Evaluation of a cancer exercise program: patient and physician beliefs.

OBJECTIVE: Participation in an exercise intervention during cancer treatment diminishes the side effects associated with cancer therapies, although such benefits vary according to the disease and the patient characteristics. A structured exercise program providing an individualized fitness program tailored to the patients' illness, treatment, and fitness level would address this variability. However, the need, desired components, and anticipated barriers of such a program have not been systematically explored from either the point of view of cancer patients or treating oncologists. METHODS: Sixty-six cancer patients and 18 medical and radiation oncologists were surveyed on the above variables. RESULTS: Cancer patients and oncologists alike perceived a need for a structured exercise program during and after medical treatment for cancer. Among cancer patients, the most commonly preferred feature was access to consultation with an exercise specialist who could take into account the patient's previous exercise and medical history. Over a third of patients reported interest in a hospital-based fitness program. Oncologists were in favor of appropriate supervision of patients during exercise, and noted insufficient time to discuss exercise in their practice. Respondents noted time and parking as barriers to participation. CONCLUSION: Overall, results support the need for a supervised exercise program during active treatment for cancer and highlight the desired features of such a program.

'Hypersynchronisation' by tissue velocity imaging in patients with cardiac amyloidosis.

OBJECTIVE: It is unknown if some patients with cardiac amyloidosis (CA) have mechanical dyssynchrony, as has been demonstrated in patients with ischaemic and dilated cardiomyopathies. The aim of this study was to assess mechanical dyssynchrony in patients with CA using tissue velocity imaging (TVI) and to define its usefulness for risk stratification. DESIGN AND PATIENTS: We included 121 patients with primary amyloidosis and 37 age-matched and sex-matched controls. Patients were divided into two groups: 60 with advanced-CA and 61 with no-advanced-CA, according to left ventricular (LV) wall thickness and diastolic dysfunction. Dyssynchrony assessment included: (1) atrioventricular dyssynchrony (dys), (2) interventricular dys, (3) intraventricular dys assessed longitudinally, using the standard deviation of time to systolic peak velocity (Ts-SD) of the 12 basal and mid level LV segments, and (4) intraventricular dys assessed radially, using the difference in radial Ts between mid anteroseptal and mid posterior segments. OUTCOME: Primary end-point was all-cause death. During a median follow-up of 13 months there were 35 events among patients. RESULTS: Contrary to the hypothesis, the intraventricular dys indices in advanced-CA patients were reduced compared to either the no-advanced-CA group or to controls (Ts-SD: 12.1 (9.0); 35.1 (18.6); 24.5 (14.1), respectively, p<0.001). This reduction was primarily the result of decreased ejection time (ET). Moreover, ET was the most significant predictor of survival (HR = 0.98, p<0.001). CONCLUSIONS: The regional timing of systolic motion measured by TVI was abnormally synchronised in the patients with advanced-CA. ET reduction plays a prominent part in this process and should be considered an essential parameter for assessment of patients with cardiac amyloidosis.

Pilot study of the impact of letrozole vs. placebo on breast density in women completing 5 years of tamoxifen.

Breast density, a strong risk factor for breast cancer, is reduced by the anti-estrogen, tamoxifen (TAM). We examined whether aromatase inhibitor (AI) therapy results in further reductions in breast density among women completing 5 years of TAM. Among a sample of women with early-onset breast cancer who were randomized to letrozole (LET)(n=56) or placebo (PLAC)(n=48) after 5 years of TAM, we examine the change in percent density at 9-15 months as well as a per-year change in PD by treatment group. There was no difference in the adjusted mean change (-1.0%, LET; -0.3%, PLAC (P=0.58)) or the percentage change (-2.7%, LET; -3.0%, PLAC (P=0.96)) in PD between treatment groups at 9-15 months. Results were similar for longitudinal change (-0.68% per year, LET; -0.12% per year, PLAC (P=0.23)). Breast density does not appear to be a clinically relevant biomarker in women who already have low PD following 5 years of TAM.

