Change in Activities of Daily Living in the Year Following a Stroke: A Latent Growth Curve Analysis.

BACKGROUND: Early prediction of future functional capability is crucial for stroke survivors' care management. OBJECTIVES: The purposes of this study were to test the trajectory of change across time in activities of daily living (ADLs) and to determine whether the National Institutes of Health Stroke Scale (NIHSS) score within 24 hours poststroke, gender, and age predict ADLs at 1, 3, 6, and 12 months poststroke. METHODS: A prospective cohort design was used. Baseline characteristics and neurological deficits were measured in 1,021 stroke survivors. The 13-item NIHSS was used to examine neurological status within 24 hours poststroke. ADLs were measured with the Barthel index at 1, 3, 6, and 12 months poststroke. A latent growth curve model was used to analyze how the dynamic changes in ADLs were related to NIHSS score, gender, and age. RESULTS: The latent growth curve model analyses revealed that, as the time following a stroke increases, survivors tend to gradually improve with regard to ADLs. In addition, lower levels of initial ADLs were associated with higher growth in ADLs over time. However, after 6 months poststroke, further gains in ADLs slowed. Based on further analysis, the findings indicate that a lower NIHSS score, being male, and a young age at time of stroke were associated with higher initial levels of ADLs. Having a higher NIHSS score, being female, and a young age at time of stroke predicted an increase in ADLs over time. DISCUSSION: To promote ADLs of stroke patients, NIHSS score at admission, gender, and age should be included as important predictors of stroke care management. The results highlight that the rehabilitation of stroke patients should be focused more on ADLs at 1-6 months poststroke.

Prevalence, Location, and Characteristics of Chronic Pain in Intensive Care Survivors.

BACKGROUND: A growing number of studies have addressed the long-term consequences of intensive care unit (ICU) treatment, but few have studied the prevalence of chronic pain and pain characteristics longitudinally. AIMS: The goal of the work described here was to investigate the prevalence and characteristics of chronic pain in ICU survivors 3 months and 1 year after ICU discharge and to identify risk factors for chronic pain 1 year after ICU discharge. DESIGN: The design used was an explorative and longitudinal study. SETTING/PATIENTS: The patients in this work had stayed >48 hours in two mixed ICUs in Oslo University Hospital, a tertiary referral hospital. METHODS: Patients completed a survey questionnaire 3 months and 1 year after ICU discharge. Pain was assessed using the Brief Pain Inventory-Short Form. RESULTS: At 3 months after discharge, 58 of 118 ICU survivors (49.2%) reported pain, and at 1 year after discharge, 34 of 89 survivors (38.2%) reported pain. The most common sites of pain at 3 months were the shoulder and abdomen; the shoulder remained the second most common site at 1 year. There was an increase in the interference of pain with daily life at 1 year. Possible risk factors for chronic pain at 1 year were increased severity of illness, organ failure, ventilator time >12 days, and ICU length of stay >15 days. The most common sites of pain were not linked to the admission diagnosis. CONCLUSIONS: These findings may enable health care providers to improve care and rehabilitation for this patient group.

Assessing quality of life in young adult cancer survivors: development of the Survivorship-Related Quality of Life scale.

PURPOSE: Scientific advances in treatments and outcomes for those diagnosed with cancer in late adolescence and early adulthood depend, in part, on the availability of adequate assessment tools to measure health-related quality of life (HRQOL) for survivors in this age group. Domains especially relevant to late adolescence and young adulthood (LAYA; e.g., education and career, committed romantic relationships, worldview formation) are typically overlooked in studies assessing the impact of cancer, usually more appropriate for middle-aged or older survivors. Current HRQOL measures also tend to assess issues that are salient during or shortly after treatment rather than reflecting life years after treatment. METHODS: To develop a new measure to better capture the experience of LAYA cancer survivors in longer-term survivorship (the LAYA Survivorship-Related Quality of Life measure, LAYA-SRQL), we completed an extensive measure development process. After a literature review and focus groups with LAYA cancer survivors, we generated items and ran confirmatory factor and reliability analyses using a sample of 292 LAYA cancer survivors. We then examined validity using existing measures of physical and mental health, quality of life, and impact of cancer. RESULTS: The final model consisted of two domains (satisfaction and impact), each consisting of ten factors: existential/spirituality, coping, relationship, dependence, vitality, health care, education/career, fertility, intimacy/sexuality, and cognition/memory. Confirmatory factor analysis and validity analyses indicated that the LAYA-SRQL is a psychometrically sound instrument with good validity. CONCLUSION: The LAYA-SRQL fills an important need in survivorship research, providing a way to assess HRQOL in LAYAs in a developmentally informed way.

