Changes in quality of life after a diagnosis of cancer: a 2-year study comparing breast cancer and melanoma patients

PURPOSE

Longitudinal studies addressing change in health-related quality of life (HRQoL) following a diagnosis of cancer have mainly focused on a single cancer type, and little is known about the differences in HRQoL over time according to the type of tumor. The current study aims to compare the change in HRQoL over 2 years following breast cancer or melanoma diagnosis and socio-demographic variables associated with HRQoL over time.

METHODS

Patients recently diagnosed with breast cancer (n = 215) or melanoma (n = 78) completed surveys within 1 month of diagnosis and 6, 12, and 24 months later. Multilevel modeling analyses were used to compare the evolution over time of HRQoL dimensions, as measured by the EORTC QLQ-C30, in both cancers. Longitudinal effect of socio-demographic variables on HRQoL was also assessed.

RESULTS

Consistent with the literature, both cancer patients experienced decreased HRQoL scores following the diagnosis before improving over time. However, our analyses revealed that this rebound effect may occur at diverse times over the course of the illness according to the type of cancer. In addition, HRQoL over time was positively associated with age and negatively related to living with a partner regardless of the type of cancer.

CONCLUSIONS

The results of the present study suggest that support in hospital units should be specific and depend on the cancer type.

Exploring the impact of staff absenteeism on patient satisfaction using routine databases in a university hospital

AIM

To explore the influence of staff absenteeism on patient satisfaction using the indicators available in management reports.

BACKGROUND

Among factors explaining patient satisfaction, human resource indicators have been studied widely in terms of burnout or job satisfaction, but there have not been many studies related to absenteeism indicators.

METHOD

A multilevel analysis was conducted using two routinely compiled databases from 2010 in the clinical departments of a university hospital (France). The staff database monitored absenteeism for short-term medical reasons (5 days or less), non-medical reasons and absences starting at the weekend. The patient satisfaction database was established at the time of discharge.

RESULTS

Patient satisfaction related to relationships with staff was significantly and negatively correlated with nurse absenteeism for non-medical reasons (P < 0.05) and with nurse absenteeism starting at weekends (P < 0.05). Patient satisfaction related to the hospital environment was significantly and negatively correlated with nurse assistant absenteeism for short-term medical reasons (P < 0.05).

CONCLUSION

Our findings seem to indicate that patient satisfaction is linked to staff absenteeism and should lead to a better understanding of the impact of human resources on patient satisfaction.

IMPLICATIONS FOR NURSING MANAGEMENT

To enhance patient satisfaction, managers need to find a way to reduce staff absenteeism, in order to avoid burnout and to improve the atmosphere in the workplace.

Antireflux surgery for non-erosive and erosive reflux disease in community practice

BACKGROUND

Antireflux surgery has been mainly evaluated in tertiary referral centres. Data regarding post-operative outcome in non-erosive reflux disease are lacking.

AIM

To assess long-term outcome after antireflux surgery performed in a community practice setting.

METHODS

We selected consecutively 60 non-erosive reflux disease patients and 61 erosive oesophagitis patients with symptomatic gastro-oesophageal reflux disease. After surgery, each subject answered a validated disease-specific health-related quality of life questionnaire and another questionnaire focusing on symptoms, late morbidity and drug use.

RESULTS

After a 43-month median follow-up, an excellent outcome was reported by less than two-thirds of patients. Quality of life scores were lower in the non-erosive reflux disease group, especially in female patients. Non-erosive reflux disease patients reported more daily symptoms and more reflux-related symptoms (P = 0.04). Proton-pump inhibitor use was higher in non-erosive reflux disease patients (P < 0.005). Multivariate analysis identified four independent predictive factors associated with better outcome, namely male gender, abnormal preoperative acid exposure, a long duration of symptoms and surgical expertise.

