The impact of the housing status on clinical outcomes and health care utilization among individuals living with HIV

ABSTRACT

The lack of stable housing can impair access and continuity of care for patients living with human immunodeficiency virus (HIV). This study investigated the relationship between housing status assessed at multiple time points and several core HIV-related outcomes within the same group of HIV patients experiencing homelessness. Patients with consistently stable housing (CSH) during the year were compared to patients who lacked CSH (non-CSH group). The study outcomes included HIV viral load (VL), CD4 counts, and health care utilization. Multivariable and propensity weighted analyses were used to assess outcomes adjusting for potential group differences. Of 208 patients, 88 (42%) had CSH and 120 (58%) were non-CSH. Patients with CSH had significantly higher proportion of VL suppression and higher mean CD4 counts. The frequency of nurse visits in the CSH group was less than a half of that in the non-CSH group. Patients with CSH were less likely to be admitted to the medical respite facility, and if admitted, their length of stay was about a half of that for the non-CSH group. Our study findings show that patients with CSH had significantly better HIV virologic control and immune status as well as improved health care utilization.     

Use of Hyaluronidase in the Treatment of Granulomatous Hyaluronic Acid Reactions or Unwanted Hyaluronic Acid Misplacement

Background. In the past, reactions or misplacement of soft tissue fillers has been fraught with anxiety because time has been the main thrust for improvement in spite of ancillary treatments. Hyaluronidase is an enzyme that dissolves hyaluronic acid in the skin and also assists in the management of granulomatous foreign-body reactions to hyaluronic acid. These reactions may be caused by allergy to the material or immunologic response to the protein contaminants in the hyaluronic acid preparations. Dissolution of material in erroneous placement of material and in allergic reactions can be a time saver and a deterrent to patient dissatisfaction.
Objective. To evaluate the use of hyaluronidase in the treatment of both allergic reactions and the erroneous misplacement of hyaluronic acid in the skin.
Methods. A case of persistent granulomatous reaction to injectable hyaluronic acid and a case of hyaluronic acid erroneous misplacement with their successful subsequent treatments using intracutaneous hyaluronidase are reported, along with illustrative examples of hyaluronidase use.
Results. The use of hyaluronidase reduced the patient discomfort within 24 to 48 hours, deterring any patient anxiety or patient dissatisfaction.
Conclusions. Hyaluronidase has a place in the treatment of allergic reactions to hyaluronidase and in the erroneous misplacement of the material.     

Relevance of Cosmeceuticals to the Dermatologic Surgeon

Background. The dermatologic surgeon is the dermatologist with special expertise in the surgical care of the health and beauty of the skin.
Objectives, Methods, Results. There is no better arena for the use of topical regimens to preserve skin quality than in the time interval devoted to before and after care with respect to surgical procedures.
Conclusion. Many of these regimens can be tailor devised with topical drugs and cosmeceuticals together in proper balance in the patient's best interest for affordable health care.
HAROLD J. BRODY, MD, HAS INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.     

Mapping out a search for environmental causes of breast cancer.

Geographic patterns and time trends for breast cancer suggest there are preventable causes that may include environmental factors. This article describes the development of new methods used in the Cape Cod Breast Cancer and Environment Study to investigate whether synthetic chemicals in the environment contribute to breast cancer risk.     

Adult daughters and parent care: a comparison of one-, two- and three-generation households.

This paper compares the effects of parent-care associated with three living arrangements of elderly widowed mothers who were being helped by married daughters: elderly mother living separately; two-generation households (mothers, daughters, sons-in-law); and three-generation households (grandchildren present). Daughters whose mothers lived separately fared the best; their mothers were the most cognitively and functionally capable and the daughters reported the fewest negative effects of caregiving. Daughters in two-generation households provided the most care; their mothers were the oldest and most impaired. Since daughters in three-generation households reported more negative mental and emotional effects of care, the unique problems of caregiving in such households are discussed.     

INVOLVEMENT OF NON-NMDA AND NMDA RECEPTORS IN GLUTAMATE-INDUCED PRESSOR OR DEPRESSOR RESPONSES OF THE PONS AND MEDULLA

1. Fifty-five intact and six baroreceptor denervated and vagotomized cats of either sex were anaesthetized intraperito-neally with urethane (400 mg/kg) and a-chloralose (40 mg/kg). Responses of the systemic arterial pressure (SAP), mean SAP (MSAP) and sympathetic vertebral nerve (VNA) and renal nerve activities (RNA) were recorded. 2. In intact animals, monosodium L-glutamate (Glu, 0.1 mol/L, 50 nL) was microinjected into pressor areas of the locus coeruleus (LC), gigantocellular tegmental field (GTF), rostral ventrolateral medulla (RVLM) and dorsomedial medulla (DM), and the depressor areas of caudal ventrolateral medulla (CVLM). The induced actions were compared before and after microinjection of either glutamate antagonists, glutamate diethylester (GDEE, 0.5 mol/L, 50–100nL), a competitive AMPA receptor blocker, or 2-amino-5-phosphonovaleric acid (D-AP5, 0.025 mol/L, 50–100 nL), a competitive N-methyl-D-aspartate (NMDA) receptor blocker. GDEE completely blocked the increases of SAP and VNA elicited from all pressor areas. D-AP5 only partially blocked the pressor but slightly blocked VNA and RNA responses from LC, GTF and DM, particularly those from RVLM. Neither GDEE nor D-AP5 blocked the depressor responses of SAP and two nerve activities elicited from CVLM. 3. In baroreceptor denervated animals, NMDA (2 mmol/L, 50–100 nL) and AMPA (0.2 mmol/L, 50–100 nL) were micro-injected into the same pressor areas of GTF, RVLM and DM and the depressor area of CVLM responsive to Glu activation (0.1 mol/L, 30 nL). In RVLM, DM and CVLM, the results of either NMDA or AMPA were similar to those induced by Glu. However, in GTF, microinjection of either NMDA or AMPA did not induce similar responses to Glu. This suggests that the nature of GTF may differ from RVLM and DM. 4. The above results suggest that the Glu-induced pressor responses from LC, GTF, DM and especially RVLM, are primarily mediated through AMPA receptors. The Glu-induced depressor responses from CVLM may not be predominantly mediated by either AMPA or NMDA receptors. 5. In both baroreceptor-intact and -denervated cats stimulation of the pressor areas often produced an increase of VNA and a decrease of RNA, while in the depressor CVLM decreased both VNA and RNA. The VNA, but not RNA were positively correlated with the pressor responses, while both VNA and RNA were positively correlated with the depressor responses. This may suggest that neurons of the sympathetic vertebral and renal nerves are topographically organized in the brain.     

Proximal femoral focal deficiency: radiologic analysis of 49 cases

Proximal femoral focal deficiency, an uncommon congenital anomaly, necessitates early radiologic classification for surgical planning and treatment. Objective radiographic criteria, including femoral length index, acetabular depth index, acetabular angle index, and shape of the proximal femur were determined in 49 patients before cartilaginous ossification of the femoral capital epiphysis; final classification was based on follow-up radiographs or findings at arthrography or surgery. These parameters were analyzed to determine the accuracy and contributions of each in classification. Correct classification into one of three groups was possible in 86% of cases with use of three of the parameters: femoral length index, acetabular depth index, and shape of the proximal femur. The acetabular angle was found to contribute insignificantly to classification. Magnetic resonance imaging, used in only one case, depicted the nonossified cartilaginous femoral capital epiphysis, thus obviating the need for invasive diagnostic procedures and facilitating early classification.