Healthcare utilization in cancer survivors: six-month longitudinal cohort data.

PURPOSE: To describe healthcare utilization and reasons for delaying medical care and to identify factors that influence high healthcare utilization and care delay among cancer survivors. METHODS: Baseline (n = 991) and 6 month follow-up data (n = 777) were collected among breast, prostate, and colorectal cancer survivors from 32 US cancer centers. Participants completed surveys on healthcare utilization (e.g., number of visits to specific providers) and delay of medical care. We categorized participants as high or low users based on median number of visits. We used logistic regression models to examine factors that predicted high healthcare utilization or delay. RESULTS: Survivors reported a median of 10.5 visits to healthcare providers and 28% reported ever delaying medical care over 6 months. Compared to prostate cancer survivors, breast and colorectal survivors were 2.4 times more likely (CI = 1.2-4.8) and 4 times more likely (CI = 2.2-7.3) to be high healthcare users, respectively. A higher quality of life score predicted high healthcare utilization (OR = 2.4, CI = 2.0-2.8) and delay of medical care (OR = 1.8, CI = 1.5-2.2). Black survivors were 1.5 times more likely than White survivors to be high healthcare users (CI = 1.1-2.0) and respondents reporting a race category other than White or Black were 1.8 times more likely to delay care (CI = 1.3-2.5). Lower levels of self-efficacy predicted greater healthcare use (OR = 0.7, CI = 0.6-0.8) and delay (OR = 0.6, CI = 0.5-0.7). CONCLUSION: Our findings suggest that race, education, marital status, cancer type, time since diagnosis, quality of life, and self-efficacy are associated with both high healthcare utilization and delay among cancer survivors.

Defining a patient-centered approach to cancer survivorship care: development of the patient centered survivorship care index (PC-SCI).

PURPOSE: This study presents the validation of an index that defines and measures a patient-centered approach to quality survivorship care. METHODS: We conducted a national survey of 1,278 survivors of breast, prostate, and colorectal cancers to identify their priorities for cancer survivorship care. We identified 42 items that were "very important or absolutely essential" to study participants. We then conducted exploratory and confirmatory factor analyses (EFA/CFA) to develop and validate the Patient-Centered Survivorship Care Index (PC-SCI). RESULTS: A seven-factor structure was identified based on EFA on a randomly split half sample and then validated by CFA based on the other half sample. The seven factors include: (1) information and support in survivorship (7 items), (2) having a medical home (10 items) (3) patient engagement in care (3 items), (4) care coordination (5 items), (5) insurance navigation (3 items), (6) care transitions from oncologist to primary care (3 items), and (7) prevention and wellness services (5 items). All factors have excellent composite reliabilities (Cronbach's alpha 0.84-0.94, Coefficient of Omega: 0.81-0.94). CONCLUSIONS: Providing quality post-treatment care is critical for the long-term health and well-being of survivors. The PC-SCI defines a patient-centered approach to survivorship care to complement clinical practice guidelines. The PC-SCI has acceptable composite reliability, providing the field with a valid instrument of patient-centered survivorship care. The PC-SCI provides cancer centers with a means to guide, measure and monitor the development of their survivorship care to align with patient priorities of care. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02362750 , 13 February 2015.

Efficacy of influenza vaccine (Fluvax) in cancer patients on treatment: a prospective single arm, open-label study.

PURPOSE: Influenza virus infection has significant morbidity and mortality in patients with medical co-morbidities who are also immunosuppressed. The efficacy of the seasonal influenza vaccine has not been well studied in patients receiving chemotherapy. We assessed the efficacy of seasonal influenza vaccine in patients with non-haematological malignancy on active treatment (chemotherapy and targeted therapy). METHODS: A prospective single arm, open label study with 53 patients with non-haematological cancers recruited during the 2011 and 2012 influenza seasons. Participants had one dose of 2011/2012 trivalent vaccine containing strains A/California/7/2009(H1N1), A/Perth/16/2009 (H3N2) and B/Brisbane/60/2008 (Fluvax) prior to or in-between treatment cycles. Haemagglutination inhibition antibody (HIA) titres in serum were measured at baseline 3, 6 and 24 weeks. Primary endpoint: seroconversion rate (SCR) at 3 weeks. Secondary endpoints: late SCR at 6 weeks. rate of sustained sero-protection titres (SPR) at 24 weeks. Seroconversion was defined as postvaccination ≥ 4-fold increase in HIA titre and sero-protection defined as a HIA ≥ 1:40. RESULTS: The SCR at 3 weeks were 35%, 30% and 22.5% to the H1N1, H3N2 and B/Bris strains, respectively. There were no new cases of late SC at 6 weeks or 24 weeks. The SPR at 3 weeks were 72.5%, 65% and 40%, respectively, to H1N1, H3N2 and B/Bris. The SPR at 24 weeks to H1N1, H3N2 and B/Bris were 40%, 52.5% and 17.5%, respectively. CONCLUSIONS: Patients on various solid tumour treatments achieve sero-protection rate congruent with the general population. The sero-protection HIA titres were not sustained at 24 weeks postvaccination.

