Adaptation of the chronic disease self-management program for cancer survivors: feasibility, acceptability, and lessons for implementation.

Self-management in chronic disease has been shown to improve patient-reported and health care-related outcomes. However, relatively little information about its utility in cancer survivorship is known. We evaluated the feasibility and acceptability of the delivery of an adaptation of the evidence-based Chronic Disease Self-management Program (Stanford) called Cancer Thriving and Surviving (CTS). Triangulated mixed methods were used to capture baseline characteristics and post-program experiences using a combination of closed- and open-ended survey items; emergent coding and simple descriptive statistics were used to summarize the data. Twenty-seven workshops were delivered by 22 CTS leaders to 244 participants between August 2011 and January 2013 in a variety of settings (48 % community, 30 % health care, 22 % regional/community cancer center). Representing a variety of cancer types, about half the participants were 1-3 years post-diagnosis and 45 % were 4 or more years from diagnosis. Program attendance was high with 84 % of participants attending four or more of the six sessions in the workshop. Overall, 95 % of the participants were satisfied with the program content and leaders, and would recommend the program to friends and family. These results confirm the feasibility and acceptability of delivery of a high-fidelity, peer-led model for self-management support for cancer survivors. Expansion of the CTS represents a powerful tool toward improving health-related outcomes in this at-risk population.

Amplification at chromosome 11q13 in transitional cell tumours of the bladder.

Amplification of several markers which map to chromosome 11q13 was detected by Southern blotting in transitional cell tumours of the urinary bladder. The oncogenes INT2 and HST and the BCL1 locus were co-amplified in 20/97 (20.6%) tumours and the locus-specific minisatellite probe pMS51 (D11S97) detected amplification in 17/97 (17.5%) tumours. The high frequency of heterozygosity (greater than 70%) detected by this latter probe on HaeIII-digested DNAs provided a sensitive means to measure low levels of gene amplification (2-fold) by comparing signals obtained from each allele. A number of probes which map to 11q were used in an attempt to map the region of amplification more precisely. PGA, PGR, STMY, D11Z1 and D11S149 were not amplified in any tumours studied. SEA was amplified in 1/59 tumours and D11S146 in 12/89 tumours. A comparison of the patterns of co-amplification of individual markers in this series of tumours revealed that of the 23 tumours with amplification at this site, 11 had co-amplification of D11S97, D11S146, BCL1, INT2 and HST, 3 had co-amplification of D11S97, BCL1, INT2 and HST, 6 had co-amplification of BCL1, INT2 and HST, 1 had co-amplification of D11S97 and D11S146 and 2 had amplification of D11S97 alone. Based on available linkage data for these markers, this suggests that a putative target gene within this amplicon lies centromeric to BCL1. Amplification at 11q13 showed no correlation with tumour grade or with HER2 amplification.

Sex differences in neurological outcomes and mortality after cardiac surgery: a society of thoracic surgery national database report.

BACKGROUND: The purpose of this study was to evaluate whether women undergoing cardiac surgery are more likely to suffer neurological complications than men and whether these complications could explain, at least in part, their higher perioperative mortality. METHODS AND RESULTS: The Society of Thoracic Surgery National Cardiac Surgery Database was examined for the years 1996 and 1997 to determine the frequency of new neurological events (stroke, transient ischemic attack, or coma) occurring after cardiac surgery. We reviewed clinical information on 416 347 patients (32% women) for whom complete neurological outcome data were available. New neurological events after surgery were higher for women than for men (3.8% versus 2.4%, P=0.001). For the whole group, the 30-day mortality was higher for women than for men (5.7% versus 3.5%, P=0.001), and among those patients who suffered a perioperative neurological event, mortality was also significantly higher for women than men (32% versus 28%, P=0.001). After adjustment for other risk factors (eg, age, history of hypertension and/or diabetes, duration of cardiopulmonary bypass, and other comorbid conditions) by multivariable logistic regression, female sex was independently associated with significantly higher risk of suffering new neurological events after cardiac surgery (OR 1.21, 95% CI 1.14 to 1.28, P=0.001). CONCLUSIONS: Women undergoing cardiac surgery are more likely than men to suffer new perioperative neurological events, and they have higher 30-day mortality when these complications occur. The higher incidence of perioperative neurological complications in women cannot be explained by currently known risk factors.

