The care of older women with early-stage breast cancer: what is the role of surgeon gender?

BACKGROUND: Over the past decade and a half, a substantial literature has documented age-dependent variations in breast cancer care. Accumulating evidence suggests that these variations impact the health outcomes of older women with breast cancer. Surgeon gender may be an important source of age-dependent variations in care. OBJECTIVE: To examine the relationship between surgeon gender and primary tumor therapy and systemic adjuvant therapy among 303 older women with early-stage breast cancer cared for by 20 surgeons in Boston, Massachusetts. METHODS: The research design was a cross-sectional observational study. The subjects were women at least 55 years of age with newly diagnosed Stage I or II breast cancer. The main outcome measure was definitive primary tumor therapy and systemic adjuvant therapy. RESULTS: After adjustment for patient and tumor characteristics, patients of female surgeons were more likely to receive definitive treatment, with the strongest effect being observed for the receipt of both definitive primary tumor therapy and systemic adjuvant therapy (odds ratio 4.5; 95% confidence interval 2.7, 7.7). CONCLUSIONS: Women with early-stage breast cancer cared for by female surgeons are more likely to receive standard therapies. Surgeons provide the initial care, both diagnostic and therapeutic, for all women with breast cancer. Their role in breast cancer care is pivotal and has a substantial impact on the nature of breast cancer care received.     

Can a disease self-management program reduce health care costs? The case of older women with heart disease

BACKGROUND: There is increasing interest in the potential for chronic disease self-management interventions to provide health benefits while reducing health care costs. OBJECTIVES: To assess the impact of a heart disease management program on use of hospital services; to estimate associated hospital cost savings; and to compare potential cost savings with the cost of delivering the program. RESEARCH DESIGN: Randomized, controlled study design. Data were collected from hospital billing records during a 36 month period. Multivariate models were used to compare health care use with cost between treatment and control groups. Estimated differences were then compared with the program costs to determine cost-effectiveness. SUBJECTS: Participants were recruited from 6 hospital sites. Screening criteria included: female, 60 years or older, diagnosed cardiac disease, and seen by a physician approximately every 6 months. The study included 233 women in the intervention group and 219 in the control group. The "Women Take PRIDE" program utilizes a self-regulation process for addressing a problematic area of the heart regimen recommended by each woman's physician. It is tailored to the unique needs of older women. MEASURES: Hospital admissions, in-patient days, emergency department visits. RESULTS: Program participants experienced 46% fewer in-patient days (P <0.05) and 49% lower in-patient costs (P <0.10) than women in the control group. No significant differences in emergency department utilization were found. Hospital cost savings exceeded program costs by a ratio of nearly 5-to-1. CONCLUSIONS: A heart disease self-management program can reduce health care utilization and potentially yield monetary benefits to a health plan.     

What is the perceived quality of life of adults with congenital heart disease and does it differ by anomaly?

Adults with congenital heart disease (CHD) represent a growing population of patients thanks to the medical and surgical advances which enable at least 85% of children to survive to adulthood. These advances may create quality-of-life (QoL) issues not previously considered. The purpose of this cross-sectional study of 124 adults with CHD was to describe their QoL as a basis for providing appropriate information, counseling, and anticipatory guidance. Thirteen patients had single ventricle physiology (SVP), 43 had cyanotic lesions with 2 ventricle repairs, and 68 had acyanotic CHD. On the basis of Sickness Impact Profile (SIP) scores, individuals with SVP had worse QoL than did those with cyanotic lesions (with 2 ventricle repairs) and acyanotic anomalies (SIP = 9.98 vs 4.61 and 3.76). SIP scores were statistically significantly different between those with SVP and those with acyanotic anomalies (P = .02). For all groups, the areas of life most affected were work and sleep and rest. Participants with SVP saw themselves as having the poorest QoL.     

The status of HIV/AIDS nursing in Australia: a specialty in decline?

Since the introduction of highly active antiretroviral therapy (HAART), occasions of service for patients with HIV/AIDS have altered drastically. HIV/AIDS nurses perceived that this change in activity had caused an exodus from the specialty by experienced nurses, and those that remained were rapidly deskilling. A survey of nurses working in HIV/AIDS in Australia and New Zealand was conducted to assess the impact of HAART on nursing skills and retention. More than 72% of respondents reported that they had lost some or many clinical HIV/AIDS nursing skills. About 37% of nurses reported that they were losing confidence in their knowledge of the management of opportunistic infections and cancers. About 27% reported larger numbers of nurses leaving their specialty area than in previous years. To enable nurses to respond rapidly to a potential decline in the effectiveness of HAART, this loss in skills and knowledge must be addressed.     

