Dose escalated neoadjuvant chemoradiotherapy with dose-painting intensity-modulated radiation therapy and improved pathologic complete response in locally advanced esophageal cancer.

We compared pathologic complete response (pCR) rate, toxicity, and postoperative complications between patients treated preoperatively with 50.4 Gy versus dose escalation with dose-painting intensity-modulated radiation therapy (dp-IMRT) to 56 Gy in locally advanced esophageal cancer. We evaluated esophageal cancer patients treated between 2006 and 2014 with preoperative IMRT chemoradiation to a dose of 50.4 Gy versus 56 Gy. The endpoints were pCR and toxicity. We identified 113 patients (50.4 Gy: n = 40; 56 Gy: n = 73). There were no significant differences in tumor or patient characteristics. Patients treated with 56 Gy demonstrated a higher pCR rate (56.2% vs. 30.0%) and lower pathologic nonresponse rate (4.1% vs. 20.0%) compared to patients treated to 50.4 Gy (P = 0.008). This remained significant on multivariate analysis (OR 3.375 95%CI 1.3-8.8, P = 0.013). Patients treated to 56 Gy also had an improved 3-year locoregional control rate compared to those treated to 50.4 Gy (93.8% vs. 78.5%; P = 0.022). The estimated 3-year freedom from failure was also superior in the 56 Gy arm (73.7% vs. 52.2%; P = 0.051), approaching significance. There were no differences in treatment related grade ≥3 toxicities, hospital admissions, feeding tube, esophageal stent placement, or dilation. There was, however, a statistically significant increase in postoperative atrial fibrillation in patients treated with 56 Gy (30.1% vs. 12.5%; P = 0.036). There was no difference in postoperative 30 or 60 day mortality. Dose escalation to 56 Gy with dp-IMRT is safe and results in significantly higher complete pathologic response rates in esophageal cancer without an increase in treatment-related toxicity. Prospective trials using dp-IMRT are needed to address the role of dose escalation on pCR rate and survival in esophageal cancer.

Comparative outcomes for three-dimensional conformal versus intensity-modulated radiation therapy for esophageal cancer.

Emerging data suggests a benefit for using intensity modulated radiation therapy (IMRT) for the management of esophageal cancer. We retrospectively reviewed patients treated at our institution who received definitive or preoperative chemoradiation with either IMRT or 3D conformal radiation therapy (3DCRT) between October 2000 and January 2012. Kaplan Meier analysis and the Cox proportional hazard model were used to evaluate survival outcomes. We evaluated a total of 232 patients (138 IMRT, 94 3DCRT) who received a median dose of 50.4 Gy (range, 44-64.8) to gross disease. Median follow up for all patients, IMRT patients alone, and 3DCRT patients alone was 18.5 (range, 2.5-124.2), 16.5 (range, 3-59), and 25.9 months (range, 2.5-124.2), respectively. We observed no significant difference based on radiation technique (3DCRT vs. IMRT) with respect to median overall survival (OS) (median 29 vs. 32 months; P = 0.74) or median relapse free survival (median 20 vs. 25 months; P = 0.66). On multivariable analysis (MVA), surgical resection resulted in improved OS (HR 0.444; P < 0.0001). Superior OS was also associated on MVA with stage I/II disease (HR 0.523; P = 0.010) and tumor length ≤5 cm (HR 0.567; P = 0.006). IMRT was also associated on univariate analysis with a significant decrease in acute weight loss (mean 6% + 4.3% vs 9% + 7.4%, P = 0.012) and on MVA with a decrease in objective grade ≥3 toxicity, defined as any hospitalization, feeding tube, or >20% weight loss (OR 0.51; P = 0.050). Our data suggest that while IMRT-based chemoradiation for esophageal cancer does not impact survival there was significantly less toxicity. In the IMRT group there was significant decrease in weight loss and grade ≥3 toxicity compared to 3DCRT.

Women's HIV transmission risk perceptions and behaviors in the era of potent antiretroviral therapies.

The availability of potent antiretroviral medications has raised new concerns regarding continued HIV transmission risk behavior among seropositive persons. Relatively little is known about how women with HIV perceive secondary transmission risk in the context of HIV treatment advances. This study describes sexual risk perceptions and behaviors of 80 women enrolled in HIV outpatient care in 1999. Participants completed structured interviews assessing sexual risk perceptions, attitudes regarding severity of HIV disease, sources of HIV prevention information, and sexual practices during the previous 6 months. Medical histories including 6-month cumulative incidence of sexually transmitted diseases (STDs) were obtained from a clinic database. Thirty-five percent of the sample had engaged in unprotected intercourse or had been diagnosed with an STD in the past 6 months. Only 5% of women believed that medication-related reductions in viral load signify safer sex is unimportant, but 15% indicated they practice safer sex less often since the advent of new HIV treatments and 40% believed AIDS is now a less serious threat. These data suggest women's perceptions of diminished disease severity may be more influential than beliefs regarding diminished infectivity. Study results have implications for framing prevention messages for women and suggest that close integration of secondary prevention and clinical HIV services may be beneficial.

