Priority symptoms in advanced breast cancer: development and initial validation of the National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy-Breast Cancer Symptom Index (NFBSI-16)

OBJECTIVES

By using methods consistent with recent regulatory guidance on patient-reported outcomes as endpoints in clinical trials, we created a new version of the Functional Assessment of Cancer Therapy-Breast Cancer Symptom Index (FBSI), with emphasis on patient input during the development process.

METHODS

We obtained input on the most important symptoms to monitor during treatment for stage III or IV breast cancer from 52 patients recruited from National Comprehensive Cancer Network institutions as well as support service organizations. Participating patients shared their top-priority symptoms/concerns through open-ended interviews and symptom checklists. To ensure adequate content coverage, we evaluated results alongside the original version of the FBSI, which was created on the basis of a survey of oncology clinicians at National Comprehensive Cancer Network institutions and items in the Functional Assessment of Chronic Illness Therapy measurement system. We also obtained input from 10 National Comprehensive Cancer Network oncologists regarding whether symptoms were primarily related to disease or treatment.

RESULTS

We selected breast cancer-related symptoms and concerns endorsed as high priority by both oncology patients and clinicians for inclusion in the new National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy-Breast Cancer Symptom Index-16 (NFBSI-16), which includes all eight items from the original FBSI and eight additional items from Functional Assessment of Chronic Illness Therapy measures. The NFBSI-16 is formatted by subscale: Disease-Related Symptom, Treatment Side-Effect, and General Function and Well-Being. Results provide preliminary support for NFBSI-16's internal consistency reliability (α = 0.87) and validity as evidenced by moderate-to-strong relationships with expected criteria.

CONCLUSIONS

Reflecting the priority symptoms of breast cancer patients and clinicians, the NFBSI-16 can be used to help evaluate the effectiveness of treatments for advanced breast cancer in clinical practice and research.

Validity of two new patient-reported outcome measures in systemic sclerosis: Patient-Reported Outcomes Measurement Information System 29-item Health Profile and Functional Assessment of Chronic Illness Therapy-Dyspnea short form

OBJECTIVE

Many patient-reported outcome (PRO) instruments used in systemic sclerosis (SSc) trials are limited by lack of validation, licensing fees, and complicated scoring systems. We assessed the construct validity for discriminative purposes of 2 new PRO instruments, the Patient-Reported Outcomes Measurement Information System 29-item Health Profile (PROMIS-29) and the Functional Assessment of Chronic Illness Therapy-Dyspnea short form (FACIT-Dyspnea), measuring health status and dyspnea in SSc patients.

METHODS

Seventy-three patients participated in a cross-sectional study at a tertiary SSc program. PROMIS-29, FACIT-Dyspnea, and legacy PRO instruments used in clinical trials (Medical Research Council Dyspnea Score, St. George's Respiratory Questionnaire, Health Assessment Questionnaire disability index, and Short Form 36) were administered. Composite severity scores using an adaptation of the Medsger Disease Severity Index were generated using clinical, diagnostic, and laboratory information. PROMIS-29 and FACIT-Dyspnea scores were compared with legacy PRO measures and composite severity scores.

RESULTS

The mean patient age (84% women) was 51 years (range 22-72 years). The mean SSc disease duration from the onset of the first non-Raynaud's phenomenon symptom was 7.2 years (range 0-45 years). Spearman's correlation coefficients across FACIT-Dyspnea and PROMIS physical functioning scores with legacy PRO instruments were generally high (range 0.50-0.86); those between PROMIS and FACIT-Dyspnea with composite disease severity scores were more modest, but statistically significant (range 0.33-0.48, P < 0.01).

CONCLUSION

PROMIS-29 and FACIT-Dyspnea are valid instruments to measure the health status of SSc patients. PROMIS-29 and FACIT-Dyspnea may be preferable to legacy instruments because they are freely available in multiple languages and simple to administer, score, and interpret.

