Palliative care for patients with acquired immunodeficiency syndrome

Distance from care predicts in-hospital mortality in HIV-infected patients with severe sepsis from rural and semi-rural Virginia, USA

There are few data regarding outcomes from severe sepsis for HIV-infected patients living in rural or semi-rural settings. We aim to describe the characteristics and predictors of mortality in HIV-infected patients admitted with severe sepsis to the University of Virginia located in semi-rural Charlottesville, Virginia, USA. We queried the University of Virginia Clinical Data Repository for cases with ICD-9 codes that included: (1) infection, (2) acute organ dysfunction, and (3) HIV infection. We reviewed each case to confirm the presence of HIV infection and severe sepsis. We recorded socio-demographic, clinical, and laboratory data. We used a generalised linear mixed-effects model to assess pre-specified predictors of mortality. We identified 74 cases of severe sepsis in HIV-infected patients admitted to University of Virginia since 2001. The median (IQR) age was 44 (36-49), 32 (43%) were women, and 56 (76%) were from ethnic minorities. The median (IQR) CD4+ T-cell count was 81 (7-281) cells/µL. In-hospital mortality was 20%. When adjusted for severity of illness and respiratory failure, patients who lived >40 miles away from care or had a CD4+ T cell count <50 cells/µL had > four-fold increased risk of death compared to the rest of the study population (AOR = 4.18, 95% CI: 1.09-16.07, p = 0.037; AOR = 4.33, 95% CI: 1.15-16.29, p = 0.03). In HIV-infected patients from rural and semi-rural Virginia with severe sepsis, mortality was increased in those that lived far from University of Virginia or had a low CD4+ T cell counts. Our data suggest that rural HIV-infected patients may have limited access to care, which predisposes them to critical illness and a high associated mortality.

[Treatment of nausea and vomiting with prokinetics and neuroleptics in palliative care patients : a review]

BACKGROUND

Many recommendations concerning the treatment of nausea and vomiting in palliative care patients exist but what is the evidence for this? Most studies dealing with this topic have focused on cancer patients under chemotherapy and/or radiation therapy or on patients with postoperative nausea. Cancer patients without chemotherapy or radiation therapy, patients without postoperative nausea, and patients having other diseases with palliative care aspects, such as acquired immunodeficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), progressive heart failure, amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) have been underrepresented in studies on nausea and vomiting so far.

OBJECTIVES

The aim of this review was to determine the level of evidence for the treatment of nausea and vomiting with prokinetics and neuroleptics in palliative care patients suffering from far advanced cancer and no longer being treated with chemotherapy or radiation therapy, AIDS, COPD, progressive heart failure, ALS or MS.

METHODS

Two different electronic databases (PubMed und Embase) were used to identify studies. Furthermore, a hand search for related articles was performed. No restriction was made concerning study types. Studies with patients undergoing chemotherapy radiation therapy or suffering from postoperative nausea, pediatric studies and studies published neither in English nor in German were excluded.

RESULTS

A total of 30 studies fulfilling the inclusion criteria were found. All studies focused on cancer patients. Despite intensive research studies in patients with AIDS, COPD, heart failure, ALS or MS were not detected. Metoclopramide is seen as an effective drug in many studies whereas the evidence for it is moderate at best. Within the group of neuroleptics, levosupiride and levomepromazine seem to have good antiemetic potential but the evidence level is low.

CONCLUSION

In patients with advanced cancer not being treated with chemotherapy or radiation therapy, metoclopramide can be used to reduce nausea and vomiting. Neuroleptics, such as levosulpiride or levomepromazine are alternatives but their adverse effects have to be considered carefully. The evidence level for prokinetics and neuroleptics is moderate to low. Concerning palliative care of patients with diseases other than cancer no studies exist. More well designed studies in palliative care patients are needed in order to facilitate evidence based antiemetic therapy. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

