Surveillance CT scans are a source of anxiety and fear of recurrence in long-term lymphoma survivors.

BACKGROUND: We aimed to assess anxiety and the psychological impact of routine surveillance scans in long-term survivors of adult aggressive lymphoma. PATIENTS AND METHODS: In this cross-sectional observational study of 70 survivors of curable adult aggressive lymphoma, we measured anxiety and the doctor-patient relationship and performed a qualitative interview (n = 30) focused on patient perception of routine follow-up imaging studies. RESULTS: Participants were diagnosed with aggressive lymphoma a median of 4.9 years (2.4-38.0 years) before enrollment. Thirty-seven percent of patients were found to meet criteria for clinically significant anxiety, which was not associated with years since diagnosis. In multivariate analysis, history of relapse and a worse doctor-patient relationship were independently associated with higher anxiety levels. Despite representing a largely cured population, in qualitative interviews patients reported fear of recurrence as a major concern and considerable anxiety around the time of a follow-up imaging scan. CONCLUSIONS: Routine surveillance scans exacerbate underlying anxiety symptoms and fear of recurrence in survivors of aggressive lymphoma. Strategies to minimize follow-up imaging and to improve doctor-patient communication should be prospectively evaluated to address these clinically significant issues.

Risk-reducing surgery in FAP: role for surgeons beyond the incision.

BACKGROUND: Although primary therapy in familial adenomatous polyposis (FAP) is surgical, little is known about patients' surgical decision-making experience. The objective was to explore the decision-making process surrounding risk-reducing surgery in FAP using qualitative methodology. METHODS: In-depth, semi-structured interviews with 14 FAP patients and 11 healthcare providers with experience caring for FAP patients were conducted. Using grounded theory, line-by-line content analysis identified categories from which themes describing patients' experiences emerged; analysis continued until data saturation. RESULTS: Median age at surgery was 23 (7-37) years; at interview 41 (19-74) years. Two patients underwent surgery secondary to cancer, the remainder for risk-reduction. Content experts included colorectal surgeons (3), geneticists (2), gastroenterologists (3), nurses (3).Three themes emerged: Information: Family was the primary information source, and patients' level of information varied. The importance of up-front information was emphasized. Influences on decision-making: Influential factors included family experiences, youth, emotional state, support, and decision-making role. Although patients often sought opinions, most (12/14) wanted an active/shared role in decision-making. Life after surgery: Patients described surgery as the "easy part," emphasizing the need for long-term relationships with care providers. CONCLUSIONS: Decisions surrounding risk-reducing surgery in FAP are unique. A decision support tool may facilitate decision-making, better preparing patients for life after surgery.

Psychosocial mediators of the relationship between race/ethnicity and depressive symptoms in Latino and white patients with coronary artery disease.

BACKGROUND: The high prevalence of depressive symptoms in patients with coronary artery disease has been well documented. However, little is known about the prevalence and correlates of depressive symptoms in Latino patients with coronary artery disease. PURPOSE: Among Latino and white patients who had percutaneous transluminal coronary angioplasty (PTCA), this study examined whether differences in the prevalence of depressive symptoms exist and the degree to which psychosocial factors (years of education, employment status, stressful life events, emotional social support) explained any differences. METHODS: Using a cross-sectional design, closed-format questionnaires were used to obtain clinical and psychosocial history. The definition of high depressive symptoms was based on a score of > or =16 on the Center for Epidemiologic Studies Depression Scale (CES-D). RESULTS: Compared to whites (n=492), Latinos (n=59) were younger, and a greater proportion were female, but fewer completed high school and fewer were employed (P<0.05). More Latinos reported experiencing > or =2 recent stressful life events, but fewer reported having emotional social support (P<0.05). There was a significant association between race/ethnicity and depressive symptoms (OR=2.3, 95% CI: 1.3-4.5). In multivariate analyses, the significance of this association diminished when psychosocial variables were added to the model. CONCLUSIONS: In this study, education, employment, stressful life events and emotional social support partially explained the observed racial/ethnic differences in depressive symptoms.

