Factors associated with viral suppression among cisgender women living with human immunodeficiency virus in the United States: An integrative review.

INTRODUCTION: Women account for 23% of new human immunodeficiency virus diagnoses in the United States, yet remain understudied. Adherence to antiretroviral therapy and consequent viral suppression are keys to preventing human immunodeficiency virus transmission, reducing risk of drug resistance, and improving health outcomes. OBJECTIVES: This review identified and synthesized peer-reviewed studies in the United States describing factors associated with viral suppression among cisgender women living with human immunodeficiency virus. METHODS: We searched five databases: Cumulative Index to Nursing and Allied Health (CINAHL), PubMed, Embase, Scopus, and PsycINFO, and reported the findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Eligible studies included: (1) peer-reviewed English-language articles published since 2010; (2) includes only cisgender women; (3) participants were at least 18 years of age; (4) reported metrics on viral loads; and (5) conducted in the United States. RESULTS: Fourteen studies in total were reviewed. Eight studies had adult women living with human immunodeficiency virus, four recruited only pregnant women, and two included only racial minority women. The most commonly reported factors negatively associated with viral suppression were substance use (n = 4), followed by availability of health insurance, financial constraint, complexity of human immunodeficiency virus treatment regimen (n = 3), and intimate partner violence (n = 2). Other factors were depression, race, and age. In addition, all four studies that included only pregnant women reported early human immunodeficiency virus care engagement as a significant predictor of low viral loads pre- and post-partum. CONCLUSION: Substance use, financial constraint, lack of health insurance, human immunodeficiency virus treatment regimen type, intimate partner violence, and late human immunodeficiency virus care pre-post pregnancy were the most common factors negatively associated with viral suppression. There is a paucity of data on viral suppression factors related to transgender and rural populations. More human immunodeficiency virus research is needed to explore factors associated with human immunodeficiency virus treatment outcomes in transgender women and cisgender women in rural U.S. regions.

Cost-effectiveness of HIV screening in emergency departments: a systematic review.

In 2016 worldwide, 1.8 million people were newly infected with HIV. About 36.7 million had HIV but 14 million were unaware, did not seek treatment and were likely to infect others. Undiagnosed HIV infection is a major contributor to transmission. Therefore, screening is critical to prevention. Although CDC recommends routine screening in the emergency department (ED), implementation is not universal or sustained. Cost-effectiveness of ED-based screening could enhance implementation. We address the question: Is HIV screening in the ED cost-effective? Using the Joanna Briggs Institute guidelines, we conducted a systematic review of economic evaluations of ED-based HIV screening. We found 311 studies with 12 duplicates. We excluded 276 studies that did not conduct economic evaluations and another three for lack of quantitative data, leaving 20 articles for the full review. We reviewed cost-effectiveness ratios (CER), incremental cost-effectiveness ratios (ICER), and average costs per diagnosis, quality-adjusted life years, averted transmissions and per patient linked to care. CER and ICER were below CDC thresholds indicating that HIV screening in the ED is cost-effective. Therefore, ED-based HIV screening should be widely implemented, supported and sustained as a cost-effective tool for combating HIV/AIDS.

Unrelieved pain and suffering in patients with advanced cancer.

Even with specialist-level palliative care, cancer pain can be difficult to treat especially when the pain is complicated by profound suffering. It is paramount to consider not only the patients' biochemical factors but also their psychosocial and spiritual/existential influences. A multidimensional approach with knowledge of the risk factors for poor pain control is important to prevent, detect, and manage risk factors for intractable pain, including psychosocial distress, addictive behavior, and delirium in patients with terminal cancer. We present 3 cases of patients with advanced cancer with intractable bone pain whose hospital courses were complicated by severe psychosocial distress and delirium. We also propose an algorithm of multidimensional approach to unrelieved pain and suffering in patients with advanced cancer.

Changes in symptoms and inpatient mortality: a study in advanced cancer patients admitted to an acute palliative care unit in a comprehensive cancer center.

CONTEXT: Although several symptoms have been shown to predict survival, little is known of the roles of symptom changes in predicting inpatient death. OBJECTIVES: To determine the association between changes in symptoms and inpatient mortality among advanced cancer patients in an acute palliative care unit (APCU). METHODS: We retrospectively reviewed the medical records of 166 consecutive cancer patients admitted to our APCU from the emergency center (EC) or clinic from June 2006 to December 2007. We recorded symptom severity and presence of delirium on admission (baseline) and on the third, fourth, or fifthth day, whichever appeared first (follow-up). The primary endpoint was the vital status at discharge. Univariate (UVA) and multivariate analyses (MVA) were used to estimate the odds of inpatient death. RESULTS: One hundred and thirty-four patients (80.7%) were discharged alive and 32 (19.3%) died in the APCU. All symptoms significantly improved at follow-up. In UVA, persistent delirium was significantly associated with inpatient mortality (odds ratio [OR] 2.59, 95% confidence interval [CI 1] 0.09-6.17, p = 0.031), although presence of baseline delirium was not. MVA revealed that greater risk of dying was jointly correlated with a high level of baseline dyspnea (OR 1.35, 95% CI 1.13-1.61, p = 0.001) and drowsiness (OR 1.25, 95% CI 1.04-1.50, p = 0.02), low level of baseline anxiety (OR 0.83, 95% CI 0.70-0.99, p = 0.038), and transfer from EC (OR 6.78, 95% CI 1.99-23.14, p = 0.002). Worsened depression was significantly related with death in UVA (OR 1.30, 95% CI 1.08-1.56, p < 0.001), but not in MVA. CONCLUSION: Changes in certain symptoms, such as worsened depression and persistent delirium, might be important predictors of inpatient death.

