Journal articles on the topic 'AIDS (Disease), Palliative treatment. Rwanda'

Background. Single-disease-focused treatment and hospital-centric care are poorly suited to meet complex needs in an era of multimorbidity. Understanding variation in palliative care’s association with treatment choices is essential to optimizing interdisciplinary decision making in care of complex patients. Aim. To estimate the association between palliative care and hospital costs by primary diagnosis and multimorbidity for adults with one of six life-limiting conditions: heart failure, chronic obstructive pulmonary disease (COPD), liver failure, kidney failure, neurodegenerative conditions including dementia, and HIV/AIDS. Methods. Data from four studies (2002–2015) were pooled to provide an analytic dataset of 73,304 participants with mean costs $10,483, of whom 5,348 (7%) received palliative care. We estimated average effect of palliative care on direct hospital costs among the treated, using propensity scores to control for observed confounding. Results. Palliative care was associated with a statistically significant reduction in total direct costs for heart failure (estimated treatment effect: −$2666; 95% confidence interval [CI]: −$3440 to −$1892), neurodegenerative conditions (−$3523; −$4394 to −$2651), COPD (−$1613; −$2217 to −$1009), kidney failure (−$3589; −$5132 to −$2045), and liver failure (−$7574; −$9232 to −$5916). The association for liver failure patients was statistically significantly larger than for any other disease group. Cost-saving associations were also statistically larger for patients with multimorbidity than single disease for two of the six groups: neurodegenerative and liver failure. Conclusions. Heterogeneity in treatment effect estimates was observable in assessing association between palliative care and hospital costs for adults with serious life-limiting illnesses other than cancer. The results illustrate the importance of careful definition of palliative care populations in research and practice, and raise further questions about the role of interdisciplinary decision making in treatment of complex medical illness.

BackgroundLow-income and middle-income countries are struggling to manage growing numbers of patients with chronic non-communicable diseases (NCDs), while services for patients with HIV infection are well established. There have been calls for integration of HIV and NCD services to increase efficiency and improve coverage of NCD care, although evidence of effectiveness remains unclear. In this review, we assess the extent to which National HIV and NCD policies in East Africa reflect the calls for HIV-NCD service integration.MethodsBetween April 2018 and December 2020, we searched for policies, strategies and guidelines associated with HIV and NCDs programmes in Burundi, Kenya, Rwanda, South Sudan, Tanzania and Uganda. Documents were searched manually for plans for integration of HIV and NCD services. Data were analysed qualitatively using document analysis.ResultsThirty-one documents were screened, and 13 contained action plans for HIV and NCDs service integration. Integrated delivery of HIV and NCD care is recommended in high level health policies and treatment guidelines in four countries in the East African region; Kenya, Rwanda, Tanzania and Uganda, mostly relating to integrating NCD care into HIV programmes. The increasing burden of NCDs, as well as a move towards person-centred differentiated delivery of services for people living with HIV, is a factor in the recent adoption of integrated HIV and NCD service delivery plans. Both South Sudan and Burundi report a focus on building their healthcare infrastructure and improving coverage and quality of healthcare provision, with no reported plans for HIV and NCD care integration.ConclusionDespite the limited evidence of effectiveness, some East African countries have already taken steps towards HIV and NCD service integration. Close monitoring and evaluation of the integrated HIV and NCD programmes is necessary to provide insight into the associated benefits and risks, and to inform future service developments.

Summary: There is a paucity of literature on suicide and cancer, especially cancer of the cervix. This study reports on suicidal behavior in these patients. The sample consisted of adult, black, Zulu-speaking women from palliative and radical oncology treatment groups who volunteered for the study. There were more patients in the palliative group who were younger, and had a more significant delay between cancer symptom presentation and seeking oncology treatment. Patients experienced: significant depression, anxiety, stress, hopelessness/helplessness, anxious preoccupation about their disease, poor current or delayed social support, feelings of being a burden to their significant others, beliefs that they would be better off dead, perceptions that they were stigmatized by society or that their communities suspected them of being HIV-AIDS positive, and suppressed anger. More patients in the palliative, compared to the radical treatment, group were inclined toward suicidal ideation with serious intent. Overall, most patients coped inadequately with their disease and its management. These patients are a high risk group for suicidal behavior and should be identified in time for appropriate psychological intervention.

Apesar das inúmeras campanhas de prevenção, a Síndrome da Imunodeficiência Adquirida (AIDS) ainda se constitui um grave problema de saúde pública. O presente trabalho teve como objetivo investigar as representações sociais do HIV/AIDS e, assim, contribuir para o tratamento psicológico desses pacientes. Foi realizada uma revisão da literatura, com levantamento bibliográfico, abordando as discussões de autores da psicologia social, entre outros, a respeito do HIV/AIDS. A AIDS é uma enfermidade que marca intensamente quem a vivencia, uma vez que afeta não apenas o corporal do sujeito, mas as demais esferas da sua vida, envolvendo, muitas vezes, sentimentos negativos, tais como: a tristeza, o desejo de morte, a angústia, entre outros, que refletem no seu bem-estar mental, físico, afetivo e social. A infecção pelo HIV estabelece uma cadeia de cuidados a serem desempenhados pelas pessoas portadoras, como consultas frequentes, realização de exames laboratoriais especiais, o uso de medicamentos e mudanças na vida social que, muitas vezes, causam dificuldades que propiciam e implicam cuidados especializados em saúde mental. Atualmente, não existe uma cura para essa doença, apenas tratamento paliativo como: uso de medicamentos, tratamento com psicólogo, tratamento com psiquiatra, entre outros.Palavras-chave: HIV/AIDS. Psicologia Social. Representação Social.AbstractDespite the several prevention campaigns, AIDS remains a serious public health problem. This study aims to investigate the social representations of HIV/AIDS and thereby contribute to the psychological treatment of these patients. A bibliographic review was performed showing the themes discussed about the social psychology according to the view of many authors, concerning the HIV/AIDS. The Acquired Immune Deficiency Syndrome (AIDS) is an illness that marks intensely those who experience it, since it affects not only the body of the individual, but the other spheres of his or her life, involving often negative feelings such as sadness, death desire , anguish, among others, reflecting on his or her mental, physical, emotional and social well-being. HIV infection establishes a chain of care to be taken by people with this illness, such as frequent consultations, conducting special laboratory tests, medication use and changes in social life that often cause difficulties that require mental health care specialist. Currently, there is no cure for this disease, only palliative treatment such as use of drugs, treatment with a psychologist, psychiatrist treatment, among others.Keywords: HIV/AIDS. Social Psychology. Social Representation.