Rate of disease progression in breast cancer: a clinical estimate of prognosis within nodal and anatomic stages.

From data obtained in the patient's history, the clinical rate of progression of disease in breast cancer patients can be estimated as slow, intermediate, or rapid. The strata defined by these rates had previously been shown to create prognostic gradients within groups of patients similar in anatomic stage or nodal status. In a second, validating cohort of 465 women with primary breast cancer, the strata delineating rate of disease progression were shown to have a cogent prognostic impact when the proportional hazards model was used to control simultaneously for nodal and anatomic status. In addition, the distinctions persisted when different types of treatment were taken into account. These findings from a multivariate analysis employing the Cox method confirmed the importance of clinical rate of disease progression in estimating prognosis of breast cancer.

'Vascular depression' hypothesis.

We propose that cerebrovascular disease may predispose, precipitate, or perpetuate some geriatric depressive syndromes. The "vascular depression" hypothesis is supported by the comorbidity of depression, vascular disease, and vascular risk factors and the association of ischemic lesions to distinctive behavioral symptoms. Disruption of prefrontal systems or their modulating pathways by single lesions or by an accumulation of lesions exceeding a threshold are hypothesized to be central mechanisms in vascular depression. The vascular depression concept can generate studies of clinical and heuristic value. Drugs used for the prevention and treatment of cerebrovascular disease may be shown to reduce the risk for vascular depression or improve its outcomes. The choice of antidepressants in vascular depression may depend on their effect on neurologic recovery from ischemic lesions. Research can clarify the pathways to vascular depression by focusing on the site of the lesion, the resultant brain dysfunction, the presentation of depression and time of onset, and the contribution of nonbiological factors.

Utilization of critical care units. A prospective study of physician triage and patient outcome.

To identify patients likely to be admitted to a critical care unit as well as those at high risk of deterioration, we studied all patients admitted to the medical service. Cardiac patients had a high likelihood of unit admission even if they were rated as not ill and stable, whereas ill and unstable noncardiac patients went to the floor. Stable cardiac or noncardiac patients who were not severely ill had very low deterioration and mortality, but unstable, severely ill patients with cardiac or noncardiac reasons for admission had high deterioration rates. If the goal is to admit patients at highest risk, the optimal strategy is to admit unstable, severely ill, and moribund patients in both the cardiac and noncardiac groups. By doing this, it is possible to decrease unit admission of patients likely to do well, increase the admission of patients likely to do poorly, while decreasing the number of patients admitted.

Why predictive indexes perform less well in validation studies. Is it magic or methods?

When prognostic indexes have been tested in a second population, they have often performed less well. Since this is believed to be inevitable, methodologic differences that may explain the discrepancies have been overlooked. Data from a prospective study of 232 patients undergoing noncardiac surgery were used to examine the effect of methodologic differences in assembly of population, postoperative surveillance, and the criteria for cardiac complications on the performance of Goldman's cardiac risk index. Our prospective population was used to simulate the methods used in Goldman's study and in three other studies using the risk index to demonstrate the potential impact of differences in population, surveillance, and outcome criteria for cardiac complications. If Goldman's detection and outcome criteria were employed and only the eligibility criteria used for assembly of the populations differed, the overall complication rates would be between 5.2% and 6.9%; and the complication rates for the different Goldman classes were similar. When both different detection strategies and different outcome criteria were used, however, important discrepancies in cardiac complication rates emerged. For example, complication rates in class 2 varied from 2% to 23%. In conclusion, important discrepancies in performance of prognostic indexes may arise from differences in surveillance strategies and definitions of outcome. With sufficient attention to methodologic consistency, the performance of predictive indexes may not inevitably deteriorate in subsequent studies.

A patient-specific measure of change in maximal function.

