Download - Hiv in orthopaedics
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HIVIN
ORTHOPAEDICS
DR MAULIK T PATEL
Department of Orthopedics,
Meenakshi mission hospital
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INTRODUCTION
ACQUIRED IMMUNODEFICIENCY SYNDROME
HUMAN IMMUNODEFICIENCY VIRUS
PANDEMIC NO CURE YET
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STATISTICS
Deaths Annually: 14,802 (1999) Death Rate: 5.4 deaths per 100,000 population (1999)
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STATISTICS
Number of Cases: 20,550 (January-June 2000) Hospital Discharges for Patients with HIV Diagnosis: 180,000 (1999) Number of Days of Care for Patients with HIV Diagnosis: 1,310,000 (1999) Average Length of Hospital Stay: 7.3 days (1999)
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INTRODUCTION DISABILITY OR LIFE THREATENING
ILLNESS CAUSED BY HIV CHARACTERISED BY HIV ENCEPHALOPATHY,HIV WASTING SYNDROME, DISEASES DUE TO IMMUNODEFICIENCY IN A PERSON WITH LAB EVIDENCE OF HIV INFECTION OR WITHOUT OTHER CAUSES OF IMMUNODEFICIENCY
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DEFINITION (1993) CDC
ANY HIV INFECTED INDIVIDUAL WITH A CD4+ T CELL COUNT OF LESS THAN 200/µL HAS AIDS REGARDLESS OF THE PRESENCE OF SYMPTOMS OR OPPORTUNISTIC DISEASE
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CLASSIFICATIONClinical categories
Cd4 count
A
Asymptomatic a/c hiv or pgl
B
Symptomatic not AorC
C
Aids indicator conditions
>500 A1 B1 C1
200-499 A2 B2 C2
<200 A3 B3 C3
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INTRODUCTION
FIRST REPORTED IN 1981 IN USA GRID VIRUS LUC MONTAGNIER 1983 , PARIS
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HUMAN IMMUNODEFICIENC
Y VIRUS REVERSE TRANSCRIPTASE ENZYME INFECTION LIFE LONG ASYMPTOMATIC FOR MANY YEARS VIRUS IS FRAGILE- DESTROYED BY BOILING
FOR ONE SECOND, 1% BLEACH ,70% ETHANOL, 2% GLUTERALDEHYDE,5% FORMALDEHYDE, 1% CHLORINE-SODIUM HYPOCHLORITE, 3% H2O2
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STRUCTURE OF HIV
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MODES OF TRANSMISSION
SEXUAL INTERCOURSE TRANSFUSION SYRINGES & NEEDLES PRENATAL & PERINATAL ORGAN TRANSPLANTS DIALYSIS
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MODES OF TRANSMISSION
HIV IS NOT TRANSMITTED BY SOCIAL CONTACTS
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LIFE CYCLE
HIV INFECTS A PERSON IN MANY WAYS AND………
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AIDS VIRUS IN BLOOD STREAM
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LIFE CYCLE
IMMUNE SYSTEM FIGHTS BACK IN THREE WAYS. WITH………….
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ANTIBODIES
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MACROPHAGES
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KILLER T CELLS
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LIFE CYCLE
THE DEFENCE IS COORDINATED BY…
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HELPER T CELLS
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LIFE CYCLE
BUT……….
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HIV ATTACHES TO CD4 RECEPTOR ON T CELLS
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LIFE CYCLE
INSIDE THE CELL IT IS SAFE ……
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VIRAL RNA IS TRANSCRIBED INTO DNA
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LIFE CYCLE
AFTER A WHILE THE VIRUS COMES OUT OF HIDING AND REPRODUCE..
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THE DNA IS TRANSCRIBED INTO MANY COPIES OF RNA
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RNA PRODUSE PROTIENS OF THE VIRUS
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PROTIENS ARE THEN CUT INTO USABLE PIECES AND PACKAGED WITH RNA
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LIFE CYCLE
THE NEW VIRUSES THUS PRODUCED …..
