Quality of life of men treated for localized prostate cancer: outcomes at 6 and 12 months.

GOALS OF WORK: Treatments for early-stage prostate cancer (PCa) are highly effective; therefore, research studies that explore quality of life (QOL) issues associated with different treatments are important. The purposes of this study were to (a) examine differences among treatment groups of men treated with either radiation therapies or radical prostatectomy for PCa and (b) examine quality of life outcomes over time. PATIENTS AND METHODS: We report outcomes 6 and 12 months after 159 men began treatment for PCa with either one of two types of radiation treatment (intensity-modulated radiation therapy plus high dose rate or intensity-modulated radiation therapy plus seed implantation) or radical prostatectomy. MAIN RESULTS: Significant differences among groups are described. Significant predictors of QOL at 6 months included urinary, bowel, and sexual symptoms, anxiety, depression, problem-focused coping, and physiological self-efficacy. Significant predictors of QOL at 12 months were urinary and bowel symptoms, stress, depression, problem-focused coping, and physiological self-efficacy. Demographic variables, race, and living status were significant predictors of quality of life at 12 months. CONCLUSIONS: Physiological symptoms and psychological symptoms were both significant predictors of QOL. The psychological factors that predicted quality of life in this study have potential for intervention and point to the next stage of the research.

Measurement of Patients' Perceptions of the Quality of Acute Stroke Services: Development and Validation of the STROKE Perception Report.

INTRODUCTION: Patients' perceptions of healthcare quality have become an important part of quality measurement. We explored patients' and family's lived experiences during acute stroke hospitalization to develop a quantitative instrument. METHODS: Focus groups were conducted using open-ended scripted questions. Interview data were coded and analyzed using an inductive approach to thematic analysis. Symmetric patient and family instruments were developed based on qualitative domains and serially refined to a set of 30 survey items, 12 stroke knowledge test items, and 5 subject demographic fields. Scales were evaluated for internal consistency reliability using Cronbach α; construct validity with exploratory factor analysis using principal components with varimax rotation was performed to determine the extent to which items in a scale measure the same underlying factor. Feasibility of an electronic cloud-based survey was also tested. RESULTS: Three main themes emerged: fast action to diagnose and treat stroke, genuine caring, and education to prevent and respond to stroke. A total of 1029 subjects completed the final instrument with no differences in perception found by race, ethnicity, or length of stay. Scales showed satisfactory internal consistency reliability (Cronbach α scores, .89-.94); factor loadings across each scale ranged from 0.55 to 0.87. Data entry by electronic pad was perceived by 77% to be more confidential than paper surveys; median score for difficulty was 4 ("easy to use"). CONCLUSION: The STROKE Perception Report enables understanding of patients' and family's beliefs about the quality of acute stroke care in essential new domains never explored before.

The Wisconsin Card Sort Test and P300 responses to novel auditory stimuli in schizophrenic patients.

The authors studied the relationship between performance on the Wisconsin Card Sort Test (WCST) and P300 activity in schizophrenics and normal controls. Fourteen male predominantly medicated schizophrenics and matched non-ill controls were administered the WCST and tests of temporal lobe (delayed verbal and spatial memory) and general intellectual functioning (Shipley). Patients were rated with negative and positive symptom scales extracted from the Brief Psychiatric Rating Scale. Subjects performed a tone discrimination task requiring identification of rare targets in both a standard oddball paradigm and a three-stimulus paradigm that included rare novel sounds. Reference independent data from 16 scalp electrodes yielded Global Field Power (GFP), from which P300 latency was determined. P300 amplitude measures included amplitude at this identified latency as well as amplitude integrated over a 100 ms time window centered over it. These amplitude measures were examined at six selected electrode locations. Schizophrenics produced smaller P300 responses that tended to be slower, but there were no group differences in the relationships between neuropsychological performance and P300 responses. Across diagnostic groups percent perseverative errors predicted lower integrated and peak P300 amplitude during the novel but not the standard oddball paradigm. The effect on integrated P300 amplitude was localized to anterior leads after novel stimuli. Negative symptoms predicted lower WCST performance, lower integrated P300 amplitude, and smaller GFP after novel stimuli. Positive symptoms predicted reduced overall GFP and specific but inconsistent reductions in parietal P300 amplitude. The results suggest relationships between dorsolateral prefrontal competence, P300 activity in response to stimulus novelty, and negative symptoms in schizophrenic patients, paralleling findings obtained from blood flow and other measures of brain activity.

Predicting mortality in patients treated differently: updating and external validation of a prediction model for nursing home residents with dementia and lower respiratory infections.