142 Background: We hypothesized that introducing supportive care management and enhanced electronic aids to nurse navigation in selective curative cases could result in cost savings and enhanced patient experience of the sort demonstrated in patients with advanced disease. Methods: To test this hypothesis, we introduced a clinical pathway in November 2016 called the Supportive Care of Oncology Patients (SCOOP) program. We limited the scope to patients receiving radiation and chemotherapy concurrently at the Helen F. Graham Cancer Center and diagnosed with potentially curable thoracic, colorectal or head and neck malignancies and seen in our mulitdisciplinary clinics (MDCs). 1. A nurse navigation check list was developed for nurse navigators in the Aerial information system to support standardization of care. The navigator has to opt out of ancillary service consults such as nutrition, behavioral health and social work. The check list includes other mandatory tasks that must be completed at various time points before, during and after the patient’s concurrent treatment. Examples include: Prescribed communication dates with the patient; capturing of scheduled consults; assessing additional/unmet needs before, during and after treatment phase. 2. A mandatory supportive and palliative care service screening during the MDC visit, and, if indicated, urgent or timely consultation. 3. Flags in the inpatient information system that alert in real time the supportive care service, the navigators and the oncologists whenever a patient is seen in the emergency room, admitted or discharged. Results: During the first year nurse navigation compliance increased from 94% to 99%.ED visits declined from 54% to 32% of SCOOP patients , admissions from 34% to 25% and readmissions from 32% to 20% . Opportunity cost savings were $1500.00 per patient. Conclusions: Much like the results observed in advanced disease, the early introduction of enhanced nurse navigation and palliative/supportive care in high acuity patients treated curatively improves the patient experience and reduces societal costs.

Background Good nutrition empowers PLWH with the ability to fight against infection ultimately slowing down disease progression. Consequently, nutrition management is a crucial component of HIV treatment, care, and support. This study aimed at assessing dietary status and associated factors among PLWH in Kigali, Rwanda. Methods We conducted a cross sectional study in three selected hospitals in Kigali from over a six-week period in July – August, 2019 to collect data from 204 HIV positive adults enrolled using systematic random sampling. Data was collected using an adapted, validated and pre-tested food frequency questionnaire (FFQ). Descriptive and multiple logistic regression analyses were performed using SPSS version 25 for windows. Results The proportion of participants with poor dietary status was 15% based on FFQ responses. The study found only three factors to be independently associated with dietary status. There was an association between dietary status and HIV status disclosure (AOR 2.5; CI 1.25 - 4.83; p=0.014). There was an association between dietary status and travel time to place of collection of ARVs (AOR 3.2; CI 1.7 - 5.8; p=0.006). There was an association between dietary status and BMI (AOR 10.2; CI 8.30 – 16.0; p<0.001). Conclusions Poor dietary status among PLWH remains a concern. The strong association between dietary status and BMI underlines the need for interventions that target PLWH to improve dietary status and ultimately nutrition status

Background: While Hodgkin lymphoma (HL) is highly curable with standard chemotherapy in high-resource settings, there are few reports of HL treatment in low-resource settings. In Rwanda, a treatment protocol using six cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) without radiotherapy has been implemented at two rural district hospitals. Here we report on the feasibility of this approach, our patient characteristics, and outcomes. Methods: We conducted a retrospective cohort study of all patients with biopsy-confirmed HL seen at Butaro and Rwinkwavu hospitals between October 2009 and June 2018. Data were extracted from clinical charts and analyzed using descriptive statistics and Kaplan-Meier logrank testing. Results: Ninety HL patients were seen at Butaro (n=85) and Rwinkwavu (n=5); 58% male, median age 16 (IQR 10.6-30.5) with 54% under age 18. Eleven (12%) were HIV positive. Mean duration of presenting symptoms at the time of intake was 54 weeks; 70% had B symptoms. Nodular sclerosis was the predominant histological subtype (47%) followed by mixed cellularity (28%). Of 24 biopsy specimens evaluated for EBV, 14 (58%) were positive, 10 (42%) negative. Most patients were staged with chest x-ray (81%); fewer had abdominal ultrasound (34%), CT (21%), or bone marrow biopsy (20%). Resulting Ann Arbor stages were I (17%), II (28%), III (32%), IV (20%), and undetermined (3%). Median time from initial biopsy to first dose of ABVD was 6.1 weeks (IQR 3.6-11.9). Of 76 patients who started ABVD, 56 (74%) completed all 6 cycles; the leading reasons for discontinuation were loss to follow up (n=9) and death (n=7). Median time to completion of the 24-week ABVD regimen was 26.1 weeks; 51 patients (67%) experienced at least one treatment delay. Neutropenia, social factors, and infection were the most common reasons for delays. Dose reductions were rare. Mean dose intensity over 6 cycles was 87.2% calculated per Owadally, et al. 2010; <86% in 40% of patients, 86-97% in 32%, and >97% in 28%. Of the 76 patients started on ABVD, 34 (45%) are in clinical remission, 21 (28%) are deceased, 2 (3%) referred to palliative care, and 19 (25%) are lost to follow up at a median interval of 48 months from intake. Univariate analysis demonstrates that stage III-IV (p=0.0000), ECOG performance status 2-4 (p=0.0004), hemoglobin <10.5 g/dL (p=0.01), WBC > 15,000 mm3 (p=0.05), B symptoms (p=0.004), and extranodal disease (0.0004) were associated with worse survival. Conclusions: We observed a strikingly younger age distribution in our cohort compared to the classic bimodal distribution reported in high income countries, suggesting biologic differences that warrant further investigation. Treating HL with standard chemotherapy in a low-resource setting through international partnership is feasible, and nearly half of patients who complete treatment may experience a clinically significant remission with this approach. Late presentation, treatment delays, and loss to follow up are among major reasons to explain the discrepancy in survival compared to high income countries. Further efforts should tackle these identified barriers to achieve better survival outcomes. Figure Disclosures No relevant conflicts of interest to declare.

