Effect of higher hemoglobin levels on health-related quality of life parameters

A large body of clinical data has consistently demonstrated that improvements in health-related quality of life (QOL) are associated with hemoglobin (Hb) and hematocrit (Hct) levels maintained in the range recommended by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI). Hb (Hct) levels between 11 and 12 g/dL (33% to 36%) yield significant improvements in QOL parameters such as cognitive function, exercise and functional ability, and overall health status. Additional data showing a strong association between improvements in QOL, hospitalization, and mortality in those with higher Hb levels underscore why all patients should attain a minimum Hb level of 11 g/dL. Recent clinical analyses indicate that increasing Hb to above 12 g/dL may be associated with incremental improvements in QOL. However, further clinical research is required to define and clarify these relationships. While higher Hb levels may be justifiable in some patients with debilitating comorbid conditions and documented clinical necessity, the NKF-K/DOQI target range currently remains the standard of care.

Costs of village community, residential campus and dispersed housing provision for people with intellectual disability

BACKGROUND

In recent years, a growing volume of research evidence has been generated about the relative cost-effectiveness of various types of community-based residential supports for people with intellectual disability (ID) in the UK. However, few reliable data are available to inform planners, commissioners or service providers about the quality and costs of providing support within residential or village communities.

METHODS

The evaluation described in the present paper aimed to fill some of the gaps in knowledge by examining the comparative costs of supporting people in village community settings, in National Health Service (NHS) residential campuses and in dispersed, community-based housing schemes. The complete service package received by each study participant was described and costed, and a series of statistical analyses was undertaken to identify factors associated with variations in the cost of support. The analyses reported in the present paper were based on comparisons of 86 people living in village communities, 133 in residential campuses and 281 in dispersed housing schemes.

RESULTS

Wide variations in cost were found, not only between models of accommodation, but between individual organizations, settings and service users. Multivariate analysis revealed that higher costs were associated with supports for people with higher levels of ID and more severe challenging behaviour. The cost of support was affected by the size of the residential setting, with smaller facilities likely to be more expensive. Associations were also found between increased costs, and services for younger users, male users and people who had not moved from a NHS hospital. Generally, more sophisticated service processes within the setting were associated with higher costs; although systematic arrangements for supervision and training of staff had a negative effect on cost.

CONCLUSIONS

The cost findings should be considered alongside evidence on outcomes. A comparison of village communities and dispersed housing schemes suggests that both models of provision appear be associated with particular benefits, although different types of setting are appropriate for different individuals and therefore, the continued development of a range of residential models is important.

Environmental opportunities and supports for exercising self-determination in community-based residential settings

Information was collected on the environmental opportunities for exercising self-determination among 281 adults with mental retardation receiving community-based residential supports. The results indicated that: (1) the majority of participants had little or no opportunity to exercise self-determination over major life decisions (e.g., with whom and where to live, the recruitment and retention of care staff); (2) even in more mundane areas, such as where and when to eat, the majority of participants were not supported to exercise effective control; (3) variation in environmental opportunities to exercise self-determination was strongly related to a range of factors including participant ability, previous residential history, and structural and procedural aspects of the residential supports currently provided.

Quality and costs of supported living residences and group homes in the United Kingdom

Information was collected on 63 adults in supported living residences, 55 adults in small group homes, and 152 adults in large group homes. Results indicated that (a) there were no statistically significant differences in service costs once these had been adjusted to take account of participant characteristics; (b) compared with participants living in small group homes, those in supported living residences had greater choice, participated in more community-based activities, experienced fewer scheduled activities, were more likely to have had their home vandalized, and were considered at greater risk of exploitation; (c) compared with participants living in large group homes, those in small group homes had larger social networks, more people in their social networks who were not staff, not family, and did not have mental retardation. These residents were considered at less risk of abuse.

Factors associated with expressed satisfaction among people with intellectual disability receiving residential supports

The aim of the present study was to identify factors associated with variations in the levels of expressed satisfaction among adults with intellectual disability (ID) receiving residential supports. Semi-structured interviews were conducted with 96 people with ID. Forty-five subjects lived in village communities and 51 received community-based residential supports. Ratings were made of the participants' expressed levels of satisfaction in seven domains: (1) their home; (2) daytime activities; (3) social and recreational activities; (4) support from services; (5) friendships and relationships; (6) choices available to them; and (7) risks. The data indicated that: (1) interviewees living in village communities expressed greater satisfaction with friendships and relationships than interviewees living in community-based residential supports; (2) in the other six domains of life satisfaction which were investigated, there were no statistically significant differences between groups; (3) interviewees expressed greater satisfaction with their accommodation and day activities than with friendships, risks and support received; and (4) a wide range of variables relating to the personal characteristics of the interviewees and support received were associated with variations in levels of expressed satisfaction. Variation in the levels of expressed satisfaction was reliably associated with variables relating to the personal characteristics of the interviewees and the nature of the support received.

