Reproducibility and predictive value of three grading systems for intraoperative adverse events in a cohort of abdominal surgery

INTRODUCTION

Intraoperative adverse events (iAEs) are increasingly recognized for their impact on patient outcomes. The Kaafarani classification and Surgical Apgar Score (SAS) were developed to assess the intraoperative course; however, both have their drawbacks. ClassIntra was validated for iAEs of any origin. This study compares the Kaafarani and SAS to ClassIntra considering predictive value and interrater reliability in a cohort of abdominal surgery to support implementation of a classification in clinical practice.

METHODS

The authors made use of the LAParotomy or LAParoscopy and ADhesiolysis (LAPAD) study database of elective abdominal surgery. Detailed descriptions on iAEs were collected in real-time by a researcher. For the current research aim, all iAEs were graded according ClassIntra, Kaafarani, and SAS (score ≤4). The predictive value was assessed using univariable and multivariable linear regression and the area under the receiver operating curve (AUROC). Two teams graded ClassIntra and Kaafarani to assess the interrater reliability using Cohen's Kappa.

RESULTS

A total of 755 surgeries were included, in which 335 (44%) iAEs were graded according to ClassIntra, 228 (30%) to Kaafarani, and 130 (20%) to SAS. All classifications were significantly correlated to postoperative complications, with an AUROC of 0.67 (95% CI: 0.62-0.72), 0.64 (0.59-0.70), and 0.71 (0.56-0.76), respectively. For the secondary endpoint, the interrater reliability of ClassIntra with κ 0.87 (95% CI: 0.84-0.90) and Kaafarani 0.90 (95% CI: 0.87-0.93) was both strong.

CONCLUSION

ClassIntra, Kaafarani, and SAS can be used for reporting of iAEs in abdominal surgery with good predictive value for postoperative complications, with strong reliability. ClassIntra, compared with Kaafarani and SAS, included the most iAEs and has the most comprehensive definition suitable for uniform reporting of iAEs in clinical practice and research.

Prophylactic abdominal drainage or no drainage after distal pancreatectomy (PANDORINA): a binational multicenter randomized controlled trial

BACKGROUND

Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative pancreatic fistula (POPF) aimed to prevent further complications as bleeding. Whereas POPF after pancreatoduodenectomy, by definition, involves infection due to anastomotic dehiscence, a POPF after DP is essentially sterile since the bowel is not opened and no anastomoses are created. Routine drainage after DP could potentially be omitted and this could even be beneficial because of the hypothetical prevention of drain-induced infections (Fisher, Surgery 52:205-22, 2018). Abdominal drainage, moreover, should only be performed if it provides additional safety or comfort to the patient. In clinical practice, drains cause clear discomfort. One multicenter randomized controlled trial confirmed the safety of omitting abdominal drainage but did not stratify patients according to their risk of POPF and did not describe a standardized strategy for pancreatic transection. Therefore, a large pragmatic multicenter randomized controlled trial is required, with prespecified POPF risk groups and a homogeneous method of stump closure. The objective of the PANDORINA trial is to evaluate the non-inferiority of omitting routine intra-abdominal drainage after DP on postoperative morbidity (Clavien-Dindo score ≥ 3), and, secondarily, POPF grade B/C.

METHODS/DESIGN

Binational multicenter randomized controlled non-inferiority trial, stratifying patients to high and low risk for POPF grade B/C and incorporating a standardized strategy for pancreatic transection. Two groups of 141 patients (282 in total) undergoing elective DP (either open or minimally invasive, with or without splenectomy). Primary outcome is postoperative rate of morbidity (Clavien-Dindo score ≥ 3), and the most relevant secondary outcome is grade B/C POPF. Other secondary outcomes include surgical reintervention, percutaneous catheter drainage, endoscopic catheter drainage, abdominal collections (not requiring drainage), wound infection, delayed gastric emptying, postpancreatectomy hemorrhage as defined by the international study group for pancreatic surgery (ISGPS) (Wente et al., Surgery 142:20-5, 2007), length of stay (LOS), readmission within 90 days, in-hospital mortality, and 90-day mortality.

DISCUSSION

PANDORINA is the first binational, multicenter, randomized controlled non-inferiority trial with the primary objective to evaluate the hypothesis that omitting prophylactic abdominal drainage after DP does not worsen the risk of postoperative severe complications (Wente etal., Surgery 142:20-5, 2007; Bassi et al., Surgery 161:584-91, 2017). Most of the published studies on drain placement after pancreatectomy focus on both pancreatoduodenectomy and DP, but these two entities present are associated with different complications and therefore deserve separate evaluation (McMillan et al., Surgery 159:1013-22, 2016; Pratt et al., J Gastrointest Surg 10:1264-78, 2006). The PANDORINA trial is innovative since it takes the preoperative risk on POPF into account based on the D-FRS and it warrants homogenous stump closing by using the same graded compression technique and same stapling device (de Pastena et al., Ann Surg 2022; Asbun and Stauffer, Surg Endosc 25:2643-9, 2011).

Temporal changes in bias of body mass index scores based on self-reported height and weight

Objectives:

To investigate temporal changes in the bias associated with self-reported (as opposed to measured) body mass index (BMI) and explore the relationship of such bias to changing social attitudes towards obesity.

