Resident Choice Made Easier

A new tool enables better care planning, delivery, and quality management for older adults.

 FEBRUARY 2013

 Kimberly Van Haitsma, PhD

Now that person-centered care is becoming the new standard in post-acute and long term care settings, providers are increasingly shifting away from the traditional medical model toward a new focus on improving consumers’ quality of life. However, making this cultural shift—to meet individualized psychosocial and physical needs—can be challenging. Providers need practical, efficient tools to translate the vision of person-centered care into on-the-ground reality.

 

A team of researchers and clinicians at a senior care provider in Philadelphia developed a new assessment tool that captures the psychosocial preferences of older adults and speeds the adoption of more person-centered care practices.

 

Known as the Preferences for Everyday Living Inventory (PELI), this useful rubric yields vital data about older adults’ individual preferences for social contact, personal development, leisure, living environment, and daily routine.

 

It can also be used to assess health care access and family involvement in care and to help providers refine and customize care plans and service delivery.

 

Nursing homes may find PELI helpful as they shift from an institutional model of clinical efficiency toward a culture of greater responsiveness to residents’ wishes, interests, and desire for a sense of purpose and control.

 

It provides a useful level of specificity that can be deployed to guide staff training; measure quality improvement; and align services more closely with expectations of consumers, families, and regulatory agencies.

How PELI Works

PELI consists of 55 questions in five domains of daily life: social relationships, growth and diversionary activities, self-dominion, and enlisting others in care. Fourteen of the questions are consistent with the minimum data set (MDS) 3.0 for nursing homes but delve more deeply into residents’ preferences for everyday living.

 

Phrased in clear, conversational language, the questions elicit basic and in-depth insights about daily preferences, such as what time individuals like to wake up, take a shower, and get dressed, and what kinds of recreational activities they enjoy.

 

Professional and paraprofessional staff can administer PELI in one sitting, or over a series of conversations. Optimally, the questions are asked annually or at more frequent intervals, as well as when a person begins receiving service and experiences a significant change in status.

 

PELI is the first tool of its kind to pass rigorous scientific testing. In 2005, it was piloted with more than 500 home health clients enrolled in the Visiting Nurse Service of New York. The tool proved to be a reliable and valid measure of preferences and was well accepted by a wide range of older adults.

 

An advisory panel of long term care experts concurred that it covered the key aspects of daily life. While PELI has been tested in home health and nursing home settings, it is also designed for use in subacute, rehabilitation, and assisted living facilities. 

Residents’ Perspective On Sharing Preferences

In the pilot study, as well as at a 324-bed nursing facility, staff found that residents enjoy reflecting on what is important in their lives and appreciate the opportunity to voice their preferences to an interested listener. These kinds of focused, thorough discussions aren’t the norm in service settings. Yet they are deeply meaningful to consumers and form the foundation for comfortable, trusting relationships with staff.

 

Emerging research indicates that integrating preferences into care delivery for older adults is beneficial. When activities are appealing, or services are provided in a familiar way, seniors are more apt to be receptive, enjoy the experience, and feel validated. These positive feelings have a measurable effect on physical and mental well-being among people of all ages.

 

Data and insights elicited by PELI ensure that the consumer’s voice is heard and help the whole team—client, family, and staff—work together toward the same goals. At the nursing home, matching preferences to activities tripled resident participation in recreational activities.

 

PELI has also been used to assess broad-ranging outcomes. So far, its use has resulted in greater congruence between preferences and activities, leading to fewer behavior issues among residents, as well as reduced levels of depression and fewer falls.

 

Data are being compiled for a more comprehensive study of this dynamic.

Advantages For Providers

Direct care staff members use PELI to get to know consumers, build relationships, and devise more successful care plans. The questionnaire provides a consistent protocol to discover each client’s unique interests, passions, and priorities.

 

“PELI is a great tool for becoming better acquainted with new residents,” says Sarah Humes, a recreation therapy supervisor.

 

“It’s especially helpful for paraprofessional staff who may not have clinical training because it provides a way for them to learn more about the residents in their care and organize the information.”

 

The nursing home team divides up responsibility for different sections of the PELI questionnaire. Recreation therapists talk to residents about their activity preferences, and certified nurse assistants handle questions about activities of daily living. Staff implement what they learn immediately and share findings at team meetings where they collaborate to customize care plans.

A Positive Response

Humes says the process also improves job satisfaction. Findings inspire staff to stretch professionally to find ways to honor customer preferences. The tool asks seniors to talk about activities that they enjoy even if they feel that they can no longer do them. When the team understands what interests and motivates residents, they are eager to work collaboratively to prevent them from giving up treasured skills and activities prematurely.

 

PELI findings have also been used to assess individual practice, such as “Am I meeting Mrs. Jones’ preferences this week?” at the unit level. Recreational therapists now aggregate residents’ preferences on each 27-person unit household to plan program offerings that meet the group’s top shared priorities.

The resulting household activity board reflects residents’ authentic interests.

 

The nationally recognized Green House Project now uses PELI in its train-the-trainers curriculum for Green House adopters nationwide. Those selected to be educators, including nurses, social workers, and activity directors, practice using PELI with an older adult and create an engagement activity based on interview findings.

 

The exercise gives educators firsthand experience with deep listening and linking preference assessment to care.

 

“PELI provides specificity for a paradigm shift that’s key to forming deep, knowing relationships with elders,” says Susan Frazier, Green House Project chief operating officer. “It helps sensitize direct care staff so they can offer life-enriching experiences that are significant to each elder. For example, residents love being asked not just if they like to read, but what they like to read and how important reading is to them.”

 

A Philadelphia nursing home began using PELI this year to measure delivery of person-

centered care. Without a structured system to gauge resident preferences, activity programming reflects the recreational therapist’s best guess as to what a resident wants. Recreational options may be biased or limited by the therapists’ own interests.

 

PELI’s impact is being measured by examining progress on one or more areas of person-centered care in both PELI and the MDS 3.0. Although quantitative data aren’t yet available, anecdotal feedback indicates that preference-based care yields better satisfaction for families, staff members, and especially residents.

When a trusted, understanding caregiver presents activities or services in a palatable way, a resident is less likely to become frustrated, confused, or agitated and more likely to become meaningfully engaged.

Studies show that staying active and connected socially are closely linked with preventing or mitigating symptoms of depression in nursing home residents.

Looking To The Future

The Abramson Center research team continues to refine the PELI tool by testing it with diverse populations of older adults. They are also conducting studies on the impact of preference-based care on nursing home residents’ quality of life, as indicated by the presence of depression or behavioral symptoms.

 

The Advancing Excellence in America’s Nursing Homes campaign recently has announced new goals that focus in part on person-centered care.

