News & Analysis Medical News & Perspectives ........p2492 New Law Allows Organ Transplants From Deceased HIV-Infected Donors to HIV-Infected Recipients
Spinal Devices and Surgeries
Global Health ............................................p2497 Polio Vaccination Campaign
Physician Workforce Projection
Why Malaria Persists in South Korea
Clinicians Examine Advances and Challenges in Improving Quality of End-of-Life Care in the ICU
University Research Costs
Cervical Cancer Survival in Kenya
US Registry for Sudden Death in the Young Launched by the NIH and CDC
Capitol Health Call..................................p2496
Electronic Health Records
Live Poultry Markets and Avian Flu
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news@JAMA: From JAMA's Daily News Site
New Assay Detects TB Bacteria and Resistance to Rifampin
Medical News & Perspectives
New Law Allows Organ Transplants From Deceased HIV-Infected Donors to HIV-Infected Recipients Preeti N. Malani, MD, MSJ
2492
suppression, explained Kaul. “In the handful of early cases where patients acquired HIV by transplantation [before donor screening could accurately pick up very early infection] or had undiagnosed HIV infection prior to transplant, the results were uniformly dismal, with patients experiencing severe complications and dying within a very short time period,” he said. Today, however, with advances in the management of HIV infection along with improvements in transplant outcomes, HIV infection is no longer a contraindication to solid organ transplantation. Kaul, who has cared for more than 20 HIV-infected patients who have undergone kidney transplantation since 2004, notes that the pretransplantation evaluation process is very stringent. To be considered candidates for transplanta-
tion, patients must have well-controlled HIV with undetectable viral loads and must be able to manage complex drug regimens of both HIV and transplant medications, which is challenging given numerous drug-drug interactions. But people living with HIV who are suitable candidates for transplantation face another hurdle: a severe shortage of donor organs. As is often the case for patients without HIV infection, many patients with HIV die awaiting transplant. Congress’ recent passage of the HIV Organ Policy Equity (HOPE) Act, which ends the federal ban on transplantation of organs from deceased HIV-infected donors to HIVinfected recipients, is expected to expand the number of donor organs available for transplantation into patients living with HIV.
An end to a US ban on transplantation of organs from deceased HIV-infected donors to HIV-infected recipients is expected to help more people with HIV infection benefit from transplantation.
JAMA December 18, 2013 Volume 310, Number 23
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a NCSU Hunt Library User on 05/17/2015
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A
recently passed law that ends a federal ban on transplantation of organs from deceased HIV-infected donors to HIV-infected recipients will help modernize health policy by addressing the reality that more people with HIV infection would benefit from transplantation. Highly active antiretroviral therapy has dramatically changed the landscape of living with HIV, improving both life expectancy and quality of life for infected patients. As a result, many patients now enjoy life expectancies that mirror those of the general population. “We have gone from a disease where nearly everyone died to one that can be managed in a way that is less burdensome than many other chronic illnesses,” said Daniel Kaul, MD, associate professor of infectious diseases at the University of Michigan. Not only are some chronic ailments more prevalent among individuals with HIV, they also appear to progress more rapidly in these patients than in the HIV-negative population. For example, among patients with HIV, co-infection with hepatitis C virus (estimated to affect as many as 30% of people with HIV) often results in liver failure. The latter is now a major cause of death among people living with HIV/AIDS. Kidney disease is also common, with HIV-associated nephropathy being the third leading cause of kidney failure among African American men, after diabetes and high blood pressure. Transplantation is often the best option for many patients with endstage organ failure. In the early days of HIV, organ transplantation was not felt to be feasible because of concerns about disease progression in the setting of heightened immuno-
News & Analysis
