A specialized home care intervention improves survival among older post-surgical cancer patients.

CONTEXT: Changes in the healthcare system have resulted in shortened hospital stays, moving the focus of care from the hospital to the home. Patients are discharged post-operatively with ongoing needs, and whether they receive nursing care post-hospitalization can influence their recovery and survival. Little information is available about the factors that influence outcomes, including the survival of older cancer patients after cancer surgery. OBJECTIVE: To compare the length of survival of older post-surgical cancer patients who received a specialized home care intervention provided by advanced practice nurses (APNs) with that of patients who received usual follow-up care in an ambulatory setting. We also assessed potential predictors of survival in terms of depressive symptoms, symptom distress, functional status, comorbidities, length of hospital stay, age of patient, and stage of disease. DESIGN: A randomized controlled intervention study. SETTING: Discharged older cancer patients after surgery at a Comprehensive Cancer Center in southeastern Pennsylvania. PATIENTS: Three hundred seventy-five patients aged 60 to 92, newly diagnosed with solid cancers, were treated surgically between February 1993 and December 1995. One hundred ninety patients were randomized to the intervention groups and 185 to the usual care group. INTERVENTION: The intervention was a standardized protocol that consisted of standard assessment and management post-surgical guidelines, doses of instructional content, and schedules of contacts. The intervention lasted 4 weeks and consisted of three home visits and five telephone contacts provided by APNs. Both the patients and their family caregivers received comprehensive clinical assessments, monitoring, and teaching, including skills training. MAIN OUTCOME MEASURE: Time from enrollment of patients into the study until death or last date known alive at the end of November 1996. RESULTS: During the 44-month follow-up period, 93 (24.8%) of 375 patients died. Forty-one (22%) of those who died were patients in the specialized home care intervention group, compared with 52 (28%) in the usual care group. Stage of disease at diagnosis differed between the two groups at baseline (38% late stage patients in the intervention group compared with 26% in the control group, P = .01), so stratified analysis was performed. Overall, the specialized home care intervention group was found to have increased survival (P = .002 using stratified log-rank test). Among early stage patients only, there was no difference in survival between the intervention and control groups. Among late stage patients, there was improved survival in the intervention group. For example, 2-year survival among late stage intervention group cases was 67% compared with 40% among control cases. When Cox's proportional hazard model was used to adjust for significant baseline covariates, the relative hazard of death in the usual care group was 2.04 (CI: 1.33 to 3.12; P = .001) after adjusting for stage of disease and surgical hospitalization length of stay. CONCLUSIONS: This is the first empirical study of post-surgical cancer patients to link a specialized home care intervention by advanced practice nurses with improved survival. Additional research is needed to test home care interventions aimed at maintaining quality of life outcomes and their effects on survival of post-surgical cancer patients.

A comparison of social functioning among black and white women with breast cancer.

Results of a comparative study of interviews with 102 women (61 white, 41 black) who were treated for breast cancer suggest that black women have more difficulty in social functioning, especially the resumption of household activities. Implications for social work practice are discussed.

Testing a theory for health-related quality of life in cancer patients: a structural equation approach.

The purpose of this study was to test a Roy Adaptation Model-based theory of health-related quality of life in patients with newly diagnosed cancer. Using a structural equation model, health-related quality of life (HRQOL) was regarded as a latent variable measured by 4 empirical indicators representing the 4 biopsychosocial response modes of the Roy Adaptation Model (RAM). The response modes are physiologic, self-concept, interdependence, and role function. These were empirically represented by physical symptoms, affective status, social support, and functional support, respectively. In this secondary analysis, 3 RAM propositions were tested in a sample of 375 newly diagnosed postsurgical cancer patients 60 years and over. These were: (a) that the 4 response modes are interrelated; (b) that environmental stimuli of gender, race, age, income, marital status, cancer treatment, and severity of illness influence the biopsychosocial response modes; and (c) that the biopsychosocial responses soon after diagnosis predict biopsychosocial responses 3 months later. The analyses did not support the proposition that all 4 response modes were interrelated. The results, however, revealed that severity of illness and adjuvant cancer treatment had the strongest association with the biopsychosocial responses and should be considered the focal environmental stimuli. The remaining environmental stimuli can be considered contextual. Also, the proposition that initial biopsychosocial responses predicted later responses was supported.

