An Open-Label, Randomized, Multi-Center Study Comparing the Sequence of High Dose Aldesleukin (Interleukin-2) and Ipilimumab (Yervoy) in Patients with Metastatic Melanoma

Combination immunotherapy with sequential administration may enhance metastatic melanoma (MM) patients with long-term disease control. High Dose Aldesleukin/Recombinant Interleukin-2 (HD rIL-2) and ipilimumab (IPI) offer complementary mechanisms against MM. This phase IV study assessed the sequenced use of HD rIL-2 and IPI in MM patients. Eligible Stage IV MM patients were randomized to treatment with either two courses of HD rIL-2(600,000 IU/kg) followed by four doses of IPI 3 mg/kg or vice-versa. The primary objective was to compare one-year overall survival (OS) with historical control (46%, Hodi et al., NEJM 2010). Secondary objectives were 1-year progression-free survival (PFS), objective response rate (ORR), and adverse events (AEs) profile. Evaluable Population (EP) included patients who received at least 50% of planned treatment with each drug. Thirteen and 16 patients were randomized to receive HD rIL-2 first, and IPI first, respectively. One-year OS rate was 75% for intention to treat population. Eighteen patients were included in EP, 8 in HD rIL-2, 10 in IPI first arm. In EP, 1-year OS, PFS and ORR rates were 87%, 68%, and 50%, respectively. The frequency of AEs was similar in both arms with 13 patients experiencing Grade 3 or higher AEs, 3 resulting in the end of study participation. There was one HD rIL-2-related death, from cerebral hemorrhage due to thrombocytopenia. In this study with small sample size, HD rIL-2 and IPI were safe to administer sequentially in MM patients and showed more than additive effects. 1-year OS was superior to that of IPI alone from historical studies.

Diaporthe Seed Decay of Soybean [Glycine max (L.) Merr.] Is Endemic in the United States, But New Fungi Are Involved

Diaporthe seed decay can compromise seed quality in soybean [Glycine max (L.) Merr.] in the warm and humid production areas of the United States during crop maturation. In the current study, 45 isolates of Diaporthe were recovered from seed sampled from soybean fields affected by Diaporthe-associated diseases in eight U.S. states in 2017. The isolates obtained belonged to 10 species of Diaporthe based on morphology and phylogenetic analyses of the internal transcribed spacer, partial translation elongation factor 1-α, and β-tubulin gene sequences. The associated species included D. aspalathi, D. caulivora, D. kongii, D. longicolla, D. sojae, D. ueckerae, D. unshiuensis, and three novel fungi, D. bacilloides, D. flavescens, and D. insulistroma. One isolate each of the 10 species was examined for pathogenicity on seed of cultivar Sava under controlled conditions. Seven days postinoculation, significant differences in the percentages of decayed seeds and seedling necrosis were observed among the isolates and the noninoculated control (P < 0.0001). While the isolates of D. bacilloides, D. longicolla, and D. ueckerae caused a significantly greater percentage of decayed seeds (P < 0.0001), the isolate of D. aspalathi caused the greatest seedling necrosis (P < 0.0001). The observation of new fungi causing Diaporthe seed decay suggests the need for a more comprehensive survey in U.S. soybean producing areas since members of the genus Diaporthe appear to form a complex that causes seed decay.

Ab Initio Molecular Dynamics Investigation of the Electronic and Structural Stability of Anionic O2-(H2O)n, n = 1-16 Clusters

We report an ab initio molecular dynamics investigation of the electronic and structural stability of water molecules binding to a nucleation O₂^- particle, O₂^-(H₂O)_n with n = 1-16, to ascertain the factors that create particularly stable species. Our results compare well with previous experimental and theoretical reports for clusters with less water content, find three new geometries for species with 7, 9, and 10 water molecules, and determine that 8, 11, 13, and 15 water molecules form remarkably stable structures around O₂^-. These special clusters correspond to well-defined compact structures formed by cubes and four-member rings made of water's hydrogen bonds interacting with a negative kernel formed by O₂^- with five water molecules, O₂^-(H₂O)₅, in which the negative charge is localized in the first four water molecules, while the fifth molecule provides geometrical stability. We assess the clusters' energetic stability based on dissociation energies, analyze electron detachment energies to understand its geometrical evolution, and investigate its charge distribution based upon isosurfaces of the highest occupied molecular orbital (HOMO). This research can help provide theoretical insight into the starting steps of nucleation of water clusters around ionic particles.

