Comorbidity, age and stage at diagnosis in colorectal cancer (CRC)

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Background: Stage at diagnosis is a crucial predictor of outcome in CRC. The purpose of this study is to determine if comorbidity and age affect the stage at which CRC is diagnosed. Identifying variables that influence stage might improve outcomes in CRC. Due to frequent contact with the health care system, we hypothesize that patients with greater comorbidity and older age are more likely to be diagnosed with early-stage disease. Methods: We present data from two distinct patient populations: using the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003-present. We also identified CRC patients treated from 2003-present at 10 non-VA, fee-for-service (FFS) practices in North and South Carolina. Data were abstracted by retrospective chart review. Comorbidity was calculated by the Charlson comorbidity index (CCI) with high comorbidity defined as CCI =3. Older age was defined as age =70 years. Data were analyzed using logistic regression where the odds of late stage at diagnosis were modeled as influenced by older age, high CCI, and race. The analysis included estimation of adjusted and unadjusted odds ratios. Results: 347 VA and 282 FFS patients were included. 98% VA vs 50% FFS were male; 43% VA vs 27% FFS were aged =70; 56% VA vs 70% FFS were white; 26% VA vs 44% FFS presented with metastatic CRC; and 21% VA vs 6% FFS had a CCI =3. In both patient populations, regression analysis showed that older age, high CCI and white race were not significant predictors of stage at diagnosis. VA 95% confidence intervals (CI's) were 0.52–1.41 (age =70), 0.50–1.75 (CCI =3), and 0.42–1.11 (white race). FFS 95% CI's were 0.52–1.53 (age =70), 0.36–2.78 (CCI =3), and 0.74–2.11 (white race). Broader 95% CI's in the FFS analysis were due to smaller sample size. Conclusions: In CRC patients, age and comorbidity were not related to stage at diagnosis. The findings are similar whether the patients were treated in a fee-for-service or VA health system. While older age and greater illness might provide more contact with the health care system, this exposure did not result in earlier diagnosis of CRC. Future studies will examine the impact of comorbidity on CRC treatment and survival.

No significant financial relationships to disclose.

Choice of adjuvant and first-line metastatic chemotherapy (CT) for colorectal cancer (CRC) treated in the Carolinas

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Background: CT choice is influenced by many factors including published evidence, guidelines, cost, reimbursement, patient considerations, key opinion leaders, and anecdote. Substantial locoregional variation in practice patterns can exist, and therefore studies of locoregional practice provide important information on local drivers of care. Methods: Using a population-based strategy, we identified CRC patients who developed metastatic disease since 6/1/03 from 9 Duke Oncology Network community practices and 1 academic practice in North and South Carolina. Demographic, comorbidity, diagnostic, stage, initial treatment, and metastatic treatment data were abstracted by retrospective chart review, double-entered and verified for accuracy. Results: Of the first 743 charts screened, 306 were eligible (mean age 61 (SD 13), 49% male; 65% white; 22% black; 77% colon cancer and 19% rectal; stages II 8%, III 16%, IV 64%). 26 earlier stage rectal cancer patients received neoadjuvant treatment, 50% infusional fluorouracil (5FU) and 42% capecitabine (Cap). 46 colon cancer patients received adjuvant CT, including 5FU/leucovorin (LVN; 54%), 5FU/LVN/oxaliplatin (21%), Cap (9%), and 5FU/LVN/irinotecan (7%). First-line CT for metastatic colon cancer (n=149) included FOLFOX+-bevacizumab (Bev; 42%), Cap/oxaliplatin +- Bev (23%), 5FU/LVN + Bev (9%), FOLFIRI +- Bev (7%), IFL +- Bev (7%), clinical trial (7%), Cap (3%), and unknown (1%). 54% of patients received Bev overall, reflecting 49% usage before 6/05 and 69% after 6/05. CT was not offered for 25 (8%) at initial diagnosis. Conclusion: Locoregional practice patterns in the Carolinas suggest that for adjuvant treatment of CRC, oxaliplatin has been used in 21% of adjuvant and 75% of first-line metastatic colon CT regimens, and that bevacizumab use has increased to 69% of first-line metastatic CRC patients.

No significant financial relationships to disclose.

Cancer screening coverage of south Asian women in Wakefield

OBJECTIVE

To measure the cervical and breast screening coverage of south Asian women in Wakefield, compared with other city residents.