Reporting catheter-associated urinary tract infections: denominator matters

OBJECTIVE

To evaluate two different methods of measuring catheter-associated urinary tract infection (CAUTI) rates in the setting of a quality improvement initiative aimed at reducing device utilization.

DESIGN, SETTING, AND PATIENTS

Comparison of CAUTI measurements in the context of a before-after trial of acute care adult admissions to a multicentered healthcare system.

METHODS

CAUTIs were identified with an automated surveillance system, and device-days were measured through an electronic health record. Traditional surveillance measures of CAUTI rates per 1,000 device-days (R1) were compared with CAUTI rates per 10,000 patient-days (R2) before (T1) and after (T2) an intervention aimed at reducing catheter utilization.

RESULTS

The device-utilization ratio declined from 0.36 to 0.28 between T1 and T2 (P = .001), while infection rates were significantly lower when measured by R2 (28.2 vs 23.2, P = .02). When measured by R1, however, infection rates trended upward by 6% (7.79 vs. 8.28, P = .47), and at the nursing unit level, reduction in device utilization was significantly associated with increases in infection rate.

CONCLUSIONS

The widely accepted practice of using device-days as a method of risk adjustment to calculate device-associated infection rates may mask the impact of a successful quality improvement program and reward programs not actively engaged in reducing device usage.

Development and validation of 11 symptom indexes to evaluate response to chemotherapy for advanced cancer

Recent guidance from the FDA discusses patient-reported outcomes as end points in clinical trials. Using methods consistent with this guidance, the authors developed symptom indexes for patients with advanced cancer. Input on the most important symptoms was obtained from 533 patients recruited from NCCN Member Institutions and 4 nonprofit social service organizations. Diagnoses included bladder, brain, breast, colorectal, head and neck, hepatobiliary/pancreatic, kidney, lung, ovarian, and prostate cancers and lymphoma. Physician experts in each of these diseases were also surveyed to differentiate symptoms that were predominantly disease-based from those that were predominantly treatment-induced. Results are evaluated alongside previously published indexes for 9 of these 11 advanced cancers that were created based on expert provider surveys, also implemented at NCCN Member Institutions. Final results are 11 symptom indexes that reflect the highest priorities of people affected by these 11 advanced cancers and the experienced perspective of the people who provide their medical treatment. Beyond the clinical value of such indexes, they may also contribute significantly to satisfying regulatory requirements for a standardized tool to evaluate drug efficacy with respect to symptomatology.

Clinical utility of family history for cancer screening and referral in primary care: a report from the Family Healthware Impact Trial

PURPOSE

To assess the effectiveness of computerized familial risk assessment and tailored messages for identifying individuals for targeted cancer prevention strategies and motivating behavior change.

METHODS

We conducted a randomized clinical trial in primary care patients aged 35-65 years using Family Healthware, a self-administered, internet-based tool that collects family history for six common diseases including breast cancer, colon cancer, and ovarian cancer, stratifies risk into three tiers, and provides tailored prevention messages. Cancer screening adherence and consultation were measured at baseline and 6-month follow-up.

RESULTS

Of 3283 participants, 34% were at strong or moderate risk of at least one of the cancers. Family Healthware identified additional participants for whom earlier screening (colon cancer, 4.4%; breast cancer, women ages: 35-39 years, 9%) or genetic assessment (colon cancer, 2.5%; breast cancer, 10%; and ovarian cancer, 4%) may be indicated. Fewer than half were already adherent with risk-based screening. Screening adherence improved for all risk categories with no difference between intervention and control groups. Consultation with specialists did not differ between groups.

CONCLUSION

Family Healthware identified patients for intensified cancer prevention. Engagement of clinicians and patients, integration with clinical decision support, and inclusion of nonfamilial risk factors may be necessary to achieve the full potential of computerized risk assessment.

