Screening for anxiety and depression in women with breast cancer. Psychiatry and medical oncology gear up for managed care.

In this study, 275 women with breast cancer attending ambulatory breast cancer clinics in two sites were evaluated for psychological distress by using three self-report instruments: a visual analogue scale for psychological distress, the Hospital Anxiety and Depression Scale, and the Brief Symptom Inventory. Results suggest that significant psychological distress exists in ambulatory women with breast cancer; all three instruments effectively measured that level of distress. Implications for the use of these instruments in educating oncological staff members, documenting need for psychiatric services in a period of capitation, and providing quality assurance evaluations of psychiatric services are discussed.

Hospital readmission and morbidity following early newborn discharge.

To examine causes of newborn hospital readmission and morbidity related to early nursery discharge, we reviewed the charts of 664 newborns readmitted from home under the age of 15 days, between 1993 and 1995. Early discharge (ED) was defined as nursery length of stay of < or = 2 days. Morbidity related to ED: onset of symptoms within 1 day of ED; and in diseases with insidious onset: serum bilirubin level > 20 mg/dL (340 mumol/L), or dehydration following poor breastfeeding since birth. Seventeen percent of all readmitted infants had ED-related morbidity; 9% had major morbidity. Onset of symptoms prior to the age of 3 days occurred in 43% of ductal-dependent cardiac lesions, intestinal obstruction, seizures, and major infections. Morbidity was less pronounced in infants who were followed up within 2 days following ED. Specific findings related to subsequent morbidity were identified in the perinatal history of infants who were readmitted with major infections and with hyperbilirubinemia. Our findings suggest that: (1) close to half of the cases with acute-onset major morbidity can be identified within 3 days of birth, and (2) attention to the perinatal history and timely follow-up will contribute to a reduction in both morbidity and complications.

Protease inhibitor combination therapies and perceptions of gay men regarding AIDS severity and the need to maintain safer sex.

BACKGROUND: Advances in the treatment of HIV disease with protease inhibitor combination therapies have been widely documented in the media. OBJECTIVES: To investigate perceptions concerning the severity of HIV/AIDS and the need to maintain safer sex practices in the light of recent HIV treatment advances. METHODS: A survey eliciting demographic characteristics, HIV serostatus and treatment information, and HIV/AIDS severity and safer sex perceptions was administered to a community sample of 379 homo-/bisexual men who reported awareness of combination therapy regimens. RESULTS: Ten per cent of all respondents agreed or strongly agreed with the statement that 'AIDS is now very nearly cured' and 13% felt that the threat of AIDS is less serious than in the past. HIV-positive men were more likely to perceive AIDS as a less serious threat or as very nearly cured. Overall, 8% of men in the sample indicated that they practice safer sex less often since new AIDS treatments came along; 18% of HIV-positive men on combination therapy regimens said they practice safer sex less frequently since treatments have advanced. Regardless of serostatus, nearly 20% of men indicated they would stop practicing safer sex if an AIDS cure was announced. CONCLUSION: It is essential to integrate behavior change counseling into HIV treatment programs and to temper optimism concerning treatment advances with recognition that the threat of HIV/AIDS remains great.

Selection and use of pressure ulcer risk-assessment tools and treatment protocols in extended-care facilities in the southwest.

PURPOSE: The purpose of this study was to investigate pressure ulcer treatment protocol selection and use by care providers in extended health care facilities. DESIGN: Descriptive survey. SETTING AND SUBJECTS: The target population was directors of extended health care facilities in the southwestern border region of Arizona, New Mexico, and west Texas. METHODS: Questionnaires were mailed to 427 directors of extended-care facilities, who were asked to self-report treatment selection methods. The results from 96 returned and usable questionnaires were analyzed. MAIN OUTCOME MEASURES: Descriptive statistics were used to analyze the returned data. RESULTS: Most (56.25%) of the respondents reported using a facility-developed assessment tool, 15.63% used no assessment tool at all, and less than 50% of the responding institutions reported using established protocols for pressure ulcer treatment. Although selection methods differed, most (61.46%) pressure ulcer treatments were reported to be determined by collaboration among nurses, physicians, and other health care providers. CONCLUSION: Selection and use of pressure ulcer risk-assessment tools and treatment protocols showed a wide range of variation by extended-care facilities. A high percentage of institutions did not report the use of established, research-based protocols for pressure ulcer treatment, although interdisciplinary collaboration for treatment selection was reported.