Development of the chemical exposure monitor with indoor positioning (CEMWIP) for workplace VOC surveys.

The purpose of this article was to research and develop a direct-reading exposure assessment method that combined a real-time location system with a wireless direct-reading personal chemical sensor. The personal chemical sensor was a photoionization device for detecting volatile organic compounds. The combined system was calibrated and tested against the same four standard gas concentrations and calibrated at one standard location and tested at four locations that included the standard locations. Data were wirelessly collected from the chemical sensor every 1.4 sec, for volatile organic compounds concentration, location, temperature, humidity, and time. Regression analysis of the photo-ionization device voltage response against calibration gases showed the chemical sensor had a limit of detection of 0.2 ppm. The real-time location system was accurate to 13 cm ± 6 cm (standard deviation) in an open area and to 57 cm ± 31 cm in a closed room where the radio frequency has to penetrate drywall-finished walls. The streaming data were collected and graphically displayed as a three-dimensional hazard map for assessment of peak exposure with location. A real-time personal exposure assessment device with indoor positioning was practical and provided new knowledge on direct reading exposure assessment methods.

The association between a patient-centered quality of care index and self-efficacy among cancer survivors.

PURPOSE: The number of cancer survivors in the US surpassed 18.1 million in 2022 and this number continues to grow. Patient self-efficacy, a patient's confidence in his or her ability to self-manage symptoms and healthcare concerns, has been linked to improved health outcomes. We thus set out to examine the association between a patient-centered care quality index and self-efficacy among cancer survivors. METHODS: Data from 777 survivors of breast, prostate, and colorectal cancers at 32 cancer centers nationwide were collected 6 months after an initial survivorship visit. Patients completed surveys assessing patient-centered care (36 items under seven factors) and individual self-efficacy (eight items). Multiple linear regression was used to examine the association between patient-centered care and patient self-efficacy, adjusting for demographics, cancer-related characteristics, and organizational characteristics of high-quality patient-centered survivorship care. RESULTS: In descriptive analyses, there were no statistically significant differences in demographic or cancer-related characteristics between cancer survivors by quality of patient-centered care. In regression models, a one-unit increase in patient-centered care was associated with a 0.23 (95% CI 0.14-0.32) increase in mean self-efficacy compared to low quality of patient-centered care when adjusting for demographics, cancer-related characteristics, and indicators of high-quality survivorship care. Individually, four of the seven factors of quality patient-centered care were statistically significantly associated with greater self-efficacy. Having a medical home was associated with the greatest increase in self-efficacy among survivors. CONCLUSION: Our findings indicate that higher quality patient-centered care is associated with greater cancer survivor self-efficacy. Given that self-efficacy is correlated with improved health outcomes and quality of life, this finding further supports the importance of high-quality patient-centered survivorship care. IMPLICATIONS OF CANCER SURVIVORS: High-quality patient-centered survivorship care was associated with higher patient self-efficacy. This association should further be explored among cancer survivors with diverse characteristics.

Identifying patients' priorities for quality survivorship: conceptualizing a patient-centered approach to survivorship care.

PURPOSE: This study explored cancer survivors' experiences with and priorities for cancer survivorship care to describe a patient-centered approach to quality survivorship care. METHODS: We conducted 22 focus groups with 170 adult survivors of breast, prostate, and colorectal cancer from six cities across the country and online. We used thematic analysis to identify participants' principles and priorities for quality survivorship care. RESULTS: Based on our analysis of a limited group of cancer survivors, we identified two core principles that underlie participants' expectations for survivorship care and 11 practice priorities that reflect opportunities to improve patient-centeredness at the individual, interpersonal, and organizational levels. The principles reflect participants' desire to be better prepared for and equipped to accept and manage their chronic care needs post-cancer treatment. The priorities reflect practices that patients, providers, and cancer centers can engage in to ensure survivors' goals for post-treatment care are met. CONCLUSIONS: Results from the study suggest the need to expand conceptualization of high-quality survivorship care. The survivor principles and practice priorities identified in this study challenge the field to organize a more patient-centered survivorship care system that empowers and respects patients and provides a holistic approach to survivors' chronic and long-term needs. IMPLICATIONS FOR CANCER SURVIVORS: Quality cancer survivorship care must reflect patients' priorities. The findings from this study can be used to develop a patient-centered framework for survivorship care that can be used in conjunction with quality guidelines to ensure survivorship care is organized to achieve both clinical and patient-centered outcomes.