Finding the underserved: directions for HIV care in the future.

The demographic, behavior, and background characteristics of 4,804 participants in 17 national demonstration projects for HIV medical and/or psychosocial support services were coded for an index of "service need" or possible under-representation in the traditional healthcare system. Fifteen items were coded including status as a person of color, lack of private insurance, unemployment/disability, problem drinking, crack cocaine use, heroin use, other illicit drug use, less than 12 years of education, criminal justice system involvement, children requiring care while the patient receives services, sex work, being the sex partner of an injection drug user, unstable housing, primary language not English, and age less than 21 or over 55 years. Most (87.7%) of the program participants had four or more of these factors present. Through CHAID modeling, those groups with the highest levels of service need and vulnerability were identified. These data suggest that these projects, designed to attract and serve individuals potentially underrepresented in the health services system, had in fact achieved that goal. Implications of the changing demographics of the HIV epidemic for the health service delivery system are discussed.

Sources influencing patients in their HIV medication decisions.

The authors surveyed 202 patients (54.5% male; 62.4% African American) enrolled at St. Louis HIV clinics to identify the importance of various sources of influence in their HIV medication decisions. Physicians were the most important source for 122 (60.4%) respondents, whereas prayer was most important for 24 respondents (11.9%). In multivariate tests controlling for CD4 counts, Caucasian men were more likely than Caucasian women and African Americans of both genders to select a physician as the most important source. African Americans were more likely than Caucasians to mention prayer as the most important source. Caucasians and those rating physicians as the most important source were more likely to be using antiretroviral medications. Respondents identified multiple important influences-hence the potential for conflicting messages about HIV medications. These findings have implications for health education practices and behavioral research in the medical setting.

Key elements for implementing comprehensive health care models for persons with HIV: a stakeholder analysis.

A semistructured interview was conducted with 69 stakeholders in three university-based health care projects that were funded to provide an integrated continuum of care for persons living with HIV/AIDS. Data from the key informant interviews yielded composite indicators of familiarity with the service model, the importance of the elements in the service model, and the perceived quality of services provided by these innovative HIV service demonstration projects. Ratings of service quality were related to ratings of the respondent's knowledge of the service demonstration project, the importance of the various elements in the service continuum, and several indicators of stakeholder characteristics using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). The groups of stakeholders most likely to give the highest quality or success ratings for these projects are identified. The implications of these findings for developing collaborative and comprehensive service models for persons with HIV/AIDS are discussed.

Disclosure of HIV status to medical providers: differences by gender, "race," and immune function.

OBJECTIVE: The authors used data from a larger study to explore differences by gender, self-reported racial identification, and immune function in disclosure of HIV-positive serostatus to medical providers (dentists, family doctors, and emergency room [ER] and obstetrics-gynecology [ob/gyn] providers). METHOD: The authors analyzed interview responses from a convenience sample of African American and white men and women receiving HIV medical care at urban hospitals and clinics in St. Louis. Missouri. RESULTS: Of 179 respondents using at least one of three types of providers, 124 (69%) disclosed their HIV status to all applicable types of providers, 39 (22%) disclosed to only one or two types of providers, and 16 (9%) did not disclose to any of these types of providers. "Race" and CD4 count, but not gender, were independently associated with disclosure to dentists, family doctors, and ER providers in multivariate logistic regression analyses. CONCLUSIONS: Differences in disclosure rates, especially among patients who may be asymptomatic, suggest a need for public health education of both medical providers and patients with HIV.

Service needs and factors related to quality of life at time of service enrollment among persons living with HIV.

This article explores the relationships of HIV risk factors, service needs, and vulnerabilities to health-related quality of life in a sample of 1,371 participants newly enrolled into 13 innovative HIV/AIDS treatment model service demonstration projects. These projects targeted services to traditionally underserved populations. Eight distinct quality of life clusters of HIV patients were used in this analysis along with patient self-identified risk factors. The quality of life clusters were based on patient self-reported quality of life dimensions. The eight clusters were differentiated based on relative strengths and weaknesses in physical functioning, energy levels, and social functioning. Data on patient need-vulnerability factors and demographic characteristics were related to these eight clusters using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Through this method, the characteristics most likely to be associated with higher and lower levels of quality of life at the time of enrollment into services were identified. The results provide further support that quality of life assessment is a useful clinical tool for monitoring patient progress.

Women with HIV: conflicts and synergy of prayer within the realm of medical care.