Methods:

Using data from the National Health and Nutrition Examination Survey covering two time periods, 1988–1994 and 2005–2008, discrepancy scores between self-reported vs measured BMI were generated. Changes in the sensitivity of BMI categories based on self-reports were examined for six weight groups, both for the US adult population as a whole and major demographic groups. Linear regression models were used to examine temporal changes in average bias, as well as attitudes about weight within each weight category and by demographic group.

Results:

Between 2005–2008 and 1988–1994, the bias towards underestimation of a person's BMI based on interview responses has declined among obese individuals, a trend evident in virtually all demographic subgroups explored. Conversely, most demographic groups showed little change in the extent of bias among underweight and normal-weight individuals. Although the 2005–2008 survey respondents underestimated their measured BMI more than the 1988–1994 respondents, this shift can be entirely explained by the increased prevalence of obesity in more recent years. In fact, obese individuals in 2005–2008 were less likely to overreport their height and underreport their weight than their counterparts in the 1988–1994. Evidence from responses to questions about ideal weight and desire to lose weight point in the direction of a shift in social attitudes, which may make it easier to ‘admit' to greater weight in surveys.

Conclusion:

Over the past 20 years, the bias in self-reported height and weight has declined leading to more accurate BMI categorizations based on self-report. This change is likely to affect efforts to find correction factors to adjust BMI scores based on self-reported height and weight.

Primary malignant brain tumor incidence and Medicaid enrollment

BACKGROUND

The relationship between socioeconomic status and health care disparities in the incidence of brain tumors is unclear.

OBJECTIVE

To identify the associations between age, sex, and Medicaid enrollment and the incidence of primary malignant brain tumors in Michigan in 1996 and 1997.

METHODS

Records were obtained from the Michigan Cancer Surveillance Program on the 1,006 incident cases during this period and cross-checked with Medicaid enrollment files.

RESULTS

Persons enrolled in Medicaid were more likely than non-enrolled persons to develop a malignant brain tumor of any type, a glioblastoma multiforme, and an astrocytoma for certain subgroups. In addition, incidence rates for malignant brain tumors in persons enrolled in Medicaid peaked at a younger age.

CONCLUSION

Sociodemographic status may be associated with cerebral malignancy and should be considered when targeting treatment and educational interventions at persons at risk.

Differential RNA accumulation of two beta-tubulin genes in arbuscular mycorrhizal fungi

RNA was isolated from spores of different arbuscular mycorrhizal (AM) fungi and used for RT-PCR with degenerate primers for beta-tubulin genes. PCR products were cloned and the sequence of several clones was analysed for each fragment. Comparison of sequences identified two loci for beta-tubulin genes with different GC content and codon usage. Btub1 sequences were most similar to beta-tubulin genes from the Oomycota, while Btub2 sequences showed highest similarity to sequences from the Zygomycota. RT-PCR experiments were carried out to monitor RNA accumulation patterns of Btub1 and Btub2 in asymbiotic germinating spores and in symbiotic extraradical hyphae of three different AM fungi. This indicated that Btub1 is constitutively expressed in Gigaspora rosea, but down-regulated during symbiosis in Glomus mosseae and Glomus intraradices. In contrast, Btub2 showed constitutive expression in the two Glomus species, but down-regulation in G. rosea. Further analysis of different fungi indicated that Btub2 primers could be used to specifically monitor RNA accumulation of AM fungi in environmental samples.

Predictors of depressive symptomatology of geriatric patients with colorectal cancer: a longitudinal view

Colorectal cancer constitutes a major health problem for elderly patients. The disease and its stage, treatment, and attendant symptoms can have significant negative impact on the mental functioning of these patients. As part of a larger longitudinal study, 158 patients 65 years of age or older with an incident diagnosis of colorectal cancer were recruited from 23 sites within a Midwestern state. Random effects regression analysis techniques were used to analyze how age, gender, race, presence of a family caregiver, co-morbid conditions, stage of disease at diagnosis, and the time-dependent variables marital status, employment status, symptoms, physical functioning, social functioning, and treatment predict depressive symptomatology at four assessments over the 1st year following diagnosis. Gender, race, co-morbid conditions, physical functioning, social functioning, and symptoms were significant predictors of depressive symptomatology over the four waves of the study. Female patients, African Americans, and patients with two or more co-morbid conditions exhibited more depressive symptomatology. Both more symptoms and more restricted physical and social functioning corresponded to higher levels of depressive symptomatology. At a clinical level of patient care, these findings mandate early identification of psychosocial difficulties experienced, an individualized symptom management plan and the application of other interventions, such as information giving, reassurance and referral to other resources, with particular attention to African American and female patients.

Predictors of depressive symptomatology of geriatric patients with lung cancer-a longitudinal analysis

BACKGROUND

Lung cancer is a major health problem throughout the world. It is the leading cause of cancer-related death in men and women in the USA, with a 5-year survival rate of only 14%. It has been hypothesized that variables such as physical and social functioning, cancer-related symptomatology, comorbid conditions, cell type, and treatment are valid predictors of the psychological response to a diagnosis of lung cancer.