‘Knowledge is power’: perceived needs and preferred services of male partners of women newly diagnosed with breast cancer

Purpose

The aim of this qualitative exploratory study was to assess the perceived needs and preferred services of male partners of women newly diagnosed with breast cancer.

Methods

Twenty-seven male partners participated in semi-structured telephone interviews. Interviews were recorded and transcribed verbatim. An inductive analysis was used to identify the patterns, themes and categories from the data.

Results

A diagnosis of breast cancer and subsequent treatment significantly affect the male partners of women diagnosed with this illness, creating ‘needs’ that require coping responses. To help them support their wife and family, they relied on their internal resources and informal sources of support. Many participants suggested that the health care system provides information addressing their needs to facilitate their role of caring for their wife. The findings did not support the clinical assumption that men would be interested in a men’s group focused on them and their needs.

Conclusions

The diagnosis of breast cancer significantly affected the male partners, creating the need for support services including information on a variety of topics. An information binder tailored specifically to their needs was the preferred method of facilitating their husbandly role and coping. Findings did not support the clinical assumption that men would be interested in a men’s group focused on them and their needs.     

Perceptions of sexual responsibility: do young men and women agree?

A nonprobability, convenience sample of 248 subjects of a large midwestern university agreed to participate in this study designed to investigate the perception of responsibility for contraception among late adolescents (over age 17), to determine whether age, gender, or sexual activity influences perceptions of responsibility, and to explore the relationship between perceived contraceptive responsibility and subsequent contraceptive choice among late adolescent males and females. The students were enrolled in an undergraduate public health class during the 1984 spring quarter. After initial data examination, 28 married subjects were eliminated from analysis. Of the final sample size of 220 students, 131 were female and 89 were male. The majority of the students, 57.5%, were between the ages of 20-22; 19% were between the ages of 17-19; and the remaining 23% were older than 22. The students completed a questionnaire anonymously as part of the development of a slide-tape program entitled "Young Men's Sexual Responsibility." Contraceptive responsibility was defined as perceived responsibility for pregnancy control, perceived responsibility to initiate conversation about contraception in a dating relationship, and perceived responsibility for who should pay for contraceptives. 63% of the students indicated that they had engaged in sexual intercourse at least once. Male students were significantly more likely to have had sexual intercourse than female students. Only 7% of the entire sample reported having had intercourse before the age of 15, but this sample consisted primarily of white, middle-class college students who may not represent students in inner-city school districts reported to have had 1st intercourse at earlier ages. 91% of the students perceived contraceptive responsibility as a shared responsibility. Of the small number of students who perceived 1 sex or the other responsible for pregnancy control, most (7%) perceived that it was the woman's responsibility. No relationship was found between age or intercourse experience and perceived contraceptive responsibility. 52.3% of the students reported using effective birth control methods at 1st intercourse, but 37.2% reported not using contraceptives. The remaining students used 2 of the least effective methods for adolescents (withdrawal, 7.2%; rhythm, 3.5%). No relationship was found between the students' perception of responsibility for pregnancy control or responsibility for initiating a conversation about contraception and the type of contraceptive used at most recent intercourse. If the concept of shared responsibility is in fact an emerging value, health professionals and educators must reconsider sex education curricula for adolescents.     

Improving sleep hygiene behavior in adults living with HIV/AIDS: a randomized control pilot study of the SystemCHANGETM–HIV intervention

AimThe aim of this study was to test the feasibility of a novel, evidence-based intervention SystemCHANGE–HIV on sleep outcomes.BackgroundInsomnia and sleep disturbances affect an estimated 74% of people living with HIV (PLWH) and is a distressing consequence of HIV disease.MethodsWe conducted a two-group randomized control study with 40 PLWH. Outcomes included change in: sleep duration, sleep fragmentation index, sleep efficiency, and self-reported sleep quality.ResultsParticipants rated the intervention as highly feasible. The intervention group experienced a 10 minute/night increase in sleep time, a 2.3%-point increase in sleep efficiency, a 2.0%-point decrease in sleep fragmentation, relative to the control group, based on the model estimates of the treatment effect.ConclusionsA behavioral change intervention focusing on sleep is feasible in PLWH. The intervention group had improved sleep compared to the control group. Future work should test the efficacy of a refined SystemCHANGE–HIV on sleep.     