Hemorrhagic and vascular complications after percutaneous coronary intervention with adjunctive abciximab.

OBJECTIVES: To examine the frequency and nature of hemorrhagic and peripheral vascular complications associated with use of abciximab during percutaneous coronary intervention and to characterize high-risk patients. PATIENTS AND METHODS: We report the frequency and severity of bleeding and vascular complications recorded prospectively in 2,559 consecutive nonselected patients who underwent percutaneous coronary intervention at Mayo Clinic, Rochester, Minn, between July 1, 1996, and April 30, 1998, 831 of whom received abciximab and 1,728 did not. Abciximab and heparin were administered according to guidelines of the Evaluation of PTCA [percutaneous transluminal coronary angioplasty] to Improve Long-Term Outcome With Abciximab GP IIb/IIIa Blockade (EPILOG). RESULTS: Patients who received abciximab were more likely to be men, were more often treated within 12 hours of an acute myocardial infarction, and were more likely to have received heparin after the procedure (8.7 % vs 4.5%, P<.001). Major bleeding occurred in 18 patients (2.4%) who received abciximab and in 10 patients (0.6%) who did not receive abciximab (P<.001). Minor bleeding occurred in 108 patients (14.3%) and in 92 patients (5.9%), respectively (P<.001). Both major bleeding and minor bleeding were more frequent among patients within 12 hours of an acute myocardial infarction and were more frequent if abciximab had been used. Multivariate analysis revealed that use of abciximab was independently associated with major and minor bleeding. CONCLUSION: In this clinical setting, use of adjunctive abciximab during percutaneous coronary intervention was associated with a significantly increased risk of both major and minor bleeding.

Is rheumatoid arthritis care more costly when provided by rheumatologists compared with generalists?

OBJECTIVE: Controversy surrounds the cost-effectiveness of rheumatologist care compared with generalist care for patients with rheumatoid arthritis (RA). Rheumatologists can provide 2 distinct types of care for RA patients: primary care and specialist care. We sought to examine the relationship between cost and type of care in a population-based cohort of patients with RA. METHODS: Data regarding specialty of care and use of health services (i.e., total direct medical costs, surgeries, radiographs, laboratory tests, hospital days) were collected from a community sample of 249 patients with RA (defined using the 1987 American College of Rheumatology diagnostic criteria) among Rochester, Minnesota residents > or =35 years of age. In a randomly selected subset of 99 of these RA patients, detailed information on all physician encounters was collected and categorized according to whether or not the care received constituted "primary care" according to the Institute of Medicine definition. Using these data, we evaluated the influence of type of care as well as specialty of provider on utilization. For these analyses, total direct costs included all inpatient and outpatient health care costs incurred by all local providers (excluding outpatient prescription drugs). RESULTS: The 249 patients with RA (mean age 64 years, 75% women) were followed up for a median of 5.4 years, while the subset of 99 RA patients (mean age 64 years, 77% women) were followed up for a median of 4.7 years. The overall median direct medical costs per person per year were $2,749 and $2,929 for the total cohort and for the subset of 99 patients, respectively. Generalized linear regression analyses (considering all visits of the 249 RA patients) revealed that after adjusting for demographics and disease characteristics, rheumatologist care (compared with nonrheumatologist care) was not associated with higher total direct medical costs (P = 0.85) or more hospital days (P = 0.35), but was associated with slightly more radiographs (P = 0.037) and significantly more laboratory tests (P < 0.0001). When considering only primary care, such care by rheumatologists was, again, not associated with higher total direct medical costs (P = 0.11) or more hospital days (P = 0.69) or more laboratory tests (P = 0.54), but was associated with slightly more radiographs (P = 0.035). CONCLUSION: Rheumatologist care is not more costly than generalist care for patients with RA. Important differences (especially in the use of laboratory tests) become apparent when the type of care provided as well as the specialty of the provider are considered in the analyses.

