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A method to rapidly identify the presence of chronic pain would enhance the care of HIV-infected individuals, but such an instrument has not been assessed in this population to date. We assessed the construct validity of the two-question Brief Chronic Pain Questionnaire (BCPQ) in HIV-infected patients by assessing the association between BCPQ responses and known correlates of chronic pain. Participants in the University of Alabama Center for AIDS Research Network of Integrated Clinical Systems cohort completed the BCPQ, along with the EuroQOL to assess physical function, the PHQ-9 to assess depression, and the PHQ-anxiety module to assess anxiety. Among 100 participants, 25% were female, the mean age was 45 (SD 12), 63% were African American, 27% were publicly insured, the median CD4(+) T cell count was 572 cells/mm(3) (IQR 307-788), and 82% had an undetectable viral load. Participants with chronic pain were more likely to have impaired mobility (43% vs. 12%, p=0.001), difficulty with usual activities (47% vs. 12%, p<0.001), lower overall health state (70 vs. 84, p=0.002), pain today (80% vs. 27%, p<0.001), depression (30% vs. 15%, p=0.10), and anxiety (43% vs. 10%, p<0.001) than those without chronic pain. This study provides preliminary evidence for the BCPQ as a brief questionnaire to identify the presence of chronic pain in HIV care settings.

Background: Many HIV-infected patients in the current treatment era have substantial symptom burden, but few HIV palliative care clinics have been described. Our objective was to describe the University of Alabama at Birmingham (UAB) HIV palliative care clinic (HPCC) and compare it to the overall HIV clinic., Methods: We conducted a chart review of patients referred to the HPCC between April 2008 and June 2011. We evaluated the reason for referral and other issues addressed during palliative care visits. Patient Reported Outcome (PRO) data was used to assess depression (PHQ-9), anxiety (PHQ-A), and substance abuse (ASSIST)., Results: Among 124 patients, mean age was 44 (range 27-64), and median CD4 count was 352 cells/mm(3) (IQR 209-639). Depression (43, 35%), anxiety (40, 32%), and current 8 (7%) or prior 68 (56%) substance abuse occurred at higher rates than in the overall HIV clinic (p<0.05). Pain was the most common reason for referral (118, 95%); most was chronic (113, 90%) and included back pain (26, 21%) and neuropathic pain (15, 12%). Other problems commonly addressed by the palliative team included nonpain symptoms such as depression (39, 48%) and anxiety (17, 21%), insomnia (25, 30%), and constipation (26, 32%)., Conclusions: This is the first description of a palliative care clinic embedded within an HIV primary care clinic in a developed country that sees patients at all stages of illness. Chronic pain and nonpain symptom management in patients with psychiatric and substance abuse comorbidities are important components of ambulatory palliative care for HIV-infected patients.

Background: Increases in multimorbidity and obesity have been noted in HIV-infected populations in the current treatment era. Patterns of multimorbid disease clustering and the impact of obesity on multimorbidity are understudied in this population., Methods: We examined obesity and multimorbidity patterns among 1844 HIV-infected patients in the UAB 1917 Clinic. Exploratory factor analysis was used to identify the underlying factor structure responsible for clustering. Patterns among the resulting morbidity factors by body mass index (BMI) category were explored. Multivariable logistic regression models were fit to identify predictors of multimorbidity cluster patterns., Results: The prevalence of multimorbidity was 65% (1205/1844). Prevalence increased with progressive BMI categories from underweight (64%) to obese (79%). Three multimorbidity clusters were identified: "metabolic," including hypertension, gout, diabetes mellitus, and chronic kidney disease (range, 0.41-0.84; P < 0.001); "Behavioral," including mood disorders, dyslipidemia, chronic obstructive pulmonary disease, chronic ulcer disease, osteoarthritis, obstructive sleep apnea, and cardiac disorders (range, 0.32-0.57; P < 0.001); "Substance Use," including alcohol abuse, substance abuse, tobacco abuse, and hepatitis C (range, 0.53-0.89; P < 0.001). Obesity was associated with increased odds of multimorbidity (obese vs. normal BMI category: OR = 1.52, 95% CI: 1.15 to 2.00)., Conclusions: Three patterns of disease clustering were identified. Obesity was associated with a higher likelihood of multimorbidity. The management of multimorbidity and obesity will need to be addressed in future clinical practice guidelines to enhance long-term outcomes of HIV-infected patients in the current treatment era.