The adaptive behavior scale-residential and community (part I): towards the development of a short form

A potential 24-item short form (SABS) of the 73-item Adaptive Behavior Scale-Residential and Community (Part I) (ABS-RC2; Nihira et al., 1993a, b) was developed, based on data from two diverse UK samples of adults with intellectual disabilities living in residential services (n = 560 and 254). SABS factor and total scores showed good internal reliability in both samples (alpha 0.89-0.98), and were highly correlated with their full ABS-RC2 Part I equivalents (r = 0.97-0.99). Regression equations were calculated for SABS factor and total scores against their full ABS-RC2 Part I equivalents. Levels of agreement between predicted quartile scores (derived from the regression equations) and actual full ABS-RC2 Part I quartile scores were high (kappa 0.75-0.89; percentage agreement 82%-92%). It is concluded that the SABS is a potentially useful research tool, although further work is clearly needed to establish the reliability and cross-cultural validity of the instrument.

Social networks of people with mental retardation in residential settings

Information was collected on the social networks of 500 adults with mental retardation receiving different types of residential supports. Results indicated that (a) the reported median size of participants' social networks (excluding staff) was 2 people; (b) 83% of participants were reported to have a staff member; 72%, a member of their family; 54%, another person with mental retardation; and 30%, a person who did not fit into any of these categories in their social network; (c) variation in the size and composition of participants' social networks was associated with a range of variables, including the personal characteristics of residents (age, autism, ability, and challenging behavior), the type of previous and current accommodation, staffing ratios, institutional climate, and the implementation of "active support."

Very large core needle biopsies of the breast: a review

The commitment to the goal of diagnosing and treating breast cancer at its earliest point of development remains strong. As a result, biopsy techniques continue to evolve. Freehand needle localizations were supplanted by fenestrated grids and hook wires. In the 1990s, stereotactic and ultrasound guided large core needle biopsy techniques were introduced, and now ultrasound and stereotactic guided vacuum-assisted procedures with 11-gauge needles are commonplace. Most recently, very large core needle biopsy devices were developed with a purpose of percutaneously diagnosing and treating nonpalpable breast lesions. However, bigger may not necessarily be better. This paper reviews the very large core needle biopsy technique and compares it to traditional large core needle biopsy. Factors such as technical success, histologic concordance, surgical margin positivity and cost are discussed.

Receipt of psychotropic medication by people with intellectual disability in residential settings

Previous studies have reported that the rate of prescription of antipsychotic medication for people with intellectual disability is far in excess of the expected prevalence of psychoses for this population. Recent research identifying factors which predict the use of psychotropic medication suggests that challenging behaviour may play a key role in determining the receipt of antipsychotic medication. The present study reports the prevalence of psychoactive medication receipt for 500 people with intellectual disability living in different forms of residential provision in the UK. Variables which predict the receipt of psychotropic medication are also identified. The results show differences between forms of residential provision in rates of medication receipt. Analyses of predictors of psychotropic medication receipt suggest that, whilst the receipt of antidepressants is predicted by symptoms of mental ill health, the receipt of both antipsychotics and hypnotics/anxiolytics is predicted by variables related to challenging behaviour.

Lifestyle related risk factors for poor health in residential settings for people with intellectual disabilities

Little information is available on the prevalence and determinants of lifestyle related risk factors for poor health (obesity, poor diet, physical inactivity, smoking and alcohol abuse) among people with intellectual disabilities. This study reports the prevalence of these risk factors for 500 people with intellectual disabilities living in different forms of residential provision in the UK. Variables which predict the presence of these risk factors are also identified. While levels of smoking and alcohol abuse were low, the prevalence of poor diet, obesity in women and physical inactivity was high. Analyses of predictors of risk factors present a mixed pattern with regard to participant and service characteristics, with greater ability and less restrictive residential settings being associated with poor diet, smoking and obesity, but physical inactivity being associated with lower ability and more restrictive settings. It is argued that increasing levels of moderate or vigorous physical activity among people with intellectual disabilities would be the single most effective way of improving the health of people with intellectual disabilities.

Assessing the impact of concomitant therapies on anemia in dialysis patients. Case study of the anemic patient

A wide variety of prescribed and over-the-counter (OTC) agents can affect the production or viability of red blood cells, thereby contributing to anemia. An apparent hyporesponse to Epoetin alfa therapy in end-stage renal disease (ESRD) patients can sometimes be traced to a medication prescribed to treat a comorbid condition. The anemic potential of many of these agents has been defined and can often be anticipated or avoided by examining and modifying the regimen. Nurses can help assess and prevent medicine-related hyporesponse to Epoetin alfa by obtaining thorough histories and providing ongoing counseling on the need to minimize exposure to substances that contribute to anemia. A case study is provided to illustrate the use of nursing assessment skills to identify potential drug-related hyporesponse to Epoetin alfa.