METHODS

As part of a larger longitudinal study, 211 patients, 65 years of age or older, with an incident diagnosis of lung cancer, were recruited from 23 sites within a midwestern state. Repeated measures analysis of variance techniques were used to analyse how age, gender, comorbid conditions, stage of disease, cell type, as well as the time-dependent variables symptoms, physical functioning, social functioning, and treatment predict depressive symptomatology at four assessments over the first year following diagnosis.

RESULTS

Social functioning (p<0.0001), symptoms severity (p<0.0001) and radiation treatment (p=0.017) were significant predictors of depressive symptomatology, with more symptoms and more restricted social functioning generally corresponding to higher levels of depressive symptomatology. Patients who had not received radiation treatment were more depressed than those who had received treatment at least 40 days prior to the interview.

CONCLUSIONS

At a clinical level of patient care, these findings mandate early identification of psychosocial difficulties experienced, an individualized symptom management plan and the application of other interventions, such as information giving, reassurance and referral to other resources.

Research design and subject characteristics predicting nonparticipation in a panel survey of older families with cancer

BACKGROUND

While recognized that loss of subjects over time may introduce bias and complicate statistical analysis in panel studies, it is seldom acknowledged that sampling bias starts with subjects who are eligible but do not participate.

OBJECTIVES

Community-based recruiters identified 1,948 subjects as eligible to participate in a descriptive panel survey of older families with cancer. Focusing on the time between identification of eligible subjects until contact for the first interview for consenting subjects, the purpose of this study was to determine if subject or research design factors predicted who was more prone to nonparticipation.

METHOD

A multivariate model explored the simultaneous effects of subject and research design characteristics on nonparticipation. Demographic and cancer characteristics, as well as features of the study protocol, were used as predictors in a multinomial logit regression model to enable a three-way comparison between nonconsenters (n = 748), consenters who dropped out prior to data collection (n = 208), and consenters who participated in the intake interview (n = 992).

RESULTS

Age and cancer diagnosis played roles in whether consent was obtained, whereas race did not affect consent but raised odds of drop out after consent. Powerful evidence emerged that design features, such as if a caregiver participated, recruitment staff roles, and payment to recruiters, affected the probability of subjects not participating or dropping out before being interviewed.

CONCLUSIONS

Findings suggest that both subject and research design characteristics affect the likelihood of nonparticipation in a panel study of older cancer patients and family caregivers. Future research involving testing of strategies addressing access and accrual issues, research staff roles, reimbursements, and responsiveness to the needs of research personnel, ill participants, and family members is warranted.

Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation

Although there is substantial evidence that cardiac rehabilitation is beneficial for post myocardial infarction (MI) patients, such programs are currently under utilized. This study examined systematic criteria predicting physician referral to and patients' participation in cardiac rehabilitation programs. Patients discharged for MI were interviewed in-hospital and at 6-12 weeks post discharge to determine referral, participation, and completion. Stepwise logistic regression analyzed factors associated with rehabilitation. Factors associated with referral to rehab were catheterization (p < 0.001), bypass surgery (p < 0.01), cardiologist/cardiac surgeon appointment (p < 0.02), and age (p < 0.01). Participation was increased for those with bypass surgery (p < 0.001), and referral to cardiologist or cardiac surgeon (p < 0.001). Type of provider significantly influences referral to and participation in cardiac rehabilitation. This suggests that encouragement plays a strong role in attendance for rehabilitation. The same strong encouragement should be given to the broader range of MI patients who stand to benefit from cardiac rehabilitation.

Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment

BACKGROUND AND OBJECTIVES

Using an instrument to measure physical functioning that was normed to the U.S. population, data were obtained from patients with a new diagnosis of breast, colon, lung, and prostate cancer. Two questions were addressed: (a) after controlling for age, and number of comorbid conditions, do site and stage of cancer predict functional limitations prior to diagnosis; (b) using age adjusted national norms on physical functioning, how well do age, number of comorbid conditions, stage, treatment and cluster of symptoms (pain, fatigue, and insomnia) explain changes in physical function between 3 months prior to and 8 weeks following diagnosis?

METHODS

Patients 65 years of age and older were accrued from 24 community oncology settings. Consenting patients were interviewed within 8 weeks of initial treatment. The SF-36 was used to measure physical functioning. Comorbidity and symptom experience were assessed through patient report and site and stage of cancer from record audits.

RESULTS

Prior to diagnosis of cancer, patients were comparable in physical functioning to the U.S. population aged 55-64, a full decade younger than the sample of cancer patients. Site and stage of disease did not account for variations in physical functioning prior to diagnosis. Compared against national norms, patients with more extensive treatments (surgery plus adjuvant therapy) reported greater loss in functioning. Pain, fatigue, and insomnia had a consistent and significant effect on losses in functioning unrelated to patients' treatments or their comorbid conditions.

CONCLUSIONS

Site and stage of cancer prior to diagnosis do not affect functioning. Older cancer patients report higher functioning than their counterparts in the U.S. population. Changes in functioning following diagnosis varied by cancer site. Treatments were related to loss in functioning, but comorbidity was not. Pain, fatigue, and insomnia were significant and independent predictors of change in patient functioning. This underscores the importance of interventions to manage symptoms early in the course of treatment for individuals.