Examining web equivalence and risk factor sensitivity of the COPD population screener

OBJECTIVES

The primary aim was to assess the equivalence of an Internet-based chronic obstructive pulmonary disease-population screener (COPD-PS) relative to a validated paper-and-pencil version. A secondary aim was to compare groups based on known COPD risk factors, such as smoking status and gender.

METHODS

Using an online panel survey organization, participants were randomized to internet or paper-and-pencil assessment where they completed the COPD-PS and other study forms. A subset of respondents also completed a test-retest reliability assessment. Finally, several thousand additional online respondents completed the COPD-PS for risk factor analyses.

RESULTS

A total of 1006 adults completed the randomized study (N = 504 online, N = 502 by mail). There were no differences between the arms in mean COPD-PS scores (mean difference: 0.12; 95% confidence interval: -0.14-+0.37; P = 0.365). In the web arm, 106/504 (21.0%) exceeded the screening cut-off compared to 101/502 (20.1%) in the paper-administration arm (difference in proportions: 0.9%; 95% confidence interval: -4.1%-+5.9%; P = 0.720). Subgroup analyses on a separate cohort of 3001 adults demonstrated hypothesized differences between groups defined by smoking status, presence of COPD, and shortness of breath.

CONCLUSION

The methods of administration that were evaluated in this study (internet vs. paper and pencil) resulted in no significant differences in COPD-PS mean scores. Furthermore, the predictive utility of the COPD-PS was not different between methods of administration, even after accounting for age and smoking status.

Patient-reported outcomes in a phase iii study of everolimus versus placebo in patients with metastatic carcinoma of the kidney that has progressed on vascular endothelial growth factor receptor tyrosine kinase inhibitor therapy

PURPOSE

A phase III, randomized, double-blind, placebo-controlled trial was conducted in patients with metastatic renal cell carcinoma. The focus of this paper is to evaluate the patient-reported outcomes.

METHODS

Patients were randomly assigned (2:1) to receive oral everolimus 10 mg once daily or placebo. The Functional Assessment of Cancer Therapy Kidney Symptom Index-Disease-Related Symptoms (FKSI-DRS) and European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30 were administered before randomization and on day 1 of each cycle. The FKSI-DRS and the EORTC QLQ-C30 Physical Functioning and Global Quality of Life scores were the primary endpoints examined. Longitudinal models were used to compare treatment arms. Sensitivity analyses were conducted to explore the impact of missing data assumptions.

RESULTS

Longitudinal trends for FKSI-DRS scores did not differ by treatment arm. Taking nonignorable missing data into account, there were significant differences between treatment arms in the trend over time for physical functioning and global quality of life, with the everolimus arm exhibiting greater decreases. All three of these measures of health-related quality of life were significantly related to progression-free survival.

CONCLUSIONS

There was no evidence of a difference between everolimus and placebo in longitudinal patterns of disease-related symptoms, and little difference between the arms in physical functioning or global quality of life trends. This supports the conclusion that delay in tumor progression demonstrated by everolimus is associated with minimal impact on symptoms, physical functioning, or quality of life, as reported by patients.

A new index of priority symptoms in advanced ovarian cancer

OBJECTIVE

This study sought to develop and examine preliminary validity of the NCCN-FACT Ovarian Symptom Index-18 (NFOSI-18), a new ovarian cancer-specific symptom index comprised of symptoms rated as highest priority by both oncology clinical experts and women with advanced ovarian cancer.

METHODS

Fifty-one women with advanced ovarian cancer rated the importance of 30 symptoms associated with advanced ovarian cancer. Ten gynecologic oncologists then rated symptoms according to whether they were predominantly disease- or treatment-related. Patient priorities were then reconciled with previously-published clinician priorities for symptom measurement in ovarian cancer. This produced the NFOSI-18. Participants also completed measures of quality of life and performance status to examine preliminary validity of the NFOSI-18.

