuberculosis in the HIV/AIDS era. World J Surg 2007; 31:1087-96; discussion 1097-8. [PMID: 17426896 DOI: 10.1007/s00268-007-0402-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has resulted in a resurgence of abdominal tuberculosis in South Africa, and these patients often present to general surgeons. We describe a single-hospital experience in a region of high HIV prevalence. METHODS A prospective database of all patients with suspected abdominal tuberculosis was maintained from January 2003 until July 2005. RESULTS There were 67 patients (20 men, 47 women) with an average age of 32 years (range 27-61 years). The erythrocyte sedimentation rate was universally elevated (105 +/- 23). Altogether, 23 patients were HIV-positive and 7 were HIV-negative. The status was unknown in the remainder. Chest radiographs demonstrated an abnormality in 17 patients (22%). Abdominal ultrasonography was performed in 59 patients and computed tomography in 12. Twelve laparotomies were performed, seven as emergencies. None in the elective laparotomy group died, whereas the mortality rate in the emergency group was 60%. Laparoscopy was insufficient for a variety of reasons. Two patients underwent appendectomy and two excision of a perianal fistula. Two patients underwent biopsy of a palpable subcutaneous node, which confirmed the diagnosis in both cases. A definitive diagnosis was achieved in all 12 patients subjected to laparotomy and at colonoscopic biopsy in 2, lymph node biopsy in 2, appendectomy in 2, perianal fistulectomy in 2, and percutaneous drainage in 2. In the remaining 47 patients the diagnosis was made on the basis of the clinical presentation and radiologic imaging. The patients were commenced on antituberculous therapy. The in-hospital mortality in this group was 10%. Therapy was continued at a centralized tuberculosis facility independent of the hospital. Surgical follow-up was poor, with only five (7%) patients completing the 6-month review at a surgical clinic. CONCLUSIONS A resurgence in tuberculosis during the HIV era produces a new spectrum of presentations for the surgeon. Emergency surgery is associated with high mortality. Bacterial and histologic evidence of infection are difficult to obtain, and indirect clinical and imaging evidence are used to commence a trial of therapy. A short-term clinical response is regarded as proof of disease. Lack of follow-up means that the efficacy of this strategy is unproven. Health policy changes are needed to enable appropriate surgical follow-up to determine the most effective management algorithm.
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Affiliation(s)
- D L Clarke
- Department of General Surgery, Nelson R Mandela School of Medicine, University of Kwa-Zulu Natal, Congella, Durban, South Africa
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Martinson NA, Omar T, Gray GE, Vermaak JS, Badicel M, Degiannis E, Steyn J, McIntyre JA, Smith M. High rates of HIV in surgical patients in Soweto, South Africa: impact on resource utilisation and recommendations for HIV testing. Trans R Soc Trop Med Hyg 2006; 101:176-82. [PMID: 16814822 DOI: 10.1016/j.trstmh.2006.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2006] [Revised: 04/05/2006] [Accepted: 04/05/2006] [Indexed: 11/26/2022] Open
Abstract
Interactions between HIV and surgical diseases are relatively poorly described in high HIV prevalence settings. We report HIV prevalence and its associations in a prospective study of adults admitted to surgical units in Soweto, South Africa. Voluntary counselling and testing (VCT) for HIV was offered to surgical inpatients. Research nurses interviewed participants at enrolment and doctors reviewed records after discharge. In HIV-infected participants, CD4 counts and viral loads were ascertained. Of 1000 participants, 537 consented to VCT, of whom 176 (32.8%, 95% CI 28.8-36.9%) tested HIV positive. A history of tuberculosis (adjusted odds ratio (AOR) 3.0, 95% CI 1.5-6.2) or sexually transmitted infection (AOR 2.7, 95% CI 1.8-4.2) was associated with HIV infection. Diagnoses of cutaneous abscesses (OR 3.4, 95% CI 1.4-8.1) and anorectal sepsis (OR 3.1, 95% CI 1.1-9.0) were associated with HIV and indicated advanced disease. There were no differences in rates of operative procedures, wound sepsis, investigations or length of stay by HIV status. Hospital-acquired pneumonia was more common in HIV-infected participants (P=0.028). In conclusion, in this high HIV prevalence setting, resource utilisation is similar between HIV-infected and uninfected patients in surgical wards where high rates of HIV in young adults support routine HIV testing. WHO clinical staging of HIV should include anal sepsis as an indicator of advanced HIV disease.
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Affiliation(s)
- Neil A Martinson
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa.
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