Child sexual abuse survivors with dissociative amnesia: what's the difference?

Although the issue of dissociative amnesia in adult survivors of child sexual abuse has been contentious, many research studies have shown that there is a subset of child sexual abuse survivors who have forgotten their abuse and later remembered it. Child sexual abuse survivors with dissociative amnesia histories have different formative and therapeutic issues than survivors of child sexual abuse who have had continuous memory of their abuse. This article first discusses those differences in terms of the moderating risk factors for developing dissociative amnesia (e.g., age, ethnicity, gender, etc.) and then mediating risk factors (e.g., social support, trait dissociativity, etc.). The differences between the two types of survivors are then explored in terms of treatment issues.

[Instrumentality of the International Classification of Functioning, Disability and Health (ICF) in classification of long-term consequences of diseases]. / Die Internationale Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF) als Klassifikationshilfe der langfristigen Krankheitsfolgen.

The ICF (International Classification of Functioning, Disability and Health) is an international classification of disease consequences and phenomena associated with health conditions. It is complementary to the already established classification of diseases (ICD). The ICF provides both a framework and a classification that comprehensively cover relevant domains of functioning to describe long-term consequences of diseases. The classification can be used as a universal language understood by medical doctors, health professionals, researchers, patients and other groups. The ICF is based on an integrative biopsychosocial model of functioning. Functioning is used as an umbrella term for all non-problematic body functions, body structures, activities and participation. Based on the biopsychosocial model the ICF comprises a hierarchical classification to describe functioning as well as environmental factors. Problems of long-term survivors as well as persons suffering from chronic diseases, relevant findings, treatment goals and treatment concepts can be managed by applying the ICF to the patients.

Sexual Violence-"Victim" or "Survivor": News Images Affect Explicit and Implicit Judgments of Blame.

A pilot study (n = 165) showed that images portraying women who have experienced sexual violence as survivors (e.g., at a self-help group) rather than as victims (e.g., in vulnerable positions) led to more positive ratings of the women depicted. In a subsequent experiment (n = 236), participants viewed either survivor or victim images, read a rape vignette, and completed explicit and implicit measures of blame. Results showed that male (but not female) participants implicitly blamed the woman more after viewing victim images, but explicitly blamed her more after viewing survivor images. Discussion focuses on theoretical and applied implications.

Evidence for increased surveillance of executive functioning in adolescent and young adult survivors of childhood cancer.

Comprehensive long-term follow-up (LTFU) for survivors of childhood cancer is critical for reducing morbidity and mortality. Current standards recommend screening all survivors for psychological and academic problems and certain survivors for neurocognitive problems based upon treatment exposures. This study aimed to determine if differences exist in executive functioning (EF) based on treatment exposures and characterize relationships between EF, treatment exposure, and internalizing problems. Participants included adolescent and young adult (AYA) survivors (N = 70) of non-central nervous system cancer, aged 14-21 presenting for LTFU. Patient-reported data were obtained on survivors' EF, internalizing symptoms, academic performance, and educational supports. Children's Oncology Group's LTFU Guidelines classified survivors as at risk or not at risk for neurocognitive deficits based on treatment exposures. Group differences, relationships, and moderation by risk group were examined. No differences were found in EF, internalizing symptoms, academic performance, or educational supports between survivors who were at risk versus those not at risk for neurocognitive deficits. Problems with EF predicted internalizing symptoms, an effect that was moderated by risk group (R2= .64 for AYA self-report; R2 = .38 for parent-proxy report). Survivors with poorer EF experienced higher levels of internalizing symptoms. These data indicate that current screening practices may not identify survivors who are not at risk for neurocognitive deficits, yet struggle with EF. Survivor care providers should consider universal screening for EF problems in AYAs, regardless of treatment exposure history. Clinical assessment of internalizing problems in survivors with EF problems is also recommended.