Background: Poor prognosis in heart failure (HF) patients with diabetes is often attributed to increased co-morbidity and advanced disease. Further, this effect may be worse in women., Objective: To determine whether the effect of diabetes on outcomes and the sex-related variation persisted in a propensity score-matched HF population, and whether the sex-related variation was a function of age., Methods: Of the 7788 HF patients in the Digitalis Investigation Group trial, 2218 had a history of diabetes. Propensity score for diabetes was calculated for each patient using a non-parsimonious logistic regression model incorporating all measured baseline covariates, and was used to match 2056 (93%) diabetic patients with 2056 non-diabetic patients., Results: All-cause mortality occurred in 135 (25%) and 216 (39%) women without and with diabetes (adjusted HR = 1.67; 95% CI = 1.34 to 2.08; p<0.001). Among men, 535 (36%) and 609 (41%) patients without and with diabetes died from all causes (adjusted HR = 1.21; 95% CI = 1.07 to 1.36; p = 0.002). Sex-diabetes interaction (overall adjusted p<0.001) was only significant in patients > or = 65 years (15% absolute risk increase in women; multivariable p for interaction = 0.005), but not in younger patients (2% increase in women; p for interaction = 0.173). Risk-adjusted HR (95% CI) for all-cause hospitalisation for women and men were 1.49 (1.28 to 1.72) and 1.21 (1.11 to 1.32), respectively, also with significant sex-diabetes interaction (p = 0.011)., Conclusions: Diabetes-associated increases in morbidity and mortality in chronic HF were more pronounced in women, and theses sex-related differences in outcomes were primarily observed in elderly patients.

The Veterans Administration Hospital-Based Home Care Program provides comprehensive primary care to homebound veterans. Unlike Medicare-funded home care, it is not oriented to episodic provision of skilled nursing care, but rather to long-term primary care in the home. The interdisciplinary composition of HBPC teams allows for innovative approaches to care and coordinated implementation of treatment plans. Outcomes assessment of care provided through HBPC has been positive, suggesting an overall improvement in function and decrease in health care costs among those using the HBPC Program. The HBPC Program offers a tested model of primary home care within a "managed care" model. Its positive features should be considered by those initiating managed primary home care within the private sector.

The purposes of this study were to assess comprehensively the nutritional status of frail older adults living in an urban area and to identify factors associated with nutritional insufficiency. Subjects were 49 adults aged > or = 65 y followed by the Jefferson County Home Health Department. Twenty-nine percent of the women and 63% of the men had a body mass index (BMI; in kg/m2) < 24. Nineteen percent had serum albumin concentrations < 35 g/L (3.5 g/dL). More than one-half of the subjects reported symptoms of oral health problems. The key dependent variables were serum albumin concentration and BMI. In univariate analyses, a lower BMI correlated with oral symptoms, male sex, increased age, and less education. Lower serum albumin concentrations were associated with advanced age, increased dependence in Activities of Daily Living (ADL), oral symptoms, and presence of a caregiver. A stepwise multiple-regression model for BMI and serum albumin showed that predictors of low BMI were increased age, less education, difficulty in chewing, and absence of dentures. Variables in the model for lower serum albumin concentrations were sex, increased age, increased dependence in ADLs, and wearing of dentures. In a secondary analysis that controlled for age, education level, functional status, and sex, oral symptoms remained associated with lower BMI but not with lower serum albumin concentrations. This study found a high prevalence of undernutrition in urban homebound older adults and suggests that oral health disability may affect nutritional status in this population.