1071 Background: Patients (pts) with Human Immunodeficiency Virus (HIV) are living longer and non-AIDS defining malignancies have been increasingly reported in these patients. Methods: Retrospective review identified 47 pts with breast cancer (BC) and HIV who were seen at the University of Miami Sylvester Comprehensive Cancer Center/Jackson Memorial Hospital between January 1999 and June 2011. Results: Pt characteristics: 46 female, 1 male, mean age 46 years (range 31-65). Race: African American 79%, Caucasian 21%. Ethnic: Hispanics 14%, non-Hispanics 86%. Premenopausal 68% postmenopausal 32%. Tumor characteristics: Stage: Tis 4%, Stage I: 6 % , Stage II: 38%, Stage III: 38%, Stage IV: 9%. ER positive (50%) her-2 positive (15%), Triple negative (21%). HIV characteristics: 36 pts with HIV before or concurrent with the diagnosis of BC. 6 pts diagnosed with HIV within 1 year of BC diagnosis. HIV dx date unavailable in 5 pts. 27% had AIDS. CD4 counts (in cells/µL)were: > 500 (23%); 201-500 (37%), 51 – 200 (20%) < 50 (20%). 15 pts were diagnosed with BC in preHAART era. Of those dx with BC after 1996, 60% were on HAART. BC treatment: 43 pts had localized disease. 32 underwent modified radical mastectomy, 8 breast conservation and 3 pts refused surgery. 26 pts received curative or palliative chemotherapy. Complications of BC treatment: serious side effects were reported in 11 (42%) including neutropenic fever/sepsis (10 pts), ARDS (1 pt). Zoster infection was reported in 12% of the pts. 3 patients developed rapidly progressive and fatal AIDS within 6 months of completion of chemotherapy. Survival: See Table. Conclusions: BC in patients with HIV infection spans the spectrum of BC presentations. Hormonal therapy, surgery and radiation therapy were well tolerated. Infectious complications were common in patients treated with chemotherapy and routine use of growth factors and prophylactic acyclovir should be considered. [Table: see text]

PURPOSE To evaluate combined limited-field radiotherapy and concentration times time (C X T) intra-CSF chemotherapy in patients with AIDS-related lymphomatous meningitis (LM). PATIENTS AND METHODS Fourteen men and one woman with AIDS had cytologically documented LM. Eleven patients had systemic non-Hodgkin's lymphoma (NHL) (all B-cell histology, including six immunoblastic, four large cell, one small cell) with leptomeningeal metastases and four patients had primary CNS lymphoma (PCNSL) (all B-cell histology, including two immunoblastic, two large cell) with CSF dissemination. Presenting neurologic examinations included cranial neuropathies (n = 7), normal (n = 4), abulia (n = 2), paraparesis (n = 2), ataxia (n = 1), hemiparesis (n = 1), and aphasia (n = 1). Standardized pretreatment evaluations included contrast cranial magnetic resonance/computed tomography (MR/CT), placement of an intraventricular reservoir, CT myelogram/contrast spine MR, ophthalmologic examination, and indium 111-pentetic acid (DTPA) CSF flow studies. Regions of bulky or symptomatic disease were treated with limited-field radiation therapy, which included whole brain in 10 patients combined with spinal cord irradiation in five patients. Concurrent systemic chemotherapy was administered in 12 patients. All patients were scheduled to receive intraventricular methotrexate (MTX) 2 mg/d for 5 consecutive days biweekly for 8 weeks (induction), followed in cytologically responding patients by MTX administered in a similar manner every 4 weeks (maintenance). In MTX-responsive and consenting patients with cytologic relapse, intraventricular cytarabine (ara-C) was administered, 25 mg/d for 3 consecutive days weekly for 4 weeks (induction), followed by ara-C administered in a similar manner every 4 weeks (maintenance). CSF cytology and neurologic examinations were performed biweekly. RESULTS In 13 assessable patients (two patients refused CNS directed therapy following standardized pretreatment evaluations), median time to tumor progression was 60 days (range, 3 to 260) and median survival duration was 125 days (range, 44 to 260). Response rate, determined clinically (four of 13 patients) and cytologically (nine of 13), was 69%. Complications included reservoir infection (n = 2) and myelosuppression (n = 11); the latter was felt to be a consequence of coadministered systemic chemotherapy. CONCLUSION There were no treatment-related deaths. We conclude that involved-field irradiation and intraventricular MTX/ara-C is effective palliative treatment of AIDS-related LM.

Background: Conventionally, anti-cancer agents were administered through the intravenous route. The major drawbacks associated with the intravenous route of administration are: severe side effects, need of hospitalization, nursing care, and palliative treatment. In order to overcome the drawbacks associated with the intravenous route of administration, oral delivery of anti-cancer agents has gained tremendous interest among the scientific fraternity. Oral delivery of anti-cancer agents principally leads to a reduction in the overall cost of treatment, and aids in improving the quality of life of patients. Bioavailability of drugs and inter-subject variability are the major concerns with oral administration of anti-cancer agents. Factors viz. physicochemical and biological barriers (pre-systemic metabolism and transmembrane efflux of the drug) are accountable for hampering oral bioavailability of anti-cancer agents can be efficiently overcome by employing nanocarrier based drug delivery systems. Oral delivery of anticancer agents by employing these drug delivery systems will not only improve the quality of life of patients but will also provide pharmacoeconomic advantage and lead to a reduction in the overall cost of treatment of life-threatening disease like cancer. Objective: This article aims to familiarize the readers with some of the recent advancements in the field of nanobased drug delivery systems for oral delivery of anticancer agents. Conclusion: Advancement in the field of nanotechnology-based drug delivery systems has opened up gateways for the delivery of drugs that are difficult to administer orally. Oral delivery of anti-cancer agents by these drug delivery systems will not only improve the quality of life of patients but will also provide pharmacoeconomic advantage and lead to a reduction in the overall cost of treatment of life-threatening disease like cancer.