Overall survival by clinical risk category for high dose interleukin-2 (HD IL-2) treated patients with metastatic renal cell cancer (mRCC): data from the PROCLAIMSM registry

BACKGROUND

Prognostic scoring systems are used to estimate the risk of mortality from metastatic renal cell carcinoma (mRCC). Outcomes from different therapies may vary within each risk group. These survival algorithms have been applied to assess outcomes in patients receiving T-cell checkpoint inhibitory immunotherapy and tyrosine kinase inhibitor therapy, but have not been applied extensively to patients receiving high dose interleukin-2 (HD IL-2) immunotherapy.

METHODS

Survival of 810 mRCC patients treated from 2006 to 2017 with high dose IL-2 (aldesleukin) and enrolled in the PROCLAIMSM registry data base was assessed utilizing the International Metastatic RCC Database Consortium (IMDC) risk criteria. Median follow-up is 23.4 months (mo.) (range 0.2-124 mo.). Subgroup evaluations were performed by separating patients by prior or no prior therapy, IL-2 alone, or therapy subsequent to IL-2. Some patients were in two groups. We will focus on the 356 patients who received IL-2 alone, and evaluate outcome by risk factor categories.

RESULTS

Among the 810 patients, 721 were treatment-naïve (89%) and 59% were intermediate risk. Overall, of the 249 patients with favorable risk, the median overall survival (OS) is 63.3 mo. and the 2-year OS is 77.6%. Of 480 patients with intermediate risk, median OS is 42.4 mo., 2-year OS 68.2%, and of 81 patients with poor risk, median OS 14 mo., 2-year OS 40.4%. Among those who received IL-2 alone (356 patients), median OS is 64.5, 57.6, and 14 months for favorable, intermediate and poor risk categories respectively. Two year survival among those treated only with HD IL-2 is 73.4, 63.7 and 39.8%, for favorable, intermediate and poor risk categories respectively.

CONCLUSIONS

Among mRCC patients treated with HD IL-2, all risk groups have median and 2-year survival consistent with recent reports of checkpoint or targeted therapies for mRCC. Favorable and intermediate risk (by IMDC) patients treated with HD IL-2 have longer OS compared with poor risk patients, with most durable OS observed in favorable risk patients. Favorable risk patients treated with HD IL-2 alone have a 2-year OS of 74%. These data continue to support a recommendation for HD IL-2 for patients with mRCC who meet eligibility criteria.

TRIAL REGISTRATION

PROCLAIM, NCT01415167 was registered with ClinicalTrials.gov on August 11, 2011, and initiated for retrospective data collection until 2006, and prospective data collection ongoing since 2011.

Improved survival and tumor control with Interleukin-2 is associated with the development of immune-related adverse events: data from the PROCLAIMSM registry

BACKGROUND

Immune related adverse events (irAEs) are associated with immunotherapy for cancer and while results suggest improvement in tumor control and overall survival in those experiencing irAEs, the long-term impact is debated. We evaluated irAE reports related to high dose interleukin-2 therapy (IL-2) documented in the PROCLAIMSM registry data base from 2008 to 2016 (NCT01415167, August 9, 2011).

METHODS

Reports on 1535 patients, including 623 with metastatic melanoma (mM) and 919 with metastatic renal cell cancer (mRCC) (7 patients had both diseases), were queried for irAEs. The timing of the event was categorized as occurring before, during or after IL-2 or related to any checkpoint inhibitor (CPI). mM patients and mRCC patients were analyzed separately. Tumor control [complete + partial response + stable disease (CR + PR + SD) was compared between those experiencing no irAE versus those with the development of irAEs. Survival was analyzed by tumor type related to timing of irAE and IL-2, and in those with or without exposure to CPI.

