JAMA : the journal of the American Medical Association
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To review current knowledge of the biology and clinical implications of human immunodeficiency virus (HIV) resistance to antiretroviral drugs, describe assays for measuring resistance, and assess their use in clinical practice. ⋯ Plasma HIV RNA level and CD4+ cell count are the primary values that should be used to guide the initiation of antiretroviral therapy and subsequent changes in therapy. Possible causes of treatment failure other than development of drug resistance that should be considered are adherence, drug potency, and pharmacokinetic issues. Genotypic and phenotypic testing for HIV resistance to antiretroviral drugs may prove useful for individual patient management. Assays under development need validation, standardization, and a clearer definition of their clinical roles. Possible current roles of resistance testing for choosing an initial regimen or changing antiretroviral therapy, as well as possible implications of the presence or absence of phenotypic resistance and genotypic changes, are discussed.
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Although the use of feeding tubes among older individuals stirs considerable controversy, population-based descriptive data regarding patient outcomes are scarce. ⋯ Gastrostomies are frequently placed in older individuals and more often in blacks; mortality rates following placement are substantial.
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Cancer pain can be relieved with pharmacological agents as indicated by the World Health Organization (WHO). All too frequently pain management is reported to be poor. ⋯ Daily pain is prevalent among nursing home residents with cancer and is often untreated, particularly among older and minority patients.