The burden of non-communicable diseases and mortality in people living with HIV (PLHIV) in the pre-, early- and late-HAART era.

OBJECTIVES: To estimate the burden of non-communicable diseases (NCDs) and mortality among PLHIV in the pre-, early- and late-HAART (highly active antiretroviral therapy) era. METHODS: We conducted a cohort study using population-based Danish medical registries including all adult HIV-infected residents of the Central Denmark Region during 1985-2017. For each HIV patient, we selected 10 comparisons from the background population matched by age, sex and municipality of residence. Based on hospital-related diagnoses we estimated the prevalence and incidence of specific NCD at diagnosis and at 5 and 10 years. RESULTS: We identified 1043 PLHIV and 10 430 matched comparisons. PLHIV had lower socioeconomic status and more were born outside western Europe. At HIV diagnosis, 21.9% of PHLIV vs. 18.2% of non-HIV individuals had at least one NCD, increasing to 42.2% vs. 25.9% after 10 years. PLHIV had higher prevalence and cumulative incidence of alcohol abuse, chronic obstructive pulmonary disease (COPD), ischaemic heart disease, mental disorders, renal and liver disease, but no increased risk of diabetes mellitus. Only PLHIV in the age groups 41-50 and > 51 years had an increased incidence of osteoporosis. From the pre- to the late-HAART era, 10-year mortality among PLHIV decreased from 45.5% to 9.4% but continued at more than twice that of uninfected comparisons. However, in the late-HAART era, the mortality of PLHIV who were alive 2 years after HIV diagnosis was approaching that of comparisons. CONCLUSIONS: Even in the late-HAART era, PLHIV have an excess mortality, which may be attributable to several NCDs being more prevalent among PLHIV. The prevalence rates of ischaemic heart disease, diabetes, osteoporosis and renal disease tend to increase over calendar time. Therefore, improvement of survival and quality of life of PLHIV neets strategies to reduce the risk of developing NCDs, including avoiding toxic antiretroviral therapy and lifestyle changes.

Postoperative pain relief and respiratory performance after thoracotomy: a controlled trial comparing the effect of epidural morphine and subcutaneous nicomorphine.

Twenty patients scheduled for lateral thoracotomy were randomly allocated to receive either epidural morphine at regular intervals or subcutaneous nicomorphine on demand for postoperative pain relief. The daily dose of opiate administered was greater in the group receiving subcutaneous nicomorphine than in the epidural group although four patients in the latter needed additional subcutaneous injections of opiate. During the first three days of the postoperative course, a profound decrease of the forced vital capacity (FVC), the forced expiratory volume in one second (FEV1), peak expiratory flow rate (PEF) and the arterial oxygen tension (PaO2) was found in both groups, whereas the visual analogue pain score showed a marked increase, and the arterial pH and carbon dioxide tension (PaCO2) remained unchanged. No significant difference could be demonstrated between the group;s. The conclusion is that epidural morphine may produce sufficient pain relief after thoracotomy, but compared with conventional pain treatment the benefits are limited.

Diagnosis and repair of traumatic tracheal and tracheobronchial disruptions.

During the period from January 1968 to December 1982, 8 patients received emergency operations for traumatic tracheobronchial rupture in the Department of Thoracic Surgery, Odense University Hospital. Half of the lesions were the result of blunt trauma; the other half were penetrating injuries or iatrogenic lesions. All of them were treated within 24 hours by direct suture of the lesion. In our experience soft, rapidly absorbable sutures should be used in the cartilaginous and membraneous parts of the larynx and trachea, and tracheotomy should be avoided where at all possible. Using these principles we have been able to avoid completely any cases of re-stenosis with its attendant complications. After operation , most patients could respire normally, and they recovered well after a few hours or days of using an uncuffed nasotracheal tube.

Pulmonary histiocytomas.

Five cases of pulmonary histiocytomas are presented (four "endobronchial" and one "pulmonary"). They occurred in two children, and three adults over a five year period. Our center has a catchment of 1 million inhabitants. The possible nature and diagnostic possibilities are discussed. The prognosis is good in young people with this disease, which, in principle, does not differ from the same proliferating histiocytic and fibroblastic disorder arising elsewhere. The histological diagnosis was based upon characteristic and consistent morphological features, common to all cases.

Perforation and rupture of the esophagus.