RESULTS

Median follow-up was 3.5+ years (range 1-8+ years), 152 irAEs were reported in 130 patients (8.4% of all PROCLAIMSM patients): 99 (16%) in mM and 53 (5.8%) in mRCC patients. 31 irAEs occurred prior to IL-2, 24 during IL-2, and 97 after IL-2 therapy. 74 irAEs were attributed to IL-2 only (during/ after IL-2). Of the 97 post IL-2 irAEs, 24 were attributed to CPI, and 15 could not be distinguished as caused by IL-2 or CPI. Tumor control was 71% for those experiencing irAE, and 56% for those with no irAE (p = 0.0008). Overall survival was significantly greater for those experiencing irAEs during/ after IL-2 therapy, compared to those with no irAE or irAE before IL-2 therapy, in mM patients, median 48 months vs 18 months (p < 0.0001), and in mRCC patients, median 60 months vs 40 months (p = 0.0302), independent of CPI-related irAEs. IL-2-related irAEs were primarily vitiligo and thyroid dysfunction (70% of IL-2 related irAEs), with limited further impact.

CONCLUSIONS

irAEs following IL-2 therapy are associated with improved tumor control and overall survival. IrAEs resulting from IL-2 and from CPIs are qualitatively different, and likely reflect different mechanisms of action of immune activation and response.

Improving Assisted Living Care

In the absence of a national measurement system, private vendors of satisfaction measurement and improvement services have played a crucial role in the quality movement in the assisted living industry. Survey responses from 175 resident-family dyads at 20 facilities were analyzed to identify priorities for service improvement from the customers' perspective. They include improving care provided by aides and management, meal service, and activities. Practical solutions for addressing these issues are presented.

Softening of cattle hoof soles and swelling of heel horn by environmental agents

Bovine soles and shavings from the heel were used in laboratory tests that examined the softening and swelling effects of rainwater, cow slurry (faeces plus urine), urine, silage effluent, and washings from recently laid concrete. Formalin, glutaraldehyde and butyraldehyde were compared for their ability to prevent softening induced by water, urine or urea plus 2-mercaptoethanol. Exposure to rainwater, slurry or urine for 72 h softened the soles on average by 16, 13 and 14 Shore Durometer Units. Silage effluent had less softening effect on soles (7 Shore Durometer Units), and pre-treating heel shavings with silage effluent reversed the swelling effect of water. Washings and scrapings taken from 3- and 7-d-old concrete surfaces prepared from Portland cement, caused swelling in heel shavings by a factor of 1.5 and 1.3. Formaldehyde, glutaraldehyde and butyraldehyde pre-treatment reduced the sole softening effect of urea plus 2-mercaptoethanol in cow soles. Formaldehyde and glutaraldehyde pre-treatment reduced the sole softening effect of urine, and formaldehyde was effective at reducing concrete washings-induced swelling. The findings are relevant to solar bruising and ulceration in cattle.

Quality of life in patients on dialysis: benefits of maintaining a hemoglobin of 11 to 12 g/dL

Clinical data have consistently demonstrated that improvements in 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 levels between 11 and 12 g/dL and Hct levels between 33% to 36% yield significant improvements in a wide variety of parameters in the physical, cognitive, and psychological/social domains.

Attaining target hemoglobin levels in patients new to dialysis: individualizing therapy based on initial hemoglobin levels

Incident patients on dialysis typically have Hgb levels that are well below the target range of 11 to 12 g/dL as recommended by the NKF-K/DOQI (NKF 2001). Despite a nationwide emphasis on anemia as a quality indicator, low Hgb levels often persist for months after dialysis is initiated. This report provides an overview of an innovative, evidence-based approach to treating anemia that can help shorten the time required to achieve target Hgb levels in patients new to dialysis.

Identifying priority actions for improving patient satisfaction with outpatient cancer care

In parallel to developing new cancer therapies, the healthcare community has the responsibility of creating positive treatment experiences for patients. Data from 5907 cancer outpatients treated at 23 hospitals across the United States were analyzed to identify the top priorities for service improvement in outpatient cancer treatment facilities. They included meeting patients' emotional needs, providing information to patients and family members, reducing waiting times, and providing convenience and coordinated care among physicians and other care providers.

The Resident Choice Scale: a measure to assess opportunities for self-determination in residential settings

BACKGROUND

A 26-item Resident Choice Scale was designed to assess service practices for promoting resident choice.

