Effects of the menopause transition and hormone use on cognitive performance in midlife women.

BACKGROUND: There is almost no longitudinal information about measured cognitive performance during the menopause transition (MT). METHODS: We studied 2,362 participants from the Study of Women's Health Across the Nation for 4 years. Major exposures were time spent in MT stages, hormone use prior to the final menstrual period, and postmenopausal current hormone use. Outcomes were longitudinal performance in three domains: processing speed (Symbol Digit Modalities Test [SDMT]), verbal memory (East Boston Memory Test [EBMT]), and working memory (Digit Span Backward). RESULTS: Premenopausal, early perimenopausal, and postmenopausal women scored higher with repeated SDMT administration (p < or = 0.0008), but scores of late perimenopausal women did not improve over time (p = 0.2). EBMT delayed recall scores climbed during premenopause and postmenopause (p < or = 0.01), but did not increase during early or late perimenopause (p > or = 0.14). Initial SDMT, EBMT-immediate, and EBMT-delayed tests were 4%-6% higher among prior hormone users (p < or = 0.001). On the SDMT and EBMT, compared to the premenopausal referent, postmenopausal current hormone users demonstrated poorer cognitive performance (p < or = 0.05) but performance of postmenopausal nonhormone users was indistinguishable from that of premenopausal women. CONCLUSIONS: Consistent with transitioning women's perceived memory difficulties, perimenopause was associated with a decrement in cognitive performance, characterized by women not being able to learn as well as they had during premenopause. Improvement rebounded to premenopausal levels in postmenopause, suggesting that menopause transition-related cognitive difficulties may be time-limited. Hormone initiation prior to the final menstrual period had a beneficial effect whereas initiation after the final menstrual period had a detrimental effect on cognitive performance.

'When will I see you again?' Using local recurrence data to develop a regimen for routine surveillance in post-treatment head and neck cancer patients.

OBJECTIVE: To develop an evidence-based regimen for routine surveillance of post-treatment head and neck cancer patients. DESIGN: Review of 10 years of prospectively collected patient data. MAIN OUTCOME MEASURES: Time of first presentation of 'new cancer event' (either first recurrence or second primary tumour). We did not evaluate whether or not the detected new cancer events were curable. RESULTS: Data from patients with primary squamous cell carcinoma of the larynx, oropharynx and hypopharynx were analysed. A total of 676 previously undiagnosed squamous cell carcinomas were recorded in these regions. In these patients there were 105 recurrences and 20 second primary cancers were recorded; 95(th) percentile of "time to a new cancer event" was calculated in years. These were for larynx 4.7 years, oropharynx 2.7 years, hypopharynx 2.3 years. The time to new cancer event was similar for early and late laryngeal cancers. Only 36 (47%) of the hypopharyngeal cancers were treated with curative intent and of these 36% had a previously undiagnosed cancer event. CONCLUSION: Local data and published evidence support a follow-up duration of 7 years for laryngeal primaries and 3 years for both oropharyngeal and hypopharyngeal primaries. Late stage oropharyngeal cancers may require longer follow up than early cancers. Patients who continue to smoke may need longer follow up. A change in local follow-up protocol to this regimen would save 10 patient slots every week with no detriment to patient care.

Comorbidity in nasopharyngeal carcinoma: a preliminary communication on the prevalence, descriptive distribution and impact on outcome.

OBJECTIVES: Comorbidity has been shown to be a determinant in treatment selection and survival in squamous cell cancer of the head and neck at various subsites. The objective of this study is to analyse the effect of comorbidity burden on outcome of nasopharyngeal cancer using the Adult Comorbidity Evaluation-27 (ACE-27) instrument. DESIGN: Retrospective analysis. SETTING: Tertiary care centres. PARTICIPANTS: This study included 59 patients diagnosed with nasopharyngeal carcinoma between 1989-2003 in the North-East of England. Exclusion criteria included non-squamous neoplasms of the nasopharynx. Comorbidity was assessed retrospectively from the notes using standard validated techniques described earlier. Tumour, treatment and survival data were obtained from prospective databases. Data was analysed using SPSS for Windows. MAIN OUTCOME MEASURES: Comorbidity and outcome of treatment. RESULTS: Comorbid burden was evident in 44% of patients, with moderate or severe comorbidity in 19%. The cardiovascular system was the most commonly affected system (27%). Cox's proportional hazard model showed age and stage of tumour to have an impact on disease specific survival. Comorbidity was not seen to predict the outcome independent of other factors. The sample size of this study is powered to detect only medium to large effects. We estimate that 614 subjects will be needed to detect a correlation coefficient of 0.1 with 80% power, assuming a type 1 error rate of 5%. CONCLUSION: This study shows for the first time that the comorbidity burden seen in nasopharyngeal cancer does not affect prognosis independent of the TNM staging.