A month in an acute palliative care unit: clinical interventions and financial outcomes.

BACKGROUND: Few cancer centers have developed acute palliative care units (APCUs). The purpose of this study is to highlight clinical interventions and financial outcomes during a typical 1-month period on an APCU. METHODS: We evaluated consecutive patients admitted to our APCU from February 1 to 28, 2009, regarding demographic information, sources of and reasons for admissions, resuscitation status, clinical interventions, disposition, and reimbursement data. RESULTS: Forty-two patients were admitted during a 1-month period. Of these, 30 (71%) were referred from the inpatient palliative care consultation team. In all, 10 (24%) patients had a full code status on admission, and 8 had their status changed to do not resuscitate (DNR) prior to discharge. A total of 11 (26%) patients were discharged home with hospice care, 12 (29%) died on the APCU, and 10 (24%) were discharged home with outpatient follow-up visits. All patients received intravenous medications and the majority received intravenous antibiotics. All patients met acute care criteria for hospitalization, and financial reimbursement was satisfactory and comparable to that of other oncology patients. CONCLUSION: The APCU model is designed for the care of very complex advanced cancer patients. Palliative interventions are given simultaneously with other medical interventions. The APCU is labor intensive and well reimbursed.

Predictors of inpatient mortality in an acute palliative care unit at a comprehensive cancer center.

GOALS OF WORK: Predicting inpatient mortality has clinical and financial implications and helps improve the care of patients with advanced cancer and their families. Models with excellent validity and reliability are available for mortality prediction in intensive care units. The purpose of the current study was to determine factors associated with increased likelihood of mortality in an acute palliative care unit (APCU). PATIENTS AND METHODS: We retrospectively reviewed the medical records of 500 patients admitted to the APCU. Basic characteristics and information on symptom intensity, vital signs, relevant laboratory tests, and the presence or absence of delirium were obtained from the records of the consultation that preceded the APCU admission. Univariate and multivariate analyses were conducted to compare characteristics of patients who died in the APCU with characteristics of those who were discharged alive. MAIN RESULTS: Of the 500 patients admitted to the APCU, 124 (25%) died. Factors that were jointly prognostic for death, using multivariate analysis were younger age (odds ratio [OR] for older patients [>/=65] 0.43, 95% confidence interval [CI], 0.25-0.73, p < 0.001), admission from another oncology floor (OR 5.64, 95% CI, 1.82-17.44, p = 0.003), hyponatremia (OR 3.02, 95% CI, 1.76-5.17, p < 0.001), hypernatremia (OR 4.14, 95% CI, 1.25-13.75, p = 0.020), high blood urea nitrogen (BUN) (OR 1.95, 95% CI, 1.15-3.30, p = 0.013), high heart rate (>/=101 bpm) (OR 1.72, 95% CI, 1.01-2.93, p = 0.047), high respiration rate (>/=21/min) (OR 1.67, 95% CI, 1.00-2.79, p = 0.048), and supplemental oxygen use (OR 2.69, 95% CI, 1.60-4.52, p < 0.001). CONCLUSIONS: We observed a significant association of certain factors with increased likelihood of APCU death in patients with advanced cancer. These findings need to be validated in a larger prospective study to develop a model for predicting APCU mortality for patients with advanced cancer.

Hypocalcemia associated with strontium-89 administration in a patient with diffuse bone metastases from neuroendocrine carcinoma.

Metastatic bone disease is often associated with severe pain in cancer patients, and has become an increasingly important quality-of-life issue. Radionuclides, such as strontium-89 (Sr-89), have provided effective palliation of metastatic bone pain. Although strontium follows the biochemical pathways of calcium in the body, changes in calcium homeostasis related to Sr-89 therapy have rarely been reported. We present a case of a 32-year-old male with poorly differentiated neuroendocrine carcinoma and extensive skeleton metastases who developed profound hypocalcemia after Sr-89 administration.

Comparison of symptom burden among patients referred to palliative care with hematologic malignancies versus those with solid tumors.

BACKGROUND: Patients with hematologic malignancies have reduced and later access to palliative care services (APCS) than do those with solid tumors. It is unclear whether these patients develop a high symptom burden at the end of life that requires special palliative care interventions. The purposes of this retrospective study were to determine whether symptoms are less severe in patients with hematologic than in those with solid malignancies on APCS and whether symptom severity is associated with early APCS. METHODS: We studied the records of consecutive patients with hematologic and solid malignancies at their first palliative care consultation (PC1). We collected information about demographics, cancer type, date of PC1, and the interval from PC1 to death (PC1-D). We reviewed the charts for the Edmonton Symptoms Assessment System (ESAS) and presence of delirium. RESULTS: We included 250 patients (125 with each type of malignancy). Median pain and drowsiness were 4 (3-5) and 7 (5-10) among hematologic compared to 5 (4-6, p=0.043) and 5 (3-6, p=0.0008) among patients with solid malignancies, respectively. Delirium was detected in 51 of 125 (41%) hematologic versus 20 of 125 (16%) solid (p=0.0001). Median PC1-D was 13 days for hematologic versus 46 days for solid (p=0.0001). There was no correlation between PC1-D and pain (r= -0.117, p=0.4 for hematologic and r=0.09, p=0.37 for solid), dyspnea (r= -0.02, p=0.85 for hematologic and r=0.09, p=0.42 for solid) or the Symptom Distress Score (r= -0.047, p=0.72 for hematologic and r= -0.093, p=0.32 for solid). CONCLUSIONS: Hematologic patients had increased delirium and drowsiness and later APCS The overall symptom severity was similar in both groups of patients and did not correlate with early APCS. Future prospective studies are needed to better define APCS patterns in this group.