Gail Connor Roche

 increased significantly, to 6.1% during a decade of time ending in 2014, according to new US hospital-based research.

In new analysis, investigators have found the proportion of patients with MS receiving palliative care and to have died in the hospital research that considered more than 225,000 people in US hospitals shows.

The rate of palliative care in MS patients to have died in the hospital increased from 7.7% to 58.8% over 10 years, a team led by Jay J. Shen, PhD, at the University of Nevada Las Vegas School of Community Health Sciences, found. At the same time, costs associated with hospitalization were less for MS patients receiving palliative care than for those not getting such care.

This was true even though patients in palliative care spent slightly more time in the hospital, and were more likely to die there.

“If clinical interventions are exhausted to improve patient outcomes and quality of life, the palliative care option may be better off for patients for symptom management and comfort,” Shen told 

 “It could be suggested to patients and families as early as possible in these kinds of situations.”

MS is one of the most common degenerative neurological diseases, affecting 400,000 individuals in the US and more than 2.5 million worldwide. Previous palliative care studies have considered people with cancer and non-cancer chronic diseases.

Some of this work has shown that hospital palliative care reduced the length of stay (LOS) and in-hospital deaths in the intensive care unit among the terminally ill, investigators wrote.

Until now, there has been little research on in-hospital palliative care for MS patients.

Shen and colleagues in Las Vegas and South Korea set out to investigate the 10-year trend. They used the national inpatient sample, the largest all-payer inpatient care database in the US. This allowed them to identify the patient and clinical characteristics associated with receiving palliative care and to assess whether palliative care affects hospital utilization and costs.

Their results differed from previous studies in which patients typically had shorter hospital stays and fewer in-hospital deaths. In comparison, MS patients who received palliative care stayed .444 days longer in the hospital than MS patients who did not receive such care.

Further, MS patients referred to in-hospital palliative care were 15.35 times more likely to die there than non-palliative care patients, although the overall in-hospital death rate was similar from 2004-2015.

On average, 31.5% of patients who received palliative care died while 2.4% of patients who did not receive palliative care died in the hospital, Shen said. Both figures rose during the study period, from 7.7% and 0.1%, respectively, in 2005, to 58.8% and 5.4%, respectively, in 2014.

Shen explained that patients were referred to palliative care after life-sustaining treatment was attempted. Such referrals may happen later with MS patients.

The study also showed total charges for MS patients who received palliative care averaged $2261 less than the costs for MS patients who did not receive such care — even with the slightly longer hospital stays for palliative care patients.

“If patients receive palliative care services instead of more expensive and aggressive clinical procedures such as mechanical ventilation, nutrition support through a feeding tube or parenteral support, the cost of care could be lower even if patients stay in the hospital a little longer,” Shen noted.

The team found a dramatic single-year increase in MS palliative care between 2010 (1.5%) and 2011 (4.5%), which could be attributable to the Affordable Care Act (ACA) becoming law in 2010.    

When speculating on the difference of palliative care results between patients with MS and other conditions, Shen suggested this may just be due to that many patients were referred to such care once dying in the hospital.

On the other hand, he noted that if MS patients were not dying, they were less likely to be referred to palliative care.

“Unfortunately, the data we used did not enable us to clearly confirm this speculation,” Shen said.

Shen concluded that palliative care may serve as a cost-effective option for patients with MS “when traditional clinical interventions are not effective and are unable to improve patients’ quality of life and satisfaction.”

 “The disease is not curable with the current medical science and technologies,” Shen said. “Patients and caregivers need help with symptom management, such as pain control, and caregiver support as disability increases throughout the disease course, which may maintain patients’ quality of life and satisfaction.”  

Ten-year trends of palliative care utilization associated with multiple sclerosis patients in the United States from 2005 to 2014

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The rate of palliative care in patients with multiple sclerosis to have died in US hospitals increased from 7.7% to 58.8% over 10 years

Multiple Sclerosis Palliative Care Spikes in United States

Influenza vaccinations among patients with diabetes rose by 20% when they were notified about scheduling their flu shot, according to a new study.

The findings, which assessed the benefits of healthcare providers issuing scripted flu shot reminders to patients, further demonstrated the need for active intervention in the face of vaccination rates among susceptible patients, including diabetes, study co-author Vishaal Kumar Dovedi, a medical student at Barts and the London School of Medicine and Dentistry, said in an interview with 

“The interventions used in this audit highlight the effectiveness of patient notification, in particular telephone calls, in improving this,” Dovedi said.