Because deceased donors with HIV represent a unique source of organs, using organs from HIV-infected donors for HIVinfected recipients is likely to benefit all patients waiting for transplantation, said Joel Gallant, MD, chair of the HIV Medical Association’s (HIVMA) Board of Directors. Gallant estimates that there are several hundred potential deceased HIV-infected kidney and liver donors per year in the United States. “If HIV patients can draw from an additional supply of donor organs, other patients will also be transplanted faster,” said Gallant. In building support for the HOPE Act, professional organizations like HIVMA cited policies that permit transplantation of organs from hepatitis C–infected donors to hepatitis C–infected recipients. Research shows that using organs from donors infected with hepatitis C for recipients with hepatitis C is safe and significantly reduces the time they spend waiting for a suitable donor organ and the risk of dying while waiting, said Gallant. He anticipates a similar ad-
vantage for HIV-infected patients who accept HIV-infected organs. In addition to increasing the supply of available organs, removal of the federal ban will allow researchers to examine the safety and outcomes of these transplants in the same way that transplantation of HIVinfected recipients with uninfected donor organs has been carefully studied. To date, there is very little experience in this arena— none in the United States—so the actual risk of using organs from HIV-infected donors remains unknown. Kaul noted that the risk of superinfection (acquisition of an HIV strain from a donor that differs from the strain infecting the recipient) requires better understanding. However, transplanting organs from HIV-infected donors with undetectable levels of circulating virus into properly selected HIV-infected recipients is believed to be safe based on what is knownaboutdiseasetransmissionriskinother settings, including hepatitis C. Even without clear guidance, the potential risks of such a procedure must be considered in the context
of the significant risk of a patient dying (10%20% per year) while on the waiting list for an uninfected organ. Both Kaul and Gallant foresee some challenges related to implementation of the HOPE Act. One issue will be the need to more formally involve infectious disease experts in the process of evaluating potential donors with HIV, particularly to determine the risk of transmitting drug-resistant HIV as well as other donor-derived opportunistic infections. “Medication-related records may not be available and families often do not know the details of a patient’s medical history,” said Kaul. Current screening protocols for infections are simply “yes” vs “no,” so parameters like HIV viral loads will need to be added to the evaluation process for HIVinfected donors. In addition, clinicians like Kaul and Gallant are left to wonder whether there will be adequate funding and resources so that researchers can ultimately determine whether these new approaches are in fact working.
Clinicians Examine Advances and Challenges in Improving Quality of End-of-Life Care in the ICU Jill Jin, MD, MPH CHICAGO—Nearly 40% of deaths in the United States occur in the hospital, and of those, more than half occur in the intensive care unit (ICU). These numbers are less than ideal when it comes to end-of-life care (Angus DC. Crit Care Med. 2004;32[3]:638643). “No one prefers to die in a hospital, especially not in an intensive care unit,” said Amy Chi, MD, pulmonary and critical care specialist at Tufts Medical Center in Boston, who led a session on improving the quality of endof-life care in the ICU at CHEST 2013, the annual conference of the American College of Chest Physicians held in October. In the past, terminally ill patients were treated via a “curative” approach—even when a cure was unlikely—until they reached a clinically nebulous point at which physicians estimated a 6-month life expectancy. Then care was transitioned to a palliative approach that focused on maximizing comfort and dignity during the dying process. The first hospital-based palliative care pro-
gram was pioneered in 1988 at Detroit Receiving Hospital with the establishment of a comprehensive support care team for patients considered “hopelessly ill.” Since then, palliative medicine has grown into its own board-certified subspecialty of medicine, and 80% of hospitals now have some sort of hospital-based palliative care services. Today, many terminally ill patients who are admitted to the hospital in critical condition have a team of both critical care specialists and palliative care specialists working together to develop a treatment and care plan. The hope is to clarify goals of care while the patient is in the ICU and optimize his or her quality of care via an overlap of comfort care and curative care principles. However, despite the significant progress made since the 1980s, there is still a long way to go in achieving this goal.