Administration of recombinant bovine somatotropin to dairy cows for four consecutive lactations.

Effects of long-term administration of recombinant bovine somatotropin (bST) to dairy cows on complete lactational performance [60 (+/- 3) to 284 (+/- 3) d in milk (DIM)] were studied for four consecutive lactations. Beginning on d 60 (+/- 3) postpartum, Holstein cows received biweekly injections (500 mg) of bST (n = 39) or a placebo (control; n = 39) during the first lactation of the study. Cows either continued on the same treatment (n = 26) or were switched to the opposite treatment (n = 29) during the second lactation. Cows that changed treatments were injected for only 16 wk during the second lactation. Six cows per treatment completed four consecutive lactations. Treatment with bST during the first lactation did not have a residual effect on milk yields during the second lactation. Injections of bST during the second lactation increased milk yield 6.5 kg/d from 60 (+/- 3) to 172 DIM. For the four lactations, cows receiving bST yielded 3.7 kg/d (14%) more milk and gained 52 kg (37%) more body weight than did controls. Pretreatment (from 0 to 56 DIM) milk yields in yr 2, 3, and 4 were not affected by previous bST treatment. Milk yield, efficiency of feed utilization, and body weights were enhanced in cows injected with bST for four consecutive lactations. Previous bST treatment did not diminish milk yields in subsequent lactations.

Cross-validation of predicted Wechsler Memory Scale-Revised scores in a normative sample of 25- to 34-year-old patients.

Equations for prorating Wechsler Memory Scale-Revised General Memory (GM) and Delayed Recall (DR) index scores ([Woodard and Axelrod, 1995]) were confirmed in the [Mittenberg et al. (1992)] normative WMS-R sample of 50 subjects between the ages of 25 and 34, and confirmed in a separate clinical sample of 30 patients with closed head injury who were age, education, and gender matched with 30 subjects from that normative sample. Predicted GM and DR index scores fell within 6 points of the obtained scores for 98% of the [Mittenberg et al. (1992)] sample and 93% to 100% of the matched head injury and normative samples, despite statistically significant differences between these groups in obtained GM, DR, and percent retention of LM I and II and VR I and II. Six points is well within the standard error of measurement of these index scores. These findings confirm the earlier cross-validation results reported by [Axelrod et al. (1996)] in a mixed sample of traumatic brain injury and other neurological insult, and suggest that this method of estimating weighted score sums for WMS-R General Memory and Delayed Recall indices may be safely used in normative samples of patients in this age range as well as neurologically compromised patients without significantly impacting index score accuracy.

Clinical utility of Wechsler Memory Scale-Revised and predicted IQ discrepancies in closed head injury.

Comparisons between Wechsler Memory Scale-Revised (WMS-R) indexes and Wechsler Adult Intelligence Scale-Revised (WAIS-R) IQ scores have been proposed to identify severity of memory deficits. However, many neurologic conditions reduce both intellectual and memory functioning, and thus, examining differences between these scores may be of little value. Closed head injured subjects who completed the WMS-R were divided into either mild injury (MI, n = 41) or moderate/severe (SI, n = 41) injury groups based on trauma severity indicators and were matched on age and level of education. The Oklahoma Premorbid Intelligence Estimation (OPIE), a regression formula that takes into account demographic variables as well as IQ performance, was calculated for each subject. Discrepancy scores were calculated between predicted IQ scores and WAIS-R IQ and WMS-R indexes. SI head-injured subjects displayed significantly larger discrepancies (19 points) between OPIE scores and Delayed Recall Indexes from the WMS-R than the MI subjects (10 points). Significantly larger percentages of subjects in the SI group displayed significant (>SD) reductions in many of the WMS-R and WAIS-R scores from estimates than subjects in the MI group. Comparing current memory functioning to estimates of premorbid intellectual ability appears to be a sensitive indicator of presence and degree of intellectual and memory dysfunction in head trauma patients. Results also provide evidence that estimates of premorbid intellectual ability can serve as estimates of premorbid memory functioning.

The effect of legislative requirements on the use of breast-conserving surgery.