 

According to Mary Jane Koren, MD, immediate past chair of the campaign, the initiative will include PELI as one of the resources offered to nursing homes as part of its evidence-based toolkit of interventions and educational materials. “It’s an intuitively straightforward tool that’s useful not just for the long-stay population but for the short-stay population as well, because it allows you to frame rehabilitation programs around patient preferences,” says Koren.

 

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Nurses in drive for 'compassionate care'

COMMENTS (648)

More emphasis should be placed on nurses providing compassionate care in hospitals, industry leaders have said.

In a new campaign aimed at reassuring the public, chief nursing officer for England Jane Cummings said action must be taken to ensure the values nurses stand for are not betrayed.

The call comes amid concern over reported neglect and abuse in hospitals and care homes.

The Patients Association said the plans must be translated into action.

Following an eight-week consultation involving more than 9,000 nurses, midwives, care staff and patients, Ms Cummings will tell a conference in Manchester how she plans to embed values such as compassion, communication, and commitment in public health care.

'Poor care a betrayal'

It is more than three years since the scandal triggered by unusually high death rates at Stafford hospital provoked deep unease over the culture of care in the health service.

Since then a succession of inquiries and reports into the NHS and other care settings has reinforced these concerns, which have become an urgent political priority.

With the launch of Compassion in Practice - a three year strategy for nursing - Ms Cummings will call for new ways of measuring patient feedback, getting trusts to review their culture of care and their staffing levels and explaining in public how they impact on standards.

Ms Cummings is expected to say: "The context for health care and support is changing. Most significantly, with people living longer, we have a greater number of older patients and people to support, many with multiple and complex needs.

"And while the health, care and support system provides a good - often excellent - service, this is not universal. There is poor care, sometimes very poor. Such poor care is a betrayal of what we all stand for."

'Difficult to implement'

Speaking to BBC Radio 4's Today programme, Peter Crome, emeritus professor of geriatric medicine at Keele University, explained what the drive was aiming at.

He said: "I believe what they mean is that nurses and other care staff - whether they're in hospitals, hospices or in the community - should take a more caring and compassionate role when it comes to looking after vulnerable groups, rather than what is often seen as a very task-oriented approach."

Prof Crome said it was possible to focus on technical aspects of nursing at the same time as basic care, adding it was crucial to have care values "reinforced in the the training environment and the working environment".

In particular, he said it was important to observe, monitor, instruct and if necessary correct those training in care.

"But without adequate numbers of trained staff, this agenda - which must be welcomed - will be difficult to implement," he said.

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Why'd you call 911

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TELEMEDICINE

Telemedicine Facilitates
‘House Calls’

By Jessica Girdwain
Aging Well
Vol. 5 No. 6 P. 10
For older adults who don’t have the means to visit a doctor, the University of Rochester Medical Center (URMC) in New York may have a novel solution: telemedicine. It’s conducting a research project with 250 participating elders, evaluating the effectiveness of using technology that’s similar to Skype or videoconferencing to conduct medical evaluations—and it’s paying off.
“This technology is patient centered and completely revolutionary,” says Manish N. Shah, MD, MPH, an associate professor of emergency medicine, community and preventive medicine, and geriatrics/aging at URMC.
The technology is especially important in the geriatrics field. The shortage of geriatricians and the large number of aging baby boomers who will need care in the coming years will put a strain on doctors. Technology that streamlines the appointment process allows more patients to be cared for in a shorter period of time.
URMC is certainly in the top tier in telemedicine practice. The technology has been around for decades. In the 1960s, it was done via telephone lines in some cases. The technology wasn’t efficient and was very expensive. But the program has developed it into a viable tool that mimics a traditional office visit but is conducted from 20 or 30 miles away.
“It’s tough to go to an office if you’re an older adult. Maybe you have to arrange transportation to go to the doctor, or maybe you have functional limitations or can’t navigate a massive medical center. With this technology, elders don’t have to worry about those things,” Shah says.
Coordinating Personnel and Equipment
So how does it work? A telemedicine technician (typically a nurse practitioner, physician’s assistant, or EMT) travels to the patient’s home or elder care facility with equipment that will facilitate conducting a typical office visit. Equipment used may include an electronic stethoscope, high-definition video camera, and an otoscope, among other instruments. They all connect to the computer via USB ports. The technician asks the patient basic health questions, takes vital signs, and photographs the patient’s medical complaint, if necessary. Healthcare workers can provide access to other indicators too. For example, they can record lung sounds and upload data onto software for the physician to evaluate. They are also trained in drawing blood and taking X-rays.
The doctor then logs on to the computer from his or her office or hospital and reads through the patient’s history, looks at the photos, and considers any other pertinent information that may contribute to arriving at a diagnosis. If a prescription is needed, computer software allows the physician to send one to the appropriate pharmacy.
“The technology is so simple,” Shah says. “You can essentially do all of the things you normally do during an office visit, but this is via the Internet.”
The time required for the doctor to “see” the patient is five to 10 minutes. Because appointments don’t need to be live, physicians can review the information at a later time. The technician may spend 30 to 60 minutes per case, depending on the care needed.
“This is certainly more efficient for the physician because it gives the doctor all of the information that’s needed in a nice neat package,” Shah says. Most importantly, it benefits elderly patients by making them more receptive to care when they don’t have to leave their homes.
Expanding Medical Coverage
“For many elders, [they] would not get any care at all if it weren’t for telemedicine,” says Terry Rabinowitz, MD, DDS, director of psychiatric consultation and telemedicine services at the University of Vermont College of Medicine and Fletcher Allen Health Care in Burlington, Vermont. He provides necessary psychiatric care for patients in two nursing homes via telemedicine in both Burlington and upstate New York.
“Over 25% of the elderly population have psychiatric conditions that need to be addressed, like depression, dementia, and delirium. Without telemedicine, they may not get the help they need. Many of these patients live in rural areas, and a doctor is not able to drive hours to see them,” he says. For example, for Rabinowitz to see patients in upstate New York, he’d have to travel two hours one way for a one-hour consultation. Of course, allotting five hours per patient isn’t sustainable for any practice.
Another benefit Rabinowitz finds is that older patients simply enjoy the technology and are happy and touched that a doctor takes special pains to see them. “What it comes down to is that telemedicine is exactly like being there face to face. If the practitioner behaves as if the patient is in the room with them, the patient will behave that way too. It takes very little time to adapt to the videoconferencing approach. In fact, if I had to, I could conduct a consultation on my iPhone,” he says, although most of his consultations are done through traditional telemedicine methods.
Successful Strategy
Physicians interested in bringing this type of telemedicine to their practices should be aware of a few points, according to Shah. First, the ideal situation for telemedicine is based on a strong geriatrics practice. URMC’s program has enrolled 250 patients in their telemedicine project, resulting in about 10 visits per week, which provides insufficient volume to keep full-time technicians and practitioners employed. The model best caters to geriatricians who are partners in a practice because they can take care of patients in an assisted-living facility together.
Also, health practitioners should be aware that telemedicine equipment can range from inexpensive—for example, a $30 webcam—to as much as $30,000 for state-of-the-art high-definition equipment. The more expensive versions would transmit with a quality and resolution equivalent to watching a high-definition television show. But the cost largely depends on what functionality is required. For Rabinowtiz, the equipment he uses falls around $4,000 because with psychiatry, he needs a good-quality camera and video monitor. “I need to see facial expressions, but I might not need to see every wrinkle in the skin,” he says.
Start-up costs include buying equipment and paying a technician’s salary. It’s worth checking with insurance providers on potential coverage of related costs, according to Shah. It’s also important to build in time for technicians to train on the equipment. URMC provides a training program that teaches technicians to use new equipment and pairs them with a geriatrician to learn how to communicate with older adults. The full training process takes about one month.
— Jessica Girdwain is a Chicago-based freelance writer who has contributed health-related articles to several national magazines.