Quality vs Quantity The concept of quality care at the end of life has always been overshadowed by that of
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quantity. If given the opportunity to live 1 extra month at the end of life, the natural tendency of most patients and families is to take it, without consideration of its quality— elements such as the degree of pain or suffering, the sedation requirements, or the need for mechanical ventilation requiring ICU-level care. “The desire not to be dead is widespread and deeply held,” explained Richard Mularksi, MD, of Kaiser Permanente in Oregon, another presenter at the session, echoing statements from an article on end-of-life care published almost 15 years ago (Finucane TE. JAMA. 1999; 282[17]:1670-1672). That feeling, combined with the fact that a precise, reliable estimate of one’s “time left” is nearly impossible to make, means shifting the focus of end-of-life care from quantity to quality is very difficult. Unfortunately, there is no easy way to reconcile this cognitive dissonance on the part of patients and their families. JAMA December 18, 2013 Volume 310, Number 23
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a NCSU Hunt Library User on 05/17/2015
2493
Spinal Devices and Surgeries
Global Health ............................................p2497 Polio Vaccination Campaign
Physician Workforce Projection
Why Malaria Persists in South Korea
Clinicians Examine Advances and Challenges in Improving Quality of End-of-Life Care in the ICU
University Research Costs
Cervical Cancer Survival in Kenya
US Registry for Sudden Death in the Young Launched by the NIH and CDC
Capitol Health Call..................................p2496
Electronic Health Records
Live Poultry Markets and Avian Flu
News From the CDC ..............................p2498 Guinea Worm Cases Declining
news@JAMA: From JAMA's Daily News Site
New Assay Detects TB Bacteria and Resistance to Rifampin
Medical News & Perspectives
New Law Allows Organ Transplants From Deceased HIV-Infected Donors to HIV-Infected Recipients Preeti N. Malani, MD, MSJ
2492
suppression, explained Kaul. “In the handful of early cases where patients acquired HIV by transplantation [before donor screening could accurately pick up very early infection] or had undiagnosed HIV infection prior to transplant, the results were uniformly dismal, with patients experiencing severe complications and dying within a very short time period,” he said. Today, however, with advances in the management of HIV infection along with improvements in transplant outcomes, HIV infection is no longer a contraindication to solid organ transplantation. Kaul, who has cared for more than 20 HIV-infected patients who have undergone kidney transplantation since 2004, notes that the pretransplantation evaluation process is very stringent. To be considered candidates for transplanta-
tion, patients must have well-controlled HIV with undetectable viral loads and must be able to manage complex drug regimens of both HIV and transplant medications, which is challenging given numerous drug-drug interactions. But people living with HIV who are suitable candidates for transplantation face another hurdle: a severe shortage of donor organs. As is often the case for patients without HIV infection, many patients with HIV die awaiting transplant. Congress’ recent passage of the HIV Organ Policy Equity (HOPE) Act, which ends the federal ban on transplantation of organs from deceased HIV-infected donors to HIVinfected recipients, is expected to expand the number of donor organs available for transplantation into patients living with HIV.
An end to a US ban on transplantation of organs from deceased HIV-infected donors to HIV-infected recipients is expected to help more people with HIV infection benefit from transplantation.
JAMA December 18, 2013 Volume 310, Number 23
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a NCSU Hunt Library User on 05/17/2015
jama.com
Michelle Del Guercio/www.sciencesource.com
A
recently passed law that ends a federal ban on transplantation of organs from deceased HIV-infected donors to HIV-infected recipients will help modernize health policy by addressing the reality that more people with HIV infection would benefit from transplantation. Highly active antiretroviral therapy has dramatically changed the landscape of living with HIV, improving both life expectancy and quality of life for infected patients. As a result, many patients now enjoy life expectancies that mirror those of the general population. “We have gone from a disease where nearly everyone died to one that can be managed in a way that is less burdensome than many other chronic illnesses,” said Daniel Kaul, MD, associate professor of infectious diseases at the University of Michigan. Not only are some chronic ailments more prevalent among individuals with HIV, they also appear to progress more rapidly in these patients than in the HIV-negative population. For example, among patients with HIV, co-infection with hepatitis C virus (estimated to affect as many as 30% of people with HIV) often results in liver failure. The latter is now a major cause of death among people living with HIV/AIDS. Kidney disease is also common, with HIV-associated nephropathy being the third leading cause of kidney failure among African American men, after diabetes and high blood pressure. Transplantation is often the best option for many patients with endstage organ failure. In the early days of HIV, organ transplantation was not felt to be feasible because of concerns about disease progression in the setting of heightened immuno-
News & Analysis