We designed a short, patient-specific index that measures changes in maximal physical, mental, and emotional function. A baseline component, given at the initial interview, documents the patients' usual activities that require the most physical exertion and mental effort, as well as the patients' ability to cope with stress. A transition component assesses the subsequent change from these patient-specific norms. The index was evaluated in two separate studies involving medical and surgical patients. In the first study, the index was administered twice to 40 patients. Reliability was excellent for all three aspects of function. The transition index had a high degree of internal consistency. In a second study of 43 hospitalized patients, the validity of the index was assessed by comparing its performance with the Sickness Impact Profile; high correlations were found. In addition, the overall patterns of change differed in the expected directions in the medical and surgical groups. This index is unique in its ability to measure change directly, is interpretable in individual patients, and could be easily applied in clinical practice and research.

Predicting postoperative pulmonary complications. Is it a real problem?

To identify predictors of postoperative pulmonary complications, a population of 278 patients, mainly hypertensive and diabetic patients undergoing elective general surgery was studied; 60% of the patients underwent abdominal surgery. Of the 278 patients, 6% had postoperative pulmonary complications: 3% had radiographic evidence of infiltrates or segmental atelectasis and 3% had clinical evidence of atelectasis. Among the two thirds of patients undergoing abdominal surgery, only patients with underlying asthma or chronic bronchitis were at increased risk. Generally, patients with better exercise tolerance by self-report, walking distance, or cardiovascular classification had lower rates. Pulmonary function tests did not help to delineate patients at higher risk of postoperative pulmonary complications. Simple clinical information provided as much data about the patients' risk as pulmonary function tests. Many of these complications occurred in patients who sustained other types of postoperative morbidity, suggesting that predicting and preventing postoperative cardiac morbidity may be the best approach to reducing postoperative pulmonary morbidity.

Reversibility of cognitive impairment in medical inpatients.

To determine outcomes of patients admitted to the hospital with global cognitive impairment and to identify factors that might predict improvement, we screened all medical ward admissions over a one-month period with Folstein's Mini-Mental State Examination. Of 115 patients, 23 (20%) scored less than 24, indicating that they were cognitively impaired. Nineteen patients survived to discharge and were followed up for three months; three additional patients died in this period. Nine (47%) of the 19 patients significantly improved their Mini-Mental State scores. Five (26%) of the 19 improved to normal. They scored better on the initial Mini-Mental State Examination and lower (less dementia) on Blessed's Dementia Rating Scale. Age, severity and stability of medical illness, presence of neurologic abnormalities, clinical course, extensiveness of medical evaluation, and psychiatric criteria for delirium did not predict improvement.

The therapeutic efficacy of critical care units. Identifying subgroups of patients who benefit.

The majority of patients are admitted to critical care units for observation and to facilitate intervention if deterioration occurs or complications develop. We attempted to determine if a reduction in mortality in a subgroup of these patients admitted directly to the critical care units could be identified. A new method using the scientific principles of a randomized trial applied to the case-control design was employed. All 1905 patients admitted to the medical service over a three-month period were prospectively evaluated for illness severity and stability. Patients who would not have been eligible for a randomized clinical trial were excluded. Based on the prospective evaluations, four prognostically distinct subgroups of patients were formed. An odds ratio for each of the prognostic groups was calculated, a ratio of greater than 1 indicating a protective effect of direct critical care admission. Only one subgroup of patients, the unstable moderately ill, had an odds ratio greater than 1 (13.3). These results, in association with the results of our previous study, suggest that at the time of admission to the hospital, direct admission to the critical care unit reduced mortality among the unstable moderately ill subgroup of patients.

Clinically defined vascular depression.