Glycemic control and outcome of diabetic patients after successful percutaneous coronary revascularization.

OBJECTIVE: Our purpose was to examine whether the outcome of diabetic patients after successful percutaneous coronary revascularization (PCR) is influenced by the degree of control of hyperglycemia at the time of revascularization. BACKGROUND: Diabetic patients have a worse outcome after PCR. METHODS: We examined whether the degree of glycemic control (HbA(1c) levels) affected the occurrence of all-cause death and death/myocardial infarction among diabetic patients after successful PCR from October 1979 through December 1998. HbA(1c) was analyzed both as a continuous and a categorical variable (good [HbA(1c) <8.0%, n = 700], moderate [8.0% < or = HbA(1c) < or =10%, n = 442], or poor [HbA(1c) >10%, n = 231] control). RESULTS: HbA(1c) levels were determined at a median (25th, 75th interquartiles) of 3 (1, 10) days after the index procedure for patients with good control, 2 (1, 7) days for moderate control, and 2 (1, 6) days for poor control. Median follow-up after successful PCR was 3.2 (1.2, 6.1) years, 3.9 (1.7,6.3) years, and 4.7 (2.1, 7.1) years, respectively. HbA(1c) as a continuous variable did not have an impact on either death (hazard ratio [95% confidence interval] 1.04 [0.98-1.10]) or death/myocardial infarction (1.02 [0.98-1.07]). As a categorical variable, patients with moderate and poor control had a similar hazard of death (0.99 [0.78-1.26] and 1. 14 [0.86-1.52], respectively) and death/myocardial infarction (1.01 [0.82-1.24] and 1.12 [0.87-1.45], respectively) relative to those with good control. CONCLUSIONS: The degree of glycemic control among diabetic patients at the time of their index intervention did not have an impact on long-term outcomes after successful PCR.

Improving hypertension control: a team approach in a primary care setting.

BACKGROUND: Blood pressure (BP) control rates in the United States have not improved significantly during the past decade. There has been limited study of improvement efforts focusing on guideline implementation and changes in the model of care to address hypertension. METHODS: Five physician (MD)/registered nurse (RN)/licensed practical nurse (LPN) teams in a large community practice modified their care model in 1997 to manage hypertensive patients as part of guideline implementation efforts. The other 25 MD teams in the same setting practiced in the usual model, but were exposed to the guideline recommendations. BP control rates of patients in each group were assessed monthly. After nine months of testing the new care model, 10 additional teams adopted the model. RESULTS: In the pilot group, hypertension control rates showed statistically significant improvement from pre- (33.1%) to postimplementation (49.7%). After adjusting for age, this was significantly greater than the improvement in the control group (p = 0.033). Medication changes were more frequent in the pilot group (32.3%) than in the control group (27.6%); however, the differences were not statistically significant. A longitudinal examination of the hypertension patients in the study showed that improved BP control was sustained for at least 12 months. DISCUSSION: A change in the model of care for hypertensive patients within a primary care practice resulted in significant, sustainable improvement in BP control rates. These changes are consistent with the chronic care model developed by Wagner; practice redesign appeared to be the most important change.

Ethical issues in addiction counseling.

Although all counselors face ethical challenges, addictions counselors encounter ethical issues that are, in many respects, unique to their discipline. This article provides an overview of these issues, which include but are not limited to (a) the lack of communication and continuity between research and clinical practice, (b) lack of agreement over the necessary professional credentials, (c) the questionable propensity of group work in the addictions field, (d) special issues of confidentiality and privileged communication, (e) boundaries of professional practice in making treatment decisions, and (f) unusual circumstances of informed consent. In addressing these issues, addictions counselors must not only uphold the ethical standards of their profession, they must also be cognizant of any federal statutes that may supersede their state regulations and act in accordance with them.

The influence of abciximab use on clinical outcome after aortocoronary vein graft interventions.