METHOD

The staff working with 560 UK/Irish adults with intellectual disability were interviewed. Specific examples of practices promoting resident choice were requested and independently rated by the interviewer.

RESULTS

The interrater reliability of Resident Choice items was found to be acceptable (subsample n = 50). The psychometric properties of the Resident Choice Scale total score and scores on eight subscales were also acceptable. Consistently strong associations were found between greater resident choice and greater resident ability and, to a lesser extent, fewer resident challenging behaviours. Few associations were found between resident choice and autism or mental health problems. Even when controlling for resident ability and challenging behaviour, consistent associations were found between greater resident choice and the concurrent variables of greater community presence, fewer institutional practices, and greater user self-reported satisfaction (subsample n = 50).

CONCLUSIONS

Taken together, this pattern of results indicates that the Resident Choice Scale shows promise as a measure of the environmental opportunities available for adults with intellectual disability to exercise self-determination. Areas for future research testing the reliability and validity of the Resident Choice Scale are outlined.

False-negative core needle biopsies of the breast: an analysis of clinical, radiologic, and pathologic findings in 27 concecutive cases of missed breast cancer

BACKGROUND

A benign diagnosis in a core needle biopsy (CNBx) of the breast performed for a clinically and/or radiologically suspicious abnormality is often due to a nonrepresentative sample. However, the discordance may not be recognized, resulting in a logistic delay in the diagnosis.

METHODS

Twenty-seven false-negative CNBxs were identified in 952 consecutive CNBxs of the breast (653 benign, 266 malignant, and 33 atypical) performed during a 1-year period. Biopsies were analyzed with respect to clinical and radiologic findings, biopsy type, type of malignancy, and interval between the original CNBx and final diagnosis. Four hundred thirty-eight (67%) of the patients with a benign CNBx diagnosis either underwent excision or had a minimum of 1-year follow-up (mean, 35.6 months; median, 36 months).

RESULTS

The cancers missed on CNBx included 6 ductal carcinomas in situ, 17 invasive ductal carcinomas, 3 invasive lobular carcinomas, and 1 non-Hodgkin lymphoma. The overall false-negative rate was 9.1%. For palpable lesions, ultrasound-guided CNBx had a lower rate of missed cancer (3.6%) compared with CNBx without image guidance (13.3%). The false-negative rate for vacuum assisted CNBx biopsy was 7.6% (3.3% for the 11-gauge needle, 22.2% for the 14-gauge needle; 5.6% for nonpalpable mass lesions, 8.2% for microcalcifications). In all seven false-negative CNBxs performed by radiologists, the discordance between the radiologic and pathologic findings was promptly recognized due to their standard follow-up protocol. The discordance between the degree of clinical suspicion, radiologic impression, and the pathologic findings was not immediately recognized in 5 of 20 false-negative CNBxs performed by surgeons (4 without radiologic guidance and 1 with ultrasound guidance), resulting in a delay in the diagnosis ranging from 112-336 days.

CONCLUSIONS

A false-negative diagnosis of breast carcinoma was found to be more common in CNBx performed without image guidance but occurred to a lesser degree in image-guided biopsies. A delay in diagnosis can be avoided by establishing a standard post-CNBx follow-up protocol.

Attitudes towards psychotherapy with older people among trainee clinical psychologists

Therapists have been described as reluctant to work with older people. A legacy of pessimism towards psychotherapy with this group has been traced back to Freud's assertions that older people are no longer educable. It remains unclear to what extent these views continue to influence today's therapists. This study explores the attitudes of trainee clinical psychologists towards psychotherapy with this age group. A cross-sectional postal survey design was used and the data were analyzed using content analysis. Three hundred and seventy-one trainees responded, representing 38% of the total population of trainees in the UK. The majority of the trainees thought that work with older people provided the opportunity to apply psychological knowledge and skills, although therapists needed to respond differently when working with an older person. Factors to take into account included cognitive decline and physical health problems. The trainees described a number of rewards and challenges associated with working with older people. The responses suggest that although a significant minority of trainees continue to hold some negative stereotypes about therapeutic work with older people, positive attitudes are also clearly evident. Further research to explore the attitudes of other healthcare professionals is recommended and the implications for training and supervision are examined.

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.