Quality of life after breast carcinoma surgery: a comparison of three surgical procedures.

BACKGROUND: Because breast-conserving surgery (BCS), mastectomy alone, and mastectomy with reconstruction are equally effective for the treatment of early stage breast carcinoma, women's choice among them often focuses on quality-of-life (QOL) issues. Information regarding QOL after these surgical treatments could help women with this decision. METHODS: Participants in this prospective study were women, age 30-85 years, with newly diagnosed breast carcinoma who underwent BCS (n = 103), mastectomy alone (n = 55), or mastectomy with reconstruction (n = 40). Quality of life was assessed after diagnosis (baseline) and at 1, 3, 6, 12, 18, and 24 months after baseline by using the Mischel Uncertainty in Illness Scale, Profile of Mood States, and Functional Assessment of Cancer Therapy for Breast Cancer. RESULTS: In multivariate regression analyses controlling for the QOL score obtained at baseline, age, and type of nonsurgical treatment, women who underwent mastectomy with reconstruction had greater mood disturbance (P = 0.002) and poorer well-being (P = 0.002) after baseline than women who had mastectomy alone; these differences remained 18 months after surgery. Although similar analyses also showed that women who underwent BCS had more mood disturbance than women who had mastectomy alone, this difference was significant only at 12 months after baseline. The BCS and mastectomy-only group did not differ significantly regarding well-being. CONCLUSIONS: Aspects of QOL other than body image are not better in women who undergo BCS or mastectomy with reconstruction than in women who have mastectomy alone. In fact, mastectomy with reconstruction is associated with greater mood disturbance and poorer well-being.

Effects of advanced nursing care on quality of life and cost outcomes of women diagnosed with breast cancer.

PURPOSE/OBJECTIVES: To evaluate quality of life (QOL) and cost outcomes of advanced practice nurses' (APNs') interventions with women diagnosed with breast cancer. DESIGN: Randomized clinical trial. SETTING: Integrated healthcare system in a midwestern suburban community. SAMPLE: 210 women with newly diagnosed breast cancer with an age range of 30-85 years. METHODS: The control group (n = 104) received standard medical care. The intervention group (n = 106) received standard care plus APN interventions based on Brooten's cost-quality model and the Oncology Nursing Society's standards of advanced practice in oncology nursing QOL was measured using the Functional Assessment of Cancer Therapy, Mishel Uncertainty in Illness Scale and Profile of Mood States at seven intervals over two years. Information about costs (charges and reimbursement) was collected through billing systems. MAIN RESEARCH VARIABLES: Uncertainty, mood states, well-being, charges, and reimbursement. FINDINGS: Uncertainty decreased significantly more from baseline in the intervention versus control group at one, three, and six months after diagnosis (p = 0.001, 0.026, and 0.011, respectively), with the strongest effect on subscales of complexity, inconsistency, and unpredictability. Unmarried women and women with no family history of breast cancer benefited from nurse interventions in mood states and well-being. No significant cost differences were found. CONCLUSIONS: APN interventions improved some QOL indicators but did not raise or lower costs. IMPLICATIONS FOR NURSING PRACTICE: The first six months after breast cancer diagnosis is a critical time during which APN interventions can improve QOL outcomes. More research is necessary to define cost-effective interventions.

Prognostic factors after conservative surgery and radiation therapy for early stage breast cancer.

A retrospective review was conducted of all early-stage breast cancer patients treated with breast-conservation surgery plus radiation therapy (BCS/RT) to determine mortality and recurrence rates and to evaluate prognostic factors for these outcomes. Between 1982 and 1988, 121 patients with stages I and II breast cancer were treated with BCS/RT at our institution. Most of the patients (83%) had re-excision of the initial biopsy site and at final surgical evaluation, only 4 patients had positive margins (3.2%). Median follow-up was 89.7 months. Cox proportional hazards regression models were used to select prognostic factors significant for breast cancer-specific mortality, overall disease recurrence, and local recurrence. Breast cancer survival rates were 92% at 5 years and 83% at 10 years. Prognostic factors predicting breast cancer mortality included positive lymph nodes (relative risk=.9; 95% confidence interval, 1.2,12.2) and a higher grade (relative risk=1.9; 95% confidence interval, 1.1,3.3). For disease recurrence, prognostic factors included positive nodes (relative risk=2.6; 95% confidence interval, 1.2, 5.5), and a negative progesterone-receptor status (relative risk=0.3; 95% confidence interval, 0.2, 0.8). Local recurrence rates were 2.5% at 5 years and 14% at 10 years. No prognostic factors were significant for local recurrence; however, most patients had negative margins after surgery.

Interaction of socioeconomic status and provider practices as predictors of immunization coverage in Virginia children.