CONCLUSIONS

In community practice, the results of antireflux surgery are inferior to those reported by tertiary centres. Outcome seems poorer in non-erosive reflux disease especially in female patients. Nearly one-third of the non-erosive reflux disease patients continue to take proton-pump inhibitors. These results highlight the need for careful selection of patients before antireflux surgery.

Differential effects of two types of antidepressants, amitriptyline and fluoxetine, on anorectal motility and visceral perception

BACKGROUND

Although antidepressants are used for functional gastrointestinal disorders, the mechanisms of their effects on gut are incompletely understood.

AIM

To assess the effects of two types of antidepressants (tricyclic, serotoninergic) on anorectal motility and visceral perception.

METHODS

A placebo-controlled, randomized, double-blind, crossover study was performed in 12 healthy male volunteers who received a single oral dose of amitriptyline (80 mg), fluoxetine (40 mg) or placebo. Drug effects were assessed using phasic isobaric distensions of the rectum with an electronic barostat (11 levels from 1 to 51 mmHg) 4 h after drug intake. Maximal rectal volume and pressure, mean and residual pressures at upper anal canal, mean pressure at lower anal canal, defecation sensation (5-level scale) and visceral perception (visual analogue scale) were recorded at each level of distending pressure.

RESULTS

Ten subjects completed the study. Compared with placebo, neither amitriptyline nor fluoxetine modified rectal compliance or visceral perception. Compared with placebo, antidepressants significantly reduced mean and residual pressures at upper anal canal (-18%, P = 0.0019, and -27%, P = 0.0002, respectively, for amitriptyline; -26%, P = 0.0001, and -33%, P = 0.0001, respectively, for fluoxetine) whereas only amitriptyline significantly reduced mean pressure at lower anal canal (-16%, P = 0.0008).

CONCLUSION

Both antidepressants similarly relaxed the internal anal sphincter, probably through a non-specific mechanism, without modifying visceral perception. Only amitriptyline relaxed the external anal sphincter.

Lack of effficacy of botulinum toxin in chronic anal fissure

BACKGROUND AND AIM

Hypertonicity of internal anal sphincter plays a major role in the persistence of chronic anal fissure. Botulinum toxin could induce internal anal sphincter relaxation without the adverse effects of surgery (long-term faecal incontinence) or topical nitrates (anal burning, headaches, hypotension).

METHODS

We conducted a placebo-controlled, randomised, double-blind study to assess the efficacy of a single injection of botulinum toxin in the internal anal sphincter of patients with chronic anal fissure in six ambulatory care clinics. Eligibility criteria included a mean value of post-defecation anal pain >or= 30 mm on a 100 mm visual analogue scale over the week preceding inclusion. Main endpoint was the proportion of patients with symptomatic improvement during the fourth week after inclusion (post-defecation anal pain below 10 mm).

RESULTS

Forty-four patients (22 in each group) were included. At inclusion, there was no significant difference between groups on age, sex ratio, pain duration, post-defecation anal pain, analgesic consumption and stool frequency. Ten (45%) and 11 (50%) patients reported symptomatic improvement on the main endpoint (P=0.76) in placebo and botulinum toxin groups, respectively. Ten patients (five in each group) had healed fissure at week 4 and ten patients (five in each group) required surgical treatment between weeks 4 and 12. Similarly, there was no significant difference between groups on other variables between weeks 4 and 12.

CONCLUSIONS

The efficacy of a single injection of botulinum toxin in the internal anal sphincter does not differ from that of a placebo in patients with chronic anal fissure.