RESULTS

An 18-item symptom index for advanced ovarian cancer was developed, including three subscales: disease-related symptoms, treatment-related symptoms, and general function/well-being. Lower NFOSI-18 scores indicate greater high-priority symptom burden. Preliminary reliability suggests good internal consistency (α=0.80). The NFOSI-18 and its subscales were significantly positively associated with quality of life validity criteria. Scores on the NFOSI-18 differed significantly by performance status, with poor performance status associated with lower NFOSI-18 scores.

CONCLUSIONS

The NFOSI-18 shows preliminary evidence for reliability and validity as a brief assessment of the most important symptoms associated with treatment for advanced ovarian cancer.

Validation of the functional assessment of chronic illness therapy-fatigue scale in patients with moderately to severely active systemic lupus erythematosus, participating in a clinical trial

OBJECTIVE

Fatigue is a common symptom of systemic lupus erythematosus (SLE). Our objective was to validate the 13-item Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale in patients with SLE.

METHODS

The FACIT-Fatigue, Medical Outcomes Study Short-Form-36 (SF-36) questionnaire, Brief Pain Inventory (BPI), and Patient Global Assessment Visual Analog Scale (Patient-GA) were completed at baseline and at Weeks 12, 24, and 52 by patients with moderately to severely active extrarenal SLE. The patients were participating in a rituximab clinical trial. The British Isles Lupus Assessment Group (BILAG) disease activity index and the Physician Global Assessment Visual Analog Scale (Physician-GA) were completed by physicians at the same visits.

RESULTS

At baseline, 254 patients completed the FACIT-Fatigue scale. Cronbach's α was > 0.95 at all visits. In cross-sectional analyses, FACIT-Fatigue scores differentiated between groups defined by BILAG General domain ratings. FACIT-Fatigue had moderate-high correlations (r = 0.5-0.8) with SF-36, BPI, and Patient-GA, but poor correlations with BILAG total score and Physician-GA (r = 0.1-0.3). At Weeks 12, 24, and 52, mean FACIT-Fatigue scale improvement was higher in patients who improved versus those who remained unchanged on the BILAG General domain. FACIT-Fatigue scale scores remained stable for patients with worsened BILAG General domain ratings compared to baseline. Distribution and anchor-based estimates suggested a minimally important difference (MID) range of 3-6 points.

CONCLUSION

The FACIT-Fatigue scale is a valid and responsive measure of fatigue in patients with SLE. MID in this SLE sample is similar to that derived previously in other populations. Since few patients experienced worsening BILAG General and Musculoskeletal domains in this study, further research is warranted to evaluate the responsiveness of FACIT-Fatigue to worsening of these domains.

Components of family history associated with women's disease perceptions for cancer: a report from the Family Healthware™ Impact Trial

PURPOSE

To determine the specific components of family history and personal characteristics related to disease perceptions about breast, colon, and ovarian cancers.

METHODS

Baseline, cross-sectional data on 2,505 healthy women aged 35-65 years enrolled from 41 primary care practices in the cluster-randomized Family Healthware™ Impact Trial, assessed for detailed family history and perceived risk, perceived severity, worry, and perceived control over getting six common diseases including breast, colon, and ovarian cancers.

RESULTS

Participants provided family history information on 41,841 total relatives. We found evidence of underreporting of paternal family history and lower perceived breast cancer risk with cancer in the paternal versus maternal lineage. We observed cancer-specific perceived risks and worry for individual family history elements and also found novel "spillover" effects where a family history of one cancer was associated with altered disease perceptions of another. Having a mother with early-onset breast or ovarian cancer was strongly associated with perceived risk of breast cancer. Age, parenthood, and affected lineage were associated with disease perceptions and ran counter to empiric risks.

CONCLUSIONS

Understanding patients' formulation of risk for multiple diseases is important for public health initiatives that seek to inform risk appraisal, influence disease perceptions, or match preventive interventions to existing risk perceptions.