HIV-related traumatic stress symptoms in AIDS caregiving family dyads.

This study assesses HIV-related traumatic stress symptoms in 135 AIDS caregiving family dyads in which the caregiver is a midlife or older mother or wife, and the care-recipient is her HIV-infected adult son or husband. Symptoms of HIV-related traumatic stress can be reliably measured in these dyads, with both caregivers and care-recipients reporting avoidant and intrusive thoughts. Among care-recipients, high symptoms are associated with high daily living assistance requirements, low dyadic adjustment, and high constriction of social activities. Among caregivers, high symptoms of traumatic stress are associated with being HIV positive, feeling overloaded by caregiving demands, and perceiving high levels of HIV stigma. Caregiving mothers and wives may feel traumatized 'courtesy' of their loved one's HIV infection, the caregiving scenario, or the resultant caregiving stress.

Defining the stenotic post-laryngectomy tracheostoma and its impact on the quality of life in laryngectomees: development and validation of a stoma function questionnaire.

OBJECTIVES: The aims of this study were to identify if: (i) size of stoma contributes to quality of life (QoL) in laryngectomees; (ii) stoma size has an impact on routine stoma care and function; and (iii) an optimal stoma size exists below which patients experience stoma problems. DESIGN: Cross-sectional study of laryngectomees. SETTING: Two tertiary care centres. PARTICIPANTS: Fifty-seven patients who had undergone total laryngectomy one to five years ago and using tracheo-oesophageal speech as their primary communication means. MAIN OUTCOMES MEASURES: Three main measures were studied: 1 a new study specific questionnaire designed to assess problems with function and care of the end tracheosto- ma; 2 QoL as assessed by the head and neck QoL instrument; 3 a precision custom designed sizer to measure the minimum stoma diameter. RESULTS: The final study-specific questionnaire contained four items assessing different aspects of stomal function. From raw total scores an overall stomal score was generated. The stoma score was moderately correlated to emotion and speech domains in head and neck Quality of Life questionnaire, indicating that different concepts were being measured. The mean minimum stoma diameter was 15.9 +/- 2.9 mm. There was a significant increase in the area under the receiver operating characteristic curve beyond a threshold value of > or 15 mm; smaller sizes were associated with a poorer stoma score (Mann-Whitney test, P < 0.001). No patient found the stoma sizer use distressing. CONCLUSIONS: Size of stoma significantly contributes to QoL in laryngectomees and stomas with minimum diameters of 14 mm or less are associated with adverse effects on routine stoma function. The study-specific stoma function questionnaire appears to be a useful instrument.

The role of family caregivers in HIV medication adherence.

This study examines the role that mid-life and older wives and mothers play in promoting medication adherence among their HIV-infected husbands or adult sons who require daily living assistance. Interviews were conducted with 112 caregiving dyads, with caregivers reporting on their own behaviours and attitudes towards medications, and care-recipients (persons living with HIV [PLH]) providing information about their own adherence practices. By examining how caregiver characteristics, behaviours, and attitudes may influence PLH adherence it is explicitly recognized that caregivers and PLH are linked within a caregiving dyad. Findings indicate that caregivers often remind PLH to take medications, but these reminders are not significantly associated with adherence. Caregivers also report strong attitudes about medication hassles, concerns over treatment failure and general concerns about adherence. Controlling for background characteristics, high perceived adherence hassles on the part of the caregiver were associated with low PLH adherence, providing evidence of shared influence within the caregiving dyad. Adherence interventions may maximize their effectiveness if they consider the role of the family caregiver because these data suggest that caregiver attitudes are linked with PLH adherence behaviours.

Does cognitive function influence alaryngeal speech rehabilitation?