The challenge of valvular heart disease: when is it time to operate?

In patients with valve disease, operating too soon exposes them to unnecessary surgical risk, but waiting too long may lead to cardiac damage and poor outcome. When to refer a patient for surgery depends on which valve is involved, the type of defect (stenosis or regurgitation), the degree of the defect, and the degree of symptoms or functional impairment.     

Post-exposure prophylaxis for HIV infection after sexual assault: When is it indicated?

To date there are no published studies on the effectiveness of HIV post-exposure prophylaxis (PEP) after sexual exposure. However, as emergency physicians we are faced with the dilemma of assessing the risk of HIV transmission and providing appropriate care for patients who present to us after sexual assault. Current practice in UK emergency departments and genitourinary clinics varies from trust to trust. There is no direct evidence that HIV PEP after rape prevents transmission or is cost effective. However, there may be certain rape cases where HIV PEP should be prescribed or at least considered. While we wait for more definitive clinical studies, HIV PEP after rape should be considered on a case to case basis. This article aims to provide emergency physicians with current scientific evidence on HIV PEP enabling them to make an informed decision on when HIV PEP is indicated after rape.     

Ready for antiretroviral therapy? Therapy decision making experiences of persons living with HIV

Readiness for therapy of people living with HIV is of major importance in the process of antiretroviral decision making. This qualitative study is part of a prospective multicentre investigation describing readiness for antiretroviral therapy (ART) and decision making in HIV-infected patients. The qualitative results present the daily experiences of people living with HIV in the treatment decision making process related to starting or changing ART. Based on a critical hermeneutic research design, interviews with twelve persons have been conducted. Two main categories were generated: "dealing with oneself and others" and "understanding and being understood". They describe the dialectical process of decision making with a focus on interactions with others. This process includes four themes: illness beliefs, health perspectives, therapy beliefs, life perspectives. The findings of this study reveal that partnerships of health care providers with HIV-infected patients are necessary for treatment decisions. Moreover; it is of major importance for health care providers to include patients' experiences and expertise and to allow time for the different dialogues.     

Migraine – more than a headache: women’s experiences of living with migraine

Purpose: In this qualitative study the aim was to explore the meaning of living with migraine. Methods: In-depth interviews were conducted with ten women about their experience of living with migraine. Halfway through the interview, the women drew a picture of what living with migraine is like, and the interview continued with the conversation being guided by the picture. The interviews were analyzed using a hermeneutic phenomenological method inspired by van Manen. Results: The analysis revealed an essence “Being obliged to endure a life accompanied by an unpredictable and invisible disorder” and three themes “Being besieged by an attack”, “Struggling in a life characterized by uncertainty” and “Living with an invisible disorder.” Conclusions: Migraine is a debilitating disorder which accompanies life in the sense that it or the threat of its return is always present, and yet invisible to others. The struggle of enduring life with migraine is worsened by the feeling of having an invisible disorder and of being doubted. There is a need to increase the knowledge among healthcare professionals about what it means to live with migraine, something this qualitative study offers.

Implications for Rehabilitation

• The meaning of living with migraine is experienced as having a debilitating disorder which accompanies life in the sense that it or the threat of its return is always present, and yet invisible to others.

• There is a need for healthcare professionals to increase their awareness of the meaning of living with migraine, to enable them to meet the needs of each person with migraine.

     

Sex and thyroid hormone status in women with rheumatoid arthritis: are there any effects of menopausal state and disease activity on these hormones?

There has been considerable interest in the role of hormones in the aetiopathogenesis of rheumatoid arthritis (RA). In this study, we aimed to investigate sex and thyroid hormone conditions according to menopausal state and disease activation in RA women. Fifty-four women with RA were included in the study. Age-matched 28 women with low back pain were used as controls. Sex and thyroid hormones were evaluated in all patients, which included the measurement of estradiol (E2), progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, thyroid-stimulating hormone (TSH), total (T) and free (F) triiodothyronine (T3) and (T) and (F) thyroxine (T4). The RA patients were subdivided according to their pre-menopausal and post-menopausal status and their disease activation conditions. Mean age was 45.68 (+/-12.5) in women (aged 22-70) with RA and 42.39 (+/-12.45) in controls (aged 22-62). There were no significant differences in sex hormones, but there were statistically significant higher levels of TT3 and TT4 in whole women with RA compared to controls. Lower concentrations of FSH were detected in active RA patients. There were statistically lower concentrations of LH and higher concentrations of TT3 and TT4 in pre-menopausal RA women, while lower concentrations of FSH were detected in post-menopausal RA women. TT3 and FT3 levels of pre-menopausal RA women were significantly higher than post-menopausal RA women. There were no significant differences for all other hormones studied. In conclusion, sex and thyroid hormones have been influenced in women with RA. Reproductive and menopausal conditions should be taken into consideration when sex and thyroid hormones studies are carried out in RA women.     