OBJECTIVE: To describe the pattern of immunization in the cohort of children who entered public schools in Virginia in 1992. DESIGN: This was a historic cohort study using stratified cluster sampling. Three strata were created based on the socioeconomic status (SES) of the children in the catchment area of each public school in Virginia. SETTING: The random sample included public elementary schools throughout Virginia. PARTICIPANTS: Immunization records were obtained for a randomly selected cohort of 2519 first-grade children in Virginia. OUTCOME MEASURES: Age at completion of recommended childhood vaccines was determined from birth to school entry by SES, race, and population density. Provider practices were assessed by ascertaining missed opportunities for simultaneous administration of vaccinations according to recommended schedules. RESULTS: Although immunization completion rates were high at school entry, low levels of immunization coverage were found in all areas of Virginia at 24 months of age regardless of SES (as measured by per capita income), population density, or race. However, under-immunization was more severe for poor children in urban areas (42.3% of children in low-SES urban areas were age-appropriately immunized at 24 months of age versus 64.0% in children in high-SES rural areas). By multivariate logistic regression, race and gender were not predictors of which children were appropriately immunized at 2 years of age after adjusting for the following: SES, population density, receiving the first DTP (diphtheria, tetanus, and pertussis) or OPV (oral polio) vaccination after 3 months of age, and failure to have the first DTP administered simultaneously with the first OPV or the second DTP administered simultaneously with the second OPV. Receiving the first DTP or OPV vaccination after 3 months of age and failure to have the first and second DTP and OPV administered simultaneously were the strongest predictors of not being age-appropriately immunized at 2 years of age. The effect of failure to vaccinate simultaneously on predicting vaccination coverage at 2 years of age was strongly modified by SES. Children who attended schools located in census tracts with per capita incomes less than $10,600 and who did not have the first and second doses of DTP and OPV administered simultaneously were 33.19 times more likely not to be age-appropriately immunized at 2 years of age compared with children who attended schools located in census tracts with per capita incomes greater than $18,800 and who received the first and second doses of DTP and OPV simultaneously (95% confidence interval: 18.29 to 60.22). CONCLUSIONS: Although beginning the immunization schedule at the recommended age was crucial to appropriate vaccination later in life, provider practices were important predictors of under-immunization. Failure to administer vaccinations simultaneously strongly influenced poorer children in Virginia. Serious delays in vaccine administration were observed not only for poor children in urban areas, but also in all areas of Virginia before school entry.

A cost-benefit analysis of smoking cessation programs during the first trimester of pregnancy for the prevention of low birthweight.

BACKGROUND: The frequency of low birthweight decreases when women quit smoking in the first trimester of pregnancy. This analysis examines the cost-effectiveness of smoking-cessation programs during pregnancy for the prevention of low birthweight. METHODS: Using data from the 1988 National Health Interview Survey and estimated costs of care for low birthweight and normal birthweight infants, a decision tree was constructed to estimate break-even costs for smoking-cessation programs, assuming a success rate of 18%. Sensitivity analyses were performed to determine how program effectiveness and changes in the population affected the break-even costs. RESULTS: For a population similar to that which participated in the 1988 National Health Interview Survey, smoking-cessation programs would be cost-effective if the program cost $80 or less. In general, to be cost-effective, a smoking-cessation program has to decrease smoking rates by 2.15% to justify every $10 in program costs. Sensitivity analyses showed that as the baseline spontaneous quit rate in the smoking population decreases, smoking-cessation programs of higher cost become more cost-effective. CONCLUSIONS: Smoking cessation programs during pregnancy may be cost-effective for preventing low birthweight if their cost is $80 or less and they achieve success rates of at least 18%.

Childhood immunization availability in primary care practices. Effects of programs providing free vaccines to physicians.

OBJECTIVE: To examine state immunization distribution programs, along with physician practice, training, and attitudinal factors that influence the availability of childhood immunizations in community practices. DESIGN: Multistate survey stratified by rural and urban practice. PARTICIPANTS: Family physicians in community practices in three states that offer free vaccines to physicians for use in Medicaid recipients (n = 287) and three geographically matched states that do not offer free vaccines (n = 266). RESULTS: Physicians practicing in states that offer free vaccines for use in Medicaid populations were more likely to offer immunizations to patients in their practices (92% vs 75%, respectively; P < .001). This difference persisted even after adjusting for other practice variables that are associated with immunization availability. Physicians who did not offer immunizations cited cost factors as the primary reason for not offering this service. Public health departments were used as the referral site for immunization services, but only 59% of the physicians performed follow-up to determine whether patients received immunizations. CONCLUSIONS: State immunization programs that provide vaccines free to physicians are highly associated with practice policies that increase immunization availability.

Cerebral cardiovascular and respiratory variables after an experimental brain missile wound.