The inner dynein arms I2 interact with a "dynein regulatory complex" in Chlamydomonas flagella.

We provide indirect evidence that six axonemal proteins here referred to as "dynein regulatory complex" (drc) are located in close proximity with the inner dynein arms I2 and I3. Subsets of drc subunits are missing from five second-site suppressors, pf2, pf3, suppf3, suppf4, and suppf5, that restore flagellar motility but not radial spoke structure of radial spoke mutants. The absence of drc components is correlated with a deficiency of all four heavy chains of inner arms I2 and I3 from axonemes of suppressors pf2, pf3, suppf3, and suppf5. Similarly, inner arm subunits actin, p28, and caltractin/centrin, or subsets of them, are deficient in pf2, pf3, and suppf5. Recombinant strains carrying one of the mutations pf2, pf3, or suppf5 and the inner arm mutation ida4 are more defective for I2 inner arm heavy chains than the parent strains. This evidence indicates that at least one subunit of the drc affects the assembly of and interacts with the inner arms I2.

Mutations in the "dynein regulatory complex" alter the ATP-insensitive binding sites for inner arm dyneins in Chlamydomonas axonemes.

To understand mechanisms of regulation of dynein activity along and around the axoneme we further characterized the "dynein regulatory complex" (drc). The lack of some axonemal proteins, which together are referred to as drc, causes the suppression of flagellar paralysis of radial spoke and central pair mutants. The drc is also an adapter involved in the ATP-insensitive binding of I2 and I3 inner dynein arms to doublet microtubules. Evidence supporting these conclusions was obtained through analyses of five drc mutants: pf2, pf3, suppf3, suppf4, and suppf5. Axonemes from drc mutants lack part of I2 and I3 inner dynein arms as well as subsets of seven drc components (apparent molecular weight from 29,000 to 192,000). In the absence of ATP-Mg, dynein-depleted axonemes from the same mutants bind I2 and I3 inner arms at both ATP-sensitive and -insensitive sites. At ATP-insensitive sites, they bind I2 and I3 inner arms to an extent that depends on the drc defect. This evidence suggested to us that the drc forms one binding site for the I2 and I3 inner arms on the A part of doublet microtubules.

Inner dynein arms but not outer dynein arms require the activity of kinesin homologue protein KHP1(FLA10) to reach the distal part of flagella in Chlamydomonas.

Inner dynein arms, but not outer dynein arms, require the activity of KHP1(FLA10) to reach the distal part of axonemes before binding to outer doublet microtubules. We have analyzed the rescue of inner or outer dynein arms in quadriflagellate dikaryons by immunofluorescence microscopy of p28(IDA4), an inner dynein arm light chain, or IC69(ODA6), an outer dynein arm intermediate chain. In dikaryons two strains with different genetic backgrounds share the cytoplasm. As a consequence, wild-type axonemal precursors are transported to and assembled in mutant axonemes to complement the defects. The rescue of inner dynein arms containing p28 in ida4-wild-type dikaryons progressively occurred from the distal part of the axonemes and with time was extended towards the proximal part. In contrast, the rescue of outer dynein arms in oda2-wild-type dikaryons progressively occurred along the entire length of the axoneme. Rescue of inner dynein arms containing p28 in ida4fla10-fla10 dikaryons was similar to the rescue observed in ida4-wild-type dikaryons at 21 degrees C, whereas it was inhibited at 32 degrees C, a nonpermissive temperature for KHP1(FLA10). In contrast, rescue of outer dynein arms in oda2fla10-fla10 dikaryons was similar to the rescue observed in oda2-wild-type dikaryons at both 21 degrees and 32 degrees C and was not inhibited at 32 degrees C. Positioning of substructures in the internal part of the axonemal shaft requires the activity of kinesin homologue protein 1.

Ambulatory monitoring of the digitized electrocardiogram for detection and early warning of transient myocardial ischemia in angina pectoris.