People with diabetes are estimated to be 6 times more likely to be hospitalized during influenza epidemics than their nondiabetic counterparts—a rate which institutions such as the World Health Organization call attention to in efforts to improve vaccination rates.

“Diabetic patients have impaired immune systems as a result of the high levels of circulating glucose in their blood,” Dovedi said. “This increases the susceptibility to infections including the influenza virus.”

Continue reading with our sister publication at 

Flu Vaccination Reminders Prove Effective for Patients With Diabetes

Lifestyle choices that an individual has the power to change can influence 

, according to a new study results involving more than 1000 patients.

The results lend to the notion that physicians managing patients with MS should be more aware of what’s a growing rate of literature linking unhealthy lifestyle behaviors and depression risks, as well as the means of modifying such risk factors, author George A. Jelinek, MBBS, MD, of the University of Melbourne, told 

About half of all MS patients experience an episode of depression during their lifetimes, but little is known of particular treatment options. Most interventions are drug-related or psychiatric, investigators wrote

Depression appears to accelerate the disease process according to the best available current evidence,” Jelinek said. “It is thus very important for people with MS to be proactive about preventing and managing depression.”

To investigate potential new approaches to help MS patients address depression, investigators researchers considered modifiable lifestyle factors including diet, vitamin D and omega-3 supplementation, exercise, meditation, alcohol, and smoking. They built on their previous work with an international sample of MS patients who’d supplied detailed information on their lifestyles.

That search considered 2466 participants, of whom 2224 (88.9%) completed the Patient Health Questionnaire-2 (PHQ-2), which asks about the frequency of depressed moods over the previous 2 weeks. Of those patients, 19.3% screened positive for depression.

The results presented “strong and clinically meaningful” associations between modifiable lifestyle risk factors and depression prevalence, investigators noted. The current study considered depression in these patients 2.5 years later.

Of the original group, 1309 individuals (93.4%) completed the PHQ-2 evaluation; 1264 (90.2%) filled out a PHQ-9 questionnaire, which assesses depression risk.  The prevalence of depression in this review was estimated at 14.5% using the PHQ-2, and 21.7% using the PHQ-9.

“As very few people changed their depression status, there was little possibility of identifying factors that predicted such a change,” Jelinek said. “We were only able to determine that alcohol consumption, diet quality and vitamin D supplement use were predictors of a change in depression status after adjusting for confounders.”

However, he noted that looking at the sample after 2.5 years—as the team had done at baseline in their previous paper&mdash;healthy lifestyle behaviors were again contemporaneously associated with improved depression status.

Current smokers were significantly more likely to have scores indicative of prevalent depression risk, based on both the PHQ-2 and PHQ-9 questionnaires. In addition, the positive associations of current smoking with depression risk were much stronger for major depression.

“Being or becoming a non-smoker clearly has multiple direct and indirect benefits for people with MS,” the researchers said.

Vitamin D and omega-3 supplementation were associated with lower frequencies of depression risk in both questionnaires. However, only the association of vitamin D supplementation to depression screening and severity persisted after the data were adjusted for potential confounders.

While the authors discovered no association between diet quality and depression risk, they did find an association between diet quality and depression severity.

“A whole food plant-based diet has been recommended for people with MS and more widely for general health,” they said.

Low physical activity was strongly associated with increased depression risk and severity. However, the team did not find an association between physical activity and a change in depression risk.

Meditation was associated with lower depression in the 2.5-year follow-up. But findings again did not indicate meditation to be associated with depression trajectory in this period.

Investigators noted that moderate alcohol intake results in a significant reduction of pro-inflammatory cytokines, “reducing inflammation, suggesting a mechanism of preventing and potentially treating depression.”

Moderate alcohol consumption was associated both with a greater probability of a patient becoming depression-free and a reduced risk of a patient becoming depressed at all, the Melbourne-based research team found.

Diet quality and vitamin D supplement use were also predictors of a change in depression status, Jelinek added. The team stressed that their findings need to be validated in more MS patient groups and supported in controlled trials.

“While we would expect to be able to better determine predictors over longer time periods of observation as more people change their depression status, our data add to the growing literature showing an important potential role for healthy lifestyle behaviors in preventing depression in the at-risk group,” Jelinek said.