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BUDDS OFF FROM THE T CELL
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LIFE CYCLE THESE THEN GO ON TO INFECT
OTHER T CELLS THUS WEAKENING THE IMMUNE SYSTEM
THIS WILL ENABLE THE ENTRY OF OTHER PATHOGENS INTO THE BODY
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PATHOGENESIS
PRIMARY HIV INFECTION,INITIAL VIREMIA & DISSEMINATION OF VIRUS
ESTABLISHMENT OF CHRONIC & PERSISTENT INFECTION
ADVANCED HIV DISEASE
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COURSE OF HIV PT
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PATHOGENESIS
ROLE OF LYMPHOID ORGANS ROLE OF CELLULAR ACTIVATION ROLE OF APOPTOSIS SUPER ANTIGENS AUTOIMMUNE PHENOMENA COFACTORS CYTOKINE NETWORK
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IMMUNE RESPONSE
HUMERAL
antibodies to p24 p17 & p55
antibodies to gp160 gp 120 gp88
gp41 CELLULAR
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ANTIBODY RESPONSE
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ANTIGENEMIA & ANTIBODY
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DIAGNOSIS
SCREENING TEST – ELISA
CONFIRMATORY - WESTERN - BLOT DIRECT HIV DETECTION
P24 AG CAPTURE ASSAY
HIV RNA BY PCR
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WESTERN BLOT
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CLINICAL MANIFESTATIONS
THE ACUTE HIV SYNDROME ASYMPTOMATIC STAGE EARLY SYMPTOMATIC NEUROLOGIC DISEASE OPPORTUNISTIC INFECTIONS NEOPLASTIC DISEASE
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MANAGEMENT
PREVENTION IS BETTER THAN CURE
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MANAGEMENT
HEALTH CARE WORKER
RISK OF INFECTION WITH A HOLLOW BORE NEEDLE PRICK – 0.3%
RISK WITH SUTURE NEEDLE IS LESS
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PREVENTION
REGULAR HAND WASHING COVER WOUNDS/SKIN LESIONS PROTECT EYES , MOUTH & NOSE NEVER TRANSFER SHARP OBJECTS
DIRECTLY NEVER RECAP A NEEDLE , PROPER
DISPOSAL OF SHARP OBJECTS CONSIDER EVERY PT AS A POTENTIAL
RISK – STICK TO UNIVERSAL PRECAUTIONS
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PREVENTION
DOUBLE GLOVES PLASTIC APRON WATER RESISTANT SHOE COVER FACE SHIELD OR GOGGLES
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EXPOSURE
SPLASH ON THE SKIN WASH THOROUGHLY WITH SOAP
& WATER DIP HANDS IN UNDILUTED
SAVLON FOR 15 SEC.
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EXPOSURE NEEDLE STICK INJURY LET THE WOUND BLEED FREELY WITHOUT PRESSING IT THOROUGHLY WASH DIP HANDS IN UNDILUTED SAVLON FOR 15 SEC. TEST THE PT FOR HIV TEST SELF AT 3 , 12 , & 24 WEEKS
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EXPOSURE
IF PT IS NEGATIVE FOLLOW UP AT 3 , 12 , 24 WEEKS
TAKE THE HISTORY OF THE PT- HIGH RISK BEHAVIOR
USE CONDOMS WITH THE PARTNER FOR 6 MONTHS
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POST EXPOSURE DRUG
PROPHYLAXIS AZIDOTHYMIDINE
WITHIN ONE HOUR OF EXPOSURE 200mg q4h FOR 72 HRS 100 – 200mg Q4H FOR 25 DAYS
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STRATEGIES HELP THE IMMUNE SYSTEM
VACCINE
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VACCINE INDUCED ANTIBODIES
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STRATEGIES
Problems with this approach. Scientists have to make sure the vaccine itself
doesn't make people ill. HIV is constantly changing, so the defenses
stimulated by a vaccine might not be effective in fighting the actual virus.
And if even a single virus escapes by hiding out inside a cell, it could go on to make thousands of copies of itself.
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STRATEGIES
ARTIFICIAL DECOY CD4 UNITS CAN BE GIVEN
HIV WILL ATTACH TO THESE INSTEAD OF T CELLS
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DECOY CD4
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STRATEGIES
USE OF DRUGS THAT LOOK LIKE BUILDING BLOCKS OF DNA
PREVENT CONVERTION OF VIRAL RNA INTO DNA
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DRUGS
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HIV is constantly changing, and eventually it is no longer tricked by these faulty building blocks. HIV becomes resistant to these drugs, and the life cycle continues the same as before. Another problem is that these drugs can damage non-infected cells which also need to make DNA to reproduce.