Predictors of pain and fatigue in the year following diagnosis among elderly cancer patients

Using data obtained from an inception cohort of 841 patients aged 65 or older newly diagnosed with breast, colon, lung, or prostate cancer, and observed at 6-8, 12-16, 24-30, and 52 weeks, three questions related to patients' experiences with pain and fatigue were posed. First, how do numbers of patients reporting neither pain nor fatigue, either symptom, or both change during the observation year? Second, did number of comorbid conditions, site and stage of cancer, treatment modalities, symptom management medication, and time affect the presence of these two symptoms? Third, do pain and fatigue predict the numbers of co-occurring other symptoms? Findings indicate that during the year patients improved with respect to their reports of pain and/or fatigue. Stage, more comorbidity, and lung cancer were related to both pain and fatigue. Chemotherapy was related to reports of fatigue, but did not have an extended effect on fatigue.

Physical functioning and depression among older persons with cancer

PURPOSE

The purpose of this study was to help identify factors to assess which elderly patients are likely to experience problems with physical and psychological functioning in association with cancer or its treatment.

DESCRIPTION OF STUDY

A study was undertaken with a sample of 420 patients with cancer who were between the ages of 65 and 98 years and had received an incident diagnosis of breast, colon, lung, or prostate cancer. An analysis of covariance technique was used to determine how cancer site, treatment type, stage of disease, gender, age, comorbidity, symptom severity, and pre-diagnosis levels of physical functioning were related to physical functioning deficit, and how all of these in turn influenced patient depressive symptomatology.

RESULTS

Pre-diagnosis physical functioning, symptom severity, and days since surgery were significant predictors of physical functioning deficit. Patients who had been treated only with surgery experienced greater physical functioning deficits than did patients who had received both surgery and adjuvant therapy. This apparent anomaly was partly explained by the time interval from surgery to interview. Higher levels of symptom severity, lower levels of prior physical functioning, and greater physical functioning deficits all predicted higher levels of depressive symptomatology.

CLINICAL IMPLICATIONS

In the care of elderly patients with cancer, it is important for healthcare providers to consider the pre-diagnosis levels of physical functioning of patients with cancer to understand and anticipate the physical and psychological consequences of cancer and its treatment. Equally important is the proper management of patient symptoms in maximizing both the physical and psychological quality of life.

Interns' self-evaluations compared with their faculty's evaluations

The accuracy with which individuals evaluate and judge their knowledge and skills is an important component of adult and life-long learning. This study compared the evaluations that interns made of themselves with those made by their faculty.

Comparison of changes in physical functioning of elderly patients with new diagnoses of cancer

BACKGROUND

Controversy surrounds the impact of site of cancer and treatments on functioning of elderly cancer patients.

OBJECTIVES

This research determines (1) whether age, gender, comorbid conditions, site and stage of cancer, and treatments are related to losses in physical functioning at 4 observations during the year after diagnosis; (2) whether symptoms are a mediating variable between treatment and function; and (3) which indicators account for true change in functioning in the year after diagnosis.

METHODS

An inception cohort of 907 patients aged > or =65 years and newly diagnosed with breast, colon, lung, or prostate cancer were accrued from 24 community oncology programs. Stage and treatment data were obtained from medical records. Physical functioning was measured with the SF-36 subscale. Interviews were conducted at 6 to 8, 12 to 16, 26 to 30, and 52 weeks after diagnosis.

RESULTS

Men scored 10 points higher on physical function than women at all observation points. Patients with > or =3 comorbid conditions scored lower in functioning. Interactions between site of cancer and treatment modalities were observed. Pain, fatigue, and numbers of symptoms were independent predictors of loss of function. Surgery, female gender, and number of symptoms predicted reliable change in function.

CONCLUSIONS

Elderly patients with cancer report levels of function similar to other chronic conditions. Scores on physical function varied by site of cancer; the pattern of change was similar among sites. Age, comorbidity, treatment modalities, and symptom reports each had an independent effect on loss of functioning. Untreated breast cancer patients had lower functioning, suggesting a possible treatment bias.

Symptomatology and loss of physical functioning among geriatric patients with lung cancer

In this study of 129 geriatric patients with lung cancer, we investigated how symptom severity varied according to treatment type, stage of disease, and gender; how change in physical functioning (prediagnosis versus post-hospital discharge) was predicted by symptomatology, prior physical functioning, comorbidity, and age; and whether differences exist according to stage of disease, treatment status, or gender. Data were gathered through patient interviews and audits of patient records. Analysis of variance (ANOVA) techniques revealed that there were no significant differences in average symptom severity scores by gender, treatment categories, or stages of disease. Significant predictors of loss of physical functioning were symptom severity, prior physical functioning and patient age. Characteristics of a profile for elderly lung cancer patients at high risk of suffering substantial losses in physical functioning include higher prior levels of physical functioning, higher levels of current symptomatology, and lower age.

