Preoperative counts of CD4 T-lymphocytes and early postoperative infective complications in HIV-positive patients.

OBJECTIVE: To assess the relationship between postoperative infective complications and the CD4 count. DESIGN: Retrospective and biometric study. SETTING: Two university hospitals, Switzerland. SUBJECT: 40 HIV-positive patients who had had CD4 counts done during the three months before operation. INTERVENTIONS: Clean and contaminated gastrointestinal and orthopaedic procedures. MAIN OUTCOME MEASURE: Postoperative infective complications. RESULTS: 15 patients developed postoperative infective complications (38%), 6 of which (40%) were HIV-related. CD4 cell count, as well as the type of operation (contaminated or clean), influenced the infective complication rate. The risk of infective complications after a contaminated procedure when the CD4 count was below 200 mm3 was more than 50%. In clean operations, even when the CD4 cell count was close to 0, the rate of infective complications was never as high as 50%. Patients with a CD4 cell count of 500 or more have a similar rate of infective complications as HIV seronegative patients. CONCLUSION: Indications for operation in HIV-positive patients must take into account the CD4 cell count and the type of operation.

[Arthroscopic removal of intra-articular loose foreign bodies of the elbow]. / Ablation arthroscopique de corps étrangers libres intra-articulaires du coude.

PURPOSE OF THE STUDY: We have retrospectively studied the results of arthroscopic removal of loose bodies in the elbow. The aim of the study was to determine if the etiology of the loose bodies could be considered as a criteria for technical difficulty and clinical prognosis. MATERIAL: 16 patients (11 men and 5 female) had an elbow arthroscopy for loose bodies removal. Their average age was 29.5 years (range: 16-49). The post-operative results were recorded in their medical files with an average follow-up of six months. METHODS: In each case we have determined the etiology of the intra-articular loose bodies. The results were analyzed according to technical difficulty and clinical outcome. RESULTS: The etiology of the loose bodies was 8 chondromatosis, 4 osteochondritis dissecans and 4 post-traumatic osteoarthritis. The removal of the loose bodies was possible in 13 cases. Three arthroscopies were interrupted because of arthritic joint space narrowing. Twelve patients with primary chondromatosis and osteochondritis dissecans were improved. We did not find any significant clinical improvement in osteoarthritic elbows. A correlation between the results and the etiologies could therefore be shown. DISCUSSION: In arthroscopic removal of elbow loose bodies, technical difficulties and clinical results are correlated to the etiology of the loose bodies and also to the statement of the osteochondral surfaces.

Acute right iliac fossa pain in acquired immunodeficiency: a comparison between patients with and without acquired immune deficiency syndrome.

A retrospective review was performed of the clinical features present in 17 patients who were human immunodeficiency virus (HIV) positive requiring a diagnostic or therapeutic procedure for suspected appendicitis. Patients who were acquired immune deficiency syndrome (AIDS) free (n = 11) and those with AIDS (n = 6) were compared. Ten of the 11 patients who were AIDS-free had appendicitis. The morbidity rate was 9 per cent, similar to that expected in seronegative patients, but the appendix perforation rate was 50 per cent. Only two of the six patients with AIDS had appendicitis. Three suffered from an HIV-related disease process. Computed tomography (CT) was performed in four of the six patients with AIDS, and was considered of diagnostic help in three. In patients with AIDS, the morbidity rate rose to 50 per cent. Surgical decision-making with regard to HIV-positive patients who were AIDS-free with suspected appendicitis should be similar to that for seronegative patients. For patients with AIDS, alternative diagnostic strategies, including preoperative CT, or possibly laparoscopy, should be considered.

[Alternative closure of the sternum after heart surgery]. / Fermeture différée du sternum après opération cardiaque.

We report on 27 patients who, between November 1986 and December 1988, had a delayed sternal closure after cardiac surgery out of the following reasons: post-ECC low output syndrome: 17 patients (15 with IABP, 11 transfemoral, 4 transaortic), haemodynamic breakdown with sternal approximation: 9 patients, diffuse bleeding: one patient. In 13 patients perioperative infarction was diagnosed (4 right heart infarctions) as a cause for the poor cardiac condition. The surgery performed had been: 26 coronary artery bypass operations (18 combined with other procedures), and one double valve replacement. The temporary closure of the wound generally is now performed by a sterile zipper (Ethizip). Sternal closure was possible one to nineteen days postoperatively, most often (19 patients) on the 2nd postoperative day. We did not note any serious complications or wound infection due to the management with delayed sternal closure. Three patients died from cardiac failure with chest open, 4 patients died six days to eight weeks postoperatively with closed chest. Among the 20 patients discharged from hospital, 17 are at present in satisfactory clinical condition, one patient suffers from recurrent angina, one from cardiac insufficiency and one is in poor general condition. As a conclusion we think that delayed sternal closure after cardiac surgery is a helpful tool in patients with 1) haemodynamic breakdown with sternal approximation, 2) diffuse bleeding.