A series of 57 esophageal perforations from the period 1963-1982 is reported. They comprised 42 iatrogenic, instrumental perforations and 15 non-iatrogenic, mainly spontaneous and postemetic ruptures. The clinical manifestations were mostly pain, fever, subcutaneous and mediastinal emphysema, pleural effusion and pneumothorax. Esophageal leak was demonstrated in 73% of contrast studies. The overall mortality rate was 25%. It was 21% in cases with primary suture closure and 50% when treatment consisted of drainage. The mortality rate was 19% when treatment was begun within 24 hours and 35% when there was longer delay. Other factors influencing the mortality rate seemed to be type and location of the perforation and age of the patient. Early surgical intervention is advocated for perforation or rupture of the intrathoracic esophagus. Data in the literature and our own findings indicate that also in cervical esophageal perforations early surgical repair is justifiable.

Closed pleural biopsy and fluid cytology in the diagnosis of suspected pulmonary cancer with pleural involvement.

In a retrospective study of 44 cases of suspected primary pulmonary cancer with pleural involvement, the diagnostic value of pleural biopsy a.m. Abrams was evaluated. Biopsy specimens in 20 patients showed malignancy, which in 16 cases provided an adequate diagnosis, while 4 patients needed pleural biopsy by means of operation. In a total of 24 cases showing biopsy specimens without malignancy there were 4 false-negative ones. Among the patients under study, closed pleural biopsy combined with pleural fluid cytology proved malignancy in 96% of the cases in which neoplastic disease of the lungs and pleura was otherwise diagnosed. These findings indicate the value of using both fluid cytology and closed pleural biopsy at an early stage of the diagnostic procedure in cases of suspected pulmonary cancer with pleural involvement.

Atrial septal defect, primum type. Results of surgical closure in 46 patients.

Surgical closure of an atrial septal defect of the ostium primum type was performed in 46 patients during the years 1965-78. All closures were performed with a Dacron patch and the mitral valve defect was sutured. The operative mortality was 6.5%. Pre-operatively, all patients had right bundle-branch block with left axis deviation. Severe heart block did not develop in any of the survivors. One of the patients who died had a partial atrioventricular block postoperatively. Arrhythmia developed in 5 patients, but was cardioverted to sinus rhythm. The operative technique of placing the lower sutures at the mitral valve parallel to the annulus to avoid the conduction bundle is emphasized. Repair of the tricuspid valve was performed in 10 cases and simultaneous closure of a secundum defect was made in 14. Preoperative catheterization revealed arteriovenous shunts ranging from 60 to 500% of the cardiac output. Recatheterization of 32 patients one year postoperatively showed residual shunts ranging from 20 to 75% in 5 patients who were otherwise without clinical symptoms. All survivors had a systolic apical murmur of the mitral insufficiency type.

Dissecting aneurysms of the thoracic aorta.

Twenty-eight cases of dissecting aneurysms of the thoracic aorta in patients with hypertension, syphilis, Marfan's syndrome and with unknown aetiology are analyzed with regard to the origins and extent of the dissection angiographically. The most common symptoms and evident radiological findings of the plain radiographs of the chest are stressed. The prognosis depends on the type of dissection.

Traumatic rupture of the thoracic aorta.

A retrospective analysis of traumatic ruptures of the aorta is presented. Importance is stressed upon the plain chest film as the primary examination. Angiography revealed false aneurysms with classic localization just distal to the left subclavian artery in 10 cases and a transverse intimal tear in one case. The detection of chronic false aneurysms is equally important as they also require surgical repair.

Prophylaxis against postoperative pulmonary embolism and deep-vein thrombosis by low-dose heparin.

The prophylactic effect of low-dose heparin on postoperative fatal and on clinically apparent but non-fatal thromboembolic complications was studied in a double-blind, prospective, randomised study comprising 1296 patients. 16 out of 653 patients in the placebo group had such complications within the treatment period of 1 week, compared with 4 out of 643 in the heparin group. This difference was statistically significant (P less than 0.05). 4 cases in the placebo group and 1 in the heparin group were fatal. After prophylactic treatment had been stopped at the end of the first postoperative week, the rate of thromboembolic complications was equal for the 2 groups. Low-dose heparin prophylaxis is thus effective and should be given routinely in patients aged over 40 years; it should also be given for more than 1 week in patients not ambulant by then.

PIP: A double-blind prospective study was conducted on 1296 patients who had undergone surgery, to observe the effects of low-dose heparin on postoperative fatal and nonfatal thromboembolic complications. 16 patients out of 652 in the placebo group had such complications within the treatment period of 1 week, compared to 4 out of 643 in the heparin group. There were 4 deaths in the placebo group, and 1 in the heparin group. Rate of thromboembolic complications was equal for both groups after termination of prophylactic treatment. Such study shows that low-dose heparin can be effective when administered routinely to patients over 40, and to patients not ambulant 1 week after operation.