419 Background: Patients presenting with advanced penile cancer with significant inguinal disease requiring extensive resection. Reconstruction is required to cover the defect and protect underlying vascular structures when undergoingl adjuvant treatment. Often the performance status or the extent of the disease makes neoadjuvant chemo/radiotherapy difficult. Although this group of patients undoubtedly have a poor prognosis, palliative resection reduces the tumour burden and allows improved wound management and quality of life. The aim of this study was to present the techniques and report the outcomes for patients with N3 disease undergoing flap reconstruction. Methods: Medical records were reviewed for penile cancer patients with fixed inguinal nodal disease either at presentation or recurrence. Resection was performed by a team comprising urological and plastic surgeons. Cancer specific survival and the impact of adjuvant chemo/radiotherapy was recorded. Results: Seventeen patients were included; mean age 62 (range 37–85) years. Nine (53%) patients had a first presentation with penile cancer and advanced nodal disease, with 8 (47%) presenting with inguinal disease recurrence. The majority (n = 13) underwent a vertical rectus abdominis musculocutaneous (VRAM) flap. Of these, 3 required femoral vein reconstruction. Where defects were smaller, a tensor fascia latae (n = 2) or a scrotal advancement flap was used (n = 1). The average length of stay was 23 days (10-45 days) regardless of type of flap. Ten patients had adjuvant radiotherapy, 5 underwent neoadjuvant chemotherapy with a 4 undergoing adjuvant chemotherapy. The disease specific survival was 595 days (range 24-3881). Complications were related to wound healing and managed conservatively. Post operative lower limb lymphoedema occurred in the majority of patients. There were no flap failures and all but one patient was discharged home. Conclusions: Aggressive surgical management for patients with extensive nodal disease and flap reconstruction is feasible. This aids wound management and improves the quality of life for patients. Survival rates can extend to over 12 months following adjuvant treatment.

Abstract Introduction Depression is a burdening disease state where up to 30% of individuals do not respond to first-line treatment. Adjunctive use of psychostimulants has been investigated for the treatment of depression in patient populations, including those with treatment-resistant depression or terminal illness. The purpose of this paper is to present a review of the literature on the efficacy of using methylphenidate to manage depression. Methods A search was conducted in PubMed, Ovid/MEDLINE, and PsychINFO using the following key words: psychostimulants, stimulants, methylphenidate, alternative therapy, depression, and major depressive disorder. All reports included were published before June 30, 2015. Results For this review 10 reports, including randomized controlled, case series, and retrospective chart review studies, were identified and assessed. Patient populations studied included patients with treatment-resistant depression, patients with terminal illness, geriatric patients, and patients with miscellaneous indications, such as history of stroke and human immunodeficiency virus (HIV), or acquired immune deficiency syndrome (AIDS). For treatment-resistant depression, treatment differences for fatigue and apathy in favor of methylphenidate were found, but no difference was found for response rates in depression. Additionally, in palliative care and hospice patients, methylphenidate was found to improve fatigue and depressive symptoms. Patients with other conditions (poststroke and HIV patients) achieved some relief of depressive symptoms. Conclusion The efficacy data for methylphenidate in depression are limited, with inconsistent results in specific patient populations that limit external validity. At this time, it should not be recommended as first-line treatment in depression. Future research should be developed focusing on long-term safety and efficacy in nonspecialized patient populations.

Nowadays chemoresistant pulmonary tuberculosis is an urgent medico-social problem, both in Ukraine, and around the world. It is established that the indicator of non-effective treatment of patients of pulmonary tuberculosis is influenced by the following factors: features of tuberculosis, personal characteristics of patients and their social status, organization of treatment. The objective of the work – to define efficiency of an antimycobacterial chemotherapy of the registered cases of a chemoresistant pulmonary tuberculosis in Zaporizhzhia region. Materials and methods of the research. The analysis of the registered 1571 cases of a chemoresistant pulmonary tuberculosis in Zaporizhzhia region during 2012–2016 is carried out. Serious associated diseases (HIV infection/AIDS, a diabetes mellitus, etc.) were criteria of an exception. Results. Among the analysed cases there were 75,1 % men and 24,9 % women. Nowadays in structure of a chemoresistant pulmonary tuberculosis males (75,1 %), people of riper years and working-age (44,4 % and 92,3 %, respectively) authentically prevail. Identification of a chemoresistant pulmonary tuberculosis happened authentically more often «at the address of patients to the doctor» (57,9 %) and «at inspection in a hospital concerning other disease» (35,2 %). On registration the a chemoresistant pulmonary tuberculosis groups of patients with new cases (37,4 %) and a recurrence of specific process (26,5 %), destructive process (78,1 %), a bacterioexcretion (98,3 %), multirefractory tuberculosis (76,3 %) and an infiltrative clinical form (71,8 %) prevailed. While today efficiency of treatment among the registered 1571 cases of a chemoresistant pulmonary tuberculosis in Zaporizhzhia region during 2012–2016 is 25,6 %, treatment is continued by another 27,4 % of patients. Some results are disturbing such as «treatment is interrupted» and «treatment failure» which made on 17,6 %, and the high frequency (33,9 %) transfer to palliative treatment of patients with treatment failure.