DEMENTIA RELATED BEAHVIOR MANAGEMENT

Dementia-Related
Behavior Management

By Mark D. Coggins, PharmD, CGP, FASCP
Aging Well
Vol. 5 No. 1 P. 32
Dementia describes a group of symptoms resulting in a gradual and progressive decline in memory, thinking, and reasoning abilities. While most dementias are progressive with no cure, approximately 20% are reversible. Healthcare professionals should closely evaluate patients with cognitive decline for possible underlying treatable conditions.
Medication-induced dementia is the most common cause of reversible dementia. Elders are especially vulnerable due to concomitant illnesses, reduced renal and liver function, and the simultaneous use of multiple medications.1
Other common reversible causes include depression, infection, high fever, vitamin deficiencies, poor nutrition, hypercalcemia, brain tumors, thyroid disorders, and hypoxia due to lung and heart diseases.
Alzheimer’s disease (AD) is the most common type of irreversible dementia. Other irreversible types include vascular or multi-infarct dementia, dementia with Lewy bodies (DLB), frontotemporal dementias (Pick’s disease), and Parkinson’s dementia (PD). Autopsy studies have shown that most dementia patients had brain abnormalities consistent with more than one dementia type.
Dementia Behaviors
In addition to progressive cognitive loss, almost all AD patients develop personality and significant behavioral changes. Mood disorders such as depression; nonpsychotic behaviors such as restlessness, wandering, and aggression; or psychotic symptoms, including hallucinations and delusions, often occur with severe disruptive behaviors, leading to 50% of nursing home admissions, according to the American Academy of Family Physicians.
Healthcare professionals should consider behaviors as a means of patient communication as AD patients lose their ability to adequately make their needs known. Agitation may be a result of underlying precipitating causes such as hunger, thirst, pain, or infection. Be aware that medication changes or poor hearing can increase confusion. Vision issues can contribute to visual hallucinations or increase a patient’s feeling of vulnerability or fear.
The failure to identify causes of these behaviors may leave a patient in distress and often results in the unnecessary use of behavior management medications. These may do little more than cause sedation and can lead to further cognitive decline, reduced patient activity, worsening incontinence, and falls, and make it more difficult for caregivers to provide assistance.
In cases where the behavior or psychiatric symptoms are severe, distressing, or may lead to harm, it may be necessary to prescribe medications.
Antipsychotic Use and Associated Risks
Antipsychotic use in dementia patients continues to be widespread despite clear and substantial risks to patient health.
All antipsychotic medications include FDA black box warnings due to the increased risk of death when used in dementia-related psychosis. Additional concerns include negative metabolic effects, weight gain, type 2 diabetes, dyslipidemia, and increased risk of stroke. Antipsychotics are also linked to a worsening decline in cognition consistent with one year’s deterioration compared with placebo.
Antipsychotics in AD patients should be reserved for behaviors that are harmful or when distressing psychotic features exist. They should be given short-term and at the lowest possible dose with frequent evaluation for discontinuation, according to the 2001 report “Psychotropic Drug Use in Nursing Homes” by the Office of Inspector General.
The widespread use of atypical antipsychotics despite the risks highlights the need for alternative behavior management medications and strategies.
Medication management in dementia patients can be complex. Unfortunately, no silver bullet exists for prescribers to call on to address dementia-related behaviors. Successful behavior management most often involves a combination of nonpharmacological approaches tailored to meet a patient’s needs in addition to one or more of the currently available medications, which often have limited supporting evidence in their effectiveness on behaviors.
Pain Treatment Can Influence Behaviors
Pain can diminish cognitive function, reduce patients’ ability to perform activities of daily living, adversely affect mood, and reduce quality of life.
In a 2010 study conducted at a Golden LivingCenter in Hendersonville, North Carolina,2 researchers found that increased pain management focus in nursing home patients with dementia helped reduce episodic behaviors. A certified geriatric pharmacist (CGP) provided education on pain assessment and treatment options to all nursing home staff and direct care assistants.
The CGP evaluated medical records of patients with such behaviors to determine whether common conditions known to cause pain, such as osteoarthritis, wounds, and neuropathy, were being treated. Recommendations based on the American Medical Directors Association pain management guidelines, including acetaminophen and other medications, were discussed with each patient’s physician, and appropriate medication changes were implemented. Following the treatment modification, the patients’ behaviors were tracked and were noted as significantly reduced, and nurses and nursing assistants noted that patients had become less resistant to care.
Additional follow-up discussions occurred between the nursing home interdisciplinary team and the CGP. As patient behaviors improved, the interdisciplinary team worked with prescribers to significantly reduce the number of antipsychotic, anxiolytic medications (benzodiazepines) and sedative/hypnotics being taken by these patients.2
Nursing home patients in Norway and England with moderate to severe dementia experiencing agitated behaviors had acetaminophen added to their existing pain orders or, if acetaminophen was already ordered, low doses of morphine, or they were given antiepileptic medications for neuropathic pain. Patients receiving more aggressive pain management had a significant reduction in undesirable behaviors. Following eight weeks of therapy, pain treatment added to the intervention group was gradually reduced. Follow-up four weeks later showed the recurrence of the behavior symptoms and further demonstrated the effectiveness of pain management in reducing negative behaviors.3
Cognitive Enhancers
Medications commonly given to slow the progression of cognitive loss in dementia have shown modest benefit in controlling behaviors.
In several studies, acetylcholinesterase inhibitors (AchEIs), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyme) demonstrated some success in reducing dementia behavioral symptoms, including apathy, anxiety, delusions, and hallucinations. These medications appear to be effective in treating psychotic symptoms in patients with DLBT and PD.
Memantine (Namenda), an NMDA receptor antagonist used alone and with AchEIs, has shown moderate improvements in behavioral symptoms, including agitation, aggression, irritability, lability, and delusions. Additional benefits have been seen when using memantine together with AchEIs.4
Antidepressants
Researchers have reviewed the evidence for the effectiveness and safety of antidepressants for dementia-related agitation and psychosis. While larger well-controlled studies are needed, many existing studies have provided hope that antidepressants, especially those known as selective serotonin reuptake inhibitors (SSRIs), have safe and tolerable side effect profiles and can be effectively used to help dementia-related behaviors in some patients.
Most of the studies involved SSRIs such as citalopram (Celexa) or sertraline (Zoloft). Improvements in depression, emotionality, anxiety, agitation, and social interaction have been seen when comparing citalopram with placebo.
In a study at the University of Pittsburgh Medical Center conducted with patients hospitalized with psychiatric disturbances related to dementia, patients receiving citalopram experienced similar results, or a 32% reduction in relieving hallucinations, delusions, and suspicious thoughts while those in the atypical antipsychotic risperidone (Risperadal) group had a 35% reduction. However, the patients receiving citalopram experienced a 4% reduction in side effects compared with a 19% increase in side effects in patients receiving risperidone.5
Many antidepressants have been shown to have favorable effects on anxiety, sleep disturbance, and agitated behaviors. Practical suggestions on ways to implement the use of antidepressants for behaviors may include selecting an agent based on the known beneficial effects and the specific behavioral symptoms exhibited.
SSRIs such as escitalopram (Lexapro) and sertraline have indications to treat anxiety. Because anxiety and agitation are often closely related, a reasonable selection of one of these antidepressants may be made for those dementia patients exhibiting signs and symptoms of depression with anxious agitated behaviors.
Prescribers may choose to start antidepressant medications such as SSRIs while slowly reducing or eliminating the use of higher risk medications, such as antipsychotics and benzodiazepines that are often used for anxiety. This can have further benefits for the patient since these medications are known to increase confusion and fall risk.