Interstitial cystitis: a retrospective analysis of treatment with pentosan polysulfate and follow-up patient survey

To evaluate the efficacy and safety of pentosan polysulfate sodium (PPS) in relieving symptoms of interstitial cystitis, the authors retrospectively reviewed charts of 260 patients in whom interstitial cystitis had been diagnosed. Subsequently, they conducted a follow-up phone interview or mail survey of those patients who were treated with PPS to investigate changes in the patients' symptoms, adverse effects, and change in quality of life. The control group consisted of patients whose interstitial cystitis had been diagnosed at cystoscopy and had a duration of at least 1 year and who had taken at least one or more oral medications for their symptoms. The average length of treatment was 9.3 months among the 27 subjects on PPS therapy. The mean length of time that they had diagnosed interstitial cystitis was 35.63 months and 48.78 months for the PPS-treated and control groups, respectively, with no statistically significant difference. Changes in frequency, urgency, and pain were greater in the treatment group and statistically significant (P = .11, P = .49, and P = .004, respectively). No change occurred in the rate of nocturia in the PPS-treated group compared with that in the control group. Symptoms of both groups improved over time, but improvement was statistically significantly greater in the treatment group (P = .001) over the treatment interval. The most common side effect attributable to PPS was diarrhea in 15% of subjects. Pentosan proved to be an efficacious option for reducing the debilitating symptoms of interstitial cystitis.

Predictors of physical functioning among geriatric patients with small cell or non-small cell lung cancer 3 months after diagnosis

This study investigated how treatment options, symptom severity, prediagnosis levels of physical functioning, comorbidity, gender, and age predicted current physical functioning in geriatric patients with small-cell or non-small-cell lung cancer, 12 weeks after their diagnosis. The study involved 146 patients aged 65 years and over with an incident diagnosis of lung cancer. Analysis of covariance revealed no significant differences in physical functioning according to treatment type, small-cell versus non-small-cell classification or gender. Significant predictors of current physical functioning were symptom severity and prior physical functioning. The characteristics of a high-risk profile for disruption in physical functioning of elderly lung cancer patients 12 weeks after their diagnosis would include preexisting physical impairment and high levels of symptomatology.

The influence of symptoms, age, comorbidity and cancer site on physical functioning and mental health of geriatric women patients

This article focuses on how cancer site, age and comorbid conditions of elderly women cancer patients influence their reporting of symptoms; how these variables in turn impact their physical functioning and mental health; and whether there are differences according to the site of the cancer. For the study, a sample of 299 women, age 65 and above, was selected from an on-going longitudinal study of cancer patients recruited from six cancer treatment centers in Michigan and who were recently diagnosed with breast, colon or lung cancer. Age, comorbidity and cancer site were predictors of symptom severity. Age, comorbidity, symptom severity and cancer site were significant predictors of physical functioning, while mental health scores were only predicted by symptom severity. Lung cancer patients reported greater losses in physical functioning than either breast or colon cancer patients, however there were no significant differences in average mental health scores among the three cancer sites. A systematic and comprehensive approach to self-care management of symptom distress provided by oncologists and other health care professionals may enable patients, especially elderly patients with comorbid conditions, to successfully alleviate or reduce the impact of symptoms on their lives.

Mismatch of classroom furniture and student body dimensions: empirical findings and health implications

PURPOSE

To examine possible mismatch between the individual body dimensions of students and the classroom furniture they use.

METHODS

A total of 74 (37 male and 37 female) sixth-through eighth-grade students in a Michigan school district participated in the study; their ages ranged from 10 years, 11 months to 14 years, 3 months. Anthropometric measurements (including elbow height, shoulder height, upper arm length, knee height, popliteal height, buttock-popliteal length, and stature) were gathered in several physical education classes, each during a single session. In addition, the furniture dimensions were measured for three styles of chairs and three styles of desks prevalent in the students' classrooms. Based on both the information about student body dimensions and furniture dimensions, measures of fit or mismatch were constructed.

RESULTS

The data indicate a substantial degree of mismatch between the students' bodily dimensions and the classroom furniture available to them. Fewer than 20% of students can find acceptable chair/desk combinations. Most students are sitting in chairs with seats that are too high or too deep and at desks that are too high. Even after controlling for body stature, girls are less likely to find fitting chairs.

CONCLUSIONS

Based on the evidence presented, many sixth through eighth graders must endure seating arrangements in their classrooms that are not conducive to learning.

The impact of new demands for assistance on caregiver depression: tests using an inception cohort

Family caregivers of patients facing high numbers of new demands for assistance following hospital discharge were more likely to experience increased levels of depression in the following six months compared with caregivers facing similar overall demands but few new demands for assistance following hospital discharge. New demands for assistance had a significant independent effect upon the levels of depression and were independent of family relationship (spouse vs nonspouse) and caregiver gender. These findings provide insight into theories of caregiver stress, begin to specify the interaction of time following the onset of a stressful event and caregivers' subsequent reactions, and suggest which caregivers may require some assistance following discharge of their patients.