The first 3-months post-stroke: what facilitates successfully living with aphasia?

This study used a qualitative approach to describe the experience of the first 3 months post-stroke in order to identify factors which facilitate successfully living with aphasia. Fifteen participants completed semi-structured interviews and self-perceived ratings of how successfully he or she was living with aphasia. A number of themes were identified from the interviews, including: a need to do things in order to be actively engaged in rehabilitation; increase independence and have a purpose in life; the importance of social support; the value of rehabilitation; a need to adapt and make adjustments; and having a positive outlook. These results suggest that a range of service delivery models need to be considered during the early stages post-stroke in order to address individual needs and so that long-term outcomes of people with aphasia may be improved.     

Quality of life of African American breast cancer survivors: how much do we know?

Women affected by breast cancer experience an array of quality-of-life issues that affect their daily living in both short-term and long-term survivorship. Because African American women experience disparities in breast cancer survival, their quality-of-life concerns may paint a different picture from those of other racial and ethnic groups. To gain a better understanding of quality of life in African American women breast cancer survivors, we conducted a review, using an adaptation of Brenner's quality-of-life proximal-distal continuum, of studies that have investigated these women's experiences and associated variables. Twenty-six studies, qualitative and quantitative, were reviewed that identified both deficits and positive outcomes of breast cancer treatment and sequelae, including physical, emotional, social, and patient-provider problems as well as heightened spirituality and positive growth. Although overall global quality of life was favorable in both African American and white survivors, differences existed in the nature and extent of deficits between these 2 survivor groups. Nursing implications of this review point to the need for further rigorous research and wide dissemination of results. Recommendations for practice include tailoring assessments and interventions within the context of the lives of African American women breast cancer survivors.     

Adolescents’ experiences of living with sickle cell disease: An integrative narrative review of the literature

BackgroundSickle Cell Disease is the commonest monogenic haemoglobinopathy worldwide. Living with a long-term condition such as sickle cell disease during adolescence constitutes a significant challenge for the key stakeholders due to the combined effects of chronic illness and adolescent development. For adolescents with sickle cell disease to be cared for and supported appropriately and effectively, it is crucial that health professionals have a comprehensive knowledge and understanding of how adolescents experience living with the condition. While there is developing literature about how adolescent’s experience sickle cell disease, this body of research has not been critically reviewed and synthesised.ObjectiveTo identify, critically appraise and synthesise primary research exploring adolescents’ experiences of living with sickle cell disease to make recommendations for practice and research.DesignIntegrative narrative review.Data sourcesA systematic search of 10 electronic databases and key journals was conducted to identify studies from the inception of databases to September 2016.Review methodInclusion criteria: adolescents with sickle cell disease aged 12–19 years, primary data on adolescents’ own perspectives, and published in English. Data were extracted on study contexts, methodology/design, theoretical constructs, participants, and key findings. Findings from included studies were synthesised using the integrative narrative approach. Additionally, the methodological quality of studies was assessed using the Hawker et al. (2002) appraisal checklist.Results683 studies were identified, of which 40 fulfilled the inclusion criteria. Nine broad themes emerged: knowledge and understanding of the condition, symptom experiences, self-management, attitude to treatment, healthcare experiences, social relationships, difference and striving for normality, school experiences, and emotional well-being and coping. Majority of the studies were of moderate quality methodologically. Quality assessment demonstrated a high risk of bias in three studies.ConclusionsSickle cell disease impacts on multiple facets of an adolescent’s life. While there are similarities in the experience of living with sickle cell disease and living with other chronic illnesses, there are essential differences in relationship dynamics and healthcare experience. The adolescents expressed less confidence in generic healthcare providers. The review highlights areas relating to symptom management and health service provision that has been under-researched and need further exploration to understand adolescents’ experiences and their support needs fully. Nursing care and research should focus more on adolescents’ developmental wellbeing, promote peer support network among adolescents with the condition and with adolescents with other chronic illnesses and collaborate with adolescents to ensure service development are developmentally and culturally appropriate.