Effects of poverty and race on outcomes in acute myeloid leukemia.

OBJECTIVES: To determine how patient race, ethnicity, and degree of poverty affect treatment and survival for acute myeloid leukemia (AML). METHODS: A linked database of the Florida cancer registry and State inpatient and outpatient hospital data for 1998-2002 was queried. Effects of demographic and treatment characteristics on survival were explored using univariate and multivariate analyses methods. RESULTS: A total of 4659 patients with AML were identified. Over 50% of patients with AML were 70 years of age or older. African American (AA) patients were diagnosed at significantly younger ages than were whites (P < 0.001). In multivariate analysis, independent predictors of worse survival in AML were aged over 50 (hazard ratios [HRs]: 1.60, 2.15, 3.04, and 3.62 over the decade-cohorts, all P < 0.001), AA race (HR: 1.27, P < 0.001), being a former or current user of tobacco (HR: 1.13, P = 0.004 and HR: 1.28, P < 0.001, respectively), residing in an area with the highest poverty level (HR: 1.15, P = 0.007), and being covered only by Medicaid (HR: 1.23, P = 0.014). No differences in outcomes were observed related to gender or ethnicity. Receipt of chemotherapy was strongly associated with improved survival (HR: 0.59, P < 0.001). When only those patients who received and appeared to respond to treatment are included, AAs continued to demonstrate a worse outcome than Whites. CONCLUSIONS: AML disproportionately affects the elderly. AA patients and patients from poorer communities with AML have significantly worse survival. Interventions to provide earlier diagnosis in these patients as well as to improve overall outcomes are needed to address these disparities.

Relationship between patient and disease characteristics, and health-related quality of life in adults with asthma.

The purpose of this study was to examine relationships between patient- and disease-related variables and health-related quality of life (HQL). This cross-sectional study surveyed adults with asthma enrolled in a managed care organization (MCO). Data were obtained from a mailed questionnaire and the MCO's patient and claims databases. The Asthma Quality of Life Questionnaire (AQLQ) and the SF-36 instruments were used. The behavioral Model of Health Services Utilization was used to characterize independent variables and their relationships to HQL. Independent variables included predisposing (age, gender, education, race, number of comorbidities, years with asthma, social support, health-belief questions); enabling (income, number of metered dose inhaler (MDI) instructors, perceived inconvenience of accessing the physician); and illness level (perceived and symptom-derived asthma severity). Multivariate linear regression models were developed to examine the relationships between the independent variables and the domain and summary scores of the AQLQ and the SF-36. The survey response rate was 63% (n=603). for the AQLQ, symptom-derived severity perceived severity education level, and the health-belief factor Barriers were significant in all five models. Symptom-derived severity had consistently higher standardized regression coefficients than perceived severity Barriers had the highest coefficient in all but the Symptoms domain model. Number of Comorbidities was significant in all eight domain and two summary score SF-36 models. Symptom-derived and/or perceived severity were also significant in all but the Mental Health domain model. Other frequently significant variables included the health-belief factor Barriers and Yearly Household Income. When assessing HQL of a population, such as this group of patients with asthma, one must consider patient and disease variables that may influence the results.

Improving HEDIS measurement: linking managed care organization and health system ambulatory care data.

This article describes one health system's efforts to improve HEDIS measurement by integrating claims information from its managed care organization with data from its medical center's automated billing, scheduling, and clinical information systems. The authors discuss problems encountered while establishing an integrated measurement process and offer suggestions for others considering such an approach.

Adaptation to pregnancy and motherhood among subfecund and fecund primiparous women.

OBJECTIVE: To examine the effects of infertility treatment on women's ability to adapt to pregnancy and motherhood. METHODS: Fecund (n = 261) and subfecund (n = 103) primiparous women receiving obstetrical care in southeastern Michigan participated in this descriptive, correlational, prospective study. The subjects completed Lederman's Pre-Natal Self-Evaluation questionnaire during the third trimester of pregnancy and Lederman's Postpartum Self-Evaluation questionnaire during the first postpartum appointment. FINDINGS: Mean scores showed that the two groups of women were not significantly different with either adaptation to pregnancy or motherhood. CONCLUSIONS & IMPLICATIONS FOR NURSING: Although subfecund women may experience stress in order to achieve a pregnancy, there do not appear to be any latent effects of this stress on their ability to adapt to pregnancy or motherhood.

Provision and receipt of social support and disregard: what is their impact on the marital life quality of infertile and fertile couples?

A longitudinal study examined perceptions of received and provided social support and disregard among members of 248 infertile and fertile married couples. Correlational and structural equation modeling analyses were conducted. Women's and men's perceptions of the amount of social support they gave to and received from their partner were highly positively related. In contrast, agreement between spouses about the amount of provided support was moderate. Both social support and disregard mediated the relationships between stress and marital quality of life. Overall, highly similar patterns of results were found for members of infertile and fertile couples. These results demonstrate the perceptual element of received support and disregard as well as the importance of considering the provider's perspective.

