The Surgeon and AIDS

Saltzman, Darin J.; Williams, Russell A.; Gelfand, Dmitri V.; Wilson, Samuel E.

doi:10.1001/archsurg.140.10.961

Cited by 41 publications

(18 citation statements)

References 77 publications

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“…Some reports continued to show increased complications 22,23,44–50 and death 44,46,49 in patients with HIV infection, but others documented declining rates of surgical complications and deaths in the HIV infection group that rivaled those experienced by uninfected individuals across many surgical specialties including orthopedics, 51–57 cardiovascular surgery, 13,58–61 bariatric surgery, 62 transplant surgery, 16,24,63 obstetrics, 10,11,64 urologic surgery, 65 neurosurgery, 66 and general surgery. 12,14,15 …”

Section: Discussionmentioning

confidence: 99%

Thirty-Day Postoperative Mortality Among Individuals With HIV Infection Receiving Antiretroviral Therapy and Procedure-Matched, Uninfected Comparators

et al. 2015

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IMPORTANCE Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized. OBJECTIVE To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level. MAIN OUTCOMES AND MEASURES All-cause 30-day postoperative mortality. RESULTS The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/µL or more, 16.3% with 50/µL to 199/µL, and 3.7% with less than 50/µL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41–3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/µL: IRR, 1.92; 95% CI, 1.02–3.60; P = .04; 200–499/µL: IRR, 1.89; 95% CI, 1.20–2.98; P = .01; 50–199/µL: IRR, 2.66; 95% CI, 1.29–5.47; P = .01; and <50/µL: IRR, 6.21; 95% CI, 3.55–10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78–6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23–1.76; P < .001) were also strongly associated with mortality. CONCLUSIONS AND RELEVANCE Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.

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Section: Discussionmentioning

confidence: 99%

Thirty-Day Postoperative Mortality Among Individuals With HIV Infection Receiving Antiretroviral Therapy and Procedure-Matched, Uninfected Comparators

et al. 2015

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“…29–35 Since the adoption of cART in the developed world, declining rates of surgical complications and deaths in HIV infected patients may rival those experienced by uninfected individuals. 36–40 In the largest surgical series published to date, Horber and colleagues found only small differences in complications and outcomes when comparing 322 HIV infected patients to contemporaneous matched uninfected controls undergoing the same surgical procedures. 41 (None of the patients in the Horberg et al .…”

Section: Discussionmentioning

confidence: 99%

“…42–44 The development and dissemination of cART has improved survival and doubtless contributed to improved modern surgical outcomes for HIV infected patients. 40 Referring providers and surgeons may also be selecting HIV infected patients for surgery that are likely to have better outcomes, accounting both for improved modern surgical outcomes and the disparity in rates of spine surgery seen in our study population.…”

Section: Discussionmentioning

confidence: 99%

Disparities in Rates of Spine Surgery for Degenerative Spine Disease Between HIV-Infected and Uninfected Veterans

King

Gordon²,

Perkal³

et al. 2012

Spine

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Study Design Retrospective analysis of nationwide Veterans Health Administration (VA) clinical and administrative data. Objective Examine the association between HIV infection and the rate of spine surgery for degenerative spine disease. Summary of Background Data Combination anti-retroviral therapy (cART) has prolonged survival in patients with HIV/AIDS, increasing the prevalence of chronic conditions such as degenerative spine disease that may require spine surgery. Methods We studied all HIV infected patients under care in the VA from 1996–2008 (n=40,038) and uninfected comparator patients (n=79,039) matched on age, gender, race, year, and geographic region. The primary outcome was spine surgery for degenerative spine disease defined by ICD-9 procedure and diagnosis codes. We used a multivariate Poisson regression to model spine surgery rates by HIV infection status, adjusting for factors that might affect suitability for surgery (demographics, year, comorbidities, body mass index, cART, and laboratory values). Results Two-hundred twenty eight HIV infected and 784 uninfected patients underwent spine surgery for degenerative spine disease during 700,731 patient-years of follow-up (1.44 surgeries per 1,000 patient-years). The most common procedures were spinal decompression (50%), and decompression and fusion (33%); the most common surgical sites were the lumbosacral (50%), and cervical (40%) spine. Adjusted rates of surgery were lower for HIV infected patients (0.86 per 1,000 patient-years of follow-up) than for uninfected patients (1.41 per 1,000 patient-years; IRR 0.61, 95% CI: 0.51, 0.74, P<0.001). Among HIV infected patients, there was a trend towards lower rates of spine surgery in patients with detectable viral loads levels (IRR 0.76, 95% CI: 0.55, 1.05, P=0.099). Conclusion In the VA, HIV infected patients experience significantly reduced rates of surgery for degenerative spine disease. Possible explanations include disease prevalence, emphasis on treatment of non-spine HIV-related symptoms, surgical referral patterns, impact of HIV on surgery risk-benefit ratio, patient preferences, and surgeon bias.

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“…This risk is decreased to 0.1% with mucous membrane exposure. 10 Cases of HIV transmission as a result of blood contact with the eye have been reported. 11 …”

Section: Discussionmentioning

confidence: 99%

Contamination Resulting From Aerosolized Fluid During Laparoscopic Surgery

Englehardt

Nowak

Seger

et al. 2014

JSLS

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Background and Objectives:Aerosolized droplets of blood can travel considerable distances on release of intra-abdominal pressure during laparoscopic surgery. This creates an environmental hazard for members of the surgical team. This study describes and provides a method of measurement of aerosolized blood contamination during evacuation of the pneumoperitoneum in laparoscopic surgery.Methods:Samples were measured by removing a trocar from the abdomen while a pneumoperitoneum of 15 mm Hg was present. A white poster board was placed 24 inches above the incision to catch the released blood spatter. By use of machine vision, luminol fluorescence, and computerized spatial analysis, data from the boards were recorded, analyzed, and scored based on the distance, size, and quantity of particulate contamination.Results:We analyzed 27 boards. Spatter was present on every board. The addition of luminol to the boards increased the amount of visible spatter. Most tests created <1000 blood spatters. Fluids are typically ejected as a fine mist. Every test included at least 1 blood spatter. The range of the average blood spatter size was 0.53 × 10–3 to 7.11 × 10–3 sq in. The amount of spatter detected did not show any apparent correlation with the patient's body mass index, the estimated blood loss, or the type of operation performed.Conclusions:Evacuation of the pneumoperitoneum during laparoscopic surgery results in consistent contamination. Most blood spatter is not visible to the naked eye. Our results suggest that all surgical participants should wear appropriate protective barriers and conscious measures should be undertaken to prevent environmental contamination during pneumoperitoneal evacuation.

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The Surgeon and AIDS

Cited by 41 publications

References 77 publications

Thirty-Day Postoperative Mortality Among Individuals With HIV Infection Receiving Antiretroviral Therapy and Procedure-Matched, Uninfected Comparators

Thirty-Day Postoperative Mortality Among Individuals With HIV Infection Receiving Antiretroviral Therapy and Procedure-Matched, Uninfected Comparators

Disparities in Rates of Spine Surgery for Degenerative Spine Disease Between HIV-Infected and Uninfected Veterans

Contamination Resulting From Aerosolized Fluid During Laparoscopic Surgery

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