Biomedical subjects
Publications and source records attributed to S D Steinberg.
Early dislodgment or malfunction of pacemaker leads can result in significant morbidity and therefore must be corrected promptly. We describe a method of changing pacemaker leads that is atraumatic, maintains central venous access, and eliminates the need for venipuncture. Our technique is simple, highly reproducible, and can be performed with standard operating room instruments.
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Tracheostomy tube insertion is periodically performed when patients with acquired immunodeficiency syndrome (AIDS) require prolonged mechanical ventilation. In this population, bedside percutaneous tracheostomy may be a better technique than conventional operating room tracheostomy because it reduces procedural cost, requires no patient transport, and requires few sharp instruments, thereby potentially decreasing risk to surgical staff. A retrospective review was conducted in the Department of Medical Records at St. Vincents Hospital and Medical Center of New York City. Nine consecutive patients diagnosed with AIDS and undergoing percutaneous tracheostomy from January 1, 1992, to December 31, 1996, were identified. All patients were males (mean age 32.1 +/- 4 years, CD4 count average 145) and were ventilator-dependent for mean of 24 +/- 3 days. The procedure was successful and without complications in all patients. Follow-up was 27 months (range 1-42 months) and in-hospital mortality was 77 per cent. The average length of survival for those patients who died in the hospital was 29 days (range, 3-120). Two patients survived the hospitalization after undergoing decannulation on postoperative days 29 and 52, respectively. Despite the poor prognosis after tracheostomy in patients with AIDS this procedure allows better oral care and may improve patient comfort. Bedside percutaneous tracheostomy can be performed with less risk to surgical personnel and patient when compared to conventional surgery. This minimally invasive procedure safely and efficiently provides prolonged tracheal access in patients with AIDS.
OBJECTIVE: The role of thoracic surgery in patients with acquired immunodeficiency syndrome (AIDS) continues to evolve. This review seeks to evaluate the outcome, morbidity, and mortality associated with video-assisted thoracoscopic surgery for empyema and pneumothorax in patients with AIDS. METHODS: A retrospective review was conducted of patients with AIDS in whom video-assisted thoracoscopic surgery was performed for empyema (group 1) or intractable pneumothorax (group 2). RESULTS: Twenty patients with AIDS (95% male, mean age 37.4 years, mean CD4 count 76 cells/ml3) underwent thoracoscopy. Surgery was performed for empyema (group 1) in 11 (55%) and intractable pneumothorax (group 2) in nine (45%). Three patients (15%) died within 30 days of the operation. At mean follow-up (29 months), overall survival was 55%. For those who survived the hospitalization and died within the follow-up period (35.3%), mean survival time was 8.2 months (range 1 month to 27 months). In group 1, surgical procedures were performed after 8 days of chest tube drainage and included pleural debridement and mechanical pleurodesis (n = 11) along with lung biopsy (n = 6). Survivals at 30 days and 29 months' follow-up were 90.9% and 45.4%, respectively. In group 2, significantly depressed CD4 counts (average 33.2 cells/ml3) were noted along with a more prolonged preoperative hospitalization (18.5 days) with 14.2 days spent with a chest tube before the operation. In this group, operative procedures included mechanical pleurodesis and talc poudrage (n = 9), bleb resection (n = 7), and lung biopsy (n = 1). Two deaths (22%) occurred within 30 days of the operation and survival at 29 months' follow-up was 66%. CONCLUSION: Video-assisted thoracoscopic surgery performed in patients with AIDS for the treatment of empyema and intractable pneumothorax is effective, can be performed with little operative morbidity and mortality, and is associated with acceptable long-term survival. Video-assisted thoracoscopic surgery is best performed soon after the diagnosis of intractable pneumothorax or empyema has been established.