DESIGN

Pairwise measurement of screening histories of women whose names appeared to be south Asian, and of non-Asian women matched by date of birth and general practice.

DATA SOURCE

Computerised records of screening histories held by West Yorkshire Central Services Agency, for the eight general practices in central Wakefield.

RESULTS

67% of south Asians and 75% of non-Asians had acceptable (not overdue) cervical screening histories (chi(2)=13.75, p<0.001). 53% of south Asians and 78% of non-Asians had acceptable breast screening histories (chi(2)=8.5, p<0.01)

CONCLUSION

Interventions should be designed to improve coverage for breast screening among south Asian women. The need for such interventions for cervical screening is equivocal.

Perceptions and experiences of primary nursing in an ICU: a combined methods approach

With the introduction of the Patient's Charter, greater emphasis has been placed on 'named nursing' (Department of Health 1991). While there is much literature extolling the benefits of this method of delivering care to patients (Reed 1988; Manley 1989; Macguire 1991); there is a dearth of empirical studies exploring primary nursing in an adult intensive care unit (ICU). In addition, little is known about how nurses feel about being a 'primary nurse'. The aim of this study was to determine qualified nurses' perceptions and experiences of the effect of primary nursing on patient care in an intensive care environment (ICU) and to explore nurses' experiences of being a primary nurse. This study was carried out in an ICU in Northern Ireland. Primary team nursing was the system of organizing care within this unit. This system consisted of teams of 'primary' and 'associate' nurses. A total of 65 qualified nurses were surveyed. Sixteen nurses took part in focus group interviews. A combined methods approach comprising a questionnaire and focus group interviews was employed for the study. Part one of the questionnaire provided data on professional and demographic details. Part two facilitated nurses to elaborate on their feelings and perceptions of the concept of primary nursing. The focus groups facilitated in-depth exploration of the respondents' personal feelings and experiences about their role as a primary nurse. The data obtained from the two-part questionnaire were analysed using descriptive statistic and content analysis. The data obtained from the focus groups were analysed using content analysis and the development of emerging themes. Analysis of the data revealed that the nurses' views were similar to those highlighted in the existing literature. Nurses perceived primary nursing to relate to the responsibility for the care of one patient, from admission to discharge with the primary nurse assessing, planning, implementing and evaluating care and the associate nurse assisting in the delivery of this care. Thus, continuity of care was seen as the major advantage of primary nursing. The findings, however, suggested that further teaching on the concept of primary nursing was required. In addition, many of the nurses admitted they experienced considerable stress, particularly in relation to their close proximity over a long period of time, with patients and their relatives. This is an important finding and highlights the need for primary nurses in ICU to have the opportunity (in some instances), to be relieved of their responsibility for a named patient, thereby reducing some of the potential for stress. It is acknowledged that the findings of this study may not be generalized beyond the identified sample. Further empirical studies exploring nurses' perceptions and experiences of primary nursing in an ICU are therefore needed.

Hyperbaric oxygen therapy: what is the case for its use?

Hyperbaric oxygen therapy can be used for a variety of indications, ranging from decompression sickness to thermal burns. This article explains why it may improve healing in diabetic foot ulcers.

Intrapericardial beta-adrenergic blockade with esmolol exerts a potent antitachycardic effect without depressing contractility

Hyperadrenergic states of various etiologies can contribute to tachycardias. Systemic beta-adrenergic blockade suppresses sinus tachycardia but may adversely affect arterial blood pressure and contractility, because the drug gains access to myocardial cells as well as to the sinoatrial node. We examined whether intrapericardial beta-adrenergic blockade with esmolol could suppress tachycardia without reducing contractility as a result of limited drug diffusion, which would be sufficient to penetrate the superficial sinoatrial node but not the deeper myocardial layers. In five anesthetized pigs, we provoked a reflex heart rate increase of 50 beats/min with hemorrhage. The rapidly acting beta-adrenergic blocking agent esmolol (1 mg/kg) was administered intrapericardially using a new percutaneous transatrial access method and a catheter system that can be rapidly and safely introduced. Esmolol equivalently suppressed hemorrhage-induced sinus tachycardia when administered intrapericardially (from 192 to 158 beats/min at 5 min, p < 0.05) or intravenously (from 177 to 151 beats/min at 1 min, p < 0.05). The antitachycardic effect of intrapericardial esmolol was prolonged compared with intravenous esmolol (10 min vs. 3 min, p < 0.05). Intrapericardial esmolol did not affect blood pressure or left ventricular dP/dt max, an index of contractility, whereas intravenous esmolol decreased blood pressure at 1 min for 2 min (p < 0.05) and simultaneously decreased left ventricular dP/dt max at 1 min for < 2 min (p < 0.05). Intrapericardial esmolol suppresses adrenergically induced sinus tachycardia without decreasing contractility or blood pressure. The transatrial approach for intrapericardial delivery of certain 1-adrenergic blocking agents could be employed to control tachycardias in emergency care and surgical settings in patients with impaired cardiac contractility and propensity to hypotension.