OBJECTIVE: The authors' goal was to examine the clinical presentation of a group of depressed elderly patients with clinically defined risk factors for vascular depression compared with a group of elderly depressed patients without such risk factors. METHOD: Cognitive deficits, disability, and depressive symptoms were examined in 33 consecutively recruited elderly patients defined as having vascular depression and 32 patients defined as having nonvascular depression according to their scores on the Cumulative Illness Rating Scale-Geriatrics. RESULTS: The patients with vascular depression had greater overall cognitive impairment and disability than those with nonvascular depression. Fluency and naming were more impaired in patients with vascular depression, and they had more retardation and less agitation as well as less guilt feelings and greater lack of insight. CONCLUSIONS: The symptoms of vascular depression are consistent with lesions that may damage striato-pallido-thalamo-cortical pathways and other areas. The concept of vascular depression can provide the impetus for investigations of prevention and treatment of cerebrovascular disease and for studies of the course of vascular depression and selection of antidepressants.

The effectiveness of a consultation. Compliance with initial recommendations.

To identify the attributes of an effective consultation, 202 general medicine consultations were analyzed to assess the extent of compliance with the consultant's initial recommendations. The overall compliance rate was 77 percent. Compliance decreased as the number of recommendations increased. The consultant made more recommendations among patients who had more complex and more severe illnesses. Although compliance did increase significantly in severely ill patients (p less than 0.01), with each severity level, compliance was higher when five or fewer recommendations were made. In fact, compliance decreased from 96 percent in severely ill patients with small consultation lists to 79 percent in those with large lists. Compliance was greatest with recommendations involving medications and least with those requiring direct physician and nursing action. Multivariate analysis confirmed that clinical severity of the patients' illnesses and the type and number of recommendations were all predictors of compliance. To promote overall compliance, consultants should limit the total number of recommendations in their initial consultation to five or fewer, focusing on issues central to current patient care. This is especially true in severely ill patients. Since recommendations that must be implemented by physicians or nurses have a lower compliance rate, consultants must carefully follow up those requests.

A new clinical index of growth rate in the staging of breast cancer.

The clinical rate of growth in patients with breast cancer can be auxometrically classified by identifying the first clinical manifestation observed by the patient (or physician) and by then noting the progression interval that elapsed before treatment and the occurrence of prognostically unfavorable transition events during that interval. These two features can be used to demarcate slow, intermediate and rapid auxometric stages, which approximate the cancer's rate of progression. A fourth stage consists of patients who have systemic or metastatic symptoms before treatment. Within any TNM (tumor-nodes-metastases) stage, degree of nodal involvement or treatment, these four auxometric stages delineate patients with distinctly different prognoses. In particular, the slow auxometric stage can be used to identify a subgroup of patients with excellent 10 year survival and other patients who have good outcomes despite an anatomically unfavorable status. Conversely, the rapid and systemic-metastatic stages identify patients with relatively poor prognoses despite an apparently favorable anatomic status. The auxometric classification is easily used, readily available and involves no technologic expense or risk. By improving the accuracy of anatomic staging, auxometry adds an important refinement to the estimation of prognosis and the evaluation of therapy for patients with breast cancer.

Absenteeism and labelling in hypertensive subjects. Prevention of an adverse impact in those at high risk.

In this work-site population, the illness absenteeism of 259 hypertensive subjects was studied in the year after they were screened and labelled. Absenteeism due to illness increased more in 48 patients who were unaware of their hypertension (newly labelled) than in the 211 subjects who were aware. Among the newly labelled subjects, only the young subjects and those with "pure" systolic hypertension experienced increased absenteeism; the older subjects with diastolic hypertension did not. The newly labelled subjects who received active follow-up and treatment with antihypertensive medication had only minimal increases in absenteeism. In contrast, those who received active follow-up without medication, and those who received only episodic follow-up had significantly greater increases. Vigorous efforts are warranted to insure active follow-up and treatment for hypertensive subjects after their condition has been labelled. Caution should be exercised in labelling, however, if no antihypertensive treatment is initiated.

General medicine consultation. Lessons from a clinical service.