Brain missile wounding (BMW) affects brainstem and medullary cadiorespiratory functions leading to immediate systemic hypertension, bradycardia, and apnea. Secondary complications may also occur because of subsequent changes in systemic and intracranial physiological variables. To delineate the immediate and secondary effects of BMW, we monitored changes in several cerebral and cardiorespiratory parameters in pentobarbital-anesthetized spontaneously breathing cats before wounding and up to 90 min afterward. Total and regional cerebral blood flow (rCBF) and cardiac output (CO) were measured (microsphere technique) and arterial blood was sampled for pH, PO2 and PCO2 once before BMW and one to four times afterward. Mean arterial blood pressure (MABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP = MABP - ICP), electrocardiogram (ECG), heart rate (HR), and electroencephalogram (EEG) were continuously recorded. Respiratory frequency (f), tidal volume (Vt), and ventilation (V) were recorded during each flow measurement and periodically throughout the experiment. Four unwounded cats served as controls and 15 cats were wounded at 1.4 J fronto-occipitally through an intact cranium. Unwounded cats showed no significant changes in any physiological variable measured during a 100 min experimentation period. Four wounded cats survived a 90 min post-BMW period and had only a transient brainstem effect including a 50% increase in MABP concurrently with 50% reductions in the f and HR. Nonsurvivors (11 of 15) lived from 1 to 41 min after wounding. These cats initially demonstrated similar changes in MABP, f, and HR to survivors, but these variables remained unstable, possibly indicating a persisting brainstem damage. Apnea accounted for death in 10 of 11 nonsurvivors. Although the primary brainstem effect might have existed in all nonsurvivors, it appears that only one cat died from reduced respiration alone. Others had one or several postwounding secondary complications: abruptly increased ICP producing a negative CPP, extreme reductions in CO or CBF and ventilation. Cardiac arrest occurred once. Thus, post-BMW mortality cannot be consistently ascribed to the impairment of a single physiological variable.

Central and peripheral biogenic amine effects of brain missile wounding and increased intracranial pressure.

This study was performed to ascertain the acute effects of brain missile wounding on brain-stem and hypothalamic biogenic amines in a group of cats anesthetized with pentobarbital (40 mg/kg). Brain wounding is associated with a concomitant increase in intracranial pressure (ICP); to separate the effects of elevated ICP alone from the effects of wounding, a second group of cats had ICP artificially increased from a normal level of approximately 5 mm Hg to approximately 140 mm Hg by infusion of mock cerebrospinal fluid into the cisterna magna. In both groups, significant epinephrine depletions (47% to 74%) occurred in the nucleus tractus solitarius, area A1C1, locus ceruleus, raphe nuclei, and posterior hypothalamus. Epinephrine levels were also significantly decreased in the anterior hypothalamus in the wounded cats. In addition, both brain wounding and artificially induced ICP increases caused significant decreases of norepinephrine in the posterior hypothalamus, and of serotonin, 5-hydroxyindoleacetic acid, dopamine, and homovanillic acid in the raphe nuclei. Only brain wounding, however, caused significant reductions of norepinephrine, dopamine, and homovanillic acid in the nucleus tractus solitarius and area A1C1. The plasma catecholamine levels resulting from brain wounding or artificially induced ICP increases were dissimilar only in the amount of time required to attain maximum plasma levels, with the wounded animals responding faster. It is concluded that the hypothalamic and brain-stem biogenic amine changes resulting from either brain wounding or increased ICP alone are reflective of a stress response. Brain-stem distortion caused by brain wounding did not appear to be a factor and monoaminergic systems appeared to remain intact despite a severe and eventually lethal brain injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Coagulation changes after an experimental missile wound to the brain in the cat.

Platelet studies (total number and platelet aggregation) and coagulation assays (fibrinogen, factor VIII, and anti-thrombin III) were performed on systemic arterial blood of four control and four experimental adult cats that sustained a penetrating missile injury to the brain. Among the brain-wounded, a significant decrease in the total number of platelets and aggregates occurred 120 minutes after injury. Fibrinogen levels decreased significantly in the brain-wounded animals by 240 minutes after injury and continued declining until the end of the 6-hour experiment. No significant changes occurred in factor VIII and antithrombin III levels in wounded as compared with control animals. These results indicate that blood coagulation factors are altered following a missile wound to the brain. These alterations may, occasionally, lead to clinically manifested bleeding disorders, specifically disseminated intravascular coagulation. Thus, early analysis and control of the coagulation system in the brain-wounded patient should be considered to prevent and treat bleeding disorders in the setting of penetrating head injury.

Brain edema following an experimental missile wound to the brain.