HIV-associated PBL is an AIDS-defining cancer, classified by WHO as distinct entity of aggressive DLBCL. To date less than 250 cases have been published, of them17 are pediatric. The pathogenesis of this rare disease is related to immunodefiency, chronic immune stimulation and EBV. Clinically is a rapid growing destructive disease mainly of oral cavity, but frequently involves extraoral and extranodal sites. The diagnosis requires tissue mass or lymph node biopsy, but core needle or fine needle biopsy is acceptable for difficult access sites. Immunophenotype is CD45, CD20, CD79a negative and CD38, CD138, MUM1 positive, EBER and KI67 is >80%. Frequently is diagnosed in patients with low CD4+ and high viral load, however is reported also in patients on effective cART and high CD4. Treatment administered is usually CHOP or CHOP-like regimens, more intensive regimens as CODOX-M/IVAC or DA-EPOCH are possible options. Intensification with ABMT in CR1 may be considered for fit patients. Rituximab is not useful for this CD20- disease. Bortezomib and new drugs were used at case report level, with transient response. CNS prophylaxis is mandatory. Use of cART is recommended during chemotherapy, keeping in mind the possible overlapping toxicities. For refractory/relapsed patients, therapy is usually considered palliative, however in chemosensitive disease intensification + ABMT or new drugs may be considered. Factors affecting outcome are achieving complete remission, PS, clinical stage, MYC , IPI. Reported median PFS ranges between 6-7 months and median OS ranges between 11-13 months. Long term survivor are reported but mostly in pediatric patients. Due to the scarcity of data on this subtype of NHL we suggest that the diagnosis and the management of HIV-positive PBL patients should be performed in specialized centers.

Abstract Objective: To review the clinical and pathological profile of HIV-associated lymphomas in the local population in order to identify prognostic factors that may define a subgroup of patients who may have better outcome. Methods: The clinical records of a cohort of 874 cases of HIV infection first seen in our institute from March 1994 to March 2006 were reviewed. Results: Twenty patients with HIV-associated lymphomas were identified. All were males. Median age was 42 (18 – 72) years. Three had primary central nervous system lymphoma (PCNSL) and 17 had systemic non-Hodgkin’s lymphoma (NHL). All PCNSLs were of B-cell origin. For systemic NHLs, 15 patients had aggressive B-cell lymphoma (diffuse large B cell lymphoma: 12, burkitt-like lymphoma: 2, mantle cell lymphoma: 1) and 2 patients had plasmablastic lymphoma. For the 3 patients with PCNSL, 1 patient deteriorated rapidly and died 12 days after diagnosis, 1 patient survived 20 months after whole-brain radiation therapy (WBRT) and died of CMV pneumonia later and 1 patient is still surviving at 88 months (mons) after WBRT while maintaining on highly active anti-retroviral therapy (HAART). For patients with systemic NHL (n = 17), 2 patients had spontaneous disease regression upon treatment with HAART, 6 received curative intent chemotherapy, 3 received palliative treatment with chemotherapy or radiotherapy, 6 patients could not receive any treatment because of poor performance status and rapid deterioration after diagnosis. The following baseline variables were included as potential predictors of survival among all patients with systemic NHL: prior AIDS diagnosis; CD4 cell count; use of HAART and treatment intent. Number of adverse factors according to International Prognostic Index (IPI) for aggressive NHL (stage III or IV disease, age > 60 years, elevated lactate dehydrogenase, ECOG performance status ≥ 2, ≥ 2 extranodal sites) was calculated. Use of HAART was a favorable prognostic factor for overall survival (p = 0.008). Median overall survival for patients receiving HAART (n = 11) was 15 mons versus 1.6 mons for those without (n = 6). Patients with ≤ 2 adverse factors according to IPI were associated with longer overall survival (p = 0.0002). Patients with IPI > 2 (n = 11) had median survival of 2 mons whereas median survival for patients with IPI ≤ 2 (n = 6) had not been reached (range of follow up duration: 7 to 120 mons). Conclusion: In our cohort, for patients with HIV-associated systemic NHL, use of HAART and IPI score ≤ 2 were associated with better survival. Figure Figure Figure Figure

In this paper, we analyse the effects of peer-educator’s campaign on the dynamics of HIV. We present a sex-structured model for heterosexual transmission of HIV/AIDS in a community. The model is formulated using integro-differential equations, which help to account for a time delay due to incubation period of infective before developing AIDS. The sex-structured HIV/AIDS model divides the population into two subpopulations, namely; females and males. Both disease Free equilibrium and the endemic equilibrium points for the model are determined and their stability are examined. The model is extended to assess the effect of peer- educational campaigns in slowing or eradicating the epidemic. The exposure risk of infection after each intervention is obtained. Basic reproductive numbers for these models are computed and compared to assess the effectiveness of each intervention in a community. The models are numerically analyzed to assess the effectiveness of the treatment free measure, namely; peer educational campaign on the transmission dynamics of HIV/AIDS using demographic and epidemiological parameters of Rwanda. The study demonstrates the use of sex-structured HIV/AIDS models in assessing the effectiveness of educational campaigns as a preventive strategy in a heterosexually active populationMathematics Subject classifications (MSC 2010): 34D20, 34K60, 92D25, 34K25, 34K28Keywords: Population dynamics, Stability, Basic reproductive numbers, Equilibrium