The effect of race on coronary bypass operative mortality.

OBJECTIVES: The study was done to determine whether race is an independent predictor of operative mortality after coronary artery bypass graft (CABG) surgery. BACKGROUND: Blacks are less frequently referred for cardiac catheterization and CABG than are whites. Few reports have investigated the relative fate of patients who undergo CABG as a function of race. METHODS: The Society of Thoracic Surgeons National Database was used to retrospectively review 25,850 black and 555,939 white patients who underwent CABG-alone from 1994 through 1997. A multivariate logistic regression model was developed to determine whether race affected risk-adjusted operative mortality. RESULTS: Operative mortality was 3.83% for blacks versus 3.14% for whites (unadjusted black/white odds ratio [OR] 1.23 [1.15-1.31]). Blacks were younger, more likely female, hypertensive, diabetic and in heart failure. Nonetheless, the influence of these and other preoperative risk factors on procedural mortality was quite similar in black and white patients. After controlling for all risk factors, race remained a significant independent predictor of mortality in the multivariate logistic model (adjusted black/white OR 1.29 [1.21, 1.38]). Proportionately, these differences were greatest among lower-risk patients. The race-by-gender interaction was significant (p<0.05). The unadjusted mortality for black men, 3.30% and white men, 2.64% differed significantly (p<0.05), whereas for women there was no difference (black, 4.49%; white 4.41%). CONCLUSIONS: Black race is an independent predictor of operative mortality after CABG except for very high-risk patients. The difference in mortality is greatest for male patients and, though statistically significant, is small in absolute terms. Therefore, patients should be referred for CABG based on clinical characteristics irrespective of race.

Prediction of operative mortality after valve replacement surgery.

OBJECTIVES: We sought to develop national benchmarks for valve replacement surgery by developing statistical risk models of operative mortality. BACKGROUND: National risk models for coronary artery bypass graft surgery (CABG) have gained widespread acceptance, but there are no similar models for valve replacement surgery. METHODS: The Society of Thoracic Surgeons National Cardiac Surgery Database was used to identify risk factors associated with valve surgery from 1994 through 1997. The population was drawn from 49,073 patients undergoing isolated aortic valve replacement (AVR) or mitral valve replacement (MVR) and from 43,463 patients undergoing CABG combined with AVR or MVR. Two multivariable risk models were developed: one for isolated AVR or MVR and one for CABG plus AVR or CABG plus MVR. RESULTS: Operative mortality rates for AVR, MVR, combined CABG/AVR and combined CABG/ MVR were 4.00%, 6.04%, 6.80% and 13.29%, respectively. The strongest independent risk factors were emergency/salvage procedures, recent infarction, reoperations and renal failure. The c-indexes were 0.77 and 0.74 for the isolated valve replacement and combined CABG/valve replacement models, respectively. These models retained their predictive accuracy when applied to a prospective patient population undergoing operation from 1998 to 1999. The Hosmer-Lemeshow goodness-of-fit statistic was 10.6 (p = 0.225) for the isolated valve replacement model and 12.2 (p = 0.141) for the CABG/valve replacement model. CONCLUSIONS: Statistical models have been developed to accurately predict operative mortality after valve replacement surgery. These models can be used to enhance quality by providing a national benchmark for valve replacement surgery.

Traumatic brain injury imaging research roadmap.