Gender differences and perceptions about childbearing among infertile couples.

OBJECTIVE: To explore gender differences and responses of infertile couples to childbearing issues. DESIGN: Data analysis from the first wave of a larger three-wave prospective panel study. Face-to-face interviews with both husbands and wives were conducted. SETTING: Husbands and wives were interviewed separately in their homes. One was generally interviewed immediately after the other. PARTICIPANTS: One hundred sixty-one infertile couples in southeastern Michigan were interviewed in 1988. MEASURES: Variables of interest included the self-recognized source of the fertility problem, the importance of children to individuals, stress associated with infertility treatment, the number of tests and treatments received, the acceptability of indicated treatments, the length of time couples expected it would take to have a child, and the ideal and expected number of children. RESULTS: Women experienced significantly more stress from tests and treatment, placed greater importance on having children, were more accepting of indicated treatments, and wanted more children than men did. CONCLUSIONS: Implications for nurses working with infertile couples are discussed, including provision of emotional support, evaluation of perceptions of success, assessment of couples' expectations, and inclusion of husbands in decision making.

Infertility and parenthood: does becoming a parent increase well-being?

There is a large literature that demonstrates that infertility has a variety of negative effects on women's and men's well-being, but little is known about the impact of becoming a parent. The effects of parenthood were examined in a longitudinal study with both wives and husbands from 174 infertile couples and a comparison group of 74 presumed fertile couples. Infertile women who became parents experienced greater global well-being but diminished marital well-being, compared with infertile women who had not become parents. Infertile men who became parents experienced the same negative effects that their wives reported, but they did not experience positive effects to the same extent. Parental status had fewer positive and negative effects on members of presumed-fertile couples. These results are discussed in terms of gender differences in the meaning of parenthood, and their implications for research and clinical services are considered.

Why are couples satisfied with infertility treatment?

OBJECTIVE: To determine which factors relate to satisfaction with infertility treatment. DESIGN: A prospective structured interview research design was used. SETTING: In-person and telephone interviews were conducted. PARTICIPANTS: Wives and husbands from 185 couples in southeastern Michigan with primary infertility were studied. MAIN OUTCOME MEASURES: There were two main outcome measures: how satisfied people were with the infertility treatment they received and why they were satisfied. RESULTS: Both men and women were satisfied with the infertility treatment they had received. The most frequently mentioned reasons for satisfaction were the technical skills and the emotional support of infertility specialists. Both men and women advised infertility specialists to be compassionate and share information with their patients. Spouses' satisfaction with treatment was the greatest predictor for both men and women. For men, using escape as a coping skill was a negative predictor for treatment satisfaction. For women, personal control and the number of infertility treatments received were other predictors for treatment satisfaction. CONCLUSIONS: As hypothesized, a variety of psychosocial factors were related to treatment satisfaction. Contrary to expectation, treatment costs and how long respondents had been trying to have a child were not related to treatment satisfaction. This study's results suggest that physicians and their staff should pay particular attention to their patients' emotional needs, to their patients' understanding of procedures explained to them, to discussing adoption with their patients, to involving men more in the infertility treatment, and to assisting women to have more control over their course of treatment.

Is fertility-problem stress different? The dynamics of stress in fertile and infertile couples.

OBJECTIVE: To compare the dynamics of fertility-problem stress experienced by wives and husbands in infertile couples with the dynamics of stress from other sources experienced by members of couples presumed to be fertile. DESIGN: Relationships of stress to four marriage factors and four aspects of life quality (subjective well-being) are examined within a causal modeling framework using data from structured interviews. SETTING: Face-to-face interviews were conducted in study participants' homes. PARTICIPANTS: Wives and husbands from 157 couples with primary infertility and from 82 presumed-fertile couples were studied. MAIN OUTCOME MEASURES: Final outcome measures were four multi-item scales assessing life quality with regard to the marriage, own self-efficacy, own health and appearance, and life as a whole. Intervening outcome scales measured four marriage factors: marital conflict, sexual self-esteem, sexual dissatisfaction, and frequency of intercourse. RESULTS AND CONCLUSIONS: Higher levels of stress, regardless of whether that stress was from attempting to solve a fertility problem or another problem, were related to reduced marital functioning and decreased life quality. For husbands, the strengths of the linkages did not depend on the source of the stress. For wives, however, the causal model suggested that fertility-problem stress had stronger negative impacts on sense of sexual identity and self-efficacy than did stress from other problems (P less than 0.05). Stress from any source had more impact on the lives of wives than of husbands, more impact on satisfaction with self and general well-being than on satisfaction with the marriage or health, and affected life quality mostly indirectly through its impacts on the marriage factors.