Abstract Background Sustainable Development Goal (SDG) 3.3, targets to eliminate HIV from being a public health threat by 2030. For better tracking of this target interim Fast Track milestones for 2020 and composite complementary measures have been indicated. This study measured the Fast Track progress in the epidemiology of HIV/AIDS in Ethiopia across ages compared to neighboring countries. Methods The National Data Management Center for health’s research team at the Ethiopian Public Health Institute has analyzed the Global Burden of Disease (GBD) 2017 secondary data for the year 2010 to 2017 for Ethiopia and its neighbors. GBD 2017 data sources were census, demographic and a health survey, prevention of mother-to-child HIV transmission, antiretroviral treatment programs, sentinel surveillance, and UNAIDS reports. Age-standardized and age-specific HIV/AIDS incidence, prevalence, mortality, Disability-Adjusted Life Years (DALYs), incidence:mortality ratio and incidence:prevalence ratio were calculated with corresponding 95% confidence intervals. Results Ethiopia and neighboring countries recorded slow progress in reducing new HIV infection since 2010. Only Uganda would achieve the 75% target by 2020. Ethiopia, Tanzania, and Uganda already achieved the 75% mortality reduction target set for 2020. The incidence: prevalence ratio for Ethiopia, Rwanda, and Uganda were < 0.03, indicating the countries were on track to end HIV by 2030. Ethiopia had an incidence: mortality ratio < 1 due to high mortality; while Kenya, Rwanda, Tanzania and Uganda had a ratio of > 1 due to high incidence. The HIV incidence rate in Ethiopia was dropped by 76% among under 5 children in 2017 compared to 2010 and the country would likely to attain the 2020 national target, but far behind achieving the target among the 15–49 age group. Conclusions Ethiopia and neighboring countries have made remarkable progress towards achieving the 75% HIV/AIDS mortality reduction target by 2020, although they progressed poorly in reducing HIV incidence. By recording an incidence:prevalence ratio benchmark of less than 0.03, Ethiopia, Rwanda, and Uganda are well heading towards epidemic control. Nonetheless, the high HIV/AIDS mortality rate in Ethiopia for its incidence requires innovative strategies to reach out undiagnosed cases and to build institutional capacity for generating strong evidence to ensure sustainable epidemic control.

Abstract Caregiving for cancer and HIV/AIDS patients is complex, and the burden may vary with the type of disease, stages of the illness, and the type of palliative care intervention. Cancer and HIV/AIDS diagnosis and treatment adversely affect not only the patients but also their families and caregivers. They are vulnerable to stress, distress, and depression. Studies in developed countries have shown high prevalence of depression among family caregivers, but the scale of the problem among family caregivers in Uganda is not known. Objective This study aimed to establish the prevalence and factors associated with depressive symptoms among family caregivers of palliative care patients at Hospice Africa Uganda. Method We used a mixed method study to determine the prevalence and factors associated with depressive symptoms among family caregivers of palliative care patients at Hospice Africa Uganda. We assessed depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9) and collected socio-demographic data using a tailored questionnaire. We used binary logistic regression to assess for the association between depressive symptomatology and caregiver socio-demographic and clinical characteristics. Results We recruited 161 family caregivers, 64% of whom were female. The study revealed a high prevalence of depressive symptoms (46%) (n = 74) among the family caregivers. Education status and religious affiliation were significantly associated with depressive symptomatology. Significance of results Family caregivers of palliative care patients face a high burden of depressive symptoms. Efforts to care for family caregivers within palliative care should include assessment and management of depressive symptoms in this population.

Abstract Background Cervical cancer treatment and care remains limited in Zimbabwe despite the growing burden of the disease among women. This study was aimed at investigating strategies to address barriers in accessing treatment and care by women with cervical cancer in Harare, Zimbabwe. Methods A qualitative inquiry was conducted to generate evidence for this study. Eighty-four (84) participants were purposively selected for interviews and participation in focus group discussions. The participants were selected from cervical cancer patients, caregivers of cervical cancer patients, health workers involved in the care of cervical cancer patients as well as relevant policy makers in the Ministry of Health and Child Care. Participants were selected in such as a way as to ensure different of characteristics to obtain diverse perspectives about the issues under study. Discussion and interview guides were used as data collection tools and discussions/interviews were audio-recorded, transcribed and translated into English. Inductive thematic analysis was conducted using Dedoose software. Results Salient sub-themes that emerged in the study at the individual patient level were: provision of free or subsidized services, provision of transport to treating health facilities and provision of accommodation to patients undergoing treatment. At the societal level, the sub-themes were: strengthening of health education in communities and training of health workers and community engagement. Salient sub-themes from the national health system level were: establishment of more screening and treatment health facilities, increasing the capacities of existing facilities, decentralization of some services, building of multidisciplinary teams of health workers, development and rolling out of standardized guidelines and reformation of Acquired Immunodeficiency Virus (AIDS) levy into a fund that would finance priority disease areas. Conclusion This study revealed some noteworthy strategies to improve access to cervical cancer treatment and care in low-income settings. Improved domestic investments in health systems and reforming health policies underpinned on strong political are recommended.

Abstract Funding Acknowledgements Type of funding sources: None. Background People living with aortic stenosis (AS) experience poor quality of life (QOL), repeat hospitalizations, and a poor prognosis in the absence of valve replacement. There is increasing equipoise in the evidence supporting the use of surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in patients likely to derive survival and QOL benefit. A transition to a palliative approach may be a better option in the setting of excessive frailty and comorbid burden. Shared decision-making (SDM) is a bidirectional exchange between patients and health care providers that enables an information exchange about the best available evidence and decisions that consider patients" priorities. The goal is to inform and empower patients to participate in choosing the right decision. Patient decision aids (PDAs) are designed to support the process of SDM and help guide these conversation. To date, Canadians living with AS have not had access to a validated PDA. Study Design We will report on the design of the SharEd DEcision-MaKing for AS (SEEK-AS) study that aims to refine and comprehensively evaluate a set of PDAs and to build capacity for SDM through a unique partnership of patient and clinical knowledge users, multidisciplinary health care providers and researchers, and policy-makers. We will summarize the pilot work completed to obtain a debrief of patient resources used in all Canadian provinces, the draft development of a PDA in concert with a health policy initiative, and the design of an electronic platform to individualize risk in real time during a consultation. We will outline the components of SEEK-AS and the use of a cross-provincial comparative case study design to investigate how to establish an effective and sustainable approach for the implementation of the PDAs using the Knowledge-to-Action conceptual framework. Implications There is a pressing need for the development of evidence-based tools to strengthen the integration of patients" perspectives in the treatment of complex valvular heart disease given the rapid pace of change in technology, indications and practice. The study of the implementation of innovative strategies to achieve this goal is essential to accelerate the pace of change in clinical care.