Depression is known to affect sleep in many patients with and without dementia. Patients receive benzodiazepines or hypnotic medications such as zolpidem (Ambien) for sleep, which has been linked to early morning falls. Physicians may choose to utilize the antidepressant mirtazepine (Remeron) at a dose of 30 mg for which there are studies showing improved sleep continuity long term.
Patients with dementia and diabetic neuropathy who exhibit undesirable behaviors may be experiencing pain. Consideration for this type of patient may be given to duloxetine (Cymbalta), an antidepressant known to help neuropathic pain and depression.
Pharmacological choices with FDA-approved indications and clear evidence in targeting behaviors in dementia are limited. However, improved nonpharmacological interventions, in addition to focused patient individualized prescribing targeting common underlying causes of behaviors seen in dementia patients, may allow for improved behavior symptom control with less risk than is currently seen today utilizing atypical antipsychotic medications.
— Mark D. Coggins, PharmD, CGP, FASCP, is the national director of clinical pharmacy services for more than 300 skilled nursing homes operated by Golden Living. He was recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

References
1. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9);1107-1116.
2. Coggins M, Evans MP, Bruce C. Effect of an interdisciplinary team approach to psychotropic drug reduction and elimination on quality measures and other clinical outcomes in skilled nursing facilities (SNFs): the Medication Evaluation Trial (MET trial). JAMDA. 2010;11(3):B9.
3. Husebo BS, Ballard C, Sandvik R, Bjarte Nilsen O, Aarsland D. Efficacy in treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomized clinical trial. BMJ. 2011;343:d4065.
4. Gauthier S, Wirth Y, Möbius HJ. Effects of memantine on behavioural symptoms in Alzheimer’s disease patients: an analysis of the neuropsychiatric inventory (NPI) data of two randomized, controlled studies. Int J Geriatr Psychiatry. 2005;20(5):459-464.
5. Pollock BG, Mulsant BH, Rosen J, et al. A double-blind comparison of citalopram and risperidone for the treatment of behavioral and psychotic symptoms associated with dementia. Am J Geriatr Psychiatry. 2007;15(11):942-952.

ALVEOLI

The alveoli

Alveoli are tiny grape-like sacs. There are two kinds of alveoli, those that exchange gases in the lungs, and those that turn blood into breast milk in the breast. The singular of alveoli is one alveolus.
"Alveoli {in the breast} are grape-like clusters of glandular tissue in which milk is synthesized from blood. Aveoli cells secrete milk. They are surrounded by a network of band-like myoepithelial cells, which cause the alveoli to contract when stimulated by the oxytocin released during the let-down, or milk-ejection, reflex. This action expels the milk into the ductules and down into the ducts."^[1]

"Air sac" redirects here. For other uses, see Air sac (disambiguation).

Alveoli in the lungs exchange oxygen with red blood cells when the heart's Sinoatrial and Atrioventricular nodes send electric signals to the hearts ventricles. The right side of the heart then contracts twice,^[source?] sending blood shooting into the pulmonary circulatory system, where capillary beds are located in the lungs. The Alveoli then exchange oxygen and discard carbon dioxide with the red blood cells, which then return to the heart's left atrium. When you breathe out, the body delivers carbon dioxide to the alveoli, and you release it in your exhalation. When you breathe in, oxygen fills the alveoli and then enters the blood, so it can be delivered to the rest of the body. In asthma there is no damage to the alveoli, which is different from another common lung disease which is called: chronic obstructive pulmonary disease, in which alveoli are damaged. A network of blood capillaries surround walls of each alveolus.The walls are extremely thin(one cell thick)and moist,thus allowing gaseous diffussion through them. There are over 300 million alveoli in each lung. If you were to spread one person's alveoli across a tennis court, they would cover over half the court!

This short article about science can be made longer. You can help Wikipedia by adding to it.

The alveoli also help for the lungs to keep out unwanted pathogens and viruses.

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NOTES FROM UNAR

Certification is required in Utah

CNAs are required by law to have a valid Utah CNA certificate prior to assuming nursing assistant duties.

There is one

exception:

If an individual works in a licensed nursing facility as an uncertified nursing assistant and is seeking initial

certification, he/she has four months (120 days) from the date of hire to obtain initial certification.

The 120 days is a onetime

only opportunity.

THE REGISTRY

****CNA training is valid for one year.

****All testing must be completed within 1 year from the completion date of training.

****All expired CNAs must test within 1 year from the certificate expiration date.

****CNA certificates must be renewed every two years

.

To qualify for renewal the Certified Nursing Assistant must perform paid services and provide proof of at least 200 hours

of

nursing or nursing related duties under the supervision of a licensed nurse for at least 200

hours at a Utah facility (during the two year period following certification)

. Renewal is two

years from

initial certificate issue date.

