Health-related quality of life and the transformation of symptoms

This paper traces the development of health-related Quality of Life instruments over the last half century. It identifies the emergence of key components of quality of life measurement in other health status questionnaires between about 1950 and 1980 and their formalization in Quality of Life instruments in the mid 1980s. The common developmental thread that linked these Quality of Life instruments and their precursors was the identification of 'distal symptoms' that represented the impact of illness beyond its immediate bodily manifestations. The measurement of distal symptoms through Quality of Life instruments also served to detach symptoms from their customary patho-physiological referent. Other contemporary examples of these free-floating symptoms reinforce the argument that the nature and meaning of symptoms has been transformed over recent decades.     

Occupational exposure to ionizing and non-ionizing radiation and risk of non-Hodgkin lymphoma

Objective To investigate the association between occupational exposure to ionizing, ultraviolet (UV), radiofrequency (RF) and extremely low frequency (ELF) radiation and risk of developing non-Hodgkin lymphoma (NHL) in a population-based case-control study. Methods The study population consisted of 694 NHL cases, first diagnosed between 1 January 2000 and 31 August 2001, and 694 controls from two regions in Australia, matched by age, sex and region of residence. A detailed occupation history was first obtained using a lifetime calendar and a telephone interview. Exposure to radiation was then assessed using a Finnish job-exposure matrix (FINJEM). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated from logistic regression models that included the matching variables as covariates. Results For ionizing radiation, the ORs were close to unity. For UV and ELF radiation, the highest exposed group of workers had ORs of 1.32 (95% CI = 0.96–1.81) and 1.25 (95% CI = 0.91–1.72), respectively. For UV radiation there was a positive dose–response when exposure was lagged by 5 and 10 years (P for trend 0.04 for both lag periods). Workers in the upper tertile of exposure for RF radiation had an OR of 3.15 (95% CI = 0.63–15.87), but the estimate was based on very small numbers. Conclusions Our results do not provide support for an association between NHL and occupational exposure to ionizing or ELF radiation. For UV radiation, our findings are consistent with a weak positive association. Further investigation focusing on UV and RF radiation and NHL is required.     

CREST syndrome: a variant of progressive systemic sclerosis, associated with interstitial pulmonary fibrosis and malignancy

We have described a patient who had a clinical picture of CREST syndrome and pulmonary interstitial fibrosis, and in whom adenocarcinoma of the lung developed over a four-year period. Despite absence in the literature of the association of lung carcinoma in patients with CREST syndrome, our case is an example of pulmonary fibrosis complicated by lung cancer without any evidence of other risk factors. We believe this to be the first report of such an association. Clinicians, therefore, must be aware that pulmonary interstitial fibrosis in patients with the CREST syndrome may represent a risk for lung cancer.     

Incomplete Relaxation between Beats after Myocardial Hypoxia and Ischemia

Recovery from hypoxia has been shown to prolong cardiac muscle contraction, particularly the relaxation phase. The present studies were designed to examine whether incomplete relaxation between beats can result from this prolongation of contraction and relaxation in isolated muscle after hypoxia and in the canine heart after both hypoxia and acute ischemia. The relationship between heart rate and the extent of incomplete relaxation is emphasized in view of the known enhancement of the velocity of contraction caused by increasing heart rate.The extent of incomplete relaxation during 10-s periods of pacing at increasing rates was examined before and after hypoxia in isometric cat right ventricular papillary muscle (12-120 beats/min) and in the canine isovolumic left ventricle (120-180 beats/min). Incomplete relaxation was quantified by measuring the difference between the lowest diastolic tension or pressure during pacing and the true resting tension or pressure determined by interruption of pacing at each rate. In eight cat papillary muscles (29 degrees C), there was significantly greater incomplete relaxation 5 min after hypoxia at rates of 96 and 120 beats/min (P < 0.02 vs. before hypoxia). In seven canine isovolumic left ventricles, recovery from hypoxia and higher heart rates also resulted in incomplete relaxation. Incomplete relaxation before hypoxia at a rate of 180 beats/min was 0.8+/-0.5 cm H(2)O and at 5 min of recovery from hypoxia was 12.6+/-3.5 cm H(2)O (P < 0.01). 12 hearts were subjected to a 1.5-3-min period of acute ischemia and fibrillation. There was significant incomplete relaxation at a rate of 140 beats/min for 5 min after defibrillation and reperfusion.These data indicate that incomplete relaxation is an important determinant of diastolic hemodynamics during recovery from ischemia or hypoxia. The extent of incomplete relaxation appears to be a function of the rate of normalization of the velocity of relaxation and tension development after ischemia or hypoxia, the heart rate, and the magnitude of developed tension or pressure.     

Fidelity or flexibility: An ethnographic study of the implementation and use of the Patient Activation Measure

Objective

To evaluate the use of the PAM in the English National Health service. The PAM is a validated scale that measures ‘activation’ (people’s knowledge, skills, and confidence in managing their health) and assigns patients to four categories of activation (low-to-high). Some evidence suggests that higher activation levels correlate to better clinical outcomes and patient experiences, and lower healthcare costs. Empirical studies of implementing the PAM are scarce.

An evaluation of a logbook for trainees in accident and emergency medicine in the United Kingdom.

The ideal requirements of a logbook for trainees in accident and emergency medicine in the United Kingdom were sought by means of a postal survey of 100 Senior Registrars and recently-appointed Consultants in the specialty. Sixty-two replies were received. An overwhelming majority supported ACLS and ATLS certification, as well as formal training in Management/Clinical Budgeting skills, the use of Information Technology, dealing with medicolegal issues and Disaster Planning. Secondments to General Practice, Regional Poisons Centres and the Emergency Services were similarly recommended. A total of 71% (42 responders) approved of a minimum of 3 years experience in an A&E Department before appointment as a Senior Registrar in the specialty. The majority of responders disapproved of acquiring laboratory-based skills. The results of the survey are discussed and suggestions for the possible role of a logbook are made.