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STRATEGIES
STOPPING THE PRODUCTION OF VIRAL PROTEINS WITH DRUGS
PREVENTION OF SPLICING
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PREVENTION OF REPLICATION
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STRATEGIES
BOOST THE IMMUNE SYSTEM OF THE PT
TREAT OPPORTUNISTIC INFECTIONS
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ORTHOPAEDIC PROBLEMS
RHEUMATOID ARTHRITIS ARTHRALGIAS REACTIVE ARTHRITIS AIDS ASSOCIATED ARTHROPATHY FIBROMYALGIA SEPTIC ARTHRITIS
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ORTHOPAEDIC PROBLEMS
RHEUMATOID ARTHRITIS-AMELIORATED IN SPITE OF HIGH LEVELS OF ANTI PHOSPHOLIPID ABS&ANTINUCLEAR ABS.
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REACTIVE ARTHRITIS
33% AIDS PTS HAVE ARTHRALGIAS
5-10% REITER’S / PSORIATIC
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AIDS ASSOCIATED ARTHROPATHY
JOINT PROBLEMS WITH NO CAUSE SUBACUTE OLIGOARTHRITIS 1 – 6 WEEKS LASTS 6 WKS – 6 MONTHS LARGE JTS-KNEE / ANKLE
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AIDS ASSOCIATED ARTHROPATHY
NONEROSIVE X-RAY NONREVEALING RESPOND TO INTRA ARTICULAR
STEROID
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AIDS ASSOCIATED ARTHROPATHY
PAINFUL ARTICULAR SYNDROME-
10% PTS
A/C SEVERE,SHARP PAIN
KNEE,ELBOW,SHOULDER
LASTS 2 – 24 HRS
NARCOTIC ANALGESICS
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FIBROMYALGIA
WIDESPREAD MUSCULOSKELETAL PAIN OF 3 MONTHS
11 OF 18 TENDER POINTS
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SEPTIC ARTHRITIS
RARE FUNGAL-
CRYPTOCOCCUS,SPOROTHRIX MYCOBACTERIAL-M.HEMOPHILUM COMMON IN HAEMOPHILIACS
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ORTHOPAEDIC PROBLEMS
SURGERY MAY PROMOTE CLINICAL AIDS IN SEROPOSITIVE PTS
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AIDS & ORTHOPAEDIC
SURGEON
IGNORANCE BREEDS FEAR
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FRACTURES
CLOSED # HEAL NORMALLY WITH CONSERVATIVE TREATMENT
HIGH INFECTION RATE WITH ORIF OPEN # -- INFECTION & NONUNION
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COLD SURGERY
INCREASED RISK OF SEPSIS RELATED TO STAGE OF AIDS
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TUBERCULOSIS
DUAL EPIDEMIC HIV & TB ARE SYNERGISTIC WASTING DISEASE , NIGHT SWEATS REST , FOOD , DRUGS PROGNOSIS POOR
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OTHER INFECTIONS
TROPICAL PYOMYOSITIS HEMATOGENOUS OSTEOMYELITIS LATE INFECTION OF IMPLANTS
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RISK OF TRANSMISSION OF HIV FROM PT TO SURGEON IS SMALL
FROM SURGEON TO PT IS EVEN LESS
RISK ACCUMULATE OVER TIME
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PUT LARGER INCISION OPERATE BY SIGHT THAN
FEEL NO SHARP INSTRUMENT
SHOULD BE HANDED DIRECTLY
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“WE MUST HAVE OPERATED ON MANY HIV POSITIVE PTS BEFORE THE DANGERS WERE RECOGNISED OR PRECAUTIONS PUT IN PLACE, BUT SENIOR SURGEONS HAVE NOT BEEN DYING OF HIV INFECTIONS.”
- J.E.JELLIS
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Increased Abdominal Visceral Fat Is Associated With Reduced Bone Density in HIV-Infected Men With Lipodystrophy
disrupted fat metabolism may account for HIV-related osteopenia.
abnormal marrow or whole body fat metabolism may affect bone cell differentiation or the marrow cytokine environment in people with HIV-related lipodystrophy."
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ANTIRETROVIRAL THERAPY
NUCLEOSIDE ANALOGUES ZIDOVUDINE DIDANOSINE ZALCITABINE STAVUDINE LAMIVUDINE
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ANTIRETROVIRAL THERAPY
NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
NEVIRAPINE DELAVIRDINE
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ANTIRETROVIRAL THERAPY
PROTEASE INHIBITORS SAQUINAVIR RITONAVIR INDINAVIR NELFINAVIR
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ANTIRETROVIRAL THERAPY
TRIPPLE THERAPY TWO NUCLEOSIDES & ONE
PROTEASE INHIBITOR
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