BACKGROUND: Hepatobiliary disease is a common manifestation of acquired immunodeficiency syndrome, although the role of surgical intervention in the spectrum of therapy is unclear. STUDY DESIGN: A retrospective review was designed to evaluate the characteristics of patients given a diagnosis of human immunodeficiency virus infection or acquired immunodeficiency syndrome and undergoing cholecystectomy between January 1, 1986, and November 1, 1995. RESULTS: The study included 40 patients (35 men, 5 women; mean age, 42 +/- 9 years), 33 (82.5 percent) with acquired immunodeficiency syndrome; their mean preoperative T-helper (CD4) cell count was 163/mL3. Gross pathologic findings included acute (n = 9, 22.5 percent) and chronic (n = 31, 77.5 percent) cholecystitis. Gallbladder specimens were positive for cholelithiasis in 28 (70 percent), Cryptococcus organisms in 5 (12.5 percent), cytomegalovirus in 3 (7.5 percent), and lymphoma in 2 (5 percent). The median follow-up time was 48 months (range, 6 to 63 months). The percentage survival was 92.5 percent (n = 37) at 30 days, and 57.5 percent (n = 23), 37.5 percent (n = 15), and 25 percent (n = 10) at 12, 24, and 36 months, respectively. The mean survival time was 25.1 months. The likelihood of survival was directly linked to the CD4 cell count. The mean survival period was 25 months for patients with CD4 cell counts less than 200/mL3 compared with 48 months for those with CD4 cell counts greater than 200/mL3. CONCLUSIONS: Although the pathologic changes identified in patients with acquired immunodeficiency syndrome may occasionally be atypical, the clinical presentation, indications for operation, and pathologic findings identified are quite common. Patients tolerate cholecystectomy well with good long-term outcome and minimal infectious complications. Even in patients with the most compromised immune status, a 2-year survival after operation is acceptable. Cholecystectomy has a clear role in the spectrum of treatment for biliary disease relative to acquired immunodeficiency syndrome.
BACKGROUND: Previous reports evaluating appendicitis in patients with human immunodeficiency virus/ acquired immunodeficiency syndrome have detailed unusual pathology, atypical clinical presentations, and poor outcomes. These reports have described small groups of patients and are inconsistent with larger surveys. STUDY DESIGN: A retrospective design was used to evaluate patients diagnosed with human immunodeficiency virus or acquired immunodeficiency syndrome undergoing appendectomy from 1986 to 1995. RESULTS: Fifty-five patients were evaluated (mean age 33.4 +/- 8.2 years, 98 percent male, 90 percent clinical acquired immunodeficiency syndrome, CD4 count 144.45 +/- 34 cells/mL3). Presenting symptoms included right lower quadrant pain (91 percent), nausea and vomiting (41 percent), diarrhea (22 percent), and generalized abdominal pain (24 percent). Significant findings on examination included right lower quadrant tenderness (91 percent), rebound (74 percent), fever (54 percent), abdominal distention (7 percent), and generalized abdominal tenderness (9.3 percent). Computed tomography was performed in 26 percent and findings were suggestive of appendicitis in 93 percent of cases. Operative findings included acute inflammation (83.3 percent), appendiceal rupture (24 percent), gangrene (29 percent), and normal-appearing appendices (5.5 percent). Unusual findings included Mycobacterium tuberculosis (1.8 percent), atypical mycobacterium (1.8 percent), and chronic appendicitis (3.7 percent). Thirty-day survival was 100 percent. Significant postoperative fevers were noted in 33 percent and lasted 4.63 +/- 1.2 days. The presence of prolonged postoperative fever was linked to lower CD4 counts (p = .05). Follow-up (mean time to follow-up, 1,656 +/- 970 days) was complete in 43 percent. Survival at follow-up was noted in 57.1 percent (mean length of survival after surgery, 837 +/- 155 days). CONCLUSIONS: Appendectomy in patients with human immunodeficiency virus/acquired immunodeficiency syndrome is associated with little morbidity or mortality. Atypical pathology is rarely identified. A higher than expected rate of rupture may be linked to delays before hospitalization or to impaired immune status.