BACKGROUND: We sought to define the cognitive domains that influence valved speech rehabilitation. METHODS: Sixteen laryngectomees with primary tracheoesophageal punctures were randomly recruited from one head and neck unit. They were assessed by a consultant neuropsychologist and a speech therapist. Speech therapy time was determined from speech therapy notes. RESULTS: The Digit Symbol Substitution Test, assessing learning speed and processing speed, correlated significantly with speech therapy time in the first (p = .002) and third (p = .014) postoperative years, respectively. Categorical fluency assessment correlated positively with speech therapy time in the first year (p = .009). Learning speed (p = .007) and categorical fluency (p = .041) correlated positively with the fall in speech therapy input between the first and third year after laryngectomy. CONCLUSIONS: Learning speed, processing speed, and categorical fluency strongly influence alaryngeal speech rehabilitation. This study highlights the potential for pre-laryngectomy cognitive assessment to help plan alaryngeal speech rehabilitation. This has significant resource implications.

Descriptive study of the type and severity of decompensation caused by comorbidity in a population of patients with laryngeal squamous cancer.

The aim of this study was to systematically identify the type and severity of all comorbid conditions in a cohort of 180 patients with laryngeal squamous cancer. The authors retrospectively surveyed the notes using the Adult Comorbidity Evaluation -- 27 index (ACE-27) and applying a systematic process of data abstraction that had previously been shown to be accurate and reliable. The results provided insight into the distribution, site and extent of decompensation caused by comorbidity. It was found that 116 (64.4 per cent) of 180 patients in the study population had some form of comorbid illness, with the cardiovascular and respiratory systems being the top two body systems affected in 43.9 per cent and 24.1 per cent respectively. One-quarter (25.8 per cent) of these 116 patients had comorbid illnesses in more than one body system. Concurrent neurological disease is associated with high mortality. The ACE-27 is a comprehensive instrument that codes all forms of comorbid diseases in the head and neck cancer setting excepting malnutrition. This study suggests that routine collection of comorbidity will be important in future outcomes analysis and in comparing treatment results between centres. Apparent improvements in treatment outcome following newer therapeutic modalities will have to take into account any changes in the comorbidity type and burden over time.

Stress buffering effects of family support in AIDS caregiving.

This study examines the effects of family support on AIDS caregiver stress over time, comparing HIV-positive and HIV-negative gay-identified men who care for a friend or partner living with HIV (PLWH). Support from the care-recipient's family of origin is assessed, and the stress buffering effects of this type of support are explored longitudinally within a stress proliferation framework for 276 men (114 were HIV-positive, 162 were HIV-negative). Among HIV-positive caregivers, emotional distress is associated with high caregiving stress and low PLWH family support. Emotional distress among HIV-negative caregivers is also associated with caregiving stress, but is not significantly influenced by support from the PLWH's family. For both groups, increasing emotional distress over a seven-month period is a function of increasing caregiver stress, but not PLWH family support. The effects of financial worry and role overload on caregiver emotional distress are conditional upon PLWH family support at Time 1 among HIV-positive caregivers, such that support buffers the distressing impact of financial worry, but may exacerbate the distressing impact of role overload. In addition to characterizing processes of stress proliferation and social support, this research also illustrates how families of choice and families of origin simultaneously shape the experience of the caregiving role and its influence on the wellbeing of gay men.

A cross-comparison of retrospective notes extraction and combined notes extraction and patient interview in the completion of a comorbidity index (ACE-27) in a cohort of United Kingdom patients with head and neck cancer.

Co-existent comorbidity is a major determinant of treatment outcome in head and neck cancer. Most of the work pertaining to this topic has been done in the United States, where the standard practice is for trained cancer registrars to grade comorbidity using validated indexes by retrospective notes review. The adult comorbidity evaluation-27 index (ACE-27) is a validated instrument that has been widely used in head and neck cancer. Although the required clinical data may be available in the notes, a significant amount of historical information is required to grade comorbidity. The aim of this study was to assess the accuracy and inter-rater reliability of the retrospective notes review process, in a typical setting in the United Kingdom (UK), by comparing the information obtained on notes review alone by a physician to that available after a structured patient interview. The study concludes that the retrospective notes review is an accurate and reliable technique for grading comorbidity whose completeness can be improved by the use of patient questionnaire as part of a structured interview.