Efficient assessment of the most important symptoms in advanced prostate cancer: the NCCN/FACT-P Symptom Index

BACKGROUND

Owing to the spectrum of symptoms, side effects, and concerns in clinically advanced prostate cancer (PC), effective symptom assessment is imperative. In line with recent regulatory guidance on the development of patient-reported outcomes, we undertook a multistep/multistudy approach to develop and test a new symptom index (NCCN FACT-Prostate Symptom Index-17 that can be used to examine the effectiveness of noncurative treatments in advanced PC.

METHODS

This included significant input from two waves of expert medical providers (n=66 and 11, respectively) and two waves of patient engagement and testing (n=50 and 24, respectively). The resulting 17-item symptom index for advanced PC was then divided into sets or categories based on whether the symptoms are predominantly disease or treatment related.

RESULTS

Preliminary reliability estimates suggest good internal consistency (α=0.86) and relationships with expected outside validity criteria are moderate to strong.

CONCLUSIONS

This new tool may help clinicians and researchers quickly target and measure important symptoms and concerns in advanced PC, leading to increased knowledge of treatment effectiveness of noncurative therapies and improvements in the quality of patient care. Copyright © 2010 John Wiley & Sons, Ltd.

Mucositis-related morbidity and resource utilization in head and neck cancer patients receiving radiation therapy with or without chemotherapy

The objective of this study was to estimate health care-resource utilization in head and neck cancer (HNC) patients. This was a prospective, longitudinal, multicenter, noninterventional study of mucositis in patients receiving radiation with or without chemotherapy for HNC. Mouth and throat soreness and functional impairment were measured using the Oral Mucositis Weekly Questionnaire-HNC. Resource utilization data were obtained from patient interviews and recorded from the patient's medical chart. Seventy-five patients were enrolled from six centers. Fifty (67%) patients received concurrent chemoradiation therapy; 34 (45%) received intensity-modulated radiation therapy. Over the course of treatment, 57 (76%) patients reported severe mouth and throat soreness. Pain and functional impairment because of mouth and throat soreness increased during the course of therapy despite the use of opioid analgesics in 64 (85%) of the patients. Complications of radiation therapy resulted in increased patient visits to physicians, nurses, and nutritionists. Thirty-eight (51%) patients had a feeding tube placed. Twenty-eight patients (37%) were hospitalized, five of whom were hospitalized twice; of the 33 admissions, 10 (30%) were designated as secondary to mucositis by their treating physician. Mean length of hospitalization was 4.9 days (range: 1-16). This study demonstrates that mucositis-related pain and functional impairment is associated with increased use of costly health resources. Effective treatments to reduce the pain and functional impairment of oral mucositis are needed in this patient population.

Development and evaluation of a simulation-based pediatric emergency medicine curriculum

PURPOSE

The infrequency of severe childhood illness limits opportunities for emergency medicine (EM) providers to learn from real-world experience. Simulation offers an evidence-based educational approach to develop and practice clinical skills.

METHOD

This was a two-phase, randomized trial with a wait-list control condition. The development phase (2005-2006) involved systematic curriculum and rating checklist creation, producing a six-case, simulation-based curriculum linked to three evaluation cases.In the validation phase (2006-2007), the authors randomized 69 residents from two EM residencies to either an intervention group that received the curriculum one month before the first assessment of all participants or a wait-list control group that received the identical curriculum three months later. A final assessment of all residents followed one month after that. Two raters evaluated all residents. Primary outcome measures are percentages of items completed correctly. The authors assessed rater agreement using intraclass correlation (ICC) and compared group performance using mixed-model analysis of variance.

RESULTS

ICCs surpassed 0.78. The instructional intervention produced a statistically significant effect for two of three evaluation cases for the validation phase of the study, a case x occasion interaction. Training year was significantly associated with better performance. In a multivariate analysis, training year and session correlated with score, but study group did not.

CONCLUSIONS

A one-day, simulation-based pediatric EM curriculum produced limited results. The evaluation approach is reasonable and reproducible for the population studied. Instructional dose strength and factors may have limited curriculum effectiveness. Focused, frequent, and effortful instructional interventions are necessary to achieve substantial performance improvements.