The incidence of smoking amongst nurses: a review of the literature

Over the years there has been an ongoing debate about the implications of the smoking behaviour of nurses in relation to their own health and in the context of their professional role and responsibilities. However it is difficult to determine with any degree of accuracy the current incidence of smoking amongst nurses and most of the available research is based on small samples which embrace nurses of different levels and status. Very few recent studies in the United Kingdom or elsewhere have focused on this issue. A confused picture therefore emerges. This paper presents a critical overview of the literature and where appropriate provides data about the incidence of smoking in comparable groups of the general population.

Why nurses smoke: a review of the literature

The smoking behaviour of nurses has been widely debated in the context of their professional role and responsibilities. There has been much speculation about why nurses smoke and possible explanations include a stressful nursing environment, peer pressure and socio economic status and education. This paper provides an overview of the literature which offers insights into the reasons why nurses smoke and compares the findings from this literature with those studies examining the smoking behaviour of women in general and young women in particular. This review reveals that many students take up smoking before commencing their training and the factors which influence nurses smoking are similar to those that influence similar groups of females in the general population.

Impact of correlated factors on bone density in individuals with a family history of osteoporosis

Previous studies have suggested that 14-47% of the variation in bone mineral density (BMD) can be predicted using clinical risk factors. The aim of our study was to determine, for the first time, the importance of these factors in individuals with evidence of a genetic predisposition to the disease. The subjects studied were 147 female and 86 male Caucasians, all with a family history of osteoporosis. Linear regression was used to determine whether age, height, weight, and years of reduced estrogen exposure were significant predictors of BMD. Males and females were examined separately, and BMD was measured at the hip and spine. The results show that these risk factors, known to be at work in the general population, are equally important in those with a family history of osteoporosis. It is clear, therefore, that they must be taken into account, and corrected for in genetic studies of the disease.

Heart rate surges during REM sleep are associated with theta rhythm and PGO activity in cats

Rapid eye movement (REM) sleep is characterized by periods of profound cardiac autonomic activation evident in heart rate surges in humans and canines. Our goals were to determine whether or not the heart rate surge phenomenon occurs in cats and to characterize concurrent central nervous system activity. Cortical and hippocampal electroencephalogram, electromyogram, electrooculogram, pontogeniculooccipital (PGO) waves, subcutaneous electrocardiogram, and respiration were recorded. Bouts of sinus tachycardia lasting >/=3.5 s achieved a rate of 210 beats/min and were present predominantly during REM sleep. Heart rate during the surges rose an average of 26.4% from 132.5 +/- 2.0 beats/min before the surge to 167.5 +/- 2.6 beats/min (P < 0.001) and returned to 130.7 +/- 2.6 beats/min (P < 0.001). The heart rate surges were invariably accompanied by increased incidence and frequency of hippocampal theta waves and increased PGO wave frequency and incidence of PGO wave clusters and eye movement clusters. The occurrence of surges was dramatically reduced from 0.11 +/- 0.03 to 0.01 +/- 0.01/15 s of REM sleep (P = 0.02) by atenolol (0.6 mg/kg iv), indicating that the phenomenon is beta(1)-adrenergically mediated. These findings suggest a coupling between central activation of cardiac sympathetic nerves and the generation of hippocampal theta waves and PGO activity.