Applicability of the adult comorbidity evaluation - 27 and the Charlson indexes to assess comorbidity by notes extraction in a cohort of United Kingdom patients with head and neck cancer: a retrospective study.

The term comorbidity stands for disease processes that co-exist and are not related to the index disease being studied. Comorbidity in cancer has been shown to be a major determinant in treatment selection and survival. Patients with head and neck cancer can have significant comorbidity owing to the high incidence of tobacco and alcohol abuse. No studies to date have addressed this problem in head and neck cancer patients in the United Kingdom. The applicability of the adult comorbidity evaluation - 27 index (ACE-27) and the Charlson index (CI) to assess the comorbidity burden by retrospective notes review is studied here. Retrospective data collection and completion of a comorbidity index in a United Kingdom setting is feasible. We conclude that the pre-assessment visit is a useful time to record comorbidity and as a significant amount of information required for grading relates to historical items, this is best done using a self-administered patient questionnaire.

A street intercept survey to assess HIV-testing attitudes and behaviors.

Nationally, it has been estimated that 44% of adults in the United States have been tested for HIV, with substantial individual and community-level variations in HIV-testing attitudes and behaviors. HIV-testing behaviors and intentions and attitudes toward HIV testing, particularly toward home tests, were assessed among 385 adults recruited in a street intercept survey from a gay-identified agency, a substance-abuse treatment program, and inner-city community venues (a shopping mall and community center). Across these Los Angeles sites, the proportion of persons reported being tested for HIV in their lifetime (77%) was higher than the national estimate. Gay-identified agency (88%) and substance-abuse treatment program participants (99%) were more likely to have been tested than were the community participants (67%). Participants from a gay-identified agency were more likely to have had an anonymous test (51%) than were those from a substance-abuse treatment program (25%) or community sites (24%). Attitudes toward HIV testing, including mail-in home-test kits and instant home tests, were very positive. Most participants were willing to pay about $20 for a home-test kit. Participants from the community sites (82%) and the substance-abuse treatment program participants (87%) endorsed notification of HIV status to health departments and sexual partners more than did participants from the gay identified agency (48%). The street intercept survey appears to be a quick and feasible method to assess HIV testing in urban areas.

Variation in health and risk behavior among youth living with HIV.

Lifetime and current health practices and risk behaviors were examined among 350 youth living with HIV (YLH) aged 14-23 years from four AIDS epicenters (72.6% male; 26.2% African American, 36.9% Latino). YLH were relatively healthy (M CD4 cells = 499), had used substantial health care and were satisfied with the care. YLH's sexual and substance-use histories indicated substantial HIV related risk acts: the median number of lifetime partners was 25 with only 8% using condoms consistently; 14.9% had injected drugs, and 61.2% had used hard drugs. Compared with females, males had more lifetime and recent sexual partners and had used more drugs. Youth who were recently sexually active (81.3%) had multiple partners. Most of the sexually active YLH used condoms consistently (81.6%). YLH who were symptomatic or had an AIDS diagnosis were likely to have recently had more seropositive sexual partners than the asymptomatic youth. Youth disclosed their serostatus to about half of their sexual partners (53.9%). YLH with AIDS used fewer hard drugs than those without an AIDS diagnosis. Health and risk behaviors of the YLH varied significantly based on their disease stage, gender, and ethnicity, suggesting the need for tailoring interventions for subgroups of YLH.

Screening for transmission behaviors among HIV-infected adults.

Existing data suggest that a substantial proportion of HIV seropositive adults reduce their substance use and sexual risk behaviors after learning their serostatus. Given the importance of implementing preventive interventions, a screening tool is desirable to allow for a brief method of identifying those who continue to engage in transmission acts. This report explores the sensitivity and specificity of a brief screener used to identify persons living with HIV who engage in unprotected sexual intercourse and/or injection drug use. HIV positive clients of a large AIDS service organization in Los Angeles (N = 178) were screened with a brief, 7-item questionnaire, and responses on the screening interview were compared with self-reports obtained in an in-depth computerized assessment administered on the same day. Participants were randomized to receive the in-depth computerized assessment administered by an interviewer, or a self-administered audio-computer assisted interview. Screener sensitivity and specificity rates were relatively low (68% and 78%, respectively), and sensitivity was lower among African Americans than non-African Americans. Multivariate logistic regression analyses indicated that false negative screener responses were associated with recent sexually transmitted disease experience, controlling for gender, ethnicity, and interview administration mode. Effective strategies need to be developed that screen persons living with HIV who may be transmitting HIV to their sexual or drug-injecting partners.