Patients with coronary artery disease have frequent asymptomatic episodes of ischemic ST-segment depression. A new solid-state recorder that analyzes the digitized electrocardiogram (ECG) in real time has been tested for accuracy in detection and quantitation of these events by comparison with a direct ECG during exercise testing and a frequency-modulated recorder during ambulatory monitoring. The device can also be programmed to produce a tone at the onset of ischemic ST-segment depression, and this tone is used to initiate self-administration of nitroglycerin in an attempt to control myocardial ischemic events. The solid-state recorder demonstrated adequate sensitivity and specificity during exercise (100% and 92%, respectively) for detection and quantitation of episodes of ischemic ST-segment depression. In addition, Monitor One accurately measured the duration of ischemic events during exercise testing (r = 0.95, p = 0.001) and the number (r = 0.92, p = 0.001) and duration (r = 0.97, p = 0.001) of ischemic events during ambulatory monitoring. When the audible tone was used to initiate use of nitroglycerin, the duration of episodes of ischemic ST-segment depression was reduced from 105 +/- 74 min/24 hours to 58 +/- 49 min/24 hours (p = 0.02). Thus, a solid-state ECG recorder capable of long-term monitoring appears to accurately detect and quantify episodes of ischemic ST-segment depression in patients with coronary artery disease. Also, patients can interact with an audible tone to key self-administration of therapy in an attempt to control asymptomatic episodes of transient myocardial ischemia.

Effects of dosing intervals on the development of tolerance to high dose transdermal nitroglycerin.

To investigate the antiischemic efficacy and development of tolerance to transdermal nitroglycerin, 14 patients with chronic, stable angina pectoris were studied using continuous ambulatory electrocardiographic monitoring. Patients demonstrated initial hemodynamic responsiveness to sublingual nitroglycerin and were titrated to a maximally tolerated dose of 30 to 60 mg/24 hours (52 +/- 5 mg). Two crossover phases were use in a randomized, double-blind, placebo-controlled manner: continuous nitroglycerin therapy (patches containing active drug worn for 24 hours) and intermittent nitroglycerin therapy (12-hour active drug followed by a 12-hour nitrate-free period). There were no differences in frequency or duration of ischemic episodes between the placebo days of each phase. A significant effect in frequency of episodes was observed between placebo and treatment days of continuous therapy (p less than 0.05). Nonsignificant reductions in frequency and duration of ischemic episodes also occurred during intermittent therapy. The major antiischemic effect of transdermal nitroglycerin therapy occurred during the first day of treatment but was lost by 48 hours. Reductions in frequency and duration of ischemic episodes (p less than 0.05) were present on day 1 of continuous therapy but ischemic episodes returned to placebo levels by day 2, suggesting the development of tolerance. Intermittent therapy did not prevent the development of tolerance on day 2 of treatment. The results demonstrate that the use of high doses of transdermal nitroglycerin in patients with chronic, stable coronary artery disease produced a beneficial reduction in the frequency and duration of ischemia. However, the antiischemic benefit was lost between 24 nd 48 hours after the onset of continuous and intermittent therapy, presumably due to tolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

Frequency of ST-segment depression produced by mental stress in stable angina pectoris from coronary artery disease.

Physical exertion is a well-documented trigger of transient myocardial ischemia in patients with coronary disease. More recently, studies have shown that mental stress may also be a cause of myocardial ischemia. The purpose of this study was to examine the relationship of physical activities and perceived mental states to myocardial ischemia while patients were going about their normal daily activities. Twenty-eight patients with documented coronary artery disease underwent ambulatory monitoring of the electrocardiogram. Physical activity and perceived mental status were recorded by patients in a diary which was then graded according to intensity of the activity. Analyses of the continuous electrocardiographic recordings were done separately from the analysis of the diaries. The time of each episode of ischemia, the duration of each episode in minutes and the number of episodes in each 24-hour period were calculated. A total of 372 episodes of ST-segment depression occurred in 912 hours of monitoring. Ischemic events occurring during usual physical and usual mental activities were most frequent (36%). Twenty-six percent of ischemic episodes occurred during increased physical activity, but usual mental activities. Interestingly, 22% of the ischemic events occurred at high levels of mental stress, but low physical activity. Ten percent of episodes occurred during sleep. Although the majority of events occurred during usual daily activities, when duration of ischemia was normalized for time spent in each category, increasing physical or mental activity was associated with an increasing duration of ischemia per unit (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Turtle lymphocyte surface antigens in chelydra serpentina as characterized by rabbit anti-turtle thymocyte sera.