Loss of physical functioning among geriatric cancer patients: relationships to cancer site, treatment, comorbidity and age

This study investigated differences in physical functioning and physical role limitations according to cancer site and treatment modality in a sample of 590 patients 65 years and older diagnosed with breast, colon, lung or prostate cancer. Analysis of covariance procedures were utilised to test for differences in levels of physical functioning and physical role limitations according to cancer site and treatment modality, adjusting for differences in age, comorbid conditions and retrospective physical functioning. Physical functioning and physical role limitations were measured using two subscales of the Medical Outcomes Studies MOS 36-item Short Form Health Survey (SF-36). Physical functioning prior to diagnosis, and to a lesser degree comorbidity, contributed significantly to current levels of physical functioning and physical role limitations. Patients with lung cancer reported lower physical functioning and physical role limitation scores than patients with prostate cancer, and patients treated with surgery only reported lower physical functioning and physical role limitation scores than patients treated with neither surgery nor radiation. No gender differences were observed among the reduced sample consisting of patients with colon or lung cancer. It is important not only that physicians and oncologists are cognizant of the fact that some cancers (particularly lung cancer) may be more physically debilitating than others, but that the patient's history of comorbid conditions and pre-existing physical limitations may be important factors in predicting current physical functioning.

Changes in living arrangements of functionally dependent older adults and their adult children

This study investigated health and sociodemographic variables associated with co-residency patterns among older patients and their adult children following discharge from an acute care hospital. Data for the analysis were obtained from 172 adult children caring for functionally impaired parents. Logistic regression was employed to determine the probability that an older parent establishes co-residency with the adult child following hospitalization instead of remaining in a separate household. Results indicate that the overall level of caregiver involvement in activities of daily living (ADL) and instrumental activities of daily living (IADL) were strong predictors of parent and adult children forming a joint household. Increased household income of caregivers was inversely related to co-residency. Decisions about co-residency following hospitalization appear to hinge both on parental need and the resources of the adult child, suggesting that the decision to move together is largely one of need and not preference.

Determinants of family care giver reaction. New and recurrent cancer

PURPOSE

The authors examined the interaction of patient and care giver variables and identified whether changes in new and recurrent patients' levels of symptoms, functioning, and depression were related to changes in care givers' reactions to providing care.

DESCRIPTION OF STUDY

During a 6-month observation period, the psychosocial status and burden of a matched sample of patients with either new or recurrent cancer and their family care givers were assessed and compared.

RESULTS

Care givers of patients with recurrent disease experienced a marginally significantly different impact on depression over time. The type of disease (new or recurrent) did not impact care givers reactions to the care they were providing for patients. Instead, patients' symptoms and symptom experience incurred a greater impact on care giver depression.

CLINICAL IMPLICATIONS

The impact of cancer on patients and family care givers must be evaluated carefully and thoroughly, regardless of whether the diagnosis is new or recurrent. Patients' symptoms and symptom experience, mobility, and dependencies in instrumental activities of daily living are primary influences in creating emotional burden and depression in the family care giver of the patient diagnosed with new and with recurrent cancer.

The impact of age, treatment, and symptoms on the physical and mental health of cancer patients. A longitudinal perspective

BACKGROUND

To describe continuing care and rehabilitation needs of cancer patients, a longitudinal design (6 months) was performed among patients 50 years of age and older with solid tumors. The study examined how age, type of treatment, site of cancer, and symptom experience affect physical functioning and their mental health; age, site of cancer and the interval of time out of treatment influence changes in their symptom experience; and age, site of cancer, the interval of time out of treatment, and changes in symptom experience influence changes in physical and mental health.

METHODS

Patients (n = 111) who completed an intake and a 6-month self-administered questionnaire were included. Treatment included chemotherapy, radiation, or hormonal treatment at intake and for 6 months. Scales of nine symptoms and physical health using activities of daily living and measures of vigorous function were composed. Mental health was measured by the Center for Epidemiological Studies--Depression Scale.

RESULTS

The analyses yielded the following findings: (1) Primary site may have had an impact on symptom experience, limitations in functioning, and mental health if more patients with lung cancer had survived to 6 months. (2) Age, gender, treatment, or change in treatment had no impact on symptoms, functioning, or mental health at intake or changes in these variables. (3) Symptom experience at intake and the changes in symptoms predicted physical functioning and mental health at intake and the changes in these variables over time. (4) Gender differences were important in predicting mental health.

CONCLUSIONS

Strategies for continuing care and rehabilitation need to focus on symptom management, and strategies need to be different for male and female patients.

Predictors of use of secondary carers used by the elderly following hospital discharge

This research examines how caregiver-patient relationship (female spouses, and adult daughters and daughters-in-law) when cross classified with patient coresidence patterns explains the level of secondary carers' involvement among patients with newly added needs for assistance at home following hospital discharge. Among 196 primary caregivers (104 spouses, 92 daughters and daughters-in-law), patient needs were divided into ADL and mobility limitations, and medical tasks. Secondary carer involvement was categorized into levels differing at two observations: one following discharge and a second 3 months later. Analyses focused on explaining the levels of involvement of secondary carers following hospital discharge and the changes in secondary carers' involvement between the two observations. The baseline and change analyses revealed that caregiver-patient relationship was more important than coresidence patterns or patients' demands in explaining assistance from secondary carers. The implications of these findings on caregivers' reactions and policies regarding home care are explored.

Caregiving transitions: changes in depression among family caregivers of relatives with dementia

Depression among family caregivers of relatives with dementia was examined at three time intervals over a 4-year period. Comparisons were made between 46 residential caregivers, 49 caregivers of institutionalized elders, and 47 bereaved caregivers. No overall difference was found between the depression paths of the three groups. Female bereaved caregivers experienced a pattern of decreasing depression following their relative's death, while male bereaved caregivers experienced an increase in depression. Findings suggest the need for further investigation of the influences of gender on bereavement following the experience of providing family care for a relative with dementia.