Cigarette smoking and health-related quality of life in Medicare beneficiaries.

This study examined associations between cigarette smoking, cancer, and self-reported physical (SF-36 Physical Component Summary Score, [PCS]) and mental health (SF-36 Mental Component Summary Score, [MCS]) among 123,567 Medicare beneficiaries enrolled in managed care plans. As expected for a sample of older individuals, the SF-36 PCS mean (42.6) was lower than the U.S. general population mean of 50. The SF-36 MCS mean (51.7) for the sample was higher than the general population mean. In addition, least squares means revealed significantly poorer health for current smokers and those who recently quit, regardless of their cancer status. Although statistically significant, the differences between current smokers and never smokers were small among those with or without cancer. Encouraging smokers to quit and providing abstinence support to persons who have recently quit may help reduce health-related impacts of cigarette use.

Reconceptualizing and operationalizing context in survey research on intimate partner violence.

Survey research in the field of intimate partner violence is notably lacking in its attention to contextual factors. Early measures of intimate partner violence focused on simple counts of behaviors, yet attention to broader contextual factors remains limited. Contextual factors not only shape what behaviors are defined as intimate partner violence but also influence the ways women respond to victimization, the resources available to them, and the environments in which they cope with abuse. This article advances methods for reconceptualizing and operationalizing contextual factors salient to the measurement of intimate partner violence. The analytic focus of the discussion is on five dimensions of the social context: the situational context, the social construction of meaning by the survivor, cultural and historical contexts, and the context of systemic oppression. The authors consider how each dimension matters in the measurement of intimate partner violence and offer recommendations for systematically assessing these contextual factors in future research.

Follow-up after childhood cancer: evaluation of a three-level model.

INTRODUCTION: Follow-up for cancer survivors is recommended to detect recurrence; monitor late-effects; record toxicity and provide care and education. We describe our experience with a three-level model developed to guide decisions about intensity and frequency of follow-up [Wallace WHB, Blacklay A, Eiser C, et al. Developing strategies for the long term follow-up of survivors of childhood cancer. BMJ 2001;323:271-274]. PROCEDURE: One hundred and ninety eight survivors (52% male) recruited over 12-months: (mean age=23.8 years, range=16-39 years; mean time since diagnosis=16.2 years, range 2.4-32.7 years) reported their number of symptoms and late-effects. Information was taken from the medical records to assign each survivor to the appropriate levels by six clinic staff independently. RESULTS: The survivors were assigned to level 1 (n=8), level 2 (n=97) and level 3 (n=93). There were seven cases of disagreement. Level 3 survivors self-reported more symptoms and late-effects than level 2 survivors. CONCLUSIONS: Coding was relatively simple for experienced clinic staff, although there were some disagreements for the survivors of ALL. The relationship between assigned level and self-reported symptoms and late-effects provides some evidence for validity of the model. We conclude that it is important to maintain flexibility to allow movement between levels for individual patients and that the default should always be to the higher level.

Racial disparity in cardiac procedures and mortality among long-term survivors of cardiac arrest.