OBJECTIVE: To evaluate whether a model that was previously developed to predict 14-day mortality for nursing home residents with dementia and lower respiratory tract infection who received antibiotics could be applied to residents who were not treated with antibiotics. Specifically, in this same data set, to update the model using recalibration methods; and subsequently examine the historical, geographical, methodological and spectrum transportability through external validation of the updated model. DESIGN: 1 cohort study was used to develop the prediction model, and 4 cohort studies from 2 countries were used for the external validation of the model. SETTING: Nursing homes in the Netherlands and the USA. PARTICIPANTS: 157 untreated residents were included in the development of the model; 239 untreated residents were included in the external validation cohorts. OUTCOME: Model performance was evaluated by assessing discrimination: area under the receiver operating characteristic curves; and calibration: Hosmer and Lemeshow goodness-of-fit statistics and calibration graphs. Further, reclassification tables allowed for a comparison of patient classifications between models. RESULTS: The original prediction model applied to the untreated residents, who were sicker, showed excellent discrimination but poor calibration, underestimating mortality. Adjusting the intercept improved calibration. Recalibrating the slope did not substantially improve the performance of the model. Applying the updated model to the other 4 data sets resulted in acceptable discrimination. Calibration was inadequate only in one data set that differed substantially from the other data sets in case-mix. Adjusting the intercept for this population again improved calibration. CONCLUSIONS: The discriminative performance of the model seems robust for differences between settings. To improve calibration, we recommend adjusting the intercept when applying the model in settings where different mortality rates are expected. An impact study may evaluate the usefulness of the two prediction models for treated and untreated residents and whether it supports decision-making in clinical practice.

Management of constipation in residents with dementia: sorbitol effectiveness and cost.

OBJECTIVE: The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia. DESIGN: We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose. SETTING: The study was conducted at a dementia special care unit at a Veterans Administration hospital. MEASUREMENT: We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function. RESULTS: There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature. CONCLUSION: Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.

Quality of life of men treated with brachytherapies for prostate cancer.

BACKGROUND: Most studies of men undergoing treatment for prostate cancer examine physical symptoms as predictors of Quality of Life (QOL). However, symptoms vary by treatment modality in this population, and psychosocial variables, shown to be important to QOL, have rarely been examined. Litwin noted a need for analysis of QOL data in men treated for prostate cancer with different modes of therapy, as studies focusing on specific treatments will increase the homogeneity of research findings. METHODS: This cross-sectional study explored physical and psychosocial predictors of QOL in men receiving one of two types of radiation treatment for prostate cancer: Intensity Modulated Radiation Therapy (IMRT) + High Dose Rate (HDR) Brachytherapy or IMRT + seed implantation. Subjects completed a biographic questionnaire; quality of life measures, which were the eight subscales of the Medical Outcome Study Short Form Health Survey (SF-36); measures of physical symptoms including the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer (RTOG/EORTC) and the Prostate Symptom Self-Report (PSSR); and measures of psychological factors, the Ways of Coping Scale (WOC), Perceived Stress Scale, the Anxiety Subscale of the SCL-90, and Strategies Used by Patients to Promote Health (SUPPH). Eight regression models including both physical and psychosocial variables were used to predict quality of life. RESULTS: Sixty-three subjects with complete data on all variables were studied. Treatment effect sizes were medium to large in predicting each of the quality of life subscales of the SF-36. Psychosocial variables were related to physical function, role function, bodily pain, general health, social function, emotional role, and mental health. Physical symptoms were related to subjects' perceived general health and mental health. DISCUSSION: The number of significant relationships among psychosocial variables and indicators of QOL exceeded the number of relationships among symptoms and QOL suggesting that psychosocial variables associate strongly with prostate cancer patients' reports of quality of life. Findings of the study may provide patients and families with knowledge that contributes to their understanding of quality of life outcomes of IMRT+ HDR and IMRT + seed implantation and their ability to make more informed treatment choices.

Management of constipation in residents with dementia: sorbitol effectiveness and cost.

OBJECTIVE: The objective of this report is to describe a cost-effective strategy for management of constipation in nursing home residents with dementia. DESIGN: We conducted a prospective observational quality improvement study of 41 residents with chronic constipation and receiving an osmotic laxative. Sorbitol was substituted for lactulose. SETTING: The study was conducted at a dementia special care unit at a Veterans Administration hospital. MEASUREMENT: We measured the number and amount of laxative use over a period of 4 weeks that were required to maintain regular bowel function. RESULTS: There was no difference in efficacy of lactulose and sorbitol. Use of additional laxatives was infrequent: Milk of Magnesia on approximately 10% of days/patient, bisacodyl suppository on 2% to 4% of days/patient, and Fleet enema only on 3 occasions. The cost of constipation management using routine administration of sorbitol and as-needed use of other laxatives was 27% to 55% lower than the cost of other constipation management strategies reported in the literature. CONCLUSION: Substitution of sorbitol for lactulose does not change efficacy of the treatment and decreases cost. Regular use of an osmotic laxative avoids the costs and discomforts of rectal laxatives.