The study, "Longitudinal Associations of Modifiable Lifestyle Factors With Positive Depression-Screen Over 2.5-Years in an International Cohort of People Living With Multiple Sclerosis," was published online in 

Health care providers managing patients with MS should remain cognizant of the link between unhealthy lifestyle behaviors and depression risks.

Lifestyle Choices May Drive Depression Associated with Multiple Sclerosis

Hispanic adults in the US who are infected with human immunodeficiency virus face a greater risk of cancers caused by human papillomavirus (HPV) than Hispanics in the general public, a new study has found.

The highest excess risk was observed for anal cancer, Ortiz said, highlighting the increased burden of this malignancy among HIV-infected individuals.

In general, the high incidence and strong persistence of HPV infections among HIV-infected patients are a result of immunosuppression. This, in turn, leads to carcinogenesis and tumor development.

To zero in on Hispanics, Ortiz and colleagues from the National Cancer Institute and other US cancer centers reviewed data from the HIV/AIDS Cancer Match Study collected by state registries. Investigators considered both the incidence and survival rates among Hispanics, non-Hispanic whites (NHW) and non-Hispanic blacks (NHB).

Among Hispanics living with HIV, there were 502 HPV-related cancer diagnoses during 864,067 person-years of follow-up. Except for oropharyngeal cancer, the risk of HPV-related cancers was higher among HIV-infected Hispanics than in the general population, investigators noted.

When the researchers compared Hispanics with HIV to NHWs and NHBs with HIV, they found that the Hispanics had higher rates of cervical and penile cancer.

Hispanic adults in the US who are infected with human immunodeficiency virus face a greater risk of cancers caused by human papillomavirus (HPV) than Hispanics in the general public.

Hispanics with HIV at Greater Risk of HPV-Related Cancers

Health care providers’ stigma toward patients with HIV is holding back HIV prevention goals, a study from the US Centers for Disease Control and Prevention (CDC) suggests.

“National HIV screening recommendations place health care providers at the helm in the fight against HIV,” Angelica Geter, DrPH, MPH, research fellow, CDC’s Division of HIV/AIDS Prevention told 

. “However, stigmatizing attitudes, beliefs, and behaviors toward vulnerable populations and people with HIV can impede progress.”

More than 1.2 million people in the US are living with HIV infection and more than 39,000 new cases are diagnosed each year, Geter and coauthors wrote in 

When providers fail to recognize and combat HIV stigma in their ranks, undiagnosed persons with HIV may go unidentified and fail to get quality care and treatment. This can limit the number of people with HIV who are virally suppressed, Geter said.

“HIV-related stigma continues to be a prevalent issue for people living with HIV and people who are vulnerable for HIV,’’ the researchers wrote. “Less stigmatizing attitudes by providers can help to reduce social and structural barriers to HIV care across the continuum.”

To explore the extent of HIV stigma in health care settings and its effect on patients, the team reviewed relevant studies published between January 2010 and July 2017. They used such keywords as “social stigma,” “discrimination,” and “health care providers” to find studies.

The search yielded 6 of 619 articles that were unique to provider perspectives of HIV-related stigma. These were included in the team’s final review.

Three themes emerged from the analysis: attitudes, beliefs, and behaviors among providers; quality of patient care; and education and training of personnel. Gender, race, religion, the type of provider, and the clinical setting all affected stigmatizing behaviors, attitudes, and beliefs.

White, male, primary care physicians and providers who had limited or no HIV stigma training in the past 12 months stood out for stigmatizing tendencies.

“Male white providers and those who work in HIV/sexually transmitted infection clinics were significantly more likely to hold stigmatizing attitudes toward people living with HIV (PLWH),” the authors wrote.

Provider stigma was less likely among those who worked in settings where policies that focused on the problem were reinforced.

“Stigma can be manifested through inadvertent behaviors and ideologies, such as homophobia, transphobia, racism, and negative views of persons who inject drugs, and can create uncomfortable environments and act as a barrier to HIV prevention, treatment, and care,” the authors wrote.

The analysis suggested that patients are often stigmatized as being poor, having a high number of sexual partners, and engaging frequently in risky sexual behavior. Stigma was found to hurt the quality of care HIV patients receive.

“Provider fear of acquiring HIV through occupational exposure led to reduced quality of care, refusal of care, and anxiety when providing services to people with HIV,” Geter said. “This fear was higher among providers with limited awareness of, or access to, post-exposure prophylaxis (PEP) within their healthcare setting or clinic.”