Evaluating the dimensionality of perceived cognitive function

Decrements in cognitive function are common in cancer patients and other clinical populations. As direct neuropsychological testing is often not feasible or affordable, there is potential utility in screening for deficits that may warrant a more comprehensive neuropsychological assessment. Furthermore, some evidence suggests that perceived cognitive function (PCF) is independently associated with structural and functional changes on neuroimagery, and may precede more overt deficits. To appropriately measure PCF, one must understand its components and the underlying dimensional structure. The purpose of this study was to examine the dimensionality of PCF in people with cancer. The sample included 393 cancer patients from four clinical trials who completed a questionnaire consisting of the prioritized areas of concerns identified by patients and clinicians: self-reported mental acuity, concentration, memory, verbal fluency, and functional interference. Each area contained both negatively worded (i.e., deficit) and positively worded (i.e., capability) items. Data were analyzed by using Cronbach's alpha, item-total correlations, one-factor confirmatory factor analysis, and a bi-factor analysis model. Results indicated that perceived cognitive problem items are distinct from cognitive capability items, supporting a two-factor structure of PCF. Scoring of PCF based on these two factors should lead to improved assessment of PCF for people with cancer.

Familial risk for common diseases in primary care: the Family Healthware Impact Trial

CONTEXT

Family history is a risk factor for many common chronic diseases, yet it remains underutilized in primary care practice.

BACKGROUND

Family Healthware is a self-administered, web-based tool that assesses familial risk for CHD; stroke; diabetes; and colorectal, breast, and ovarian cancer, and provides a personalized prevention plan based on familial risk. The Family Healthware Impact Trial evaluated the tool.

DESIGN

In this cluster RCT, participants completed baseline and 6-month follow-up surveys. The intervention group used Family Healthware directly after the baseline survey. Controls used the tool after completing the follow-up survey.

SETTING/PARTICIPANTS

Patients aged 35-65 years with no known diagnosis of these six diseases were enrolled from 41 primary care practices.

MAIN OUTCOME MEASURES

The prevalence of family-history-based risk for coronary heart disease (CHD); stroke; diabetes; and colorectal, breast, and ovarian cancer was determined in a primary care population.

RESULTS

From 2005 to 2007, 3786 participants enrolled. Data analysis was undertaken from September 2007 to March 2008. Participants had a mean age of 50.6 years and were primarily white (91%) women (70%). Of the 3585 participants who completed the risk assessment tool, 82% had a strong or moderate familial risk for at least one of the diseases: CHD (strong=33%, moderate=26%); stroke (strong=15%, moderate=34%); diabetes (strong=11%, moderate=26%); colorectal cancer (strong=3%, moderate=11%); breast cancer (strong=10%, moderate=12%); and ovarian cancer (strong=4%, moderate=6%). Women had a significantly (p<0.04) higher familial risk than men for all diseases except colorectal and ovarian cancer. Overweight participants were significantly (p<or=0.02) more likely to have a strong family history for CHD, stroke, and diabetes. Older participants were significantly (p<or=0.02) more likely to report a strong family history for CHD and stroke as well as colorectal and breast cancer.

CONCLUSIONS

This self-administered, online tool delineated a substantial burden of family-history-based risk for these chronic diseases in an adult, primary care population.

TRIAL REGISTRATION

NCT00164658.

Profile of outpatient hysteroscopy in the United States from 1994 to 1996

OBJECTIVE

To estimate use of hysteroscopic surgery for evaluating genital tract bleeding and related disorders.

STUDY DESIGN

Using the U.S. National Survey of Ambulatory Surgery, we performed a retrospective, cross-sectional study of women undergoing outpatient hysteroscopy. Rates of procedures were tabulated for all years available (1994-1996). Comparison was made across age, ethnicity, and geographic distribution. Complication rates for operative injury and pulmonary edema were estimated from corresponding diagnosis codes.