Family and out-of-pocket costs for women with breast cancer

Other than loss of income to family members, little attention has been given to costs incurred by women with breast cancer and their families. Informal costs, such as the family labor for patient care and nonreimbursed out-of-pocket expenditures to care for the patient with breast cancer, need to be considered. Informal costs of women who survived for at least 3 months after the observation are compared with informal costs of a group of patients who died during the subsequent 3 months. Data for this longitudinal descriptive study were obtained from a convenience sample of 62 women with new or recurrent breast cancer. Data were collected at intake and at 3-month intervals across the 6-month observation. Data are presented for the out-of-pocket costs, primary family care-giver and "other" family labor costs, and total costs. Considering all costs, the 3-month average was $2,720 (SD, $3314) for the survivors and $7905 (SD, $5448) for the decedents. Regressions of costs on predictors were performed; survivors' status and patient dependencies in activities of daily living were the only significant predictors. Family care costs need to be considered along with the formal and direct reimbursable medical costs as an essential component of breast cancer care cost.

The costs of family contributions to the care of persons with dementia

This study focuses on the costs of dementia care incurred by families. Cost components operationalized include: costs of unpaid caregiver labor services, paid and unpaid family labor, paid and unpaid services of nonfamily persons, and cash outlays for equipment and services. Among 182 families of dementia patients, average care costs for a 3-month period amount to $4,564. Cash expenditures average only 29% of total care costs, with unpaid labor accounting for 71% of the family care costs. Total care costs rise by $1,158 for each additional dependency in an activity of daily living (ADL), while reliance on paid services is 5% higher for each additional $10,000 household income and drops by 25% if the patient lives in the caregiver's household.

Gender bias in the measurement properties of the Center for Epidemiologic Studies Depression Scale (CES-D)

Confirmatory factor-analytic models are used to examine gender biases of individual items of the Center for Epidemiologic Studies Depression (CES-D) Scale. In samples containing 708 cancer patients and 504 caregivers of the chronically ill elderly, two CES-D items are identified as producing biased responses in comparisons of male and female respondents. Three additional CES-D items are excluded on the basis of other psychometric problems, yielding a subset of 15 CES-D items that capture almost all the information of the original 20-item CES-D scale but are free of any gender bias. Gender differences in mean levels of depressive symptomatology are significantly reduced, but not eliminated, when the 15-item scale is used.

The influence of cancer patients' symptoms and functional states on patients' depression and family caregivers' reaction and depression

In this article the paths among cancer patients' physical and mental health and the reactions and mental health of their family caregivers were examined. Data for these analyses came from a cross-sectional sample of cancer patients who were recruited through ambulatory outpatient chemotherapy units, and their family caregivers. Patients' depression was explained largely by their symptomatology and, to a lesser extent, by loss of mobility. Patients' physical limitations impacted caregivers' daily schedules but not their physical health. Patients' levels of depression were related to those of their caregivers. However, caregivers' optimism proved to be a significant predictor of their mental health and reactions to caregiving.

The influence of cancer patients' symptoms and functional states on patients' depression and family caregivers' reaction and depression

In this article the paths among cancer patients' physical and mental health and the reactions and mental health of their family caregivers were examined. Data for these analyses came from a cross-sectional sample of cancer patients who were recruited through ambulatory outpatient chemotherapy units, and their family caregivers. Patients' depression was explained largely by their symptomatology and, to a lesser extent, by loss of mobility. Patients' physical limitations impacted caregivers' daily schedules but not their physical health. Patients' levels of depression were related to those of their caregivers. However, caregivers' optimism proved to be a significant predictor of their mental health and reactions to caregiving.

The cost of cancer home care to families

BACKGROUND

For the most part, previous research on costs of cancer care has focused on the formal medical care costs. Research on home care for patients with cancer has emphasized direct care costs (expenditures). Among indirect costs, only loss of income to family members has been studied. However, a major component of indirect costs, the family labor expended to care for the patient with cancer, needs to be included for a more realistic appreciation of home care costs.

METHODS

The costs of family labor are estimated by imputing monetary values for the time spent caring for the patient with cancer. The assigned monetary cost either is equated with income losses of the helper in question or is based on a putative market value of the expended labor time. In addition, out-of-pocket expenditures examined in this study cover all cancer care-related expenses for which the patient was not reimbursed by third parties. Data were obtained from a convenience sample of 192 patients with cancer and their families in lower Michigan.

RESULTS

When family labor is included in the cost calculations, average cancer home care costs for a 3-month period ($4563) are not much lower than the costs of nursing home care. The substantial variation in home care costs (standard deviation [SD] = $4313) appears to be unrelated to the type of cancer diagnosis, type of treatment, or time since diagnosis but seems to be driven by the functional status of the patient and the family living arrangements.

CONCLUSIONS

Outpatient care for patients with cancer coupled with greater reliance on home care appear to be economically attractive because costs to families usually are underestimated.

