Acqired immunodeficiency diseases in Surgery

1. Acqired immunodeficiency diseases in Surgery millo tama 2002 batch

2. Los Angeles--A technician who was cut by a scalpel that came in contact with HIV-positive blood was awarded $102,500 on Thursday in a lawsuit against an HIV-positive patient who did not disclose her condition before the operation. A Superior Court jury ruled that patient Jan Lustig committed fraud and negligent infliction of emotional distress on surgical technician Diane Boulais. Even though Boulais has tested HIV- negative thus far, her attorney told jurors that she lives in fear of the disease developing in later months. Boulais said, "I am thrilled. It is a message that will help all health care workers." Lustig's attorney, Evan Wolfson, said the decision would be appealed. Boulais alleged that Lustig, a clinical psychologist from Vancouver, Wash., concealed her HIV -positive status because she knew no surgeon would perform breast reduction surgery on her as a result. The lawsuit says Lustig arranged for a breast reduction operation at The Breast Center in suburban Van Nuys, Calif., in 1991. She signed papers claiming she had no medical problems and wasn't being treated or observed for any illness. Boulais was helping remove stitches from Lustig when a scalpel nicked her finger, cutting it deeply. Subsequently, Lustig admitted she was HIV- positive, said Boulais' lawyer, Rex Beaber. Lustig said she had approached other physicians for the surgery but was rejected when they learned she was infected. "I was withholding information that was personal and private. I don't consider withholding information a lie. To me a lie is done with evil intent," she said in her testimony.

3. HISTORY • First Recognised In USA In 1981 • Reports From NewYork & LosAngeles about sudden outbreak of 2 Rare Diseases - Kaposi’s Sarcoma And Pneumocystis Carinii

4. EPIDEMOLOGY • is a Global Pandemic. • 37 Million Cases World Wide. • 2\3 In Sub - Saharan Africa. • 50% Cases Are Women. • 2.5 Million Children < 15yrs. • According to the Joint United Nations Program On Aids In 2003 – 5 Million New Cases. • 3 Million Deaths from AIDS . • 4th Leading Cause Of Death.

5. LIFE CYCLE • HIV binds to Cell surface via Receptors • Viral uncoating in Cytoplasm. • RNA Viral Genome Transcribed To DNA Copy-RT Enzyme. • DNA Copy Integrated Into Host Genome In Cell Nucleus. • Viral DNA Is Translated To RNA Copies In Cytoplasm. • Viral Peptide Chains Translated From Cytoplasmic Viral RNA. • HIV Protease Cleaves Functional Viral Protein From Polypeptide. • Virion Assembly. • Viral Release From Cell Surface.

6. MODES OF TRANSMISSION • HIV is present in Blood , Semen & Other Body Fluids such as Breast Milk & Saliva. • HIV is Transmitted - Both Homosexual & Heterosexual. - Blood & Blood Products. - By Infected Mother to Infant either Intrapartum , Perinatally or via Breast Milk.

7. NATURAL HISTORY OF DISEASE • PRIMARY INFECTION • ASYMPTOMATIC INFECTION • MILDLY SYMPTOMATIC • ACQUIRED IMMUNODEFICIENCY SYNDROME

8. PRIMARY INFECTION is symptomatic in 70% - 80% cases. occurs 2-4 wks after exposure. plasma HIV RNA level>1million copies/ml. CD4 count to 300-400 cells/mm3. recovery occurs after 1-2wks. return of CD4 count & fall in the viral load.

9. 1.GENERAL FEVER PHARYNGITIS HEADACHE ARTHRALGIA LETHARGY ANOREXIA LYMPHADENOPATHY 2.NEUROLOGIC MENINGITIS ENCEPHALITIS PERIPHERAL NEUROPATHY MYELOPATHY 3.DERMATOLGIC ERYTHEMATOUS MACULOPAPULAR RASH MUCOCUTANEOS ULCERATION CLINICAL MANIFESTATIONS

10. ASYMTOMATIC INFECTION • REMAINS WELL WITH NO EVIDENCE OF DISEASE. • PRESENCE OF PERSISTENT GENERELISED LYMPHADENOPATHY • SUSTAINED VIRAEMIA WITH A DECLINE IN CD4 COUNT.

11. MILDLY SYMPTOMATIC DISEASE INDICATES IMPAIRMENT OF THE CELLULAR IMMUNE SYSTEM. CORRESPOND TO ARC . INCLUDED IN THIS CATEGORY ARE C/C WEIGHT LOSS FEVER DIARRHEA CANDIDIASIS & HAIRY LEUCOPLAKIA HERPES ZOSTER SEVERE PID &CERVICAL DYSPLASIA BACILLARY ANGIOMATOSIS & ITP

12. ACQUIRED IMMUNODEFICIENCY SYNDROME DEFINED BY DEVELOPMENT OF SPECIFIED OPPORTUNISTIC INFECTION,TUMOURS etc. INTERVAL FROM INFECTION TO THE DEVELOPMENT OF AIDS IS AROUND 7-10YRS.