The 564 consultations performed by a general medicine consultation service during its first year were analyzed in order to provide a concrete definition of this new academic domain. Of the consultations, 52 percent were for patients on the surgical service. Among these patients, the most common reason for consultation was the preoperative management of chronic illness, specifically, hypertension, diabetes, and angina; 47 percent of such patients had two or more chronic illnesses. The service recommended cancellation of planned surgery in 2 percent and postponement in 9 percent of the 210 patients seen preoperatively. Patients on the psychiatric service accounted for 47 percent of the consultations. In this group, diagnostic issues were the most common reasons for consultation, that is, abdominal pain, dementia, and the suspicion of thyroid disease. Only 12 percent of the patients were seen for prognostic reasons, usually related to the planned use of electroconvulsive therapy or tricyclic antidepressants. The service was evaluated by the referring physicians who rated the service favorably on its "mechanics," as well as on its qualitative performance. However, complaints of triviality were voiced when the average length of the list of recommendations seemed disproportionate to the complexity of the problems. The service was also evaluated by the residents who had provided consultations. From their perspective, the service was more successful in teaching the "art" of consultation than the "science." This experience provides an operational definition of the work facing a general medicine consultation service as well as data useful in focusing future educational programs and research efforts.

Closing the clinics: would it close the teaching hospital?

To improve their overall financial position, many teaching hospitals have considered decreasing the size of their clinics. To assess the effect this would have on the inpatient service, the medical ward service of The New York Hospital was studied during the 1981 to 1982 academic year. In 50 percent of hospitalizations, patients were enrolled in the clinic system before admission. In an additional 19 percent of hospitalizations, patients had either been previously seen in the emergency room or hospitalized at this institution, but never seen in a clinic. In the remaining 31 percent of hospitalizations, the patient's admission was the first contact with the institution. This group of "new" patients simply replaced the patients who died (14 percent) or were lost to the system through transfer to chronic-care facilities (11 percent) or referral to community physicians (7 percent). Twenty percent of patients discharged to a clinic were readmitted during the study year as opposed to only 3 percent of patients who were transferred to chronic-care facilities or referred to community physicians. The clinic system is the principal source of referral into the ward service and the most effective mechanism for insuring that a patient needing rehospitalization returns to the hospital. It is concluded that major reduction of clinic size will result in severe contraction of the inpatient service.

Realizing the potential of clinical judgment: a real-time strategy for predicting outcomes and cost for medical inpatients.

PURPOSE: We sought to determine whether illness severity and anticipated level of function, as evaluated at the time of admission, were associated with outcomes and costs of care for patients admitted to the medical service. METHODS: All 1,759 patients admitted to the medical service at a large urban academic medical center between July 1, 1997, and September 30, 1997 (excluding those admitted directly to the intensive care units or for protocol chemotherapy), were evaluated and categorized by the admitting intern by illness severity (not ill, mildly ill, moderately ill, severely ill, or moribund) and anticipated level of function at discharge (excellent, good, fair, or poor) as part of their routine sign-out process. Interns' ratings were always available within 24 to 28 hours of admission. In-hospital mortality, length of stay, cost of hospitalization, and anticipated billing revenue were evaluated. RESULTS: Patients who were more severely ill had significantly greater in-hospital mortality. For example, mortality was 1.1% (11 of 972) among those who were not ill or mildly ill, 3.6% (26 of 724) among those who were moderately ill, and 15% (9 of 60) among those who were severely ill. Illness severity (P = 0.003) and anticipated functional status (P < 0.01) were significant predictors of in-hospital mortality. Illness severity and function were also significant predictors of greater length of stay and greater costs of hospitalization (all P < 0.0001). The 389 patients who were moderately ill with fair or poor anticipated function were associated with the largest cumulative losses (about $330,000 during the 3-month period), whereas the 798 mildly ill patients with good or excellent function were associated with the largest cumulative profits ($550,000). CONCLUSION: Physicians' estimates of patients' illness severity and anticipated function at the time of discharge, as made by interns using a system designed to help them sign out to their colleagues, predict outcomes and costs of hospitalization. Such a system may be useful in developing new approaches to management strategies based on prognosis.