A pain assessment tool for people with advanced Alzheimer's and other progressive dementias.

Appropriate pain management can only be achieved through accurate pain assessment that is individualized, ongoing, and well documented. Assessment tools must focus on the patient as the authority on pain's existence and severity; however, self-reports are not feasible when patients lose their ability to verbally communicate. This article describes a scientifically proven pain assessment tool that can be used for patients with advanced dementia and Alzheimer's Disease.

Antibiotics and mortality in patients with lower respiratory infection and advanced dementia.

OBJECTIVES: To describe long-term mortality rate and to assess associations between mortality rate and antibiotic treatment of lower respiratory infection in patients with advanced dementia; antibiotic treatment allocation was independent of mortality risk-leaving less room for biased associations than in previous multicenter observational studies. DESIGN: Prospective study (2004-2009). Multilevel Cox proportional hazard analyses with adjustment for mortality risk were used to assess associations between antibiotics and mortality using time-dependent covariates. SETTING: A US Department of Veterans Affairs nursing home. PARTICIPANTS: Ninety-four residents with advanced dementia who developed 109 episodes. MEASUREMENTS: Survival, treatment, mortality risk, illness severity, fluid intake, and several other patient characteristics. RESULTS: Ten-day mortality was 48%, and 6-month mortality was 74%. Antibiotics were used in 77% of episodes. Overall, antibiotics were not associated with mortality rate (Hazard Ratio [HR] 0.70, Confidence Interval [CI] 0.38-1.30); however, antibiotics were associated with reduced 10-day mortality rate (HR 0.51, CI, 0.30-0.87; rate after 10 days: 1.5, CI 0.42-5.2). Benefit from antibiotics was less likely with inadequate fluid intake, and when experiencing the first episode. CONCLUSION: In our sample of male nursing home residents with advanced dementia and lower respiratory infection, mortality was substantial despite antibiotic treatment. Antibiotics prolonged life but in many cases only for several days. Treatment decisions should take into account that antibiotics may delay death but may also prolong the dying process, indicating a need for accurate prediction of mortality and study of characteristics that may alter effectiveness of antibiotics.

Retrospective study on the development of spinal deformities following sternotomy for congenital heart disease.

STUDY DESIGN: Retrospective review with a minimum of 3 years of follow-up. OBJECTIVE: We hypothesize that following median sternotomy there may be an increase incidence of both sagittal and coronal spinal deformity. We also think that heart size and a cyanotic cardiac condition are also risk factors for development of spinal deformity. The purpose of this study was to determine the incidence and characteristics of spinal deformity in patients following sternotomy for congenital heart disease. SUMMARY OF BACKGROUND DATA: Patients with congenital heart disease are at an increased risk to develop scoliosis. METHODS: A total of 108 patients underwent a median sternotomy for the treatment of congenital heart disease and met inclusion criteria. The medical record was reviewed to gather demographic data and medical and surgical history. Serial chest and spine radiographs were reviewed. RESULTS: Scoliosis developed in 28% of the patients (10 males, 20 females). The mean follow-up was 13 years (range, 3-26 years). The mean coronal Cobb angle was 25 degrees (range, 11 degrees-88 degrees). Of these, 7 patients presented with curves of > or = 30 degrees. The mean age at diagnosis of scoliosis was 14 years (range, 2-33 years). A kyphotic deformity developed in 22% (24 patients). In patients with scoliosis, the mean sagittal kyphosis was 34 degrees (range, 2 degrees-73 degrees). Patients with a cyanotic cardiac condition had a trend toward severe scoliosis. There was no correlation between the development of scoliosis or kyphosis and the age at time of procedures, number of surgeries, gender, or heart size. CONCLUSION: The risk of developing scoliosis in children with congenital heart disease is more than 10 times that of idiopathic scoliosis. Spinal deformities, including scoliosis and/or kyphosis, were found in 34% of the patients. The sagittal alignment in scoliosis patients tends toward kyphosis.

Exploratory factor analysis: strategies used by patients to promote health.