A test of the fit between the Corbin and Strauss Trajectory Model and care provided to older patients after cancer surgery.

The Corbin and Strauss Trajectory Model proposed that nursing care should differ along a trajectory of eight phases to meet patients' and families' needs. Seventy-nine patients with breast, prostate, or gastrointestinal cancer were determined to be in either the stable or the unstable phase of their illness. Contrary to expectations, documented nursing interventions did not significantly differ between stable and unstable trajectory phases, although significant differences were found when comparisons were made across cancer sites. These findings suggest that the trajectory framework may require modification for use with oncology patients.

Caregiving to very low birthweight infants: a model of stress and immune response.

Mothers of preterm, very low birthweight (< or = 1500 g; VLBW) infants experience the stress of caring for small, fragile infants at the same time that they are recovering from the relative immunosuppression of pregnancy and when many health behaviour changes (e.g., nutrition) occur which also may influence immune status. The purpose of this study was to examine changes in anxiety and depression and in health behaviors, as well as lymphocyte proliferation and natural killer cell activity in mothers of preterm, VLBW infants compared to mothers of healthy term infants. Mothers of preterm VLBW infants have decreased in vitro lymphocyte response to mitogens compared to mothers of healthy term infants over time, and this difference could not be explained by anxiety, depression, or health behaviors. However, among mothers of VLBW infants, anxiety was related to decreased lymphocyte proliferation response at 1 month postpartum. There was no relationship between maternal depression and lymphocyte proliferative response in mothers of term infants. Natural killer cell activity did not differ between the two groups of mothers, nor was there a relationship between natural killer cell activity and maternal anxiety, depression, or health behaviors. Thus, lymphocyte proliferative response to mitogens may be an important biologic market of increased stress in mothers of VLBW infants in the first couple of months postpartum.

A SAS macro for stepwise correlated binary regression.

Several regression methods have been proposed for the analysis of correlated binary data, but none deals with the selection of covariates when there exist a large number of potentially relevant covariates. We present a SAS macro based on a stepwise selection procedure for the analysis of correlated binary data. Using regression methods based on generalized estimating equations originally proposed by Liang and Zeger and extended by Prentice, we describe a score test for forward selection, a Wald's test for backward elimination, and a test for model adequacy based on generalized scores. The methodology and the accompanying computer macro program written in SAS IML are illustrated with data from a prospective study of functional decline in the activities of daily living in a group of elderly patients.

Evaluation of HER-2/neu (c-erbB-2) oncogene expression in whole organ sections of supraglottic squamous cell carcinoma.

Adequate pathologic material and careful clinical follow-up are prerequisites for the analysis of the expression of particular oncogenic proteins that are prognostically important in squamous cell carcinoma of the larynx. The Gabriel Tucker, Jr, Collection of 150 whole organ specimens allows for the potential immunohistochemical study of the entire tumor. Sections from 32 supraglottic carcinomas were studied immunohistochemically for the presence of HER-2/neu (c-erbB-2) oncogene expression. Long-term follow-up data were available in all cases to assist in determining the prognostic significance of the specified oncogene in supraglottic squamous cell carcinoma. Our study revealed that joint presentation of immune staining for c-erbB-2 and positive lymph node status was significantly associated with distant metastasis (p=.00760).

A prospective longitudinal investigation of spousal bereavement examining Parkes and Weiss' Bereavement Risk Index.