Brain edema occurs after brain injury and may be life threatening. The occurrence and type of brain edema, its magnitude, and time course have never been ascertained following a missile wound to the brain. We therefore measured the development of brain edema in a series of cats in which a right cerebral hemisphere wound was made with a 2.0 mm, 31.7 mg steel sphere with a velocity of 240-300 m/s (0.9-1.4 J). The entire brain was surveyed for postwounding brain edema by determining the wet weight minus dry weight. Brain edema was seen to develop only in the white matter about the missile wound track in the injured cerebral hemisphere. There, brain water rose from 66 to 73%; white matter sodium also increased significantly from approximately 150 mEq/kg dry weight to 254 mEq/kg dry weight. Potassium levels remained essentially unchanged. This vasogenic edema was relatively mild, peaked at 24-48 h after wounding, and resolved spontaneously within a week without specific treatment. We infer that brain edema following an uncomplicated cerebral missile wound in the human brain is also mild, self-limited, and may resolve spontaneously without special treatment.

Brain edema after an experimental missile wound.

We have developed an experimental model to study cerebral pathophysiology associated with a missile wound to the brain. After wounding, vasogenic edema occurs about the missile wound track in the injured cerebral hemisphere. This edema is relatively mild, does not appear life-threatening, peaks at 48 hr after wounding, and spontaneously resolved in 1 week.

Experimental missile wound to the brain.

Among civilians in the United States, 33,000 gunshot wound deaths occur each year; probably half of these involve the head. In combat, head wounds account for approximately half of the immediate mortality when death can be attributed to a single wound. No significant reduction in the neurosurgical mortality associated with these wounds has occurred between World War II and the Vietnam conflict, and very little research into missile wounds of the brain has been undertaken. An experimental model has been developed in the anesthetized cat whereby a ballistic injury to the brain may be painlessly reproduced in order that the pathophysiological effects of brain wounding may be studied and better treatments may be designed to lower the mortality and morbidity rates associated with gunshot wounds. Prominent among physiological effects observed in this model was respiratory arrest even though the missile did not injure the brain stem directly. The incidence of prolonged respiratory arrest increased with increasing missile energy, but arrest was often reversible provided respiratory support was given. It is possible that humans who receive a brain wound die from missile-induced apnea instead of brain damage per se. The mortality rate in humans with brain wounding might be reduced by prompt respiratory support. Brain wounding was associated with persistently increased intracranial pressure and reduced cerebral perfusion pressure not entirely attributable to intracranial bleeding. The magnitude of these derangements appeared to be missile energy-dependent and approached dangerous levels in higher-energy wounds. All wounded cats exhibited postwounding increases in blood glucose concentrations consistent with a generalized stress reaction. A transient rise in hematocrit also occurred immediately after wounding. Both of these phenomena could prove deleterious to optimal brain function after injury.

Measles in schools: age at vaccination vs risk of disease.

In January and February 1983, ten students in three schools in Batesville, AR developed measles. The index case was in a 7-year-old unvaccinated student who had just returned from a trip to Florida. Risk of measles for inadequately immunized students (unimmunized or immunized before their first birthday) in schools was 22 times greater than for those who had been immunized on or after 12 months of age. Measles transmission occurred despite 90% of the school children having had documented evidence of adequate vaccination.

Imported measles outbreak in a university.

In 1981, a measles outbreak in an Arkansas university involved 16 students and four persons who were contacts of these students. The first two cases were in students who recently returned from Honduras. Of the 16 students with measles, 12 had significant gastrointestinal symptoms; five had elevated liver transaminase, and eight were hospitalized. Only two of the students were considered adequately immunized. A voluntary immunization clinic held on the university campus resulted in 67 per cent of 3,076 students being vaccinated.

Role of immune complexes in rheumatoid polyarteritis.

Serial clinical and serological observations were made on a patient with necrotising polyarteritis associated with rheumatoid arthritis. Significant levels of circulating immune complexes, as determined by a C1q binding assay, were observed up to 2 years before the clinical manifestations of polyarteritis but rose abrumptly immediately before and concurrently with the onset of polyarteritis. Concomitant serial determinations of C3, latex fixation titres for anti-immunoglobulin, and patterns of fluorescence of antinuclear antibody afforded insight into the nature of these somplexes, as did clinical and serological response to glucocorticoid and cytotoxic therapy. Our data suggest that the antibody involved in the complex was of the IgG class and capable of complement fixation.

Candida tropicalis arthritis - assessment of amphotericin B therapy.

A 28 year old male heroin addict developed Candida tropicalis infection of the knee joint in association with candidemia. Assessment of amphotericin B therapy was facilitated by the determination of serum and synovial fluid amphotericin B concentrations using a radiometric bio-assay method. The results indicate that adequate synovial fluid drug levels were achieved with intravenous systemic therapy.