Growth and growth biomarker changes after adenotonsillectomy: systematic review and meta-analysis.

OBJECTIVE: To determine the effect of adenoidectomy and/or tonsillectomy ("adenotonsillectomy") upon growth and growth biomarkers, in the context of sleep disordered breathing (SDB). SDB in children, primarily due to adenotonsillar hypertrophy, increases the risk of growth failure. DESIGN: Systematic review and meta-analysis. PubMed, ERIC and Cochrane Reviews databases from January 1980 to November 2007 were searched for studies reporting: pre/post-adenotonsillectomy height and weight changes as percentage increased or decreased, raw data, z scores or centiles, or: IGF-1 and/or IGFBP-3 serum-level changes as z scores or raw data. For anthropometrics, the meta-analysis included studies presenting z scores or centiles. SETTING: Observational studies. PATIENTS: Otherwise healthy children, not selected for obesity. MAIN OUTCOME MEASURES: Pre/post-surgery changes in standardised height and weight, and IGF-1 and IGFBP-3. RESULTS: Of 211 citations identified, 20 met systematic review criteria. SDB was an enrolment criterion in 13 of the studies, and one of several enrolment criteria in three. Meta-analysis findings for pre/post-surgery changes were: standardised height: 10 studies, 363 total children, pooled standardised mean differences (SMD) = 0.34 (95% CI 0.20 to 0.47); standardised weight: 11 studies, 390 total children, pooled SMD = 0.57 (95% CI 0.44 to 0.70); IGF-1: 7 studies, 177 total children, pooled SMD = 0.53 (95% CI 0.33 to 0.73); IGFBP-3: 7 studies, 177 total children, pooled SMD = 0.59 (95% CI 0.34 to 0.83). CONCLUSIONS: Standardised height and weight, and IGF-1 and IGFBP-3 increased significantly after adenotonsillectomy. Findings suggest that primary care providers and specialists consider SDB secondary to adenotonsillar hypertrophy when screening, treating and referring children with growth failure.

Attitudes on end-of-life care and advance care planning in the lesbian and gay community.

Gay men and lesbians have special interests in documenting their preferences regarding advance care planning and end-of-life care. A 64-item survey instrument was developed to ascertain the preferences of this community regarding approaches to end-of-life care, viewpoints on physician-assisted suicide (PAS) and euthanasia, and practices regarding advance care planning. The survey was completed by 575 participants recruited through community-based health care and social service organizations serving the lesbian and gay community, primarily in the New York metropolitan area. Respondents represent a diverse group of women (36%) and men (63%) from various age, racial/ethnic, and religious/spiritual backgrounds; 10% were human immunodeficiency virus (HIV)-positive. Respondents' perspectives on end-of-life care are generally consistent with findings from other attitudinal studies of U.S. adults: a majority supported legalization of PAS and preferred a palliative approach to end-of-life care. However, the gay community sample revealed even stronger support for assisted suicide and palliative care. Although respondents completed advance directives at a higher rate than adults generally, the legal importance for gay men and lesbians to execute directives should encourage health care providers and community organizations to assume a larger educational role on advance care planning. Results confirm other reports on the need to address provider communication skills. It is speculated that the HIV epidemic was a major influence behind these results because of the overwhelming personal impact of the epidemic on most gay men and lesbians during the past two decades.

Housing needs of persons with HIV and AIDS in New York State.

OBJECTIVE: To understand the scope and magnitude of housing needs among persons with HIV/AIDS in New York State. DESIGN: Both housing providers and non-housing providers were identified through state-wide lists and regional resource guides. All identified housing providers and a random sample of identified non-housing providers, by region, were approached. Interviewers conducted telephone interviews with qualified representatives from each organization. RESPONDENTS: All major providers of HIV/AIDS housing services (n = 144) and a random sample of other providers of HIV/AIDS services (n = 87) were interviewed. VARIABLES UNDER STUDY: Data that were gathered included: agency profiles, client demographics, and clients' need for and use of housing services. RESULTS: One-third of housing agency clients were either homeless or living in a welfare hotel, while one-tenth of non-housing agency clients lived under such conditions. Nearly one-third of all clients were living doubled-up, and half had problems paying for rent or utilities. The majority of clients required supportive services such as substance abuse treatment or mental health care. CONCLUSIONS: With the advent of protease inhibitor therapy, stable and adequate housing has become especially critical for persons with HIV/AIDS. However, public assistance "reforms" are likely to exacerbate their housing needs, and may ultimately compromise the potential benefits of treatment.

Housing issues of persons with AIDS.

The housing status of persons with HIV/AIDS is a central issue in their care and prognosis. We conducted eight focus groups to explore the housing needs of special populations of persons with HIV/AIDS in New York State; these populations included substance users, ex-offenders, persons with documented histories of homelessness, and rural dwellers/migrant workers. For the focus groups, 52 participants were recruited from the clientele of health and social service agencies. A major theme was the potent effect that housing situations had on participants' health. Participants frequently attributed lowered T-cell counts and increased lethargy to the stress associated with governmental rules and paperwork. Lack of money, inadequacy of entitlements, and high costs of housing were the major barriers to securing stable and appropriate housing. Furthermore, participants experienced housing discrimination based on HIV status and experience with the criminal justice system or drugs.

Social and medical factors affecting hospital discharge of persons with HIV/AIDS.