Ritonavir-saquinavir dual protease inhibitor compared to ritonavir alone in human immunodeficiency virus-infected patients

The objective of this study was to evaluate the antiretroviral efficacy and safety of ritonavir (600 mg twice a day [b.i.d.])-saquinavir (400 mg b.i.d.) compared to ritonavir (600 mg b.i.d.) in patients pretreated and receiving continued treatment with two nucleoside analogs. The study was placebo controlled, randomized, and double blind. Inclusion criteria included protease inhibitor naive status and a viral load of >10,000 copies/ml. The main end point was viral load at week 24. Forty-seven patients were included (25 given ritonavir and 22 given ritonavir-saquinavir) and monitored until week 48. At inclusion, 23% had had at least one AIDS-defining event. Previous treatment durations (mean and standard deviation) were 42 +/- 25 and 37 +/- 23 months, viral loads were 4.75 +/- 0.62 and 4.76 +/- 0.50 log(10) copies/ml, and CD4 cell counts were 236 +/- 126 and 234 +/- 125/mm(3) in the ritonavir and ritonavir-saquinavir groups, respectively. At week 24, viral loads were 2.81 +/- 1.48 and 2.08 +/- 1.14 log(10) copies/ml (P = 0.04) and CD4 cell counts were 330 +/- 151 and 364 +/- 185/mm(3) (P = 0.49) in the ritonavir and ritonavir-saquinavir groups, respectively. Similar results were observed at week 48. Moreover, at week 48, 40 and 68% (P = 0.05) and 28 and 59% (P = 0.03) of patients achieved viral suppression at below 200 and 50 copies/ml in the ritonavir and ritonavir-saquinavir groups, respectively. At week 24, six patients in the ritonavir group but only one in the ritonavir-saquinavir group had key mutations conferring resistance to protease inhibitors. Clinical and biological tolerances were similar in both groups. In nucleoside analog-pretreated patients, ritonavir-saquinavir has higher antiretroviral efficacy than and is as well tolerated as ritonavir alone.

Comparison of the two-sided single triangular test to the double triangular test

Comparative clinical trials are designed to determine whether a new treatment has either superior or different efficacy than a standard, that is, if theta represents a measure of treatment difference, to test the null hypothesis H(0): theta = 0 against the alternative hypothesis H(1) of either superior (theta > 0, one-sided) or different (theta not equal 0, two-sided with H(1)(+): theta > 0 and H(-)(1): theta < 0) efficacy. The triangular test (TT), a group sequential method, allows for early stopping of such trials. Its one-sided version (single TT) and two-sided version (double TT) were implemented in the first release of PEST software. The third release of PEST proposed a modification of the single TT, allowing rejection of H(0) in favor of H(-)(1) when very early data show strong inferiority of the new treatment as compared with the standard. Thus, our aim was to compare this modified single TT, referred to as a two-sided test in PEST 3, with the double TT and two-sided single-stage design (SSD). The statistical properties of the SSD and double TT were perfectly similar under all hypotheses. The modified single TT was underpowered as compared to the two others (the probability of falsely accepting H(0) strictly under H(-)(1) was 0.65 instead of 0.05), but the average sample number function was lower than the one of the double TT under all H(-)(1) hypotheses (-56% strictly under H(-)(1)). We conclude that the modified single TT offers a two-sided conclusion with many fewer patients than the double TT, but at the expense of a strong decrease in power under H(-)(1).

Compartmentalised inducible nitric-oxide synthase activity in septic shock

BACKGROUND

Previous experimental studies support a role for inducible nitric-oxide synthase (iNOS) in the pathogenesis of severe sepsis. The aim of the study was to characterise iNOS activity in different tissues in patients with septic shock.

METHODS

13 consecutive patients with septic shock caused by cellulitis were enrolled. Skin, muscle, fat, and artery samples were obtained from normal, inflamed, and putrescent areas to measure iNOS activity, and concentrations of tumour necrosis factor alpha (TNFalpha) and interleukin 1beta (IL-1beta). In two patients, iNOS activity was also assessed in peripheral blood mononuclear cells (PBMC) incubated with microorganisms causing the sepsis, or in macrophages isolated from suppurating peritoneal fluid incubated with IL-1beta.