The prevalence of advanced dementia (AD) is expected to increase dramatically over the next few decades. Patients with AD suffer from recurrent episodic illnesses that frequently result in transfers to acute care hospitals. The default pathway followed by some emergency physicians, internists and intensivists who see those patients is to prioritize disease-directed therapies over attention to the larger picture of AD. While this strategy is desired by many families, some families prefer a different approach. This essay examines the reason why there can be a failure to focus on the over-arching issue of AD and offers suggestions for improvement. Gaps in information and physician workload are important factors, but we argue that until physicians who see patients in emergency departments learn to pause first and ask “Why are we doing this?” they will revert to their comfort zone of ordering tests and therapies that may be unwanted. A separate emergency palliative care pathway may be one solution. Shifting the focus back to the larger picture of AD and away from the physiologic disturbance of the moment may alter the trajectory of care in ways that truly respect the wishes of some patients and their families. On s’attend à ce que la prévalence de la démence avancée (DA) augmente de façon extrêmement importante au cours des prochaines décennies. Or, il arrive que des patients atteints de DA soient aux prises avec des maladies épisodiques récurrentes qui entraînent fréquemment un transfert dans un hôpital de soins actifs. La voie suivie par défaut par certains urgentologues, internistes et intensivistes qui reçoivent ces patients consiste à donner la priorité à l’application de traitements axés sur la maladie plutôt qu’à aborder le problème plus large de la DA. Cette stratégie satisfait bien des familles, mais certaines préfèrent une autre approche. Cet article examine pourquoi on semble vouloir éviter de s’attarder au problème récurrent de la DA et offre des suggestions d’amélioration. Des lacunes en matière d’information ainsi que la charge de travail des médecins sont sûrement des facteurs importants qui mènent à cette situation. Toutefois, nous soutenons que tant que les médecins qui voient ces patients au service des urgences ne prendront pas le temps de s’arrêter et de se questionner sur leur choix d’actions, ils se limiteront à se retirer dans leur zone de confort qui consiste à prescrire des tests et des traitements qui risquent d’être inopportuns. Une voie distincte en matière de soins palliatifs d’urgence peut s’avérer être une solution. En déplaçant l’accent mis sur les troubles physiologiques du moment pour le mettre sur le problème plus large de la DA, la trajectoire des soins pourrait être modifiée de façon à mieux respecter les désirs de certains patients et de leur famille.An 84-year-old bed-bound man with severe Alzheimer’s dementia presents to the emergency department with pneumonia, accompanied by his 3 daughters. He has been hospitalized 4 times in the past 2 years for antibiotic-associated Clostridium difficile diarrhea. Antibiotics and intravenous fluids were started by the first physicians who saw him. An internist was consulted to take over his care.In 2016, 564,000 Canadians were living with dementia. Each year 25,000 new cases of dementia are diagnosed, and it is expected that by 2030 there will be close to 1 million Canadians who have dementia.1 People with advanced dementia (AD) suffer with cognitive deficits and are unable to communicate, ambulate and have incontinence. They are at high risk for imminent death,2,3 an under-recognized fact even among health care professionals.4 In contrast to patients with terminal cancer and end stage heart disease, most patients with AD do not die from devastating acute events (like bowel obstruction, or heart failure) that result from the progression of their primary disease. Instead, they die from recurrent episodic illnesses that can be treated with relatively simple therapeutic responses (like intravenous fluids or antibiotics). 3 These include pneumonias, urinary tract and skin infections, influenza, problems with eating (including aspiration) and dehydration. It is not surprising that in the United States that 19% of nursing home residents with cognitive impairment experience at least one transfer to a hospital in the last 120 days of life.5When these patients arrive in the emergency department (ED), the default pathway is to prioritize disease-directed therapies (e.g., intravenous fluid and antibiotics) over attention to the larger picture of AD. The physiologic disturbances receive intense focus and the AD is seemingly forgotten. These patients often suffer from treatable symptoms, including pain and shortness of breath.3 In some (but not all) cases, patients may receive care they don’t really want, families may be afraid to express their true wishes, and health care professionals may deliver care they suspect is unnecessary, or even harmful. This essay examines the reasons why this phenomenon occurs and offers suggestions for improvement by encouraging acute care clinicians to pause and ask themselves, “Why are we doing this?” and by engage family members in focused goals of care discussions that include outcomes of aggressive disease-directed treatments and palliative approaches.There are many reasons why the physicians who treat these patients in acute care hospitals (primarily emergency physicians, internists/hospitalists and intensivists) prioritize life-sustaining therapies over relief of burdensome symptoms as the default strategy. Information gaps affect the process of care. These physicians likely assume that a transfer to an acute care facility indicates the (sometimes mistaken) desire for life-sustaining interventions by the patient’s relatives. Transfer decisions are a human endeavour, and thus are subject to error6 especially when personnel worry about blame. While nearly half of all transfers from nursing homes to the ED are for cardiovascular and respiratory problems, 7 key factors influencing decisions to transfer as reported by family physicians include medico-legal concerns, family pressure, the capability of nursing home staff and the physician’s workload.8Even in Ontario, where nursing home residents are legally required to have annually updated instructions about whether transfer to acute care hospitals is indicated, the process only works as well as the nature of the counselling and discussion (which is often perfunctory) that takes place before the patients or their legal substitutes sign that document. In the United States, it is unclear how and whether the rapid uptake of Physician Orders for Life-Sustaining Treatment in nursing homes has affected end-of-life care in AD.9 From an economic and medico-legal perspective, there is no incentive for nursing homes or their staff to manage the acutely ill nursing home patient themselves, and every incentive to transfer care to an ED even when “no transfer” instructions are clearly recorded. The physician who meets the patient for the first time in the ED often lacks familiarity with the patient’s