Precursive depression among HIV infected AIDS caregivers over time.

This study examines depression among HIV infected AIDS caregivers, documenting and explaining variation in health within a stress proliferation framework. Longitudinal data for 376 HIV- and HIV+ caregiving men who self-identify as gay are analyzed to establish how changes in depression are influenced by care-related stressors and by being a member of the gay, HIV-affected community. This research identifies the mechanisms by which the caregiver stress process unfolds distinctively among caregivers with AIDS-related health problems, in comparison to HIV- caregivers. Three waves of data are analyzed using longitudinal multiple regression models. Among HIV infected caregivers, mental health is affected by deteriorating health, perceptions of AIDS alienation/stigma, internalized homophobia, role overload, and financial worry. For both groups, depression is a function of social constriction and AIDS-related bereavement. The precursive nature of caregiving among these HIV infected men may magnify the stress of being in poor health, gay, and stigmatized.

Nutritional consequences of radiotherapy in early laryngeal carcinoma.

In treating patients with malignant head and neck disease, radiotherapy may compromise their oral intake and, thus, their nutritional status. This study aimed to assess a subgroup of patients who received small field radiotherapy, where their early primary tumour itself would not be expected to affect swallowing and where significant nutritional problems are not traditionally identified. A retrospective analysis of hospital records was undertaken on 61 patients, treated for T1 and T2 N0 laryngeal squamous cell carcinoma with primary radical radiotherapy over a three year period (1993-1995 inclusive). At presentation, 97% had their weight and height recorded, enabling calculation of their body mass index (BMI); 13% presented with a BMI < 20 kg/m2 and the 26% of patients who complained of weight loss at presentation had a mean percentage weight loss of 5.35%. During treatment, 79% of patients had their weight recorded and 49% had a documented mean percentage weight loss of 6.4%. The mean BMI at the end of treatment was significantly lower than at presentation (P = 0.03). These effects occurred despite 80% of patients having at least one dietetic consultation (mean 3.5 consults), and 75% having received high protein/high calorie supplementation. The percentage weight loss during treatment correlated significantly with the gamma-glutamyl transpeptidase (gamma-GT) level at presentation. The biochemical markers, haemoglobin and albumin, were normal in the great majority at presentation and fell non-specifically during treatment in 82% and 56% of patients, respectively. We conclude that significant numbers of patients with early laryngeal malignancy are undernourished at presentation and, despite dietetic support, endure considerable nutritional problems during radiotherapy. Attention to nutritional issues is mandatory even in this group of patients previously considered to be less at risk because of the site and early stage of their disease.

The management of massive pneumocephalus and cerebrospinal fluid rhinorrhoea as a consequence of biopsy in a patient with inverted papilloma.

Nasal polypectomy is a common ENT operation. Cerebrospinal fluid (CSF) rhinorrhoea and pneumocephalus are rare complications. We present a patient who developed both these complications after biopsy of nasal polyps which subsequently proved to be an inverted papilloma. He had a defect in the ethmoid roof, which was repaired. Whilst endoscopic repair of CSF leak is increasing in popularity, in this patient because of his pathology and difficulty of access a more traditional lateral rhinotomy approach was made with a successful outcome. An overview of the management of these complications is presented.

AIDS caregiving and health among midlife and older women.

This study reports on analyses of survey data from 121 midlife and older women engaged in AIDS caregiving in Los Angeles and San Francisco. These data revealed that these women provided substantial support to persons living with HIV or AIDS (PWAs) despite other role commitments associated with family and work. Although the characteristics of these women differed according to their relationship to the PWA (mother, wife, sister, or friend), they tended to be similar with regard to both the amount of care provided and its impact on their health. The results indicated that the severity of the PWA's illness and the duration of caregiving were more consequential to health than were the hands-on tasks of caregiving.