Attitudes about infertility interventions among fertile and infertile couples.

BACKGROUND: There has been marked progress in the development of infertility interventions. This paper reports attitudes about 11 interventions for infertility. METHODS: Face-to-face interviews were conducted with each member of 185 infertile and 90 presumed fertile couples in southeastern Michigan. RESULTS: Seven of these interventions were generally viewed favorably and four were generally viewed negatively, regardless of the couple's fertility status. Infertile couples viewed all interventions, except for adoption, more favorably than did fertile couples. Multidimensional scaling was used to cluster the interventions according to similarity in endorsement. These clusters form a continuum from interventions that allow only one member of the couple to be a biological parent to the most noninvasive techniques. All clusters remain roughly equidistant from adoption, in which neither member of the couple is a biological parent. CONCLUSIONS: Interventions that produce a child who is biologically related to only one member of the couple were viewed most negatively. Members of couples who were receiving fertility treatment made finer discriminations among infertility interventions than did individuals who had not received treatment.

Psychosocial, treatment, and demographic predictors of the stress associated with infertility.

OBJECTIVE: To determine which psychosocial, treatment, and demographic factors relate to the amount of perceived stress that infertile women and men experience. DESIGN: A cross-sectional, structured interview research design was used. SETTING: In-person interviews were conducted in study participants' homes. PARTICIPANTS: Wives and husbands from 185 couples in Southeastern Michigan with primary infertility were studied. MAIN OUTCOME MEASURES: A nine-item rating scale of perceived stress associated with infertility was the outcome measure. RESULTS: For both women and men, stress was significantly positively correlated with treatment costs and number of tests and treatments received; stress was significantly negatively correlated with confidence that one will have a child and perceived control. For women only, attitudes about infertility treatments, importance of children, attributions of responsibility to physicians, and social support also significantly related to perceived stress. For men only, income, number of physicians seen, and self attributions of responsibility also significantly related to perceived stress. CONCLUSIONS: As hypothesized, a variety of treatment characteristics and psychosocial factors were related to experienced stress. Contrary to expectation, demographic factors such as age and number of years married were not related to experienced stress. This study's results suggest that attempts by health care providers to increase patients' sense of control, optimism (within realistic limits), and social support should reduce stress.

Stress from infertility, marriage factors, and subjective well-being of wives and husbands.

Stress associated with the inability to have a child is linked to four aspects of marriage and to five dimensions of life quality. Data come from 157 couples who met a standard medical definition for infertility. Wives and husbands were interviewed independently, and most of the following findings apply to both. A causal model suggests that fertility problem stress has direct effects that increase marital conflict and decrease sexual self-esteem, satisfaction with own sexual performance, and frequency of sexual intercourse. Also, fertility problem stress has both direct and indirect effects (via the marriage factors) that decrease evaluations of life-as-a-whole, self-efficacy, marriage, intimacy, and health. The negative effects on life quality are stronger for wives than for husbands. The model suggests that the life quality of couples with fertility problems could be improved if health care providers and couples themselves took steps to reduce such stresses and/or reduce their impact on the marriage factors.

[Computer tomography of the renal bed after nephrectomy]. / Výpocetní tomografie luzka po nefrektomii.

An early diagnosis of the tumour relapse after performed nephrectomy for a malignant kidney tumour is necessary in order to influence further fate of the patient. The most suitable method for determining a correct diagnosis is computer tomography. The authors present a cohort of 79 patients with a pathological finding in 21 of them. In the other patients the finding after the operation proved to be normal, i.e. the bed was free after the performed nephrectomy, retroperitoneal vessels were free and the line of m. psoas on the surgically treated side proved to be intact. Computer tomography can prove not only the relapse, but also metastatic affection of other organs, particularly in the liver and adrenals.

[Examination of the injured spleen using computer tomography]. / Vysetrení poranené sleziny výpocetní tomografií.

In blunt abdominal injury the most frequently injured organ is the spleen. A rapid and precise diagnosis of an injured spleen is therefore of great importance for early and correct therapeutic procedure. The authors present a group of 56 patients, who have been examined in the 1981-1987 years after blunt injuries of the belly by computer tomography. In 12 cases there was the diagnosis of subcapsular haematoma of the spleen, intraparenchymatous rupture was present in eight patients. In the remaining 36 cases the trauma of abdominal organs was not confirmed. All findings were verified by surgery or a control computer tomography and clinical examination of the patients. The authors demonstrate typical traumatic conditions. Computer tomography is a very useful method which enables a rapid, precise and non-invasive diagnosis of different degree of the spleen injury, its possible complications and differentiates these conditions from uninjured spleen. The authors present a brief survey of pictures of injured spleen in other methods of examination. In comparison with those methods, computer tomography is the most effective one, which provides a complex information of other organs of abdominal cavity. It also enables a considerate examination of patients severely injured and in non-cooperating ones.