****

Renewal notices are mailed as a courtesy only, approximately 45 days before the renewal date

to the

last known address on file with the Registry. The candidate is responsible for the renewal

of their license.

****Do not rely on your place of work or anyone else to send in your renewal. Should your

license not be renewed in the allowed timeframe, you will need to pay for vouchers and retest.

The UNAR must be kept informed of your current address. If your address or name changes at any time after you

are placed on the Registry. You may call the registry with your new address or send us written notification. If it is

a name change, you will need to send supporting documentation, such as a copy of your social security card or

Utah drivers license, or a copy of your marriage certificate with your new name.

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Facility Totals ID# Written %%% Var. Skills %%% Var. Total %%% Var.
================================================== ==== ======= === ==== ======== === ==== ======== === ====
C C CNA 1054 125 97 +5 109 96 +5 136 78
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PASS RATES FOR 2013. NOT AS HIGH AS I'D LIKE BUT 5% BETTER THAN THE AVERAGE. THAT'S NOT 97% PASS RATE FOR WRITTEN AND 96% FOR SKILLS


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FLU

Updated and age-adjusted estimates of influenza vaccine effectiveness for the 2012-13 season show it was moderately effective overall, but much less so in seniors.

Overall, influenza vaccination reduced the risk for medical visits resulting from influenza A and B by 56% — including by 47% from influenza A (H3N2) and by 67% from influenza B, according to a report issued by the Centers for Disease Control and Prevention.

The preventive benefits against influenza B were consistent across age groups. The adjusted vaccine effectiveness estimates against influenza A (H3N2) viruses also were largely consistent (46%-58%) for people ages 6 months to 64 years, but the vaccine effectiveness estimate was only 9% among people ages 65 and older.

Confirmation of the protective benefits of the 2012-13 influenza vaccine among people 64 and younger, the report's authors wrote, "offers further support for the public health benefit of annual seasonal influenza vaccination and supports the expansion of vaccination, particularly among younger age groups."

Meanwhile, the low rate of effectiveness among seniors "reinforces the need for continued advances in influenza vaccines, especially to increase protective benefits for older adults."

"This finding should not discourage future vaccination by [people ages 65 and older], who are at greater risk for more severe cases and complications from influenza," the authors wrote. "Influenza vaccines remain the best preventive tool available, and [vaccine effectiveness] is known to vary by virus type/subtype, age group, season, host immunity and the outcome measured."

The authors noted the vaccine effectiveness estimates in the report are limited to the prevention of outpatient medical visits instead of more severe illness outcomes such as hospitalization or death.

To clinicians, the authors advise maintaining "a high index of suspicion for influenza infection among persons with acute respiratory illness while influenza activity is ongoing. Early antiviral treatment can reduce influenza-associated illness severity and complications."

The authors recommend "initiating antiviral medications for patients with suspected influenza, regardless of their influenza vaccination status," if they are 65 or older, hospitalized, have progressive or complicated illness or otherwise are at higher risk for complications from influenza.

"Antiviral treatment can be initiated empirically, preferably within 48 hours after illness onset, and should not be delayed pending confirmatory diagnostic testing nor be dependent upon tests with limited sensitivity (e.g. negative rapid tests). Among hospitalized patients, treatment should be initiated on admission."

The vaccine effectiveness estimates are not final, according to the report. An increased sample size and adjustment for additional potential confounders (such as chronic medical conditions and functional status) at the end of the season could change them.

The full report is available in the Feb. 22 edition of the Morbidity and Mortality Weekly Report at www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a2.htm?s_cid=mm6207a2_w.

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STAFFING RATIOS

D.C. Hospitals And Nurses Fight Over Staffing Ratios

Topics: Quality, States

By David Schultz

Feb 22, 2013

Hospital administrators in Washington, D.C., are furiously lobbying against a bill modeled on a California law that would require them to maintain a minimum nurse-to-patient ratio at all times.
Nursing unions say the proposed Patient Protection Act codifies into law minimum staffing levels that are needed to maintain patient safety, while hospitals say the cost of hiring new nurses to comply with the law would put them out of business.
The ratios called for in the bill vary depending on the hospital department. In a pediatrics unit, the bill would require no less than a 1-to-4 nurse-to-patient ratio. In the operating room, hospitals would have to maintain a 1-to-1 ratio -- one nurse for every patient at all times.
Deidre Beckford, a nurse at MedStar Washington Hospital Center who has worked there for more than 20 years, says understaffing has forced her to take care of five to six patients at a time.
"There are times when I have to do the dressing on patients and I can’t get to it," she said. "I have to put antibiotics on patients and they're late. You have to turn patients every two hours and you can’t get to it. It infringes on their care."
Washington Hospital Center didn’t respond to Beckford’s claims about infringed patient care, but its chief nursing executive, Sue Eckert, said in an email to KHN that the hospital manages its staffing levels collaboratively with nurses and that those levels can fluctuate depending on how many patients it has and how sick those patients are.
The nursing bill in D.C. would reduce some of this fluctuation. It’s modeled after a nearly identical law that took effect in 2004 in California, the only state to require minimum staffing ratios in its hospitals. So far, it’s unclear whether this requirement has had a positive or negative effect in California hospitals.
Studies have shown that the law has led to an increase in nurse hiring in California and a decrease in nurse turnover due to burnout. But researchers also found that the law put significant financial pressure on some hospitals.
When it comes to the ultimate question of whether this law reduced patient mortality, Teresa Serratt, a nursing professor at the University of Nevada, Reno, who has examined the effects of the California law, says the data are inconclusive.
"That's the big question everyone wants an answer to," she said.
Citing positive outcomes of the California law, the labor union National Nurses United is strongly pushing for the staffing ratio bill in D.C., which has been assigned to a committee but has no scheduled hearings as of yet. Nine of the Council’s 13 members signed on as co-introducers last week.
But the District of Columbia Hospital Association is waging an all-out campaign against it, supporting a competing bill that contains many of the same provisions as the Patient Protection Act but without the staffing ratio mandate. Robert Malson, the association’s president, says his organization is also scheduling individual meetings with every council member to try to persuade some of them to change their minds.
Malson said he's been informing them of "exactly which hospitals would go out of business, and in which sequence" if the Patient Protection Act passes, though he wouldn’t share that information with KHN.
He said the bill is an attempt to get legislators involved in D.C. hospitals' labor negotiations with its nurses, which have been far from harmonious in recent years. Almost two years ago, nurses at Washington Hospital Center staged a 24-hour strike a few months after voting overwhelmingly to join NNU, the largest nursing union in the country.
Serratt says the dueling bills are a sign that the relationship between hospitals and nurses in D.C. has grown dysfunctional.
"If you have really strong communication and good people on both sides of the table, we wouldn’t have the government getting in the middle of this kind of stuff," she said.


