FINDINGS

Compared with normal and inflamed areas, iNOS activity was increased in putrescent areas for muscle (71-fold [95% CI 20-259] vs normal areas, 69-fold [19-246] vs inflamed areas; p<0.01 for each) and for fat (68-fold [23-199] and 49-fold [18-137], respectively; p<0.01), but not for skin. Compared with normal areas, putrescent areas of arteries showed increased iNOS expression (1280-fold [598-3153]; p<0.01). Compared with normal areas, TNFalpha and IL-1beta were increased in putrescent areas of arteries (223-fold and 41-fold, respectively; p<0.01 for each). PBMCs and tissue macrophages expressed iNOS. Plasma nitrite/nitrate concentrations inversely correlated with mean arterial pressure and systemic vascular resistance.

INTERPRETATION

In human septic shock we found that iNOS activity is compartmentalised at the very site of infection and parallels expression of TNFalpha and IL-1beta. PBMCs and tissue macrophages can be a cellular source for iNOS.

A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin

CONTEXT

The hypothalamic-pituitary-adrenal axis is a major determinant of the host response to stress. The relationship between its activation and patient outcome is not known.

OBJECTIVE

To evaluate the prognostic value of cortisol levels and a short corticotropin stimulation test in patients with septic shock.

DESIGN AND SETTING

Prospective inception cohort study conducted between October 1991 and September 1995 in 2 teaching hospital adult intensive care units in France.

PARTICIPANTS

A total of 189 consecutive patients who met clinical criteria for septic shock.

INTERVENTION

A short corticotropin stimulation test was performed in all patients by intravenously injecting 0.25 mg of tetracosactrin; blood samples were taken immediately before the test (T0) and 30 (T30) and 60 (T60) minutes afterward.

MAIN OUTCOME MEASURES

Twenty-eight-day mortality as a function of variables collected at the onset of septic shock, including cortisol levels before the corticotropin test and the cortisol response to corticotropin (delta max, defined as the difference between T0 and the highest value between T30 and T60).

RESULTS

The 28-day mortality was 58% (95% confidence interval [CI], 51%-65%) and median time to death was 17 days (95% CI, 14-27 days). In multivariate analysis, independent predictors of death (P < or = .001 for all) were McCabe score greater than 0, organ system failure score greater than 2, arterial lactate level greater than 2.8 mmol/L, ratio of PaO2 to fraction of inspired oxygen no more than 160 mm Hg, cortisol level at T0 greater than 34 microg/dL and delta max no more than 9 microg/dL. Three groups of patient prognoses were identified: good (cortisol level at T0 < or = 34 microg/dL and delta max > 9 microg/dL; 28-day mortality rate, 26%), intermediate (cortisol level at T0 34 microg/dL and delta max < or = 9 microg/dL or cortisol level at T0 > 34 microg/dL and delta max > 9 microg/dL; 28-day mortality rate, 67%), and poor (cortisol level at T0 > 34 microg/dL and delta max < or = 9 microg/dL; 28-day mortality rate, 82%).

CONCLUSION

Our data suggest that a short corticotropin test has a good prognostic value and could be helpful in identifying patients with septic shock at high risk for death.

Safety and efficacy of ritonavir and saquinavir in combination with zidovudine and lamivudine

BACKGROUND

Ritonavir is a potent inhibitor of cytochrome P4503A4 that strongly increases saquinavir bioavailability. In this study we assessed the safety and antiretroviral efficacy of the combination of these two compounds in patients pretreated and receiving continued treatment with zidovudine and lamivudine who were protease inhibitor naive and who had a CD4 cell counts below 200/mm3.

METHODS

In this 48-week pilot study, all patients received 600 mg ritonavir and 400 mg saquinavir twice daily. Administration of zidovudine and lamivudine was continued without a change in previous doses. Viral load, CD4 cell count, and the emergence of resistance to the two protease inhibitors were evaluated repeatedly up to week 48.