BACKGROUND: We studied the effect of state legislation requiring the disclosure of options for the treatment of breast cancer on the use of breast-conserving surgery in clinical practice. METHODS: The National Cancer Institute's Surveillance, Epidemiology, and End Results registry provided data on women from 30 through 79 years of age who underwent breast-conserving surgery or mastectomy for local or regional breast cancer from 1983 through 1990. We examined the trend over time in use of breast-conserving surgery among patients in four sites (Connecticut, Iowa, Seattle, and Utah) where there were no state laws specifically requiring the disclosure of options for the treatment of breast cancer by physicians. For four additional sites (Detroit, Atlanta, New Mexico, and Hawaii) that had such legislation, we determined whether the rate of breast-conserving surgery after the legislation was different from the expected rate. RESULTS: An attorney rated the legislation as giving most direction to physicians in Michigan, followed by Hawaii, Georgia, and New Mexico. The rate of breast-conserving surgery was up to 8.7 percent higher than expected in Detroit for six months after the passage of the Michigan law (P<0.01). The rate was up to 13.2 percent higher than expected in Hawaii for 12 months after that state's law was passed (P<0.05) and up to 6.0 percent higher than expected in Atlanta for 3 months after the passage of the Georgia law (P<0.01). After these transient increases, the surgery rates reverted to the expected levels. No significant effect was detected in New Mexico, where only a resolution without legal force was passed. CONCLUSION: Legislation requiring physicians to disclose options for the treatment of breast cancer appeared to have only a slight and transient effect on the rate of use of breast-conserving surgery.

An active focus of high prevalence of fogo selvagem on an Amerindian reservation in Brazil. Cooperative Group on Fogo Selvagem Research.

Fogo Selvagem (FS) is an autoimmune disease characterized by subcorneal vesicles and antidesmoglein-1 autoantibodies. Previous epidemiologic data have linked the onset of FS to exposure to an environmental antigen(s). This investigation describes a unique human settlement with an extraordinarily high prevalence of FS. This community is made up of Amerindians belonging to the Terena tribe, which has settled on the Limao Verde reservation in the state of Mato Grosso do Sul in Brazil. Twenty-six well-characterized FS cases have been identified within a total population of 998, yielding a prevalence of 2.6%. Seventeen of the patients (65 %) were males, and over 50% were older than 30 y of age. The incidence of the disease shows temporal periodicity, i.e., years with several cases of FS alternating with years with no cases. Over one-half of the cases occurred in genetically related family members. Another Terena reservation, the Ipegue/Taunay, located 90 km west of the Limao Verde reservation, was also evaluated as a control group. This reservation, with a population of 2203, had no recorded cases of FS. Thus, the Limao Verde reservation represents a new focus of FS in which the disease exhibits temporal, geographic, and familial clustering. These results suggest that the environmental antigen or antigens precipitating FS are endemic to the Limao Verde reservation. This reservation appears to be an ideal population for carrying out sero-epidemiologic, genetic, and environmental studies aimed at disclosing the etiology of FS.

Use and perceived effectiveness of pressure ulcer treatments in extended care facilities.

This study investigated the use and perceived effectiveness of available treatment products and procedures for pressure ulcers in extended care facilities (ECFs) in the southern border regions of Arizona, New Mexico, and west Texas. Respondents completed a questionnaire evaluating the effectiveness of products and procedures used by their facilities within the last 5 years. Using descriptive statistics, data from a sample of 96 ECFs in the southwestern United States were analyzed. Respondents reported a variety of products and procedures as effective, but the effectiveness of many of these products has not been supported by research, and some products have been found to be potentially harmful. ECFs are urged to select and use research-based, effective treatment protocols and guidelines for pressure ulcers.

Minimal increase in use of breast-conserving surgery from 1986 to 1990.

Substantial geographic and hospital-based variations have been documented in the use of breast-conserving surgery (BCS) in 1986. The authors studied the patterns of adoption of this procedure from 1986 to 1990. National Medicare inpatient claims were used to study women aged 65 to 79 who underwent an operation for local or regional breast cancer in 1986 (38,679 patients) or 1990 (43,083 patients). Breast-conserving surgery was used for 5,509 (14.1%) of the Medicare patients in 1986 and 6,476 (15.0%) in 1990. The only region with an increase in BCS use from 1986 to 1990 was New England. Many hospitals had low volumes of operations, with a median of six to seven patients annually. Ten percent of the hospitals performed 55% of the conservative operations. Large hospitals, urban hospitals, and those with higher patient volumes or a cancer center were somewhat more likely to have increased use of BCS by 1990. Despite the substantial evidence supporting BCS as an alternative to mastectomy, the overall use of BCS in Medicare inpatients increased minimally from 1986 to 1990. Many patients are treated in hospitals with little experience with BCS. Hospitals using more BCS in 1986 were somewhat more likely to increase the use of BCS by 1990.