RESULTS

The estimated number of women undergoing outpatient hysteroscopy was 197,800, 225,900 and 232,000 for the years 1994-1996, respectively. Twenty percent of cases included operative hysteroscopy. Commonly associated diagnoses included menorrhagia, postmenopausal bleeding, uterine polyps and leiomyoma. The most common concomitant procedures performed included dilation and curettage, laparoscopy and uterine lesion destruction, not elsewhere classified. Complication rates were 2.3 per 1,000 hysteroscopies, but 3 times higher for operative hysteroscopy.

CONCLUSION

Hysteroscopy is a commonly performed procedure in the United States, largely in association with uterine bleeding disorders.

Predictors of persistent detrusor overactivity after transvaginal sling procedures

OBJECTIVE

Determine predictors of persistent postoperative detrusor overactivity and urge urinary incontinence after sling procedures for stress urinary incontinence

STUDY DESIGN

Three hundred five women with mixed urinary incontinence underwent sling procedures for stress urinary incontinence. Risk factors for persistent detrusor overactivity and urge urinary incontinence were examined using logistic regression models.

RESULTS

Women (31.5%) who had postoperative resolution of detrusor overactivity. Transobturator slings had the lowest rate of persistent detrusor overactivity (53%), followed by retropubic (SPARC = 66%; TVT = 64%) and bladder neck slings (86%). Predictors for persistent detrusor overactivity included age (odds ratio [OR], 1.38; P = .001), prior hysterectomy (OR, 1.95; P = .012), paravaginal repair (OR, 0.46; P = .015), nocturia (OR, 1.91; P = .013), maximum cystometric capacity (OR, 0.79; P < .001), detrusor overactivity volume (OR, 0.83; P = .006), urethral closure pressure (OR, 0.83; P < .001), and maximum urinary flow rate (OR, 0.77; P = .014). Persistent urge urinary incontinence was predicted by sling type (P < .001).

CONCLUSION

When treating women with mixed urinary incontinence, age, nocturia, maximum cystometric capacity, and choice of sling procedure impact persistence of detrusor overactivity and urge urinary incontinence.

Shaking rigors in parturients

OBJECTIVE

To describe the frequency, duration and timing of shaking rigors during parturition and their associations with several clinical variables.

STUDY DESIGN

A total of 467 term, singleton paturients at a single hospital over a 13-month recruitment period were observed by their labor nurses for shaking rigors. Thirteen clinical variables, including length of labor, were also recorded. Multiple regression procedures were used to evaluate associations with presence or absence, number and total duration of rigors. The relationship in time between shaking rigors and sentinel events in labor was also examined. With this sample size, we had > 80% power to detect differences as small as 0.26 effect size units for continuous measures, or ORs of 1.75 or greater for categorical measures, when comparing patients with and without rigors.

RESULTS

In total, 57% of parturients experienced at least 1 rigor. Epidural usage was related to risk, duration and number of rigors. Increased maximum temperature was associated with an increased chance of rigors. Epidural, birth and maternal fever were antecedent events.

CONCLUSION

Over half of parturients experienced shaking rigors. Epidural administration and fever were associated with an increased probability of rigors and an increased number of episodes.

Impact of hysterectomy on stress urinary incontinence: an identical twin study

OBJECTIVE

This study uses the unique properties of twin research design to evaluate whether hysterectomy impacts stress urinary incontinence (SUI).

STUDY DESIGN

As part of the Evanston Twins Sister Study, we performed bivariate and multivariate analyses on 83 identical twin pairs discordant for hysterectomy.

RESULTS

In bivariate analysis, SUI was less common in women who had prior hysterectomy (P =0.028). Multivariate analysis suggested that SUI was significantly less common after hysterectomy (odds ratio [OR], 0.55, confidence interval [CI], 0.30 to 1.00). Exclusion of twin pairs with a history of pelvic floor defect surgery eliminated the statistical relationship between hysterectomy and SUI (OR, 0.79, CI, 0.4 to 1.40).