Evaluating the effectiveness of a smoking cessation intervention designed for nurses

The purpose of this study was to evaluate the effectiveness of offering an individualised approach to smoking cessation to qualified nurses and student nurses in Northern Ireland. Twenty-two qualified nurses and 32 student nurses enrolled in the intervention. A further 23 qualified nurses and 33 student nurses expressed interest in giving up smoking, but did not wish to be included in the intervention. They were assigned to the comparison group. Objective verification utilising salivary cotinine measurements of continuous abstinence at 6 months and 1 year demonstrated that 24% of student and qualified nurses in the intervention groups stopped smoking compared with 7% of those in the comparison groups. Both of these differences are statistically significant (Fisher's Exact Probability Test p = < 0.05). This suggests that the individualised approach as used in this study is an appropriate method of helping motivated nurses to quit.

Validity of adolescents' report of maternal age

Examined the validity of adolescents' reports of their mother's age. Most research on the validity of self-report focuses on personal behaviors such as alcohol and substance use, or response bias due to social desirability. Few studies investigate the validity of adolescents reporting of nonsensitive information. Data from 80 mother-adolescent pairs were collected. The sample included 9th graders from four high school English classes, equal numbers of males and females, and 15% African Americans. The correlation between mothers' reports and youths' reports of mother's age was .99, and 95% of the youth were within a year of their mother's correct age. No race or gender differences were found. These results allow researchers to examine adolescent outcomes for youth born to teen mothers without the expense of also collecting data from their mothers. Results also suggest that adolescents' self-reports of other nonsensitive familial data may also be valid.

Deaf children's understanding of beliefs and desires

Twenty-two children (5-12 year old) who were profoundly, prelingually deaf were given two tests designed to tap their 'theory of mind', that is, their ability to attribute independent mental states to other people. The tests were versions of Baron-Cohen, Leslie, and Frith's Sally-Anne task and of Baron-Cohen's breakfast task. Seventy percent of the children were successful on all questions requiring belief attribution, a considerably and significantly larger percentage than the 29% obtained by Peterson and Siegal for a similar sample, though it is still lower than would be expected on the basis on chronological age. Children were universally successful on questions requiring the attribution of desire. We discuss implications of the findings.

Impact of childhood brain injury on work and family finances

Parents of children who suffer brain injuries are often surprised by the extent to which work and family finances are disrupted. In this paper, work and financial problems are described, predictors are identified, and ways to minimize problems are discussed. Eighty-two children treated at two Massachusetts trauma centres were given an extensive battery of medical, functional, and psychosocial tests during hospitalization. At 1 and 6 months post-discharge they were retested and their parents were surveyed about work and financial difficulties. Trouble maintaining regular work schedules and injury-related financial problems were common. At highest risk for work and financial problems were families of children with severe injuries who had four to nine impairments, along with children hospitalized > 2 weeks who were not discharged to home. Surprisingly, families with HMO coverage reported significantly fewer financial problems, and this relationship was not due to differences in socioeconomic status or injury severity. Health-care providers need to pay more attention to the potential impact of injury on work and family finances. Providers can help at-risk families muster child-care services, deal effectively with employers and insurance companies, and plan for the future.

Pediatric trauma: impact on work and family finances

OBJECTIVES

National data now exist on incidence, prevalence, and cost of injury. However, the personal impact of injury on work and family finances has not been thoroughly studied. We examine the extent and nature of work and financial problems after pediatric trauma and identify predictors. Clinicians are alerted so they can better counsel parents about potential postinjury work and financial difficulties.

METHODS

Staff collected comprehensive data on the acute care and short-term rehabilitation of 182 Massachusetts children with injuries. Consenting parents were surveyed and their children were given a battery of medical, functional, and psychosocial tests. Information on work and financial impact at 1 and 6 months postinjury was available from 120 parents.

RESULTS

Given these children's generally mild injuries, the impact on work and family finances was remarkable. For many families work and financial problems were short-lived; however, for others serious problems remained at 6 months postdischarge. Families whose children were severely injured were at highest risk for work and financial problems. Middle-class parents and parents on public assistance or in our other insurance category reported more work and financial problems than those in health maintenance organizations. Long acute hospital stay and four or more impairments at discharge were also strong predictors.

CONCLUSION

Childhood injury can lead to serious work and financial problems for families. Given the central role of the family in pediatric rehabilitation, clinicians and policymakers involved in acute trauma care and rehabilitation should pay greater attention to the financial repercussions of injury.