RESULTS

Sixteen patients were included in the study. Previous nucleoside analog treatment duration was 48+/-22 months (mean +/- SD). Two patients quit taking both protease inhibitors within 2 weeks. The ritonavir dose had to be reduced in 10 other patients because of side effects. Between inclusion and week 48, plasma viremia varied from 4.87+/-0.43 to 3.00+/-1.29 log10 copies/mL and CD4 cell counts ranged from 98+/-61 to 250+/-139/mm3. Ten patients (63%) had viral loads below 200 copies/mL and 7 (44%) had viral loads below 50 copies/mL. A single key mutation that conferred ritonavir resistance I84V and V82A/V developed in two patients. A mutation at codon 54 developed in another patient. These mutations were associated with repeated cessations of antiretroviral treatment. No lipodystrophy was observed.

CONCLUSION

Ritonavir and saquinavir in combination are quite well tolerated and induce a high and sustained antiretroviral efficacy. A four-drug combination that includes these two protease inhibitors should be considered as a first line of treatment in patients with low CD4 cell counts.

Methodological issues in pharmacokinetic-pharmacodynamic modelling

This article presents the theoretical and practical aspects involved in the design and analysis of pharmacokinetic-pharmacodynamic modelling studies. The main features of the protocol of pharmacokinetic-pharmacodynamic studies are discussed with special focus on experimental designs in relation to individual and population approaches. Some basic pharmacodynamic models (such as linear, log-linear, hyperbolic and sigmoid models) are presented as well as more complex time-dependent models (effect compartment and physiological indirect response, tolerance models) which are required when the concentration-effect relationship shows a hysteresis loop. The methods of estimation, with special focus on the individual and populations approaches, are covered, along with the way pharmacodynamic models and methods of estimation can be applied to real data and the information required to criticise the results of modelling. We also present some real problems frequently encountered when performing pharmacokinetic-pharmacodynamic modelling and give some potential solutions (problems with hysteresis loops, lack of convergence, problems with residuals). The last section discusses the significance of pharmacodynamic parameters.

A computer simulation model for the spread of nosocomial infections caused by multidrug-resistant pathogens

A Monte Carlo simulation model was developed for the spread of antibiotic-resistant bacteria in hospital units. The model allows for the representation of every patient and staff member. Staff-patient interactions, staff handwashing compliance, admission of colonized patients, and antibiotic use are included in the model. The simulation model provides colonization curves for patients and staff and offers the possibility of simulating different kinds of hospital units. Simulation of the spread of an antibiotic-resistant pathogen in an intensive care unit was performed. We studied the impact of handwashing compliance on colonization. The importance of handwashing in preventing colonization and the influence of admission of colonized patients in perpetuating an epidemic were confirmed by the model. The model offers a new approach to modeling the spread of nosocomial pathogens in hospital units. It allows one to study the impact of infection control measures and represents a valuable educational tool for staff.

Modeling the spread of resistant nosocomial pathogens in an intensive-care unit

OBJECTIVES

To show the value of mathematical modeling in simulating the spread of nosocomial pathogens in an intensive-care unit (ICU), to provide a framework for listing available knowledge; to predict the benefits of various control measures; and to supplement the epidemiological assessment of these measures.

DESIGN

Simulated outbreak of a nosocomial pathogen in an ICU, based on a deterministic compartmental model describing both person-to-person spread and indirect spread between patients through staff members.

INTERVENTIONS

Stimulation of three typical colonization control measures: effective handwashing compliance among staff members, ICU antimicrobial policy, and curtailing ICU admission of colonized patients.

RESULTS

In controlling colonization, effective handwashing compliance reduced staff member colonization, but only moderately limited patient colonization unless the ICU was isolated strictly by curtailing the admission of colonized patients. The impact of antibiotic policy was very slight.

CONCLUSIONS

In the field of nosocomial infection, mathematical modeling appears to be valuable tool that can be used to evaluate the magnitude of the expected effects of control strategies and to guide the selection of the best randomized clinical trials to pursue.