clinical course and his or her family, which coupled with a lack of communication training for these circumstances, inhibits addressing goals of care directly.10Physician workload is also an important factor. In a busy ED, an empathetic conversation that elucidates patients’ goals of care, educates families about the outcomes of care11 and offers the option of prioritizing attention to symptoms takes time and requires a higher cognitive load than ordering tests, intravenous fluids and antibiotics. In addition, the process of acute care, once initiated, may be a contributing factor. Family members see that life-prolonging therapies can be given, making it more difficult for them to decide to forgo disease-directed therapies once started without being overwhelmed by a sense of guilt. Finally, precise prognostication in a patient with AD is fraught with hazards.12 All of these factors play a role, but overall, until the physicians who see patients in the ED acquire the expertise to routinely address goals of care, and experience the rewards and sense of professional fulfillment that can be derived from sparing patients unwanted invasive care, the opportunity to prioritize comfort may not be offered. Those physicians will revert to their comfort zone of checking the electrolytes, obtaining a chest x-ray and urine culture which then results in a discussion that starts by asking families questions like, “Do you want us to treat the hypernatremia?” When phrased that way, few family members (even those who are physicians) are prepared to say “No.”While assessing goals of care for patients with AD may currently be viewed as impractical in the busy ED, perhaps the right models have not been proposed. Complexity has not deterred the rapid response in EDs for patients with acute strokes and ST-elevation myocardial infarctions. One solution may be to develop a separate “emergency palliative care pathway” where the primary task is prioritizing relief of burdensome symptoms and eliciting true preferences.13 thus avoiding stressful lengthy stays in the chaotic ED where patients with AD are often of low priority. Interventions aimed upstream from the ED may include increasing resources for training of nursing home staff along with the provision of decision aids to assist caregivers in the clarification of goals of care prior to transfer to the ED.14Some patients with AD and their families may prefer prioritizing comfort above all else but may not be offered the chance to make that choice. In a survey of elderly hospitalized Canadians, 70% reported wanting to focus on providing comfort rather than life-prolonging treatment, yet 54% of these patients are admitted to intensive care units at the end of life. 15 Even if this circumstance occurs in a minority of the dementia patients who are sent to EDs, the substantial rise in the number of people with dementia means that it will occur much more commonly in the future. In these cases, emergency physicians and the consultants that they approach for help can play a critical role if they push the pause button before beginning empiric disease-directed therapies, and simply ask patients’ families, “What is your understanding of your loved one’s prognosis?” and, “ What are you hoping for?” On the one hand, these conversations take time. On the other, they can be efficient, focus on these simple questions, and describe outcomes of care including potential discomforts associated with treatments. By shifting the focus back to the larger picture of AD and away from the physiologic disturbance of the moment, they may alter the trajectory of care, ultimately reducing the burden to patients and their families. We can facilitate patients’ wishes and honour the truly vital role that family members play as members of the health care team.Returning to the case, after a 7-minute discussion of the goals and options for care, led by the internist, the patient’s daughters were unable to decide upon the best course of treatment. A phone call to his wife was made, and she indicated that comfort measures were “what he would want.” After initiating oxygen and subcutaneous morphine for relief of pain and dyspnea in the ED, the patient was transferred to the ward with palliative care physicians. He received comfort-directed care and died peacefully 4 days later surrounded by his family. Competing InterestsNone declared AcknowledgementsWe thank S. Ryan Greysen MD, Gurpreet Dhaliwal (both of University of California San Francisco), Lewis A. Lipsitz MD (Harvard), Howard Ovens MD and Barry J. Goldlist MD (both of University of Toronto) for comments on an earlier draft.References1. Alzheimer Society of Canada. Report summary Prevalence and monetary costs of dementia in Canada (2016): a report by the Alzheimer Society of Canada. Health promotion and chronic disease prevention in Canada: research, policy and practice. October 2016:231–32.2. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000;284(1):47–52.3. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of AD. N Engl J Med 2009;361(16):1529–38. doi:10.1056/NEJMoa0902234.4. Chang A, Walter LC. Recognizing dementia as a terminal illness in nursing home residents: Comment on "Survival and comfort after treatment of pneumonia in AD." Arch Intern Med 2010;170(13):1107–1109. doi:10.1001/archinternmed.2010.166.5. Gozalo P, Teno JM, Mitchell SL, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med 2011;365(13):1212–21. doi:10.1056/NEJMsa1100347.6. Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. Emergency department use by nursing home residents: effect of severity of cognitive impairment. Gerontologist 2012;52(3):383–93. doi:10.1093/geront/gnr109.7. Jensen PM, Fraser F, Shankardass K, Epstein R, Khera J. Are long-term care residents referred appropriately to hospital emergency departments? Can Fam Physician 2009;55(5):500–505.8. McDermott C, Coppin R, Little P, Leydon G. Hospital admissions from nursing homes: a qualitative study of GP decision making. Br J Gen Pract 2012;62(601):e538–e545. doi:10.3399/bjgp12X653589.9. Halpern SD. Toward evidence-based end-of-life care. N Engl J Med 2015;373(21):2001-2003. doi:10.1056/NEJMp1509664.10. Lamba S, Nagurka R, Zielinski A, Scott SR. Palliative care provision in the emergency department: barriers reported by emergency physicians. J Palliat Med 2013;16(2):143–47. doi:10.1089/jpm.2012.0402.11. Givens JL, Jones RN, Shaffer ML, et al. Survival and comfort after treatment of pneumonia in AD. Arch Intern Med 2010;170(13):1102–107. doi:10.1001/archinternmed.2010.181.12. Mitchell SL, Miller SC, Teno JM, et al. Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA 2010;304(17):1929–35. doi:10.1001/jama.2010.1572.13. Grudzen CR, Stone SC, Morrison RS. The palliative care model for emergency department patients with advanced illness. J Palliat Med 2011;14(8):945–50. doi:10.1089/jpm.2011.0011.14. Hanson LC, Zimmerman S, Song M-K, et al. Effect of the goals of care intervention for AD. JAMA Intern Med 2017;177(1):24–28. doi:10.1001/jamainternmed.2016.7031.15. Fowler R, Hammer M. End-of-life care in Canada. Clin Invest Med 2013;36(3):E127–E132.