The purpose of this study was (a) to describe spousal bereavement both prospectively and longitudinally and (b) to examine the validity of the Bereavement Risk Index (BRI) published by Parkes and Weiss (1). Psychological distress was measured in 46 subjects across five time intervals beginning prior to a spousal death from lung cancer and ending 25 months after the death using the Brief Symptom Inventory (BSI) (2). The hypothesis that the BRI discriminates between bereaved spouses at high and low risk for psychological distress was supported by measurements taken within two months of the patient's diagnosis (prior to death), at 6 weeks following the death, and at 6 and 13 months thereafter. These findings support the need for early identification of individuals at high risk for negative bereavement outcomes even prior to the spousal death.

Leucine kinetics during a brief fast in diabetes in pregnancy.

The effect of diabetes in pregnancy on leucine turnover and oxidation was examined in 12 insulin-dependent diabetic (IDDM) subjects and 12 gestationally diabetic (GDM) subjects during the third trimester of pregnancy. The data were compared with those in normal pregnant women studied during the same time period and reported previously. Eight of the IDDM subjects were on continuous subcutaneous insulin infusion (insulin pump), and four were on conventional twice-daily insulin treatment. Of the GDM group, seven were on insulin therapy and five were on dietary management. Leucine kinetics were quantified using [1-13C]leucine tracer in combination with respiratory calorimetry and measurement of lean body mass using the H2[18O] dilution method. In addition, glucose kinetics were measured in insulin-treated subjects using [6,6(2)H2]glucose tracer. Despite rigorous metabolic control, fasting plasma glucose (IDDM 5.5 +/- 1.9 mmol/L [P < .05], GDM 4.7 +/- 1.3 [P < .01], controls 3.6 +/- .6, mean +/- SD) and hemoglobin A1 ([HbA1] IDDM 7.9 +/- 1.9%, GDM 7.5% +/- 2.1%) levels were higher in diabetic subjects. Although total insulin levels were higher in insulin-treated diabetic subjects, free-insulin concentrations were similar in all groups. Rates of excretion of urinary urea nitrogen and respiratory quotients were also similar. The rate of glucose turnover was lower in insulin-treated subjects compared with normals. Leucine flux, a measure of the rate of protein breakdown, and leucine oxidation were higher in IDDM and insulin-treated GDM subjects. The rate of leucine oxidation was increased in conventionally managed IDDM and insulin-treated GDM subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Maternal-fetal substrate relationships in the third trimester in human pregnancy.

The maternal-fetal relationship of metabolic substrates was examined in 12 mothers undergoing cordocentesis for clinical reasons between 23 and 36 weeks' gestation. Twenty cordocentesis procedures were performed. Blood glucose, insulin, beta-hydroxybutyrate, glycerol and lactate were measured in simultaneously obtained maternal and fetal samples. There was a linear correlation between fetal and maternal concentration of glucose (y = 0.687x + 0.756, R2 = 0.65 and p = 0.001), and beta-hydroxybutyrate (y = 0.443x + 0.16, R2 = 0.938 and p = 0.0001). No relation between fetal insulin and glucose concentration was observed. No correlation was seen between maternal and fetal lactate concentration. The data on glycerol could be divided into two groups. When the fetal glycerol levels were below 100 mumol/l, the fetal glycerol concentration was always less than the simultaneously obtained maternal level. However, when the fetal glycerol levels were greater than 100 mumol/l, the corresponding maternal levels were lower than that in the fetus. The exact mechanism or significance of higher fetal glycerol levels remains unknown. These data demonstrate the usefulness of cordocentesis in the understanding of fetal metabolism. In correlation with isotopic tracer, cordocentesis could provide detailed insight into human fetus in the future.

Catecholamine response at birth in preterm newborns.