Quality and costs of community-based residential supports, village communities, and residential campuses in the United Kingdom

The costs, nature, and benefits of residential supports were examined for 86 adults with mental retardation living in village communities, 133 adults living in newly built residential campuses, and 281 adults living in dispersed housing schemes (small community-based group homes and supported living). Results indicated that (a) the adjusted comprehensive costs of provision in dispersed housing schemes were 15% higher than in residential campuses and 20% higher than in village communities; (b) dispersed housing schemes and village communities offered a significantly greater quality of care than did residential campuses; and (c) there appeared to be distinct patterns of quality of life benefits associated with dispersed housing schemes and village communities, with both approaches offering a greater quality of life than did residential campuses.

Initial experience with the advanced breast biopsy instrumentation device

OBJECTIVE

The Advanced Breast Biopsy Instrumentation (ABBI) device (United States Surgical; Norwalk, CT) is designed to percutaneously excise nonpalpable breast lesions. Because this is a new technique, we report our initial experience with regard to technical success, complications, and histologic margins for malignancies.

SUBJECTS AND METHODS

From May 14, 1997, until March 4, 1998, 89 consecutive patients elected to undergo the ABBI procedure. Preprocedure imaging included screening mammography and additional mammographic and sonographic studies when deemed necessary. Lesions were targeted by the surgeons. Specimen radiography was performed for all lesions, and the images were interpreted by radiologists. Pathologic analysis was provided or reviewed by a dedicated breast pathologist. Parameters analyzed included technical success, complications, lesion size, histologic diagnosis, and margin status for malignant lesions.

RESULTS

There were 29 patients with 30 noncalcified masses, 53 patients with clustered calcifications, three patients with masses and calcifications, three patients with asymmetric densities, and one patient with architectural distortion. Eighteen ABBI procedures were aborted, converted to core biopsy, or failed to remove the targeted lesion. Fifteen patients experienced a total of 19 complications; 10 of the complications required treatment and follow-up after the biopsy. Of 11 malignant tumors revealed by ABBI, four had negative margins. Seven of these 11 malignant tumors had positive margins.

CONCLUSION

The ABBI procedure had a high number of complications and technical failures and did not reliably provide cancer-free margins for malignant tumors. Women with nonpalpable breast lesions that need a tissue diagnosis are better treated by stereotactic or sonographically guided needle biopsy.

Major aphthous-like ulcers in two patients infected with human immunodeficiency virus

Two patients infected with human immunodeficiency virus (HIV) presented with persistent, large, and painful oral ulcers. Results of cultures and examination of a biopsy specimen were negative for infection and malignancy. Major aphthous-like ulcers should be considered in the differential diagnosis of oral ulcers in the HIV-infected patient.

Special patient populations: onychomycosis in the HIV-positive patient

Superficial fungal infections, including onychomycosis, have become an increasing problem as the number of patients with HIV infection or AIDS has grown. Superficial fungal infections and other cutaneous and noncutaneous disorders are correlated with a decline in the patient's CD4 cell count and are markers of disease progression. For those HIV-positive patients with fungal nail infections, the introduction of the new triazole antifungal agents (e.g., itraconazole, fluconazole) has markedly improved the therapeutic outcome. Unlike traditional topical or oral antifungal therapies, whose clinical utility was limited by relatively poor efficacy and the need for prolonged treatment, the new triazoles fulfill one of the foremost goals of HIV-infected patients: rapid symptomatic improvement of onychomycosis. For many patients, particularly those who live in areas with a high incidence of HIV, the psychologic rewards associated with the alleviation of this unsightly and "telltale" condition are immeasurable.

Localized facial telangiectasias following frostbite injury

Two patients presented with localized facial telangiectasias a consequence of superficial frostbite injury. Trauma from frostbite resulted in the permanent formation of these telangiectasias. We review the morphology of the different degrees of frostbite and discuss the involvement of angiogenesis as a response to tissue insult.

Clinical manifestations of photosensitivity in patients with human immunodeficiency virus infection

A number of light-induced pathologic changes in the skin of individuals with HIV infection have been reported in the dermatologic literature. The relationship between HIV and one of these more well-defined types of photosensitivity, PCT, while still uncertain seems definable and related to an infectious origin. The relationship of retrovirus infection and photosensitivities that are of idiopathic origin in HIV-infected individuals, as well as non-infected individuals, is much more conjectural. The association seems, however, to be more frequent than co-incidental, and the link probably resides in the realm of altered immune modulation. Since individuals with HIV frequently require phototherapy, such light-induced problems are likely to become more common. It is important that the dermatologist recognize these relationships.

Telangiectases in human immunodeficiency virus-positive patients

Telangiectases have been noted as a cutaneous manifestation of the acquired immunodeficiency syndrome and are characteristically distributed across the upper chest in a crescentic pattern between the clavicles. We describe the observation of diffuse upper body telangiectasia in a forty-seven-year-old, human immunodeficiency virus-seropositive man. Histopathologic examination revealed dermal telangiectasia with perivascular plasma cells. Although we are aware of the association between telangiectases and human immunodeficiency virus seropositive findings, we believe that this is the first documented observation of diffuse upper body telangiectasia in a human immunodeficiency virus-seropositive patient.