The past decade has seen impressive advances in the types of neuroimaging information that can be acquired in patients with traumatic brain injury. However, despite this increase in information, understanding of the contribution of this information to prognostic accuracy and treatment pathways for patients is limited. Available techniques often allow us to infer the presence of microscopic changes indicative of alterations in physiology and function in brain tissue. However, because histologic confirmation is typically lacking, conclusions reached by using these techniques remain solely inferential in almost all cases. Hence, a need exists for validation of these techniques by using data from large population samples that are obtained in a uniform manner, analyzed according to well-accepted procedures, and correlated with closely monitored clinical outcomes. At present, many of these approaches remain confined to population-based research rather than diagnosis at an individual level, particularly with regard to traumatic brain injury that is mild or moderate in degree. A need and a priority exist for patient-centered tools that will allow advanced neuroimaging tools to be brought into clinical settings. One barrier to developing these tools is a lack of an age-, sex-, and comorbidities-stratified, sequence-specific, reference imaging data base that could provide a clear understanding of normal variations across populations. Such a data base would provide researchers and clinicians with the information necessary to develop computational tools for the patient-based interpretation of advanced neuroimaging studies in the clinical setting. The recent "Joint ASNR-ACR HII-ASFNR TBI Workshop: Bringing Advanced Neuroimaging for Traumatic Brain Injury into the Clinic" on May 23, 2014, in Montreal, Quebec, Canada, brought together neuroradiologists, neurologists, psychiatrists, neuropsychologists, neuroimaging scientists, members of the National Institute of Neurologic Disorders and Stroke, industry representatives, and other traumatic brain injury stakeholders to attempt to reach consensus on issues related to and develop consensus recommendations in terms of creating both a well-characterized normative data base of comprehensive imaging and ancillary data to serve as a reference for tools that will allow interpretation of advanced neuroimaging tests at an individual level of a patient with traumatic brain injury. The workshop involved discussions concerning the following: 1) designation of the policies and infrastructure needed for a normative data base, 2) principles for characterizing normal control subjects, and 3) standardizing research neuroimaging protocols for traumatic brain injury. The present article summarizes these recommendations and examines practical steps to achieve them.

Efficacy of flecainide for the reversion of acute onset atrial fibrillation.

The efficacy and safety of intravenous flecainide to convert recent-onset atrial fibrillation (AF) (present for greater than or equal to 30 minutes and less than or equal to 72 hours and a ventricular response greater than or equal to 120 beats/min) was investigated. A total of 102 patients without severe heart or circulatory failure were randomized to receive either intravenous flecainide (2 mg/kg, maximum dose 150 mg; 51 patients) or placebo (51 patients) in a double-blind trial. Digoxin (500 micrograms intravenously) was administered to all patients who had not previously been receiving digoxin. The electrocardiogram was monitored continuously during the study. In 29 (57%) patients stable sinus rhythm was restored within 1 hour after flecainide and in only 7 (14%) given placebo (chi square 18.9; p = 0.000013; odds ratio 8.3; 95% confidence interval 2.9-24.8). Reversion to sinus rhythm within 1 hour after starting the trial medication was considered a pretrial end point and likely to be due to a drug effect. At the end of the 6-hour monitoring period, 34 patients (67%) in the flecainide group were in sinus rhythm whereas only 18 (35%) in the placebo group had reverted (chi square 8.83, p = 0.003; odds ratio 3.67; 95% confidence interval 1.5-9.1). Significant hypotension, although short lived, was more common in the flecainide group. One patient given flecainide developed torsades de pointes and was successfully electrically cardioverted. Flecainide is useful for the management of recent-onset AF both for control of the ventricular response and conversion to sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversion of recent-onset atrial fibrillation to sinus rhythm by intravenous flecainide.