Patient attitudes concerning health behaviors during pregnancy: initial development of a questionnaire

The major determinant of infant mortality in the United States is low birthweight (LBW). Health behaviors related to LBW are inadequate prenatal care, poor nutrition, smoking, and moderate to heavy alcohol use. Before interventions can be designed to assist women in modifying these health behaviors, more must be understood about their causes. The Health Belief Model (HBM) is a framework for analyzing beliefs that motivate health behaviors and is well established as a model for understanding health behavior decisions. The chief aim of this study was to develop an instrument to assess women's health beliefs during pregnancy. Questions for the instrument were generated around the four major constructs of the HBM: perceived susceptibility, seriousness, benefits, and barriers. Four focus group interviews, a literature review, and consultation with an HBM expert provided content for questions. The questionnaire was administered to a convenience sample of 127 women. The measurement models were tested using confirmatory factor analysis. Parsimony was achieved by reducing the original 106-item scale to 64 items. The final instrument provides support for the HBM but not for all of its discrete constructs.

Confirmatory factor analysis (CFA) as a method to assess measurement equivalence

Employing the example of a multidimensional caregiver reaction scale, the use of confirmatory factor analysis techniques to establish measurement equivalence across comparison groups is discussed. The discussion is organized around the key concept of factorial invariance which provides the yardstick for assessing measurement equivalence.

The caregiver reaction assessment (CRA) for caregivers to persons with chronic physical and mental impairments

The development and testing of a multidimensional instrument to assess the reactions of family members caring for elderly persons with physical impairments, Alzheimer's disease, and cancer is reported. Forty items were administered to a sample of 377 caregivers of persons with physical impairments and Alzheimer's disease. Five dimensions of caregivers' reactions were identified through exploratory factor analysis. Using confirmatory factor analysis on an independent sample (N = 377), these dimensions were tested for factorial invariance across spouse and nonspouse caregivers and between caregivers of persons with cancer and those caring for persons with Alzheimer's disease. The subscales also had a high level of factorial invariance across a three-wave panel study (N = 185). The subscales appeared consistent with first order tests of construct validity.

Promoting positive well-being in employed mothers: a pilot study

In this quasi-experimental pilot study, women who were returning to work within 6 months after the birth of a first baby were assigned to participate in a control group (n = 13) or a six-session small group intervention (n = 18). The content of the group intervention was developed based on a stress and coping framework (Lazarus & Folkman, 1984). The experimental and control groups were surveyed at 2 months after their return to employment and on their baby's first birthday on measures of well-being in marriage, work, and parenting. Repeated measures analysis of covariance was used to examine differences over time between the experimental and control group with length of maternity leave and number of hours worked as covariates. Participants in the intervention reported increasing levels of marital satisfaction over time, whereas the control group experienced a decline in marital satisfaction over time (p = .04). Implications for practice and research are presented.

Assessment of the attitudes of family caregivers toward community services

Previous research has not taken into account the influence of attitudinal variables on the use of community services by dementia caregivers. The Community Service Attitude Inventory (CSAI) was developed to provide a measurement tool to further understanding of community service use by family caregivers. Testing of the CSAI revealed five distinct components of family attitudes toward use of community services.

Support patterns for spouse-caregivers of cancer patients. The effect of the presence of minor children

This study examines the support received by spouse-caregivers of cancer patients with minor children. The pattern of help encountered by these caregivers is compared to that of other caregivers, either living alone with the cancer patient or together with their adult children. This comparison leads to an exploration of compensatory support patterns depending on the source of help and the living arrangements. The study is based on a convenience sample of 232 spouse-caregivers of cancer patients in the Midwest. The findings suggest that other family members are willing to provide additional support when minor children are present in the household of the caregiver-patient dyad. However, this compensatory pattern does not extend to the situation of caregiver and patient living alone, nor do friends and neighbors engage in compensatory support behavior.

Knowledge and use of community services among family caregivers of Alzheimer's disease patients

The number of people with dementia residing within the community is steadily increasing. Community services can alleviate the burdens experienced by families, but are used infrequently by families of dementia patients. Caregivers (N = 93) of dementia patients were surveyed regarding their knowledge and use of community services. The most frequently used services were family support groups and home health aides. Overall, service use was low despite high levels of perceived availability of services. Older and less educated caregivers had higher levels of uncertainty about service availability. Depressed caregivers were less likely to know about service availability. Implications for practice and research are presented.

Out of pocket expenditures by family caregivers of dementia patients residing in the community

Out of pocket expenditures by families (N = 182) of relatives with dementia residing in the community were examined. Average expenditures for a three month period were $1,149. The relationship between illness variables, income, insurance coverage and total expenditures is described.

Responses of elderly spouse caregivers

In this paper three categories of variables were identified to predict spouses' reactions to caregiving roles: patient characteristics, the caregiving environment, and characteristics of the caregiver. Measures of these variables were administered to 159 spouse caregivers. Four domains of caregivers' responses were identified: negative emotional reactions, feelings of responsibility for the patient, feelings of abandonment by family, and impact of caregiving on daily schedules. These domains were influenced most by patient negative behaviors, physical health, and age, and by caregiver age, employment, and emotional status. Amount of assistance, affective support, and hours of care also were predictive of spouse responses.