BACKGROUND: It is unknown whether white and black Medicare beneficiaries have different rates of cardiac procedure utilization or long-term survival after cardiac arrest. METHODS AND RESULTS: A total of 5948 elderly Medicare beneficiaries (5429 white and 519 black) were identified who survived to hospital discharge between 1990 and 1999 after admission for cardiac arrest. Demographic, socioeconomic, and clinical information about these patients was obtained from Medicare administrative files, the US census, and the American Hospital Association's annual institutional survey. A Cox proportional hazard model that included demographic and clinical predictors indicated a hazard ratio for mortality of 1.30 (95% CI 1.09 to 1.55) for blacks aged 66 to 74 years compared with whites of the same age. The addition of cardiac procedures to this model lowered the hazard ratio for blacks to 1.23 (95% CI 1.03 to 1.46). In analyses stratified by race, implantable cardioverter-defibrillators (ICDs) had a mortality hazard ratio of 0.53 (95% CI 0.45 to 0.62) for white patients and 0.50 (95% CI 0.27 to 0.91) for black patients. Logistic regression models that compared procedure rates between races indicated odds ratios for blacks aged 66 to 74 years of 0.58 (95% CI 0.36 to 0.94) to receive an ICD and 0.50 (95% CI 0.34 to 0.75) to receive either revascularization or an ICD. CONCLUSIONS: There is racial disparity in long-term mortality among elderly cardiac arrest survivors. Both black and white patients benefited from ICD implantation, but blacks were less likely to undergo this potentially life-saving procedure. Lower rates of cardiac procedures may explain in part the lower survival rates among black patients.

Constructing the meaning of survivor with former pediatric brain tumor patients.

Although the term survivor is frequently used in cancer discourse, the meaning of survivor and how people identify with this term can be difficult to understand. The purpose of this qualitative study is to explore the meaning of the term survivor from the perspective of young adults who have experienced a pediatric brain tumor (PBT). A constructivist grounded theory was utilized in this study with 6 young adults who had a PBT. This study also used semistructured interviews with participants who also completed reflective journals, which were focused on the survivor concept. Data were analyzed through coding strategies and constant comparative methods. Findings present 4 major themes of process: (a) reviewing the illness experience, (b) qualifying as a survivor, (c) thinking positive, and (d) being changed. These themes are important to consider in the construction, interpretation, and understanding of how the majority of this population do not identify with the current social use of the term survivor. Clearly, there is a need for a clearer understanding of survivor and how it specifically applies to those who have had a PBT. Everyone should remain conscious and consider how a broad, generalizing term such as survivor may influence a person's attitude and advocacy toward their health.

Polygraphic sleep criteria as predictors of successful aging: an exploratory longitudinal study.

BACKGROUND: A cohort of 57 elderly healthy volunteers (34 male, 23 female) was studied in a sleep laboratory on four consecutive nights when their average age was 63.5 +/- 3.7 years. Thirty subjects (20 male, 10 female) were assessed 14 years later; 21 had either died in the meantime or were very ill, and 6 did not participate for other reasons. METHODS: Two operationalizations of successful aging were applied: survival in relatively good health (30 survivors vs. 21 nonsurvivors), and cognitive competence as assessed in the survivors by means of tests of cognitive function. RESULTS: Whereas none of the sleep characteristics determined at baseline distinguished the survivors from the nonsurvivors, several parameters [REM (rapid eye movement) sleep latency, REM density, and NREM (non-REM) shifts] were significantly correlated with one or more measures of cognitive functioning at follow-up. These polygraphic sleep parameters also distinguished a subgroup of cognitively fully competent subjects from those who, according to their performance in tests of cognitive function, could be considered as mildly demented. CONCLUSIONS: While the REM latency and density findings support the theory of a functional link between brain cholinergic activity, timing, and density of REM sleep and cognitive functioning, the positive association between the number of NREM shifts at baseline and cognitive performance 14 years later is difficult to explain. It is suggested that the findings of the present study, in particular the potential predictive value of REM latency and REM density for cognitive functioning in the old, need replication in other subject samples followed for similar time periods.

Comparing directly measured standard gamble scores to HUI2 and HUI3 utility scores: group- and individual-level comparisons.