OBJECTIVES: The purpose of this study was to evaluate the effect of abciximab use on clinical outcome in aortocoronary vein graft interventions. BACKGROUND: Although large randomized trials have demonstrated a significant benefit of abciximab use in the setting of percutaneous coronary interventions, there is relatively little data with respect to the use of this agent in percutaneous vein graft interventions. METHODS: Three hundred and forty-three patients were identified; 210 undergoing vein graft intervention without abciximab and 133 patients with abciximab. RESULTS: There were differences in baseline clinical and angiographic characteristics between the two groups; advanced age, unstable angina, older vein grafts and thrombus containing lesions were relatively common in both groups. Angiographic and procedural success rates were similar with or without the use of abciximab (89% vs. 92%, p = 0.15, and 85% vs. 91%, p = 0.12, respectively). The in-hospital composite end point of death/Q-wave myocardial infarction (QWMI)/repeat revascularization was similar between the two groups. Utilizing statistical modeling to adjust for baseline differences between the groups, abciximab use did not influence the cumulative long-term composite end point of death/MI/repeat revascularization. CONCLUSIONS: This study demonstrates that in this relatively high-risk population undergoing aortocoronary vein graft interventions, the administration of abciximab periprocedurally does not appear to reduce major adverse clinical events.

Baseline clinical and angiographic variables associated with long-term outcome after successful intracoronary stent implantation.

Although randomized studies have demonstrated improved outcomes with stents over balloon angioplasty in straightforward coronary narrowings in low-risk patients, this advantage is less clear for complex lesions and high-risk patients. This study was designed to identify clinical and angiographic variables that are associated with long-term outcome after stent implantation. We identified 1,709 patients undergoing successful stent placement without in-hospital major adverse events. We analyzed clinical, lesional, and procedural variables to determine their correlation with outcome. Mean duration of follow-up was 1.6 +/- 1.4 years. Cox proportional-hazards models and stepwise methods were used to assess which covariates were potentially related to each end point. The occurrence of death/myocardial infarction (MI) was associated with any history of congestive heart failure (relative risk [RR] 3.3, 95% confidence interval [CI] 2.3 to 4.7, p <0.0001), procedure within 24 hours of MI (RR 2.3, CI 1.3 to 4.1, p = 0.0048), vein graft intervention (RR 1.8, CI 1.3 to 2.6, p = 0.0007), and prior MI (RR 1.8, CI 1.2 to 2.6, p = 0.004). Repeat revascularization was associated with multivessel stent placement (RR 1.8, CI 1.2 to 2.8, p = 0.006) and stent for abrupt closure (RR 1.7, CF 1.1 to 2.7, p = 0.03), but was less frequent with de novo lesions and right coronary artery lesions (RR 0.6, CI 0.5 to 0.8, p = 0.0007, and RR 0.8, CI 0.6 to 1.0, p = 0.05, respectively). The cumulative end point of death/MI/repeat revascularization was associated with congestive heart failure (RR 1.7, CI 1.3 to 2.2, p <0.0001), multivessel stent placement (RR 1.6, Cl 1.1 to 2.3, p = 0.03), warfarin therapy (RR 1.4, CI 1.2 to 1.8, p = 0.001), and procedure within 24 hours of MI (RR 1.5, CI 1.1 to 2.1, p = 0.02), but was less frequent with complete revascularization and right coronary artery intervention (RR 0.8, CI 0.7 to 0.99, p = 0.04, and RR 0.7, CI 0.6 to 0.9, p = 0.009, respectively). Thus, this study demonstrates that there are readily identifiable characteristics in patients treated successfully with stents that are associated with long-term outcome.

Childhood abuse recollections in a nonclinical population: forgetting and secrecy.