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CNA Class

 Fun and games at virtual day.

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I wouldn't have bothered to get out of bed

I just had an Alzheimer resident tell me "the program was stupid and now they won't let me leave. What kind of program is this? If I had known it was going to be like this I wouldn't have bothered to get out of bed!"
I had to agree!

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Smoking Deaths Now Equal in Women and Men

By Nancy Walsh, Staff Writer, MedPage Today

Published: January 23, 2013

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

 

Action Points

• The risk of death from cigarette smoking continues to increase among women, and the increased risks are now nearly identical for men and women as compared with persons who have never smoked, a study has found.
• Note that individuals who quit between ages 25 and 34 had a 10-year increase in life expectancy.

Smoking continues to kill Americans at a staggering rate, with women now as likely to die from tobacco-related disease as men, two large surveys found.
In one national survey, the rate of all-cause mortality was three times higher for smokers than for nonsmokers, with a hazard ratio of 2.8 (95% CI 2.4 to 3.1) for men and 3 (95% CI 2.7 to 3.3) for women, according to Prabhat Jha, MD, of the Center for Global Health Research in Toronto, and colleagues.
In a second study, the relative risk of death from any cause among a contemporary cohort of smokers was 2.80 (95% CI 2.72 to 2.88) for men and 2.76 (95% CI 2.69 to 2.84) for women, reported Michael J. Thun, MD, of the American Cancer Society in Atlanta, and colleagues.
"Most people in the U.S. assume that smoking is on its way out. But the grim reality is that smoking still exerts an enormous toll on the health of Americans," Steven A. Schroeder, MD, of the University of California San Francisco, wrote in an editorial accompanying the studies in the Jan. 24 New England Journal of Medicine.
The study by Jha and colleagues included 216,917 adults who participated in the U.S. National Health Interview Survey during the years 1997 to 2004.
Those who reported current smoking had less education, were less likely to be overweight or obese, and drank more alcohol.
Women in this cohort were less likely than men to quit smoking.
During about 7 years of follow-up, 7,479 men and 8,236 women in the cohort died.
Analysis of the mortality data revealed that people who had never smoked were twice as likely to live to age 80 compared with current smokers.
Among men, the likelihood of living to 80 was 61% (95% CI 55 to 67) for nonsmokers, falling to 26% (95% CI 18 to 33) for those who continued to smoke.
For women, the corresponding numbers were 70% (95% CI 64 to 76) and 38% (95% CI 30 to 45), according to Jha and colleagues.
Hazard ratios for death from lung cancer were "notably high" for both women (HR 17.8, 95% CI 11.4 to 27.8) and men (HR 14.6, 95% CI 9.1 to 23.4), the researchers found.
In addition, hazard ratios for death from ischemic heart disease among current smokers were 3.5 (95% CI 2.7 to 4.6) for women and 3.2 (95% CI 2.5 to 4.1) for men.
Jha and colleagues also examined the effects of smoking cessation and found that individuals who quit between ages 25 and 34 had a 10-year increase in life expectancy, while those who quit at ages 35 to 44 had a 9-year increase.
Even those who quit at ages 45 to 54 had a gain of 6 years, and those who stopped between ages 55 and 64 could expect an additional 4 years.
Overall, smoking cessation by about age 40 reduced the risk of death by 90%, the researchers found.
Between 1965 and 2010 the prevalence of smoking among American adults fell from 42% to 19%, but 30 million people worldwide begin smoking each year.
"On the basis of current rates of smoking initiation and cessation, smoking, which killed about 100 million people in the 20th century, will kill about 1 billion in the 21st century," Jha and colleagues predicted.
Limitations of the study included the possibility of confounding variables and cause of death misclassification.
The study by Thun and colleagues compared mortality rates in several historical and contemporary cohorts over three time periods, 1959 to 1965, 1982 to 1988, and 2000 to 2010.
In the earliest time period, the relative risk for lung cancer-related mortality among smokers was 12.22 for men but only 2.73 for women, yet by the latest period the risk for men was 24.97 and had risen to 25.66 for women.
Between the 1980s and the later periods there also was a doubling of mortality risk associated with chronic obstructive pulmonary disease in men, from a relative risk of 9.98 to 25.61, and in women, from 10.35 to 22.35.
This increase may relate to the different design of cigarettes today, which allow deeper inhalation into the lung parenchyma, the investigators wrote.
In the latest cohort, risks of death from ischemic heart disease also rose among smokers, to 2.86 for women and 2.50 for men.
The researchers noted that the finding of "nearly identical" risks for women and men in the latest time period was "new and confirms the prediction that, in relative terms, 'women who smoke like men die like men,'" meaning that they begin earlier and smoke more heavily than in the past.
Limitations of this study included its population of predominantly white adults who were mostly 50 and older.
In his editorial, Schroeder emphasized the increased importance of smoking as a health hazard for women.
"More women die of lung cancer than of breast cancer. But there is no 'race for the cure' for lung cancer, no brown ribbon, and no group analogous to the Susan G. Komen Breast Cancer Foundation," he pointed out.
In addition, the growing stigma associated with smoking has resulted in the habit being concentrated among the less privileged, and "it risks becoming invisible to those who set health policies and research priorities," he wrote.
Further efforts toward smoking prevention and cessation remain an urgent need, he concluded.


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AIDS and aides

AIDS

I had a students ask me the other day if you see much AIDS in nursing homes in Utah. Honestly, I've only seen one AIDS patient at clinical in the past couple of years. That resident was young (in his 30's) and was in the facility for a cancer secondary to HIV. He also had severe weakness. He died a couple of weeks past admission. That is not the norm. More people are living with AIDS as a chronic illness.

Seeing how students reacted to the resident was interesting. I remember in the 90's nurses and aides didn't want to take care of HIV patients and were freaked out by the disease. This resident, everyone wanted to take care of. I think the students wore him out by taking such excellent care of him. It was a nice change.

If you do have a resident with HIV remember standard precautions are the same for everyone. Wash your hands and wear protective equipment (gloves, gowns, mask) if you are going to come into contact with bodily secretions! If you are not coming into contact with any secretions then you are not at risk for catching anything!

Information about AIDS

A.D.A.M. Medical Encyclopedia.

AIDS

Acquired immune deficiency syndrome

Last reviewed: April 30, 2012.

AIDS (acquired immune deficiency syndrome) is the final stage of HIV disease, which causes severe damage to the immune system.

Causes, incidence, and risk factors

AIDS is the sixth leading cause of death among people ages 25 - 44 in the United States, down from number one in 1995. Millions of people around the world are living with HIV/AIDS, including many children under age 15.

Human immunodeficiency virus (HIV) causes AIDS. The virus attacks the immune system and leaves the body vulnerable to a variety of life-threatening infections and cancers.

