Reports from the field-Disease management

AIDS patients need dedicated units

A study by researchers at the University of Pennsylvania in Pittsburgh concludes that AIDS patients experience better outcomes when treated in dedicated AIDS units and magnet hospitals than when treated in general hospital units.

Researchers compared differences in the 30-day mortality rates and care satisfaction rates of AIDS patients in dedicated AIDS units, scattered bed units in hospitals with and without dedicated AIDS units, and in magnet hospitals. In total, researchers analyzed data on 1,205 patients in 40 units in 20 hospitals and on 820 nurses working in those hospitals.

Results include:

• Patients in magnet hospitals had odds of dying that were lower by a factor of 0.40 compared to patients in conventional scattered bed units.

• Patients in dedicated AIDS units and scattered-bed units of hospitals with dedicated AIDS units had lower odds of dying by factors of 0.61 and 0.56 respectively compared to patients in conventional hospitals.

• An additional nurse per patient day reduced odds of dying in 30 days by more than 50%.

• an increase of .25 nurses per patient day lowered the odds of dying in 30 days by 20%.

• Patients whose physicians were not associated with an AIDS specialty service were roughly three times more likely to die in 30 days than those patients whose physicians were associated with an AIDS specialty service.

[See: Aiken LH, Sloane DM, Lake ET, et al. Organization and outcomes of inpatient AIDS care. Med Care 1999; 37:760-772.]

Centers lack resources for asthma care

Federally funded community health centers often lack the resources needed to follow current guidelines for optimal asthma care, according to a recent study in the Journal of the National Medical Association.

Researchers collected data on community health center clinicians, pharmacy services, and patient characteristics from 35 community health centers in eight southeastern states during a 12-month period. More than 60% of patients treated in those centers had incomes below the poverty level, and nearly 75% were either uninsured or receiving Medicaid.

Current national guidelines for asthma treatment emphasize early use of anti-inflammatory medication, especially steroid inhalers. Underuse of inhaled steroids has been associated with higher asthma hospitalization rates, and overuse of beta-agonist medication has been associated with increased asthma symptoms, morbidity, and even death.

83% provided no peak flow meters

A review of asthma treatment in the 35 community health centers found:

• 82% of centers provided beta-agonist inhalers, but 46% provided no steroid inhalers to patients.

• 83% of centers provided no peak flow meters to asthma patients.

• 65% of centers were unable to provide simple spacers to maximize the benefit of metered inhaler doses.

• Drug samples were the most common resource that centers used to treat low-income patients.

[See: Rust GS, Murray BS, Octaviani H, et al. Asthma care in community health centers: A study by the Southeast Regional Clinician's Network. J Natl Med Assoc 1999; 91:398-403.] t

Stem-cell transplant benefits blood cancers

The largest study to date comparing stem-cell transplant outcomes to those of bone-marrow transplant found that stem-cell transplants offer clear advantages. The findings offer hope for patients with advanced-stage leukemia and those who have suffered one or more relapse as well as patients with lymphomas that did not respond to treatment, according to a report presented at the 41st Annual American Society of Hematology meeting held recently in New Orleans.

In a three-year, multi-center study, 168 patients with a variety of blood cancers were randomly assigned to receive either bone-marrow or stem-cell transplants. The two-year survival rate among the marrow transplant patients was 45% compared to 70% for the stem-cell patients.

Patients may get 'best of both worlds'

"The results are exciting because most strategies aimed at reducing relapse are associated with higher toxicities, more complications, and higher mortality," says researcher William Benzinger, MD, with the Fred Hutchinson Cancer Research Center's Clinical Research Division in Seattle. "This data suggests that stem-cell transplants may offer the best of both worlds: fewer relapses with fewer complications."

The evidence is convincing enough that the Fred Hutchinson Cancer Research Center has switched from bone-marrow transplants to stem-cell transplants for its high-risk patients, says Benzinger. However, he adds that the advantage of stem cells over marrow transplants for low-risk patients remains less clear due to a lack of data.

In addition, other studies in the literature suggest that stem-cell patients have higher rates of chronic graft-vs.-host disease, which may not occur until three to five years after transplant. In a delayed reaction, the donor immune cells attack the patient's skin, liver, eyes, mouth, esophagus, and joints and must be controlled with immune suppression drugs.

"We won't know for another year or two whether chronic graft-vs.-host disease shows up among these patients," notes Benzinger.

[For more information, visit the center's Web site at www.fhcrc.org.]