We compared the extrauterine adaptation of preterm with term newborn infants, by sequentially measuring plasma catecholamine (CAT) levels at birth and during the first 24 h of life. Twenty-seven preterm appropriate-for-gestational-age (AGA) infants, less than 35 weeks gestation, were compared with 26 healthy near-term AGA infants. Modes of delivery and umbilical arterial pH (mean 7.28) did not differ. Infants with asphyxia, presumed sepsis or hypoglycemia were excluded. CAT (norepinephrine, epinephrine, dopamine) levels were measured by radioenzymatic assay in blood samples from maternal vein, cord vein, cord artery and blood samples obtained at 1, 2 and 24 h of postnatal age. At birth, the cord arterial CAT levels were significantly higher than maternal venous CAT levels in both groups of neonates. Plasma epinephrine levels (mean +/- SD) at 1 and 2 h of postnatal age were significantly higher in preterm than in near-term newborns (0.98 +/- 0.82 nmol/l vs. 0.30 +/- 0.21 nmol/l at 1 h; 0.98 +/- 0.68 nmol/l vs. 0.28 +/- 0.29 nmol/l at 2 h; p < 0.05). The norepinephrine and dopamine measurements did not differ between the two groups studied at birth, 1, 2 and 24 h of postnatal age. These data indicate that the preterm infants (25-35 weeks gestation) are capable of mounting a catecholamine response at birth similar to near-term newborns. The persistent elevation of epinephrine in preterm infants at 1 and 2 h of life may be attributed to either slower clearance of epinephrine or continued stimulation during clinical care in the NICU.

Retrospective study of fetal effects of prolonged labor before cesarean delivery.

Rising cesarean rates call for review of the indications for this procedure. Suspicion that subtle operatives, not reflected in morbidity and mortality rates, might be present inspired the study presented here. Three hundred fifty-two cesarean operations were done at Huron Road Hospital in the years 1952-1954. Examination of family records identified 97 probands delivered by cesarean after prolonged active labor before or during that period. Research efforts yielded 54 cases that were free of complications and had full historic data for both proband and sibling(s) of the same parentage, totaling 122 children. The intelligence quotient (IQ) scores of these families compared with that of the proband undergoing successive hours of labor suggested a detrimental effect of increasing length of trial labor. Statistical analyses of the 30 families in which the probands' trial labors exceeded 12 hours support that notion, as the probands had significantly lower IQ scores than their siblings born by elective cesarean with no labor (P = .006 to P less than .001). Probands had the lowest IQ scores in their families significantly more often (P less than .025) than could be expected to occur randomly. A similar pattern of school success occurred within the families.

Clinical management of keratoconus. A multicenter analysis.

The clinical management of 746 eyes in 417 patients referred for keratoconus from January 1984 through January 1988 was retrospectively analyzed. In 357 patients, 554 eyes (74%) did not require surgery and were managed with contact lenses or spectacles, 156 eyes (21%) in 137 patients either underwent penetrating keratoplasty (PK) (140 eyes) or surgery was recommended (16 eyes), and 36 eyes (4%) in 34 patients underwent epikeratoplasty. Comparing baseline and final examination findings, the nonsurgical group showed a significant improvement in average best-corrected visual acuity from 20/30 to 20/25, the PK group from 20/70 to 20/25, and the epikeratoplasty group from 20/40 to 20/30. Average keratometry was unchanged in the nonsurgical group, but decreased by 10.7 diopters (D) for the PK group and 6.5 D for the epikeratoplasty group. Corneal cylinder was unchanged in the nonsurgical group, whereas there was a reduction of the percentage of eyes with indeterminant cylinder from 55 to 2% in the PK group and from 36 to 0% in the epikeratoplasty group. Previous contact lens history, best-corrected visual acuity of 20/50 or worse, and average keratometry of 55 D or greater at baseline were associated with a significant risk for PK. No baseline variables were associated with significant risk for epikeratoplasty, suggesting that this group was similar to the nonsurgical group, except for contact lens intolerance. The nonsurgical management of keratoconus continues to play a predominant role in the management of this disorder in a referral population.