Spontaneous reversion to sinus rhythm is a frequent occurrence in recent-onset atrial fibrillation (AF). In a randomized, double-blind, controlled study, intravenous flecainide (2 mg/kg, maximum dose 150 mg) was compared with placebo in the treatment of recent-onset AF (present for greater than or equal to 30 minutes and less than or equal to 72 hours' duration and a ventricular response greater than or equal to 120 beats/min). Intravenous digoxin (500 micrograms) was administered concurrently to all patients in both groups who had not previously taken digoxin. The trial medication was administered over 30 minutes. Exclusion criteria included hemodynamic instability, severe heart failure, recent antiarrhythmic therapy, hypokalemia and pacemaker dependence. One hundred two consecutive patients with recent-onset AF were enrolled in the study. All patients underwent continuous electrocardiographic monitoring in the intensive care or coronary care unit. Twenty-nine (57%) patients given flecainide and digoxin, but only 7 (14%) given placebo and digoxin, reverted to sinus rhythm in less than or equal to 1 hour after starting the trial medication infusion and remained in stable sinus rhythm (chi-square 18.9, p = 0.000013; odds ratio 8.3, 95% confidence interval 2.9 to 24.8). At the end of the 6-hour monitoring period, 34 patients (67%) in the flecainide-digoxin group were in stable sinus rhythm, whereas only 18 patients (35%) in the placebo-digoxin group had reverted (chi-square 8.83, p = 0.003; odds ratio 3.67, 95% confidence interval 1.5 to 9.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Renal sparing treatment of upper tract malignant urothelial tumours using photodynamic therapy (PDT)-three case reports.

Urothelial cancers of the upper urinary tract are usually treated by excision of the kidney, ureter and cuff of the bladder on the affected side. These three cases demonstrate the feasibility, safety and efficacy of photodynamic therapy as a renal sparing procedure for urothelial tumours.

Steam locomotive ergonomics.

A retrospective study of some of the ergonomic factors of the man/machine interface of the steam locomotive of the 19th century. Reference is made to the dominance of mechanical requirements over human engineering factors, to the perceptual task of drivers, and to the specialised form of the machine and its control position. Examples are given of the application of some ergonomics to control position design in the 20th century, and the present day 'non-steam' control positions are described so as to form comparisons with the 19th century control position practices.

Dendritic cells for active immunotherapy: optimizing design and manufacture in order to develop commercially and clinically viable products.

Dendritic cell (DC) active immunotherapy is potentially efficacious in a broad array of malignant disease settings. However, challenges remain in optimizing DC-based therapy for maximum clinical efficacy within manufacturing processes that permit quality control and scale-up of consistent products. In this review we discuss the critical issues that must be addressed in order to optimize DC-based product design and manufacture, and highlight the DC based platforms currently addressing these issues. Variables in DC-based product design include the type of antigenic payload used, DC maturation steps and activation processes, and functional assays. Issues to consider in development include: (a) minimizing the invasiveness of patient biological material collection; (b) minimizing handling and manipulations of tissue at the clinical site; (c) centralized product manufacturing and standardized processing and capacity for commercial-scale production; (d) rapid product release turnaround time; (e) the ability to manufacture sufficient product from limited starting material; and (f) standardized release criteria for DC phenotype and function. Improvements in the design and manufacture of DC products have resulted in a handful of promising leads currently in clinical development.

Underlying family-size preferences and reproductive behavior.

Although about half the married women in a US survey said they wanted one or two children, underlying family-size preferences indicate a potential for many to have larger families. Using a measure of family-size preference that probes beyond single-valued statements, it is found that identical stated family-size desires or intentions may have different meanings for different people. Differences are systematically related to the stage in family building at which contraception begins, to current (or likelihood of future) use of effective methods, to the probability of continued childbearing, and to unwanted pregnancies.

PIP: Data from the 1973 National Survey of Family Growth (NSFG) were used to report on underlying preferences for number of children among U.S. married women as well as how such preferences may differ from single-valued statements of desired family and how they are related to reproductive behavior. The 7459 cases on which the findings rest come from a 4-stage probability sample of married women in the childbearing ages (15-44). Different sampling ratios were used for blacks and whites to ensure sufficient cases for detailed analysis, with a weighting system to ensure effectiveness. The data reveal that while about 1/2 the married women state that they want only 1 or 2 children, the underlying preferences of many indicate a potential for larger families; 1/3 of this group has a bias toward a moderate-size or large family, despite statements to the contrary. For the country as a whole, 45% of all wives of childbearing age have an underlying preference for a small family, 25% favor a moderate size, and 30% have a bias toward a large family. Identical statements about desired family size, or about expected or intended number of children, do not have the same meaning for everyone, in the sense that such responses may be supported by a range of underlying preferences, as reflected in the IN-scale measure. In other words, statements about desired size represent only partial information, and the extent to which underlying preferences depart from the conventional responses obtained provides further information that is important for interpretation and for fertility prediction. Various subgroups of the population differ considerably in the way their underlying preferences relate to their single-valued statements. Women in very low income or low educational strata who say they prefer or intend to have 2 or 3 children are much more likely than high status women to have underlying preferences for a large family size, suggesting that they will be less likely to achieve their preferred or intended family size.