Common bacteria, yeast, parasites, and viruses that usually do not cause serious disease in people with healthy immune systems can cause fatal illnesses in people with AIDS.

HIV has been found in saliva, tears, nervous system tissue and spinal fluid, blood, semen (including pre-seminal fluid, which is the liquid that comes out before ejaculation), vaginal fluid, and breast milk. However, only blood, semen, vaginal secretions, and breast milk have been shown to transmit infection to others.

The virus can be spread (transmitted):

• Through sexual contact -- including oral, vaginal, and anal sex
• Through blood -- via blood transfusions (now extremely rare in the U.S.) or needle sharing
• From mother to child -- a pregnant woman can transmit the virus to her fetus through their shared blood circulation, or a nursing mother can transmit it to her baby in her breast milk

Other methods of spreading the virus are rare and include accidental needle injury, artificial insemination with infected donated semen, and organ transplantation with infected organs.

HIV infection is NOT spread by:

• Casual contact such as hugging
• Mosquitoes
• Participation in sports
• Touching items that were touched by a person infected with the virus

AIDS and blood or organ donation:

• AIDS is NOT transmitted to a person who DONATES blood or organs. People who donate organs are never in direct contact with people who receive them. Likewise, a person who donates blood is never in contact with the person receiving it. In all these procedures, sterile needles and instruments are used.
• However, HIV can be transmitted to a person RECEIVING blood or organs from an infected donor. To reduce this risk, blood banks and organ donor programs screen donors, blood, and tissues thoroughly.

People at highest risk for getting HIV include:

• Injection drug users who share needles
• Infants born to mothers with HIV who didn't receive HIV therapy during pregnancy
• People engaging in unprotected sex, especially with people who have other high-risk behaviors, are HIV-positive, or have AIDS
• People who received blood transfusions or clotting products between 1977 and 1985 (before screening for the virus became standard practice)
• Sexual partners of those who participate in high-risk activities (such as injection drug use or anal sex)

Symptoms

AIDS begins with HIV infection. People who are infected with HIV may have no symptoms for 10 years or longer, but they can still transmit the infection to others during this symptom-free period. If the infection is not detected and treated, the immune system gradually weakens and AIDS develops.

Acute HIV infection progresses over time (usually a few weeks to months) to asymptomatic HIV infection (no symptoms) and then to early symptomatic HIV infection. Later, it progresses to AIDS (advanced HIV infection with CD4 T-cell count below 200 cells/mm3 ).

Almost all people infected with HIV, if they are not treated, will develop AIDS. There is a small group of patients who develop AIDS very slowly, or never at all. These patients are called nonprogressors, and many seem to have a genetic difference that prevents the virus from significantly damaging their immune system.

The symptoms of AIDS are mainly the result of infections that do not normally develop in people with a healthy immune system. These are called opportunistic infections.

People with AIDS have had their immune system damaged by HIV and are very susceptible to these opportunistic infections. Common symptoms are:

• Chills
• Fever
• Rash
• Sweats (particularly at night)
• Swollen lymph glands
• Weakness
• Weight loss

Note: At first, infection with HIV may produce no symptoms. Some people, however, do experience flu-like symptoms with fever, rash, sore throat, and swollen lymph nodes, usually 2 - 4 weeks after contracting the virus. This is called the acute retroviral syndrome. Some people with HIV infection stay symptom-free for years between the time when they are exposed to the virus and when they develop AIDS.

Signs and tests

CD4 cells are a type of T cell. T cells are cells of the immune system. They are also called "helper cells."

The following is a list of AIDS-related infections and cancers that people with AIDS may get as their CD4 count decreases. In the past, having AIDS was defined as having HIV infection and getting one of these other diseases. Today, according to the Centers for Disease Control and Prevention, a person may also be diagnosed with AIDS if they are HIV-positive and have a CD4 cell count below 200 cells/mm3, even if they don't have an opportunistic infection.

AIDS may also be diagnosed if a person develops one of the opportunistic infections and cancers that occur more commonly in people with HIV infection. These infections are unusual in people with a healthy immune system.

Many other illnesses and their symptoms may develop, in addition to those listed here.

The following illnesses are common with a CD4 count below 350 cells/mm3:

• Herpes simplex virus -- causes ulcers/small blisters in the mouth or genitals, happens more often and usually much more severely in an HIV-infected person than in someone without HIV infection
• Herpes zoster (shingles) -- ulcers/small blisters over a patch of skin, caused by reactivation of the varicella zoster virus, the same virus that causes chickenpox
• Kaposi's sarcoma -- cancer of the skin, lungs, and bowel due to a herpes virus (HHV-8). It can happen at any CD4 count, but is more likely to happen at lower CD4 counts, and is much more common in men than in women.
• Non-Hodgkin's lymphoma -- cancer of the lymph nodes
• Oral or vaginal thrush -- yeast (typically Candida albicans) infection of the mouth or vagina
• Tuberculosis -- infection by tuberculosis bacteria mostly affects the lungs, but can also affect other organs such as the bowel, lining of the heart or lungs, brain, or lining of the central nervous system (brain and spinal cord)

Common with CD4 count below 200 cells/mm3:

• Bacillary angiomatosis -- skin sores caused by a bacteria called Bartonella, which may be caused by cat scratches
• Candida esophagitis -- painful yeast infection of the tube through which food travels, called the esophagus
• Pneumocystis jiroveci pneumonia, "PCP pneumonia," previously called Pneumocystis carinii pneumonia, caused by a fungus

Common with CD4 count below 100 cells/mm3:

• AIDS dementia -- worsening and slowing of mental function, caused by HIV
• Cryptococcal meningitis -- fungal infection of the lining of the brain
• Cryptosporidium diarrhea -- extreme diarrhea caused by a parasite that affects the gastrointestinal tract
• Progressive multifocal leukoencephalopathy -- a disease of the brain caused by a virus (called the JC virus) that results in a severe decline in mental and physical functions
• Toxoplasma encephalitis -- infection of the brain by a parasite, called Toxoplasma gondii, which is often found in cat feces; causes lesions (sores) in the brain
• Wasting syndrome -- extreme weight loss and loss of appetite, caused by HIV itself

Common with CD4 count below 50/mm3:

• Cytomegalovirus infection -- a viral infection that can affect almost any organ system, especially the large bowel and the eyes
• Mycobacterium avium -- a blood infection by a bacterium related to tuberculosis

In addition to the CD4 count, a test called HIV RNA level (or viral load) may be used to monitor patients. Basic screening lab tests and regular cervical Pap smears are important to monitor in HIV infection, due to the increased risk of cervical cancer in women with a compromised immune system. Anal Pap smears to detect potential cancers may also be important in both HIV-infected men and women.