Because deceased donors with HIV represent a unique source of organs, using organs from HIV-infected donors for HIVinfected recipients is likely to benefit all patients waiting for transplantation, said Joel Gallant, MD, chair of the HIV Medical Association’s (HIVMA) Board of Directors. Gallant estimates that there are several hundred potential deceased HIV-infected kidney and liver donors per year in the United States. “If HIV patients can draw from an additional supply of donor organs, other patients will also be transplanted faster,” said Gallant. In building support for the HOPE Act, professional organizations like HIVMA cited policies that permit transplantation of organs from hepatitis C–infected donors to hepatitis C–infected recipients. Research shows that using organs from donors infected with hepatitis C for recipients with hepatitis C is safe and significantly reduces the time they spend waiting for a suitable donor organ and the risk of dying while waiting, said Gallant. He anticipates a similar ad-
vantage for HIV-infected patients who accept HIV-infected organs. In addition to increasing the supply of available organs, removal of the federal ban will allow researchers to examine the safety and outcomes of these transplants in the same way that transplantation of HIVinfected recipients with uninfected donor organs has been carefully studied. To date, there is very little experience in this arena— none in the United States—so the actual risk of using organs from HIV-infected donors remains unknown. Kaul noted that the risk of superinfection (acquisition of an HIV strain from a donor that differs from the strain infecting the recipient) requires better understanding. However, transplanting organs from HIV-infected donors with undetectable levels of circulating virus into properly selected HIV-infected recipients is believed to be safe based on what is knownaboutdiseasetransmissionriskinother settings, including hepatitis C. Even without clear guidance, the potential risks of such a procedure must be considered in the context
of the significant risk of a patient dying (10%20% per year) while on the waiting list for an uninfected organ. Both Kaul and Gallant foresee some challenges related to implementation of the HOPE Act. One issue will be the need to more formally involve infectious disease experts in the process of evaluating potential donors with HIV, particularly to determine the risk of transmitting drug-resistant HIV as well as other donor-derived opportunistic infections. “Medication-related records may not be available and families often do not know the details of a patient’s medical history,” said Kaul. Current screening protocols for infections are simply “yes” vs “no,” so parameters like HIV viral loads will need to be added to the evaluation process for HIVinfected donors. In addition, clinicians like Kaul and Gallant are left to wonder whether there will be adequate funding and resources so that researchers can ultimately determine whether these new approaches are in fact working.
Clinicians Examine Advances and Challenges in Improving Quality of End-of-Life Care in the ICU Jill Jin, MD, MPH CHICAGO—Nearly 40% of deaths in the United States occur in the hospital, and of those, more than half occur in the intensive care unit (ICU). These numbers are less than ideal when it comes to end-of-life care (Angus DC. Crit Care Med. 2004;32[3]:638643). “No one prefers to die in a hospital, especially not in an intensive care unit,” said Amy Chi, MD, pulmonary and critical care specialist at Tufts Medical Center in Boston, who led a session on improving the quality of endof-life care in the ICU at CHEST 2013, the annual conference of the American College of Chest Physicians held in October. In the past, terminally ill patients were treated via a “curative” approach—even when a cure was unlikely—until they reached a clinically nebulous point at which physicians estimated a 6-month life expectancy. Then care was transitioned to a palliative approach that focused on maximizing comfort and dignity during the dying process. The first hospital-based palliative care pro-
gram was pioneered in 1988 at Detroit Receiving Hospital with the establishment of a comprehensive support care team for patients considered “hopelessly ill.” Since then, palliative medicine has grown into its own board-certified subspecialty of medicine, and 80% of hospitals now have some sort of hospital-based palliative care services. Today, many terminally ill patients who are admitted to the hospital in critical condition have a team of both critical care specialists and palliative care specialists working together to develop a treatment and care plan. The hope is to clarify goals of care while the patient is in the ICU and optimize his or her quality of care via an overlap of comfort care and curative care principles. However, despite the significant progress made since the 1980s, there is still a long way to go in achieving this goal.
Quality vs Quantity The concept of quality care at the end of life has always been overshadowed by that of
jama.com
quantity. If given the opportunity to live 1 extra month at the end of life, the natural tendency of most patients and families is to take it, without consideration of its quality— elements such as the degree of pain or suffering, the sedation requirements, or the need for mechanical ventilation requiring ICU-level care. “The desire not to be dead is widespread and deeply held,” explained Richard Mularksi, MD, of Kaiser Permanente in Oregon, another presenter at the session, echoing statements from an article on end-of-life care published almost 15 years ago (Finucane TE. JAMA. 1999; 282[17]:1670-1672). That feeling, combined with the fact that a precise, reliable estimate of one’s “time left” is nearly impossible to make, means shifting the focus of end-of-life care from quantity to quality is very difficult. Unfortunately, there is no easy way to reconcile this cognitive dissonance on the part of patients and their families. JAMA December 18, 2013 Volume 310, Number 23
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a NCSU Hunt Library User on 05/17/2015
2493