How many children do couples really want?

Program workers and policy makers may be seriously misled if they put too great a reliance on statements about preferred family size. Underlying biases toward more or fewer children than the stated number affect the timing and effectiveness of contraceptive practice, and may help explain discrepancies between desired and achieved family size.

Levels of reliability in fertility survey data.

A number of factual and attitudinal questions asked in the 1973 Taiwan KAP-4 survey were repeated in a postenumeration survey one month later in order to assess the reliability of responses of the 286 women reinterviewed. The level of reliability is found to vary depending on the measures used and on whether the focus is aggregate data or individual responses. Analysis of consistency of responses shows that while overall reliability at both aggregate and individual levels is reasonably good, there is greater reliability for factual than for attitudinal data. Nevertheless, consistency of responses on factual questions varies considerably depending on the salience of the topic to the respondent. Estimates of reliability are shown to depend on the measure used and on the skewness of the distributions of the responses.

The measurement of family size preferences and subsequent fertility.

A new method for measuring preferences for number of children is presented and related to the subsequent fertility of a panel of married women over a five-year period. TheI-scales, developed on the basis of unfolding theory, reflect the individual's utility function for children. They differ from global stated preferences and are more fine-grained measures, sensitive to variations from a first choice. Scales obtained at an initial interview were found to be consistently predictive of fertility in the prospective period, net of a number of other variables usually associated with differential fertility. Their potential both as independent and dependent variables in research is discussed.

Reproductive goals and achieved fertility: a fifteen-year perspective.

A measure of underlying family size preference obtained for a sample of Detroit married women in 1962 is related to their fertility over a 15-year follow-up period. The data represent completed fertility. The I-scale preference measure used differs from the conventional single-valued statement of number of children wanted; it is a more fine-grained measure reflecting the respondent's utility for children as evidenced by her entire preference order. The scales are found to be consistently predictive of fertility over the 15-year prospective period, net of other variables usually associated with differential fertility. The results for the just-married sample, in which preferences and expectations are not confounded with the number of children already born, are particularly striking, with underlying preference much better than expected family size as a predictor of fertility over the entire reproductive cycle. The question of prediction for continuous and discontinuous marriages is discussed.

Economic considerations in family growth decisions.

Abstract Examination of the fertility patterns of a sample of white Detroit couples at selected stages of the family life cycle indicates that, in a large American metropolis, family income is more closely related to the time when a family is formed and has its children than to the number of children it expects to have. In a longitudinal study, current income is strongly related to the timing of demographic events-the age at marriage, whether pre-maritally pregnant, the time interval from marriage to a given parity, and fertility during a two-year follow-up period. This paper also explores the hypothesis that a family's evaluation of its economic position and the choices it makes about important family expenditures has a relation to fertility apart from the family's objective current income level. Couples who consider their income adequate for their needs or relatively greater than that of their friends or peers, and those who expect substantial increases in the future, tend to expect more children than those who do not. Small but consistent differences obtain over the parities studied. Variables indexing alternative family expenditure patterns, such as cars, or savings for college education for children, are associated with lower family size expectations and longer spacing patterns.

Clinical examination of patients in the intensive care unit.

The severity of their illness ensures that many patients requiring intensive care have abnormal physical signs. Clinical examination remains a useful and effective way of detecting these and monitoring the patient's response to treatment.