Strategies used by patients to promote health (SUPPH) was used to measure self-care self-efficacy in patients with cancer. The objectives of this study were (1) to determine the extent to which self-efficacy theory explained the factor structure of the SUPPH and (2) to determine the relationship of demographic data with factors of the SUPPH. Subjects were diagnosed with prostate cancer (PCa) and treated with either: (a) radical prostatectomy, (b) intensity modulated radiation therapy (IMRT) + radioactive seed implantation, or (c) IMRT + high dose rate. Subjects completed a demographic questionnaire and the SUPPH. Exploratory factor analysis of the SUPPH was performed using a varimax rotation. Subjects (n = 265) were predominately white and averaged 68 years of age. The model explained 81.3% of the total sum of eigenvalues. Two factors of the SUPPH were identified: physiological efficacy information and performance efficacy information. Younger subjects who were fully employed and earning more money had significantly higher performance self-efficacy than older subjects who were working part time and earning less money. Results are congruent with Bandura's (1997) description of self-efficacy. Use of the SUPPH may facilitate research validating Bandura's (1997) assertion that an individual's self-efficacy is related to quality of life (QOL) during chronic illness. Additional research focusing on self-efficacy and PCa patients' QOL may lead to efficacy enhancing interventions that will improve QOL of patients with PCa.

Spinal deformity after combined thoracotomy and sternotomy for congenital heart disease.

UNLABELLED: Patients with congenital heart disease are at an increased risk to develop scoliosis. The purpose of this study was to determine the incidence of spinal deformity in patients after thoracotomy and sternotomy for congenital heart disease. METHODS: Sixty-eight patients underwent thoracotomy followed by a sternotomy and met inclusion criteria. The medical records were reviewed to gather demographic data and medical and surgical history. Serial radiographs were reviewed. RESULTS: Scoliosis developed in 26% of the patients (10 boys, 8 girls). The mean Cobb angle was 40 degrees (range, 15-78 degrees). The mean age at diagnosis of scoliosis was 10.7 years (range, 2.9-17 years). The mean follow-up was 14.9 years (range, 5-20 years). Twelve percent (8 patients) required posterior spinal fusion. A kyphotic deformity developed in 21% (14 patients). In patients with scoliosis, the mean kyphosis was 38 degrees (range, 2-88 degrees). Patients with a cyanotic cardiac condition had a 4-fold incidence of scoliosis. There was no correlation between the development of scoliosis or kyphosis and the age at time of procedures, number of surgeries, sex, heart size, or side of the aortic arch. CONCLUSIONS: The risk of developing scoliosis in children with congenital heart disease is more than 10 times that of idiopathic scoliosis. Spinal deformities, including scoliosis and/or hyperkyphosis, were found in 38% of the patients. Curves develop at a younger age, which increases the risk of progression. The sagittal alignment in scoliosis patients tends toward hyperkyphosis. The thoracic spine receives a "double hit" when both procedures are combined.

Prospective study of quality of life of patients receiving treatment for prostate cancer.

BACKGROUND: No research was found that compared quality of life (QOL) outcomes of prostate cancer patients receiving intensity-modulated radiation therapies with prostate cancer patients receiving radical prostatectomy. OBJECTIVES: To (a) describe differences in QOL before and after three types of treatment for prostate cancer: radical prostatectomy, intensity-modulated radiation therapy + seed implantation (permanent brachytherapy), or intensity-modulated radiation therapy + high dose rate radiotherapy (temporary brachytherapy); and (b) investigate demographic, physical, and psychosocial variables that impact QOL of men with prostate cancer. METHODS: Data were collected on three occasions: baseline (prior to treatment), 1 month, and 3 months after beginning treatment. Measures included biographic data, physiological, and psychological measures. Analysis of variance and hierarchical regression were used to examine patterns, describe differences, and identify predictors of QOL in the three treatment groups. QOL was conceptualized as a multidimensional construct that included physical, psychological, social, and functional well-being and prostate cancer concerns. RESULTS: Groups differed significantly in bowel and urinary symptom scores and prostate cancer concerns at baseline, and in urinary and depressive symptoms at 3 months. There were no significant group differences at 1 month. DISCUSSION: Significant differences were found in QOL as measured with the Functional Assessment of Cancer Treatment-Prostate after treatment with radical prostatectomy, intensity-modulated radiation therapy + seed implantation, or intensity-modulated radiation therapy + high dose rate radiotherapy. Findings may provide healthcare providers with knowledge about treatment sequelae for prostate cancer, enable healthcare providers to educate patients about QOL outcomes of treatment for prostate cancer, and enable patients to make more informed treatment decisions.