13. CD4 COUNT & HIV RELATED DISEASES • < 500 • BACTERIAL INFECTION • TUBERCULOSIS • HERPES SIMPLEX • HERPES ZOSTER • CANDIDIASIS • HAIRY LEUKOPLAKIA • KAPOSIS SARCOMA

14. CD4 < 200 • PNEUMOCYSTIS CARINI • TOXOPLASMOSIS • CRYPTOCOCOSIS • COCCIDIODOMYCOSIS • CRYPTOSPORIDIOSIS

15. CD4 < 50 • Disseminnated Mycobacterium Avium Complex Infection • Histoplasmosis • Cytomegalo Virus Retinitis • CNS Lymphoma

16. CDC CLASSIFICATION

18. CLINICALSYNDROMESSPECIFICCONDITIONS

19. DIAGNOSIS • DEPENDS UPON DEMONSTRATION OF ANTIBODIES TO HIV OR DIRECT DETECTION OF HIV OR ONE OF ITS COMPONENTS. • SCREENING TEST-ELISA • CONFIRMATORY TEST-WESTERN BLOT • OTHER TESTS DNA PCR ,RNA PCR ,THE DNA ASSAY OR P24 ANTIGEN CAPTURE

20. MANAGEMENT • TREATMENT OF THE VIRUS. • PREVENTION OF OPPORTUNISTIC INFECTION.

21. AIM • TO REDUCE THE VIRAL LOAD. • IMPROVE THE CD4 COUNT.

22. ANTIRETROVIRAL DRUGS

23. HIV lifecycle

24. NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS • ZALCITABINE,DIDANOCINE,LAMIVUDINE,ZIDOVUDINE,STAVUDINE ,ABACAVIR • MOA - Intracellular Phosphorylation - inhibits Viral RT • A/E - Anemia, Neutropenia - most Common Nausea , Anorexia , Headache, Peripheral Neuropathy & Pancreatitis

25. NON NUCLEOSIDE RT INHIBITORS NEVIRAPINE , EFAVIRENZ MOA- Directly Inhibits HIV RT A/E - Rashes,Nausea,Headache-commonest Fever , Rise in Liver Enzymes

26. PROTEASE INHIBITORS • INDINAVIR , SAQUINAVIR , RITONAVIR, NELFINAVIR , LOPINAVIR • MOA - Prevents Posttranslational Clevage of Polypeptides into Functional Viral Protiens • A/E - GIT Intolerance , Paresthesia, Rash , Abnormal Distribution of Fat & Exacerbation of DM

27. FUSION INHIBITORS • ENFUVIRTIDE • MOA - Inhibits Fusion of Viral & Cellular Membranes • A/E – Local Injection Reaction, Hypersensitivity Reaction & Increased Rate of Bacterial Pneumonia

28. WHEN TO START ‘HAART‘(highly active anti retro viral therapy) • CD4 COUNT < 350/MICROLITER • VIRAL LOAD > 20,000 COPIES/ML • ALL CASES OF SYMPTOMATIC HIV DISEASES • INTEREST OF THE PATIENT

29. REGIMEN • PI + 2NRTI • NNRTI + 2NRTI • 3NRTI

30. PREVENTION • EDUCATION • COUNSELLING • BEHAVIOUR MODIFICATION are the Corner Stones of a HIV Prevention Strategy.

31. ThePracticeof‘SaferSex’. • InjectionDrugUsersavoidSharingofNeedles • HIVInfectedMotherWithAntiretroviralTherapyDuringPregnancy&InfantDuring1stWkOfLife. • AvoidBreastFeedingFromInfectedMother.

32. POST EXPOSURE PROPHYLAXIS • Immediately clean the Contaminated Area by washing under Running Water • PEP should be Started Within 1 Hr • Prophylaxis Consist of ZIDOVUDINE - 250mg BD LAMIVUDINE - 150mg BD INDINAVIR - 800mg TDS FOR 1 MONTH

33. Transplant Patient ▪Organs & drugs • Infection-pneumonia,ulcer,chorioreti -CMV(50%)graft -transfusion ▪prevention & CF ▪diagnosis & Rx ▪EBV-lymphoproliferative ds prophylax

34. Neoplasia • Impaired immunosurveillance • Infection • Agents • Early signs • Rx

35. Malnutrition • Malnourished/consequence ds • DTH-Children/operation • Rx-cvf -enteral(physiological) ▪immunonutritional support

36. Burn & Trauma • MHC class ιι(monocyte) • Agent • Nadir(1,2)-7 days • Rx-interferon ץ -glucan -GMSF

37. Shock • Decreased- complement - neutrophil - B&T alteration ▪Clinical,Experimental-severity

38. Transfusion • -PG E derivative -suppressor cell products -mixed lymphoid reaction ▪pathogen(donated blood)

39. Diabetes • Poor perfusion-vascular -fat type 2 -hyperglycaemia ▪normal Glu-neutr,CD4 ▪inf-destabilise control

40. Aging • Immunosurveillance • -T cell with low mitogen -IgG Ab vaccine -DTH skin test -sensitivity to PG E ▪lung,skin,o/p,thermal,nutrition

41. Post Splenectomy • Paeds & adolescent-sepsis • Liver-Ab opsonin clearance -a/c Ab production IgM ▪pneumococcal,meningo,H.influenza

42. Surgical Site Infection • Hypoxaemic-environment • Systemic oxygenation • Temperature core body • -Oxygen -temperature -glucose control

43. THANK YOU