Nausea and vomiting in HIV: a symptom review

Nausea and vomiting are two of the most common symptoms experienced by those with HIV. While the causes are most commonly attributed to medication side effects, infectious causes, gastroparesis and psychosomatic, therapy aimed at controlling symptoms has not been well studied. Since nausea and vomiting have been identified as the most common cause of discontinuation of highly active antiretroviral therapy (HAART) therapy, and due to the extensive morbidity associated with these symptoms, we sought to review and discuss causes and management of these symptoms in HIV-infected patients and demonstrate the need for further research in this area. Such studies could include investigation into the prophylactic use of antiemetics with initiation or modification of HAART therapy to monitor patient compliance. In addition, anticipatory nausea and vomiting should be further studied, as it could prove to be quite prevalent, as in cancer patients.

Impact of HIV/AIDS on care and outcomes of severe sepsis

INTRODUCTION

There has been dramatic improvement in survival for patients with HIV/AIDS; however, some studies on patients with HIV/AIDS and serious illness have reported continued low rates of intensive care. The purpose of this study was to examine patterns of care and outcomes for patients with severe sepsis and HIV/AIDS and compare them with those of patients with severe sepsis without HIV/AIDS.

METHODS

We assessed data from all 1999 discharge abstracts from all non-federal hospitals in six US states. Patient demographic characteristics, discharge diagnoses, resource use, and outcomes were extracted. Analyses were performed using chi-square, Wilcoxon rank sum, or regression techniques, as appropriate.

RESULTS

We identified 74,020 patients with severe sepsis (7,638 (10.3%) had HIV/AIDS) using ICD-9-CM codes. Patients with severe sepsis and HIV/AIDS had a similar mean length of stay (16.9 days versus 17.7 days; p = 0.0669), had lower mean hospitalization cost (24,382 dollars versus 30,537 dollars; p < 0.0001), were less likely to be admitted to the intensive care unit (37% versus 56%; p < 0.0001), and had a greater mortality (29% versus 20%; p < 0.0001) than those without HIV/AIDS. After adjustment for cohort differences, patients with severe sepsis and HIV/AIDS had increased likelihood of death (OR (95% CI) = 2.41 (2.23-2.61)) and were substantially less likely to be admitted to the intensive care unit (OR (95% CI) = 0.54 (0.51-0.59)). When compared with those with severe sepsis and HIV/AIDS, patients with severe sepsis without HIV/AIDS were universally more likely to be admitted to the intensive care unit, even when they had comorbid illnesses with equal or worse expected in-hospital mortality (e.g., metastatic cancer).

CONCLUSION

For patients with severe sepsis, there are differences in care and outcomes for those with HIV/AIDS. Further research is needed to examine the delivery of care for patients with severe sepsis and HIV/AIDS.

A symptom review: nausea and vomiting in HIV

Nausea and vomiting are symptoms often experienced by individuals with HIV disease. The etiologies are multifactorial, yet the symptoms have not been well studied in HIV research. Interventions currently used are adapted from the oncology setting and remain to be tested on patients with HIV. The purpose of this article is to review and discuss the symptoms of nausea and vomiting and to emphasize the need for research in this area.

Symptoms and attitudes of 100 consecutive patients admitted to an acute hospice/palliative care unit

One hundred patients admitted to an acute hospice/palliative care unit in a U.S. teaching hospital were evaluated using a standardized data acquisition tool that assessed the presence of physical symptoms and attitudes concerning admission to such a specialty unit. Patients entering the unit between June 1995 and October 1995 completed the tool within 24 hours of admission. Symptoms reported were fatigue in 81 patients, anorexia in 70, dyspnea in 61, xerostomia in 58, cough in 52, pain in 49, confusion in 37, depression in 37, constipation in 35, nausea in 30, insomnia in 23, and vomiting in 22. Of the 59 patients and family/friends that responded to the question "How do you feel about hospice care?", 53 gave a positive response. When asked about the best aspects of the unit, the most common response related to the care the patient and family received (23 responses, 39%). We conclude that patients admitted to an acute inpatient hospice/palliative care unit have multiple symptoms and a high degree of satisfaction with the environment.