Providers and non-HIV specialty doctors were more likely to exhibit stigma if they had limited opportunities for clinical education.

The researchers suggested several ways to counteract provider stigma. Health professionals might consider assessing themselves and their attitudes via online surveys such as “Test Yourself for Hidden Bias.”

Clinical practices can diversify their workforce and provide HIV sensitivity training.

Clinicians can also adopt an “opt-out” approach to HIV testing, in which patients are informed that an HIV test will be performed unless they explicitly decline, the authors wrote.

“Prevention interventions and policies in various health care settings can be informed by better understanding how healthcare provider stigma may influence HIV care,” Geter said.

“Understanding and addressing health care provider stigma will have an effect on HIV engagement and care by allowing patients to feel more supported during their HIV diagnoses and lifetime of HIV-related medical interactions,” she added.

HIV-Related Stigma by Healthcare Providers in the United States: A Systematic Review

Stigma may cause undiagnosed individuals with HIV to go unidentified and fail to get quality care and treatment. 

Persistent Stigma Among Providers Inhibits HIV Prevention Goals

As many as three-quarters of individuals with hepatitis C virus (HCV) experience disorders related to the virus beyond the impact on their livers, the 

HCV-related kidney disease, depression, skin disorders, lymphoma and other conditions can seriously impact a patient, even without severe damage to the liver, studies have shown. There’s also growing evidence as to how HCV intersects with other disease states, Tina Broder, MSW, MPH, Program Director of NVHR, told 

 “Our hope in highlighting the extrahepatic manifestations of HCV is to show that curing HCV patients may help improve health conditions beyond liver function,” Broder said.

To publicize that point, NVHR is creating a campaign aimed at both clinicians and patients that emphasizes the importance of managing the virus as a system-wide condition. The group is distributing informational “

” produced from a review of scientific research and input from staff and a clinical consultant with expertise in HCV. The aim is to help make a business case for treating patients regardless of the severity of their liver disease and to broaden treatment access, Broder said.

As many as 3.9 million people in the US have chronic HCV, the US Centers for Disease Control and Prevention (CDC) estimates. Of every 100 individuals infected with the virus, 75 to 85 of them will develop chronic HCV. Five to 20 of these patients will progress to cirrhosis in 20 to 30 years. As many as 5 will die from cirrhosis or liver cancer, the CDC estimates.

Hepatitis C-related effects on parts of the body besides the liver can be an early indicator of HCV infection, NVHR says. And the virus may be driving other chronic conditions that primary care providers must spend their time managing.

“The evidence showing that HCV infection is a risk factor for other health conditions continues to grow,” Broder said. “Concurrently, research is beginning to show that in the era of direct acting antivirals (DAAs), early HCV treatment can cure and possibly prevent the development of extrahepatic manifestations associated with HCV.”

One of the virus’s most serious non-liver manifestations is mixed cryoglobulinemia (MC) vasculitis, a condition is characterized by a buildup in the blood of abnormal proteins, called cryoglobulins, which result from the body’s immune response to the presence of HCV.

“Over time, this leads to inflammation of blood vessels and disruption of blood flow to various parts of the body,” Broder said.

About 20% to 30% of individuals with MC vasculitis will experience kidney disease. As many as 10% will develop B-cell non-Hodgkin’s lymphoma, a cancer of the immune system. If not detected early, these conditions can be fatal. 

HCV also is associated with rare health conditions. Porphyria cutanea tarda is a skin disorder that results in painful lesions, abnormal hair growth, or changes in skin color. Sicca syndrome, which causes dryness of the eyes and mouth, is another uncommon HCV-related condition, Broder said.

“Perhaps more surprising is that HCV is also associated with common health conditions such as diabetes, cardiovascular disease, and depression,” she said. “HCV-infected individuals are at increased risk for these conditions compared to the general population.”

HCV patients with these chronic comorbidities are more likely to have poor health outcomes. A recent meta-analysis suggests that patients infected with hepatitis C are almost twice as likely to die from cardiovascular disease than those without the infection. 

“This highlights the importance of recognizing HCV as a disease that affects the entire body and understanding the role of HCV in a patient’s overall health,” Broder said.

NVHR will host a webinar in the spring featuring clinical experts and a patient perspective on the topic.

A majority of patients with hepatitis C experience disorders outside of the liver that are related to the virus.