Although outpatient care and pharmaceuticals have rendered community-based care possible, hospitals remain the locus of the most costly and intensive HIV/AIDS care. Little is know, however, about the impact of patients' social circumstances upon hospital length of stay. This paper examines the impact of housing status, living arrangements, and a range of barriers to discharge on hospital length of stay. Findings are based on retrospective medical chart reviews by nurses and social workers of 749 HIV/AIDS hospitalizations, occurring between June-August 1991 in four New York City medical centers. One third of the sample experienced at least one barrier to discharge. Medical need barriers were the most common (18%), and were associated with the longest length of stay (35.3 days), followed by home care and housing barriers (32.7 and 30.2 days, respectively). Fourteen percent of the sample were either homeless or in unstable housing situations (e.g., transient or "doubled up") prior to admission. Homelessness and unstable housing were associated with a 5 day increment in hospital length of stay, and remained a significant factor even controlling for morbidity. These results indicate that inadequate housing remains a significant barrier to discharge among hospitalized persons with HIV/ AIDS.

Correlates of voluntary human immunodeficiency virus antibody testing reported by postpartum women.

OBJECTIVES: This study examined attitudes, knowledge, and behaviors reported by postpartum women in an AIDS epicenter toward voluntary human immunodeficiency virus (HIV) counseling and testing. METHODS: From February 1993 to March 1994, a convenience sample of 544 women underwent postpartum interviews at a municipal hospital in the Bronx, New York City. Demographic information and obstetric, sexual, drug use, and HIV testing histories were elicited, and selected variables were abstracted from the medical charts. Univariate and multivariate logistic regression analyses were performed. RESULTS: Seventy-nine percent of women were voluntarily tested for HIV. In the multivariate model, the strongest individual correlate of HIV testing was a history of drug use. Other independent correlates were being age 25 or younger, having only one child, knowing someone who died of AIDS, and having stigma-related concerns about testing. In univariate analysis, women with a drug risk were more than nine times as likely as others to have delivered without receiving any prenatal care during this pregnancy. CONCLUSIONS: Voluntary counseling and testing programs can succeed in testing a majority of hospitalized childbearing women. However, women at risk of drug use, who more often reported testing, were probably tested outside of prenatal care settings. Efforts to reduce vertical transmission of HIV infection must focus on bringing more women, especially women who use drugs, into prenatal care.

Self-perceived unmet health care needs of persons enrolled in HIV care.

We examined the prevalence of, and factors associated with unmet health service needs among persons with HIV disease. Data were examined from 1,851 participants in the U.S. AIDS Cost and Service Utilization Study, drawn from 26 medical care providers in 10 cities. Geographic areas with large numbers of AIDS cases, and health care providers within them were chosen as study sites. After completing a screener questionnaire, potential participants at each site were stratifed by illness stage, HIV exposure route, and insurance status; a systematic random sample within those strata were selected for the study. Participants completed a comprehensive survey of HIV-related service use and costs, which also asked them to identify unmet health service needs. Analyses identified the relationship between unmet needs and: stage of illness, type of insurance, source of care, living arrangement, and AIDS prevalence of respondents' geographic region. At least one unmet need was reported by 20% of the sample. Needs for non-institutional services, e.g, dental care, mental health, and medications were more likely to be unmet than need for emergency room and hospital care. While most factors significantly affected the odds of having an unmet need, the greatest effects were found for private insurance and HIV asymptomatic status, both of which decreased the odds of unmet needs by approximately 50%. These findings suggest that insurance coverage for services required during the chronic phase of HIV illness is inadequate and should be augmented.

The impact of housing status on health care utilization among persons with HIV disease.

This study sought to identify the prevalence of unstable housing situations, and for whom they occurred, and to examine differences in health care utilization by housing status. Housing status and inpatient and outpatient health care utilization of 1,851 HIV-infected individuals was ascertained through interviews. Nine percent of respondents were in unstable housing situations. Unstable housing was associated with significantly lower functional status. The unstably housed were more likely to visit an emergency room (p < 0.05) and had fewer ambulatory visits than persons with stable housing (p < 0.03). They incurred nearly five more hospital days and their average hospitalization was approximately 1.5 days longer than the stably housed, although these differences were not significant. Utilization of ambulatory care is lower among unstably housed persons with HIV disease, which may have led to their increased reliance upon emergency rooms and hospitals. Helping HIV-infected individuals maintain adequate housing could reverse this pattern.

Theory and method: a social work approach to unmet needs.

Social workers who plan or administer programs are fundamentally concerned with meeting the needs of the clients served. The social work profession, while proficient at needs assessments, has paid insufficient attention to research into social bases of unmet service needs. This study is an examination of unmet needs of persons with HIV diagnosis. It utilizes the Health Behavior Model, within the framework of the ecological perspective. The study is presented as a case example to illustrate the value of this research methodology for administration, programming, and policy in the human services.

Rare diseases, drug development, and AIDS: the impact of the Orphan Drug Act.

The Orphan Drug Act provides public subsidies and incentives to spur the development of drugs for rare diseases--drugs that the private sector might otherwise consider unprofitable to produce. Although the act has achieved numerous successes, the high prices and extraordinary sales generated by some orphan drugs lead to a pivotal policy question: how can the act be used to meet the legislative goal of stimulating drug development for small patient populations without resulting in prices that make drugs inaccessible? This question is explored using the example of AIDS drugs, many of which received subsidies under the act, to illustrate central points. The history of the act, its weaknesses, and strategies for reform are described as well.

AIDS and families: cultural, psychosocial, and functional impacts.

AIDS has touched the nation's families on a number of levels. More than a decade into the epidemic, it is clear that the cultural, psychosocial, and functional impact of AIDS stretches beyond that on our traditional concept of kin to a broader view of family. At the cultural level AIDS has challenged our notions of who is and functions as a family, while also shaping our behaviors and language. Within families, the psychosocial impact of a family member having a stigmatized illness generates a range of emotional responses. While certain of these responses are common to all families, they will also vary by the family constellation affected. At the functional level we see an illness in which persons other than kin often play important caregiving roles. In all family types family caregiving for persons with AIDS brings about role reconfiguration, financial, and other impacts.