In a recent survey of women with HIV, prayer was mentioned as a very important source in decision making about HIV antiretroviral therapy. As a follow-up to this finding, we conducted in-depth interviews with 51 women attending a comprehensive HIV care center to better understand the role of prayer in their decisions about taking antiretroviral therapy. The sample consisted predominately of African American (80%) women with a median age of 31 years from St. Louis and surrounding areas. Forty-seven (92%) reported that prayer was an important source for HIV medication decision making, with 30 (59%) considering prayer more important than the physician. Twenty-nine (57%) perceived a qualitative difference between prayer and the physician, which created a sense of conflict for some. Thirty (59%) wished that the physician knew more about the role of prayer in their lives. Our findings reveal compelling issues: (a) the willingness of the women to talk about prayer as a resource and its importance in HIV disease management, (b) the roles that prayer and the physician play in HIV medication decision-making, and (c) ways prayer can be addressed in a medical setting.

Factors associated with HIV-infected patients' recognition and use of HIV medications.

In 1996, we interviewed 224 HIV-infected patients (54% men, 63% African American) receiving HIV medical care in St. Louis, Missouri about their recognition, prior use, and current use of HIV medications. Of 221 respondents who had heard of at least one antiretroviral drug, only 2 respondents reported they had never taken antiretroviral drugs. Multivariate logistic regression among respondents with CD4 counts <500 cells/mm3 identified sociodemographic variables (gender, race, education, and site of care) that were significantly (p < .05) associated with never having heard of, never having used, and not currently using specific antiretroviral drugs. African Americans in general, African American women, or African Americans with 12 years of schooling were more likely never to have heard of didanosine (ddI)/zalcitabine (ddC), stavudine (d4T), lamivudine (3TC), protease inhibitors, and non-nucleoside reverse transcriptase inhibitors (NNRTIs). In addition, women were more likely never to have heard of protease inhibitors, and respondents with < or = 12 years of schooling were more likely never to have heard of NNRTIs. African Americans were more likely never to have taken azidothymidine (AZT), and African American women were more likely never to have taken 3TC and protease inhibitors. Sociodemographic variables were not significantly associated with current use of specific antiretroviral drugs among those with CD4 levels <500 cells/mm3, nor with recognition, prior use, or current use of Pneumocystis carinii pneumonia prophylaxis among those with CD4 counts <200 cells/mm3. Findings indicate that, even among patients receiving HIV care, African Americans, women, and those with < or = 12 years of schooling were more likely never to have heard of and never to have used various specific antiretroviral medications. More focused efforts are needed to help patients become aware of available antiretroviral drugs and to encourage greater use of these drugs among all patients for whom the drugs are indicated.

Building comprehensive HIV/AIDS care services.

This article presents the experiences of three innovative programs for HIV/AIDS-related health care funded by the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Program. The Comprehensive Healthcare projects were funded as part of a larger initiative for innovative HIV service delivery models, consisting of 27 grantees, the funding agency (HRSA), and an Evaluation and Dissemination Center. These projects--the University of Nevada School of Medicine's Early Nutrition Intervention in HIV and AIDS project, the University of Vermont and State Agricultural College's Rural HIV Service Delivery project, and Washington University School of Medicine's Helena Hatch Special Care Center for Women--have developed specialized medical care models within the context of a continuum of services in a medical clinic. This article serves to describe the initial experiences of these three service demonstration projects, and some of the lessons learned as a result of their implementation. All of these projects share the goal of providing integrated services, such as medical care, nutrition, case management, and social and mental health services to people living with HIV/AIDS. However, the projects target different populations, (e.g., those in rural areas versus those in a large inner city), and use contrasting service delivery models of comprehensive HIV care. These projects have undertaken diverse activities and have used numerous effective strategies to increase their ability to provide a continuum of care and services for people living with HIV/AIDS. Based on the valuable lessons that the Comprehensive Healthcare projects learned during the first 2 years of funding, a number of collective recommendations have been made. It is expected that these suggestions will prove extremely useful to other programs that consider offering comprehensive health-care services to people living with HIV/AIDS or other complex medical conditions.

Attitudes and practices of hemophilia care providers involved in HIV risk-reduction counseling.

Hemophilia physicians, nurses, and social workers attending a national conference were asked to complete a questionnaire assessing their attitudes and practices regarding HIV risk-reduction counseling. All of the 150 respondents reported recommending the use of condoms to their clients, but only two-thirds felt comfortable demonstrating a condom, while fewer could explain condom choices or how to make safe sex more pleasurable. Less than half questioned their clients about history of STDs, sexual practices, or level of sexual satisfaction. Those who devoted 50 percent or more time to HIV risk-reduction efforts reported being more complete in their assessment and more comfortable in their counseling role. Providers claimed it would help if they had more time (84%) and better skills (64%, especially nurses) for this practice. Because HIV prevention services in hemophilia are delivered by a team, further studies are required to determine the aggregate impact of their intervention on the client.