OBJECTIVE: This study investigated the relationship of interrupted memories of childhood abuse with the secrecy of the abuse. METHODOLOGY: Fifteen hundred people were randomly selected from the membership of the American Counseling Association and sent a questionnaire regarding childhood abuse history. Four hundred and twenty-three usable questionnaires were returned and analyzed. RESULTS: Thirty-two percent of the sample reported childhood abuse. Fifty-two percent of those reporting abuse also noted periods of forgetting some or all of the abuse. On the two survey items assessing secrecy, 76% of respondents reporting childhood abuse indicated there had been a time when no one but themselves and their abuser knew about the abuse; 47% indicated that an abuser tried to get them to keep the abuse secret. Forty percent endorsed both secrecy items. Respondents who reported forgetting abuse also reported one or both elements of secrecy more frequently than those who reported continuous memories of abuse. CONCLUSION: These findings are consistent with those of other studies that suggest that, among adults reporting childhood abuse, the experience of forgetting some or all abuse is common. Secrecy of the abuse appears to be associated with the experience of forgetting childhood abuse for many individuals.

Identifying the race or ethnicity of SSI recipients.

The Social Security Administration (SSA) has, from its beginnings, recorded the race and ethnicity provided by those who apply for a Social Security card. Although some of these data are eventually used in published tabulations when persons file for benefits, problems with the data prevent a larger selection of published tables. These problems stem from: incomplete internal SSA computer processing; changes in the racial coding schemes over time; and missing codes for younger cohorts of applicants. In spite of these problems, more data can be shared with the public. This article shows how matching administrative files and using statistical techniques make it possible to associate a race/ethnicity code with the great majority of persons receiving a payment under the Supplemental Security Income (SSI) program, a means-tested program for persons who are aged or disabled. The article follows a 1-percent sample of SSI recipients through several steps in an attempt to develop a race code. This approach can provide data for the next several years on the race of all SSI recipients, as well as data on race and ethnicity for recipients under age 40. Beyond the next few years, these techniques will become less useful, and other methods will be needed. SSA is in the process of revising its standards for classification of federal data on race and ethnicity. The census for year 2000 will include coding changes. Other federal agencies will be given as long as January 2003 to comply with the new guidelines.

Noncitizens and the Supplemental Security Income program.

The Supplemental Security Income (SSI) program, established by the Social Security Amendments of 1972 (Public Law 92-603), was designed to provide cash assistance to needy aged, blind, and disabled citizens, and noncitizens lawfully admitted for permanent residence or permanently residing under color of law. Since then, this means-tested program has undergone many legislative changes that affect the eligibility status of noncitizens. This article, presented in three parts, discusses the legislative history of noncitizen eligibility, and details relevant laws enacted since the program's inception; provides current data on the trends and changes of the noncitizen population; and describes the larger population of foreign-born SSI recipients, of which the noncitizens are a part. Data on the number of SSI recipients born abroad but who had become citizens before applying for SSI payments were not previously available. Analytical data are from the Supplemental Security Record (SSR) matched to the Social Security Number Identification (Numident) file.

Living arrangements of SSI recipients.

This article updates one that appeared in the Bulletin in July 1990. It describes living arrangements of persons receiving payments under the Supplemental Security Income (SSI) program from October 1994 through September 1995. The data were taken from the Quality Assurance review conducted by the Social Security Administration (SSA). This procedure is used by SSA to determine the frequency and causes of incorrect determinations of eligibility and payment amounts. It is difficult to describe the living arrangement for the "typical" recipient. Nevertheless, some interesting patterns emerge in an analysis of the data. About 59 percent (owners and renters combined) of the 6.3 million SSI recipients lived in their own households. Approximately 32 percent of them shared a living arrangement with someone else and about 5 percent of the recipients lived in an institution. Of those SSI recipients living in households, about 36 percent lived alone. Less than 13 percent lived with only their spouses or with only their spouses and minor children. Approximately 11 percent of those in households were child recipients living with parents. An additional 15 percent of the SSI recipients lived in households with only other related adults (other than a spouse or parents).