Treatment

There is no cure for AIDS at this time. However, a variety of treatments are available that can help keep symptoms at bay and improve the quality and length of life for those who have already developed symptoms.

Antiretroviral therapy suppresses the replication of the HIV virus in the body. A combination of several antiretroviral drugs, called highly active antiretroviral therapy (HAART), has been very effective in reducing the number of HIV particles in the bloodstream. This is measured by the viral load (how much free virus is found in the blood). Preventing the virus from replicating can improve T-cell counts and help the immune system recover from the HIV infection.

HAART is not a cure for HIV, but it has been very effective for the past 12 years. People on HAART with suppressed levels of HIV can still transmit the virus to others through sex or by sharing needles. There is good evidence that if the levels of HIV remain suppressed and the CD4 count remains high (above 200 cells/mm3), life can be significantly prolonged and improved.

However, HIV may become resistant to one combination of HAART, especially in patients who do not take their medications on schedule every day. Genetic tests are now available to determine whether an HIV strain is resistant to a particular drug. This information may be useful in determining the best drug combination for each person, and adjusting the drug regimen if it starts to fail. These tests should be performed any time a treatment strategy begins to fail, and before starting therapy.

When HIV becomes resistant to HAART, other drug combinations must be used to try to suppress the resistant strain of HIV. There are a variety of new drugs on the market for treating drug-resistant HIV.

Treatment with HAART has complications. HAART is a collection of different medications, each with its own side effects. Some common side effects are:

• Collection of fat on the back ("buffalo hump") and abdomen
• Diarrhea
• General sick feeling (malaise)
• Headache
• Nausea
• Weakness

When used for a long time, these medications increase the risk of heart attack, perhaps by increasing the levels of cholesterol and glucose (sugar) in the blood.

Any doctor prescribing HAART should carefully watch the patient for possible side effects. In addition, blood tests measuring CD4 counts and HIV viral load should be taken every 3 months. The goal is to get the CD4 count as close to normal as possible, and to suppress the amount of HIV virus in the blood to a level where it cannot be detected.

Other antiviral medications are being investigated. In addition, growth factors that stimulate cell growth, such as erthythropoetin (Epogen, Procrit, and Recomon) and filgrastim (G-CSF or Neupogen) are sometimes used to treat AIDS-associated anemia and low white blood cell counts.

Medications are also used to prevent opportunistic infections (such as Pneumocystis jiroveci pneumonia) if the CD4 count is low enough. This keeps AIDS patients healthier for longer periods of time. Opportunistic infections are treated when they happen.

Support Groups

Joining support groups where members share common experiences and problems can often help the emotional stress of devastating illnesses. See AIDS - support group.

Expectations (prognosis)

Right now, there is no cure for AIDS. It is always fatal without treatment. In the U.S., most patients survive many years after diagnosis because of the availability of HAART. HAART has dramatically increased the amount of time people with HIV remain alive.

Research on drug treatments and vaccine development continues. However, HIV medications are not always available in the developing world, where most of the epidemic is raging.

Complications

When a person is infected with HIV, the virus slowly begins to destroy that person's immune system. How fast this occurs differs in each individual. Treatment with HAART can help slow or halt the destruction of the immune system.

Once the immune system is severely damaged, that person has AIDS, and is now susceptible to infections and cancers that most healthy adults would not get. However, antiretroviral treatment can still be very effective, even at that stage of illness.

Calling your health care provider

Call for an appointment with your health care provider if you have any of the risk factors for HIV infection, or if you develop symptoms of AIDS. By law, the results of HIV testing must be kept confidential. Your health care provider will review results of your testing with you.

Prevention

See: Safe sex to learn how to reduce the chance of catching or spreading HIV and other sexually transmitted illnesses (STIs)

Tips for preventing HIV/AIDS:

• Do not use illicit drugs and do not share needles or syringes. Many communities now have needle exchange programs, where you can get rid of used syringes and get new, sterile ones. These programs can also provide referrals for addiction treatment.
• Avoid contact with another person's blood. You may need to wear protective clothing, masks, and goggles when caring for people who are injured.
• Anyone who tests positive for HIV can pass the disease to others and should not donate blood, plasma, body organs, or sperm. Infected people should tell any sexual partner about their HIV-positive status. They should not exchange body fluids during sexual activity, and should use preventive measures (such as condoms) to reduce the rate of transmission.
• HIV-positive women who wish to become pregnant should seek counseling about the risk to their unborn child, and methods to help prevent their baby from becoming infected. The use of certain medications dramatically reduces the chances that the baby will become infected during pregnancy.
• The Public Health Service recommends that HIV-infected women in the United States avoid breastfeeding to prevent transmitting HIV to their infants through breast milk.

Safer sex practices, such as latex condoms, are highly effective in preventing HIV transmission. HOWEVER, there is a risk of acquiring the infection even with the use of condoms. Abstinence is the only sure way to prevent sexual transmission of HIV.

The riskiest sexual behavior is receiving unprotected anal intercourse. The least risky sexual behavior is receiving oral sex. There is some risk of HIV transmission when performing oral sex on a man, but this is less risky than unprotected vaginal intercourse. Female-to-male transmission of the virus is much less likely than male-to-female transmission. Performing oral sex on a woman who does not have her period has a low risk of transmission.

HIV-positive patients who are taking antiretroviral medications are less likely to transmit the virus. For example, pregnant women who are on effective treatment at the time of delivery, and who have undetectable viral loads, give HIV to their baby less than 1% of the time, compared with 13% to 40% of the time if medications are not used.

The U.S. blood supply is among the safest in the world. Nearly all people infected with HIV through blood transfusions received those transfusions before 1985, the year HIV testing began for all donated blood.

If you believe you have been exposed to HIV, seek medical attention IMMEDIATELY. There is some evidence that an immediate course of antiviral drugs can reduce the chances that you will be infected. This is called post-exposure prophylaxis (PEP), and it has been used to prevent transmission in health care workers injured by needlesticks.

There is less information available about how effective PEP is for people exposed to HIV through sexual activity or injection drug use, but it appears to be effective. If you believe you have been exposed, discuss the possibility with a knowledgeable specialist (check local AIDS organizations for the latest information) as soon as possible. Anyone who has been sexually assaulted should consider the potential risks and benefits of PEP.

References

1. Quinn TC. Epidemiology of human immunodeficiency virus infection and acquired immunodeficiency syndrome. In: Goldman L, Schafer AI,eds. Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap392.
2.  Sterling TR, Chaisson RE. General clinical manifestations of human immunodeficiency virus infection (including the acute retroviral syndrome and oral, cutaneous, renal, ocular, metabolic, and cardiac diseases). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 121.

Review Date: 4/30/2012.

Reviewed by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Jatin M. Vyas, MD, PhD, Assistant Professor in Medicine, Harvard Medical School; Assistant in Medicine, Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.