Auditory startle response is diminished in rats after recovery from perinatal copper deficiency.

Recovery from perinatal copper deficiency was studied in female and male Sprague Dawley rats for 6 mo. Month-old offspring reared by dams on copper-deficient treatment starting d 7 of pregnancy had up to 80% reductions in regional brain copper concentrations compared with offspring from copper-supplemented dams. Liver copper concentrations and plasma ceruloplasmin diamine oxidase activities of copper-deficient rats were restored to control levels within 1 mo of nutritional repletion with dietary copper. However, brain copper concentrations, with the exception of the hypothalamus and medulla, remain lower than in controls even after 5 mo of treatment. Rats were screened for startle responses and foot splay after 1, 3 and 5 mo of repletion. Diminished auditory startle was evident in rats of both sexes at all repletion times tested, whereas tactile startle and preimpulse inhibition of tactile startle were not influenced by prior copper deficiency, suggesting auditory sensory perception abnormalities. In a separate study, postweaning male rats deprived of dietary copper for 5 wk exhibited clear signs of copper deficiency but normal acoustic startle responses and foot splay. Long-term neurochemical and behavioral abnormalities persist in rats after perinatal copper deficiency.

Dietary NaCl-restriction prevents the calciuria of KCl-deprivation and blunts the calciuria of KHCO3-deprivation in healthy adults.

Previous studies have demonstrated that dietary potassium deprivation in healthy human subjects eating diets otherwise containing normal quantities of NaCl is accompanied by an increase in urinary calcium excretion. This increase in urinary Ca excretion occurs in association with reductions in urinary Na and Cl excretion together with trends for weight gain and is delayed for several days after the initiation of K-deprivation, suggesting that it is mediated by NaCl retention and expansion of the extra-cellular volume. The present studies were thus undertaken to determine whether dietary NaCl restriction prevents the calciuric effect of subsequent K-deprivation. When dietary NaCl intake was limited to 5 +/- 3 mmol/day among 10 healthy adults, subsequent deprivation of KCl (-67 mmol/day) in 5 subjects of deprivation of KHCO3 (-64 mmol/day) in 5 subjects prevented any significant increase in daily urinary Ca excretion during five days of K-deprivation. There was, however, a small but significant cumulative increase above control in urinary Ca excretion at the end of KHCO3-deprivation, averaging + 1.9 +/- 0.6 mmol; P < 0.05. When KCl was restored to the diets urinary Ca excretion increased while restoration of KHCO3 to the diets caused urinary Ca to fall to rates below control. We conclude that the calciuria of K-deprivation when NaCl is present in the diet is largely dependent upon NaCl retention by the kidneys and subsequent ECF-volume expansion. In addition, HCO3 is anti-calciuric.

The Neuman Systems Model as applied to the terminally ill client with pressure ulcers.

Nursing practice can be enhanced by using a systems approach to the client with multifaceted health problems. The Neuman Systems Model, based on the conceptual framework of stress and reaction to stressors, provides a framework for organizing a holistic approach to the nursing care needs of the terminally ill client with pressure ulcers.

Use of psychoactive substances in three medical specialties: anaesthesia, medicine and surgery.

In order to determine the prevalence of psychoactive substance use in three specialty groupings, 1,624 questionnaires were sent to physicians in medicine, surgery and anaesthesia; all had trained at the same academic institution. A response rate of 57.8% was achieved. Comparison of prevalence of impairment rates showed no differences between Surgery (14.4%), Medicine (19.9%) and Anaesthesia (16.8%). Substance abuse was clearly associated with a family history of abuse; 32.1% of the abusers had a family history of such abuse compared with 11.7% of the non-abusers. Increased stress at various career stages did not appear to increase substance abuse; problem areas during medical life times were similar for each specialty. Substances most frequently used were marijuana (54.7%), amphetamines (32.9%); and benzodiazepines (25.1%). Seventy-three used psychoactive drugs which were non-prescribed. Drug counselling programmes were judged inadequate by most. Use of alcohol and drugs by faculty members was reported by a number of respondents.