Nursing a person who had suffered a myocardial infarction

The life-threatening experience of an acute myocardial infarction stimulates a wide variety of physical and psychological responses for both the person and his family. The nurse's role is to assist a person through a major life crisis from a dependent to an independent status. The Roper, Logan and Tierney model for nursing provides a suitable framework for nursing a person who has suffered a myocardial infarction. This approach to care ensures that maximum health potential is achieved.

Familiality of cancer in Utah

The Utah Population Database allows examination of the genetic relationships among the 35.7% of all cancer cases in the state that have genealogical records. Familial clustering of cancer is measured by the Genealogical Index of Familiality and is examined by site, and within site by age of onset, histology, and gender. Most cancer sites examined show excess familiality for all cases considered together. Subsets of individuals with certain characteristics showed unusually high levels of familial clustering, specifically lymphocytic leukemias and especially chronic lymphocytic leukemia, lobular breast cancer, early lip cancer, early melanoma, and female lung cancers of alveolar/adenoma histology. These may represent characteristics of the most penetrant forms of inherited susceptibilities, those which are enhanced by environmental factors, chance aggregations, rare inherited syndromes, or a combination of these factors.

Evaluation of the USDA Protocol for Detection of Listeria monocytogenes

This study compared the recovery of Listeria monocytogenes from Fraser broth incubated 26 h versus 48 h. L. monocytogenes was isolated from 60 of 1,088 samples analyzed. Samples included meat products and environmental swabs from meat and dairy plants. Recovery of L. monocytogenes occurred in two samples after 48 h incubation but not at 26 h, resulting in 3.3% false negatives at 26 h. L. monocytogenes was detected in two samples at 26 h incubation in which the Fraser broth did not blacken. A 6.7% incidence of false negatives resulted if one considers only blackened Fraser broth. Additionally, 659 of the primary enrichments were streaked directly onto selective media. This procedure recovered L. monocytogenes in 76.7% of the total number of samples positive; failure to recover L. monocytogenes occurred in eight Fraser broth enrichments from positive primary enrichments.

Variability of serum bile acid concentrations over time in dairy cattle, and effect of feed deprivation on the variability

Twelve nonlactating dairy cows, free of signs of liver disease and with normal serum activities of liver-derived enzymes and normal liver biopsy tissue, were examined over a 72-hour period for serum total bile acid concentrations. The cattle were fed hay twice daily, and blood samples were obtained every hour for 24 hours, every other hour for 24 hours, then every hour for 24 hours. After 3 weeks, the study was repeated on 6 of the cattle, thus providing data for eighteen 72-hour periods. Serum bile acid concentration varied greatly over the 72 hours, with the range being from one third to 3 times the median. There were variations by as much as 60 mumol/L from 1 hour to the next. After another 3 weeks, 8 of the cattle were deprived of hay for 48 hours and then fed hay morning and afternoon of the third (last) day of the study. There was no significant reduction in bile acid concentration after withholding the hay, but the variability was reduced (P = 0.02) during the last 20 hours of the hay-deprivation period. In 3 ancillary studies, serum bile acid concentrations were examined over a 48-hour period in 2 cows in early lactation, 3 cows in midlactation, and two 6-month-old heifers. The cows were fed hay and grain twice daily, and the heifers were fed only hay twice daily. In comparison with values for the 12 nonlactating cows fed hay twice daily, mean serum bile acid concentration in the recently freshened cows was significantly (P < 0.002) higher (62.9 vs 22.0 mumol/L).(ABSTRACT TRUNCATED AT 250 WORDS)

Serum bile acid concentrations in clinically normal cattle: comparison by type, age, and stage of lactation

Serum total bile acid concentrations were determined for various types and ages of cattle. There was extreme variability among all the cattle, but the variance was twice as large (0.50 vs 0.22 in logarithmic scale) for beef cattle than for dairy cattle. There was no significant difference in serum total bile acid concentrations between beef cattle and dairy cattle in midlactation. Values for calves < 6 weeks old and for 6-month-old heifers were significantly (P = < 0.05) lower than values for lactating dairy cows. The 5th to 95th percentile range of values (mumol/L) for beef cattle was 9 to 126; for lactating dairy cattle, 15 to 88; and for 6-month-old dairy heifers, 11 to 64.