Directly measured standard gamble (SG) utility scores reflect the respondent's assessment and valuation of their own health status. Scores from the health utilities index (HUI) are based on self-assessed health status but valued using community preferences obtained using the SG. Our objectives were to find if mean directly measured utility scores agree with mean HUI mark 2 (HUI2) and mean HUI mark 3 (HUI3) scores. Also, if individual directly measured utility scores agree with HUI2 and HUI3 scores, and whether HUI2 and HUI3 scores agree. Questionnaires based on the HUI2 and HUI3 health-status classification systems were administered by interviewers to 140 teenage survivors of extremely low birthweight (ELBW) and 124 control group teens. Respondents were asked to think about their own usual health states using six dimensions from HUI2 and value that state using the SG. Mean SG scores are compared with mean HUI2 and mean HUI3 scores using paired sample t-tests. Mean HUI2 scores are compared with mean HUI3 scores. Agreement among scores is assessed using intra-class correlation coefficient (ICC). The effect of severity of health-state morbidity on agreement was assessed using three approaches. ELBW cohort mean (standard deviation) SG, HUI2, and HUI3 scores were 0.90 (0.20), 0.89 (0.14), and 0.80 (0.22). Results for controls were 0.93 (0.11), 0.95 (0.09), and 0.89 (0.13). Mean SG and HUI2 scores did not differ; mean SG and HUI3 did differ; mean HUI2 and HUI3 also differed. At the individual level for ELBW, the ICCs between SG and HUI2, SG and HUI3, and HUI2 and HUI3 scores were 0.13, 0.28, and 0.64. For controls the ICCs were 0.14, 0.24, and 0.56. HUI2 scores appear to match directly measured utility scores reasonably well at the group level. HUI2 and HUI3 scores differ systematically. At the individual level, however, HUI2 and HUI3 scores are poor substitutes for directly measured scores.

Racial disparities in cardiac care: geography matters.

Racial disparities in health care have been well-documented, although the reasons for many of these disparities remain obscure. An intriguing possibility is that geographic factors--the places where certain groups live or obtain health care--contribute to racial disparities, especially in the use of new medical technologies. This Issue Brief examines racial disparities in the use of life-saving cardiac procedures and mortality after cardiac arrest, and considers how geographic differences in health care affect these disparities.

Validation of comprehensive assessment of activities of daily living in stroke survivors.

This study determined whether the Functional Independence Measure (FIM) and the Frenchay Activities Index (FAI) could be used together as a more comprehensive score to assess the activities of daily living (ADL) in stroke survivors. Subjects were recruited from stroke patients consecutively admitted to the inpatient neurology or rehabilitation department at a university hospital in southern Taiwan. We interviewed 209 first stroke survivors at least 1 year after stroke onset during their clinical visits, at home, or in long-term care institutions. Combinations of FIM and FAI as a comprehensive assessment of ADL were measured. All items of the FIM and the FAI were included in a non-parametric factor analysis to determine their underlying constructs. Two comprehensive functional independence scores were then computed as functions of the FIM and FAI scores. The distributional characteristics of the comprehensive scores were examined. Approximately 90% of the total variation was explained by three factors. One single factor comprised all the items from FIM, while the FAI items loaded on two other factors, suggesting that FIM supplements FAI without overlap in content. We further demonstrated that the presence of ceiling or floor effects when either the FIM or the FAI was used could be removed using combined scores of the two instruments. The FIM and the FAI assessed different domains with good construct validity. A comprehensive assessment of functional independence obtained by combining the FIM and the FAI scores is potentially more appropriate and useful for clinical and research applications in stroke patients.

Psychodynamic-supportive group therapy model for elderly Holocaust survivors.

The physical and mental consequences of the Holocaust combined with difficult present events and the problems of old age can have devastating effects on survivors. Our clinic has recently introduced a psychodynamic-supportive group therapy model for elderly Holocaust survivors. The model includes specific integrative interventions, which are based on Horowitz's model of mourning and coping with stress and the leaders' clinical experience. The aim of the group is to improve the patients' homeostasis and enhance their ego functions and adaptation to inner and outer worlds. The theory and working model are described.