Development of an ELISA to detect anti-BP180 autoantibodies in bullous pemphigoid and herpes gestationis.

Autoantibodies associated with the subepidermal blistering disorders bullous pemphigoid and herpes gestationis react with a 180-kD transmembrane hemidesmosomal protein, designated BP180. The BP180 ectodomain is composed of a series of interrupted collagen triple helical domains. Located on one of the noncollagenous extracellular segments of this protein is an immunodominant epitope, designated MCW-1, recognized by patient autoantibodies. In this investigation we have developed an enzyme-linked immunosorbent assay system to detect antibody reactivity against the MCW-1 epitope with the use of a bacterial fusion protein containing the BP180 autoantibody-reactive site. The following sera were assayed for reactivity with this recombinant protein: bullous pemphigoid (n = 62), herpes gestationis (n = 28), endemic pemphigus foliaceus (n = 17), lupus erythematosus (n = 15), and normal human sera (n = 22). This enzyme-linked immunosorbent assay-based protocol was shown to be highly specific (98.3%) in detecting autoantibody activity in bullous pemphigoid and herpes gestationis patients. Fifty-three percent of bullous pemphigoid sera and 71% of herpes gestations sera, but none of the control sera, yielded positive results in this assay. Of the patient sera that were known to react with full-length BP180, almost all showed reactivity with the MCW-1 antigenic site of this protein. Autoantibodies detected in this assay were predominantly of the immunoglobulin G class. The results presented here lend support to the hypothesis that this well-defined antigen/antibody system may be relevant in pathogenesis.

Splanchnic insulin dynamics and secretion pulsatilities in abdominal obesity.

Insulin secretion, clearance dynamics, and their relationship to peripheral plasma insulin and glucose levels were monitored during three 12-h periods of overnight rest, intake of three meals, and continuous enteral feeding of mixed nutrients. The low-frequency ultradian and the high-frequency insulin secretion pulsatility characteristics during the steady-states of overnight rest and continuous enteral feeding were also examined. In abdominally obese subjects, the insulin secretion rate was consistently higher than normal by 2.3-fold. Peripheral plasma insulin levels were increased by 3.4-fold during the overnight period and by 4- to 5-fold during the two fed states. Endogenous insulin clearance was significantly reduced during feeding. Both low- and high-frequency insulin secretory pulsatilities were detected in the abdominally obese subjects. Pulse periods were within the normal range. Pulse maxima, nadirs, and absolute amplitudes were increased concomitant with the increase in insulin secretion. Ultradian relative pulse amplitudes, however, were blunted. A significantly higher pulse-to-pulse variability was observed in the abdominally obese subjects compared with normal subjects. Furthermore, a significantly higher level of interindividual variability in the nutrient-stimulated insulin secretion and in the ultradian pulse characteristics was observed. Thus in abdominal obesity, the increase in pancreatic insulin output is limited and the secretory pulsatilities are aberrant, suggesting a defect in the insulin secretory process. Diminished insulin clearance contributes to the degree of peripheral hyperinsulinemia compensating for the insulin resistance characteristic of this form of obesity.

Suppression of shivering by breath holding, relaxation, mental arithmetic, and warm water ingestion.

Four methods of suppressing cold-induced shivering were evaluated in 26 young male volunteers exposed to 0.0 +/- 1.0 degrees C air for 135 min. Voluntary relaxation of musculature (R), breath holding (BH), warm (50 degrees C) water ingestion (W), and performance of a mental arithmetic task (MA) were applied in a counterbalanced order following 2 h of cold exposure. Surface electromyograms of seven muscles were recorded and converted to root mean square voltage (RMS) as a measure of shivering intensity. Mean skin and rectal temperatures decreased significantly, 4.9 degrees C and 0.3 degrees C, respectively (p < or = 0.01). Mean reduction of EMG activity was 35% during R, 24% during BH, 18% during MA, and 5% during W. R was significantly more effective than BH, MA, and W, and BH and MA were significantly more effective than W in reducing shivering. These results indicate that, at small decreases in rectal temperature, shivering can be voluntarily suppressed to some extent during relaxation, breath holding, and mental arithmetic.