CONCLUSION

Hysterectomy, when analyzed with all cases, was associated with reduced SUI. When concurrent pelvic floor defect surgeries were excluded from the analysis, we found no relationship between hysterectomy and the risk of SUI afterward.

Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals

BACKGROUND

The effect of large-scale expanded surveillance for methicillin-resistant Staphylococcus aureus (MRSA) on health care-associated MRSA disease is not known.

OBJECTIVE

To examine the effect of 2 expanded surveillance interventions on MRSA disease.

DESIGN

Observational study comparing rates of MRSA clinical disease during and after hospital admission in 3 consecutive periods: baseline (12 months), MRSA surveillance for all admissions to the intensive care unit (ICU) (12 months), and universal MRSA surveillance for all hospital admissions (21 months).

SETTING

A 3-hospital, 850-bed organization with approximately 40,000 annual admissions.

INTERVENTION

Polymerase chain reaction-based nasal surveillance for MRSA followed by topical decolonization therapy and contact isolation of patients who tested positive for MRSA.

MEASUREMENTS

Poisson and segmented regression models were used to compare prevalence density of hospital-associated clinical MRSA disease (bloodstream, respiratory, urinary tract, and surgical site) in each period. Rates of bloodstream disease with methicillin-susceptible S. aureus were used as a control.

RESULTS

The prevalence density of aggregate hospital-associated MRSA disease (all body sites) per 10,000 patient-days at baseline, during ICU surveillance, and during universal surveillance was 8.9 (95% CI, 7.6 to 10.4), 7.4 (CI, 6.1 to 9.0; P = 0.15 compared with baseline), and 3.9 (CI, 3.2 to 4.7; P < 0.001 compared with baseline and ICU surveillance), respectively. During universal surveillance, the prevalence density of MRSA infection at each body site had a statistically significant decrease compared with baseline. The methicillin-susceptible S. aureus bacteremia rate did not statistically significantly change during the 3 periods. In a segmented regression model, the aggregate hospital-associated MRSA disease prevalence density changed by -36.2% (CI, -65.4% to 9.8%; P = 0.17) from baseline to ICU surveillance and by -69.6% (CI, -89.2% to -19.6%]; P = 0.03) from baseline to universal surveillance. During universal surveillance, the MRSA disease rate decreased during hospitalization and in the 30 days after discharge; no further reduction occurred thereafter. Surveillance with clinical cultures would have identified 17.8% of actual MRSA patient-days, and ICU-based surveillance with polymerase chain reaction would have identified 33.3%.

LIMITATION

The findings rely on observational data.

CONCLUSION

The introduction of universal admission surveillance for MRSA was associated with a large reduction in MRSA disease during admission and 30 days after discharge.

Use of a single-item screening tool to detect clinically significant fatigue, pain, distress, and anorexia in ambulatory cancer practice

Fatigue, pain, distress, and anorexia are four commonly encountered symptoms in cancer. To evaluate the usefulness of a single-item screening for these symptoms, 597 ambulatory outpatients with solid tumors were administered a self-report screening instrument within the first 12 weeks of chemotherapy. Patients rated the severity of each symptom on a 0-10 scale, at its worst over the past three days, with higher ratings associated with higher symptom levels. From this sample, 148 patients also completed a more comprehensive assessment of these symptoms. Two criteria were used to determine optimal cut-off scores on the screening items: 1) the sensitivity and specificity of each screening item to predict clinical cases using receiver-operating characteristics analysis and 2) the proportion of patients at each screening score who reported that some relief of the target symptom would significantly improve their life. Optimal cut-off scores ranged from 4 to 6 depending on the target symptom (area under the curve range=0.68-0.88). Use of single-item screening instruments for fatigue, pain, distress, and anorexia may assist routine clinical assessment in ambulatory oncology practice. In turn, such assessments may improve identification of those at risk of morbidity and decreased quality of life due to excess symptom burden.