Spleen and thymus suspensions from the turtle, Chelydra serpentina were examined by indirect immunofluorescence with a rabbit anti-turtle thymocyte serum (RATT). After the species-specific antibodies had been absorbed out, the antisera labeled all lymphocytes in the thymus and spleen. The specificity of RATT for thymocytes was greater than the specificity for splenic lymphocytes. The presence of two antigens, one thymus specific, TS, and another shared by both thymocytes and splenic lymphocytes, LS, is suggested. The TS antigen was absent from a minor subpopulation of turtle thymocytes and may represent a mature population of T-like cells in the thymus.

Surface immunoglobulin on granular and agranular leukocytes in the thymus and spleen of the snapping turtle, Chelydra serpentina.

Spleen and thymus suspensions from the turtle, Chelydra serpentina were examined by indirect immunofluorescence and found to contain both agranulocytes and granulocytes positive for surface Ig. Among the splenic agranulocytes , 50% of the lymphocyte and monocyte population was positive for surface Ig. In the thymus only 7% of the thymocytes were positive. Ninety-two percent of the granulocytes, composed primarily of basophils and eosinophils, were positive for surface Ig in both the thymus and spleen. The presence of surface immunoglobulins on turtle splenic leukocytes was confirmed by sheep red blood cell (SRBC) immunization studies. Basophils, lymphocytes and monocytes from immunized turtles formed SRBC rosettes, while eosinophils from immunized turtles were found to specifically phagocytose SRBC. Splenic leukocytes from control turtles did not phagocytose or rosette with SRBC. This study demonstrates that indirect immunofluorescent techniques can be used to identify surface immunoglobulin on turtle granulocytes as well as agranulocytes .

The effects of hydrodynamic shear stress on fertilization and early development of the purple sea urchin Strongylocentrotus purpuratus.

Life in the highly turbulent surf zone poses a severe challenge to reproduction in free-spawning animals. Not only can breaking waves quickly dilute the gametes shed by spawning organisms, but turbulence-induced shear stresses may limit fertilization and interfere with normal development. A Couette cell was used to re-create some of the effects of turbulent water motion to study effects of environmentally relevant shear stresses on fertilization in the purple sea urchin (Strongylocentrotus purpuratus). Although low shear stresses improved fertilization success (presumably by increasing mixing), exposure to high shear stresses (of the magnitude found in the surf zone) substantially decreased fertilization success, probably by interfering with contact between egg and sperm. Furthermore, eggs fertilized at high shear stresses often showed abnormal development and low survival of eggs through the blastula stage.

Assessment of Health-Care Worker Exposure to Pandemic Flu in Hospital Rooms.

This study examines the effectiveness of a current Airborne Infection Isolation Room (AIIR) in protecting health-care workers (HCWs) from airborne-infection (AI) exposure, and compares HCW AI exposures within an AIIR and a traditional patient room. We numerically simulated the air-flow patterns in the rooms, using room geometries and layout (room dimensions, bathroom dimensions and details, placement of vents and furniture), ventilation parameters (flow rates at the inlet and outlet vents, diffuser design, thermal sources, etc.), and pressurization corresponding to those measured at a local hospital. A patient-cough was introduced into each simulation, and the AI dispersal was tracked in time using a multi-phase flow simulation approach. The measured data showed that ventilation rates for both rooms exceeded 12 air-changes per hour (ACH), and the AIIR was at almost 16 ACH. Thus, the AIIR met the recommended design criteria for ventilation rate and pressurization. However, the computed results revealed incomplete air mixing, and not all of the room air was changed 12 (or 16) times per hour. In fact, in some regions of the room, the air merely circulated, and did not refresh. With the main exhaust flow rate exceeding the main supply, mass flow rate conservation required a part of the deficit to be accounted for by air migration from the corridor through the gaps around the main door. Hence, the AIIR was effective in containing the "infectious aerosol" within the room. However, it showed increased exposure of the HCW to the AI pathogens, as the flow from the ceiling-mounted supply louver first encountered the patient and then the HCW almost directly on its way to the main exhaust, also located on the ceiling. The traditional patient room exhibited a similar flow path. In addition, for the traditional patient room, some cough-generated aerosol is observed very close to the gaps around the door to the corridor, indicating that the aerosol may escape to the corridor, and spread the infection beyond the room. The computational results suggest that ventilation arrangement can have an important role in better protecting the HCW from exposure to airborne infectious pathogens.