Trends in the characteristics of DI and SSI disability awardees and duration of program participation.

We analyze the effects of trends in the age and diagnostic mix of new disability awardee cohorts from 1975 through 1993 on expected duration on the Disability Insurance (DI) and Supplemental Security Income (SSI) rolls. The 1975-93 shift toward younger awardees is estimated to increase duration by 1.4 years for DI and about 5 years for SSI. Much of the increase in SSI duration is attributable to the recent influx of childhood awardees. For working age adults, the DI and SSI trends are comparable. We also estimate that about half of the 1975-93 increase in DI duration is explained by the increase in the proportion of younger DI-insured workers. During the 1993-2006 period, the effect of changes in the age mix of DI-insured workers will be reversed. This will moderate, but not eliminate, likely upward pressures on caseloads arising from the anticipated rise in incidence rates and the future effects of past increases in expected duration.

Labor-force participation and earnings of SSI disability recipients: a pooled cross-sectional times series approach to the behavior of individuals.

This article examines two important aspects of work behavior, labor-force participation, and earnings among persons who since 1976 have become entitled to SSI disability benefits and received payments for a full calendar year or longer during the intervening time period. A data set was developed containing the records of a random sample of all individuals who had ever received Supplemental Security Income (SSI) disability benefits and matched to earnings records maintained by the Social Security Administration (SSA). A multivariate analysis based on a pooled cross-sectional time series approach was employed using individual-level data to first estimate the probability of an SSI recipient performing work and then to estimate, among those who worked, the level of earnings. For this analysis, the SSI population was divided into three distinct groups based on their diagnosis: the nondevelopmentally disabled, the developmentally disabled (other than the mentally retarded), and the mentally retarded. The analysis provides information about the impact that individual characteristics (such as age, education, diagnosis, and so forth) play in the decision to work and in determining the level of earnings. The analysis also addresses yearly variations in labor-force participation and earnings.

Reinventing SSI statistics: SSA's new longitudinal file.

Supplemental Security Income (SSI) statistics have been published in the Social Security Bulletin since the program began in 1974. For the most part, these statistics have been snapshots of current caseloads. Now, a new SSI longitudinal file permits a retrospective look at past program data. It also permits us to redefine key program indicators and to produce new distributions for these data. In this article, we take a look back in time at SSI applications, caseloads, and awards, and describe how these data were obtained from the SSI administrative computer files.

Length of stay on the Supplemental Security Income Disability Program.

This article analyzes duration on the Supplemental Security Income (SSI) disability rolls prior to age 65 among children and working-age adults, based on a 10-year followup of 1974-82 cohorts of new awardees by utilizing monthly data from administrative records for 1974-92, and on statistical projections beyond the followup period. Although SSI means testing is responsible for a high proportion of early suspensions, when multiple spells are accounted for, long stays dominate. The estimated mean length of all first SSI spells is 5.5 years. It is 11.3 years for disabled children, 1.3 years for disabled adults eligible for both the Social Security Administration's Disability Insurance (DI) and SSI, and 6.4 years for adults eligible for SSI only. When multiple spells are accounted for, the projected mean total preretirement-age SSI disability stay almost doubles to 10.5 years for all awardees and increases to 26.7 years for children.

Disability patterns among SSI recipients.

In December 1993, about 3.8 million persons under age 65 received Supplemental Security Income (SSI) payments because of a disability. More than half of these recipients had some form of mental disorder. In recent years, the number of disabled SSI recipients has climbed sharply. At the same time, there has been a change in the disability patterns among these recipients. The proportion of recipients with mental disorders, particularly those with psychiatric illness, is increasing steadily. Many of these recipients enter the SSI program in their youth and may stay in the program for many years. Similar increases and disability patterns in the Social Security Administration's Disability Insurance (DI) program imply program related causes, including recent changes to the disability requirements and outreach efforts. These changing disability patterns have implications for the size and shape of future SSI caseloads.