Improving rates of cervical cancer screening and Pap smear follow-up for low-income women with limited health literacy

Adult literacy is an independent and important predictor of health behavior. In 1993, the National Adult Literacy Survey conducted by the U.S. Department of Education demonstrated that one-third of the U.S. population over age 16 (44 million adults) is functionally illiterate. Several studies link low health literacy to self-reported poor health status, poor health behavior, and inadequate knowledge about disease. Epidemiologic studies of cancer prevention have not detected strong racial and ethnic disparities in disease detection and progression, resulting in an emphasis on behavioral and intervention-based research. Low literacy presents a wide-reaching barrier to disease prevention that, unlike race/ethnicity, is potentially modifiable. Here, we explore the relationship between health literacy and health behaviors related to cervical cancer prevention in an effort to address concerns about low rates of screening and follow-up in vulnerable populations. Our goal is to improve our understanding of the health impact of low literacy among urban women and to inspire interventions that will promote disease prevention behaviors in this population, particularly with regard to cervical cancer.     

Quality improvement efforts in oncology: are we ready to begin?

Large variations in the quality of cancer care are a matter of concern in the United States. Despite spending over 15% of our GNP on health care, more than any other country in the world, some cancer patients face significant risks of dying from their treatment precisely because of their choice of physician. The Institute of Medicine has reported that variations in the quality of cancer are large, and that low-experienced providers are more likely to provide a lower quality of medical care. Increased pressures to contain costs have led to concern that the quality and outcomes of cancer care may only worsen. One reaction to this situation is a greater reliance on “report cards.” In an effort to address both quality and cost issues, providers are looking outside the health care sector for guidance for more acceptable alternatives to report cards, which are often viewed as punitive. The approach that they most often have selected recently is termed continuous quality improvement (CQI) or total quality management (TQM). In this article, we describe the potential benefits and drawbacks of CQI efforts in oncology, review experiences with four different CQI cancer programs, and make recommendations about future CQI efforts.     

The role of inadequate health literacy skills in colorectal cancer screening

Colorectal cancer is ideally suited for early detection strategies that are likely to improve survival rates. Screening with either a fecal occult blood test (FOBT) or flexible sigmoidoscopy has been shown to identify precancerous polyps or cancers in early stages. However, persons with limited education and of lower socioeconomic status infrequently participate in screening programs in general and have very low rates of colorectal screening. Low literacy, which is common among persons with limited education and low income, may be an overlooked factor in understanding patients' decision making about colorectal cancer screening. This article provides information from focus groups about colorectal cancer screening, which we examine in the context of relevant literature on cancer screening and literacy. Using the health belief model, we examine the association between inadequate health literacy skills and low rates of colorectal cancer screening. The theoretical model also provides insights into strategies for improving knowledge, attitudes, and beliefs and screening rates for this challenging patient population.     

Locally advanced head and neck cancer

Opinion statement The simultaneous administration of chemotherapy and radiation has produced a significant impact on the treatment of advanced squamous cell carcinomas of the head and neck. Although no single regimen has emerged as the “standard” approach, recent trials have consistently demonstrated the superiority of combined treatment programs over radiotherapy alone for local tumor control and overall survival. More-over, multimodal treatment has emerged with important ancillary goals of organ preservation, improved cosmesis, and enhancement of quality of life. With improving survival in all stages of disease, much attention can be given to identifying effective measures to reduce the risk of metachronous primary cancers in this high-risk group.     

Sources of coercive behaviours in psychiatric admissions

OBJECTIVE: Coercion during psychiatric admissions has been a topic of debate for many years. Although there has been considerable research on patients' perceptions of coercion, there has been no work on who places pressures on patients to be admitted. METHOD: This article integrates interview data from interviews with patients, admitting staff and family and friends to describe the pressures brought to bear on patients to be admitted. RESULTS: Health-care professionals appear to be the most important source of pressures on patients, and to have the most impact on patients' perceptions of coercion. However, there are differences in type of pressure, and the pressures used by family and friends appear to have the most longstanding impact. CONCLUSION: Legal and clinical efforts to reduce the level of coercive pressures on patients need to recognize the importance of mental-health professionals, including especially those who are not legally mandated to participate in the admission process.     

Association of Adult Achalasia and Alacrima

Achalasia is the best described motor disorderof the esophagus. Associations with familialglucocorticoid deficiency and alacrima (triple Asyndrome) have been described in the pediatricpopulation, but no attention has been paid to the possibilityof this association in adults. Tear production wasassessed in 20 patients with achalasia and 20 age- andsex-matched controls. Deficient tears were found in four achalasics compared with none among thecontrols (P < 0.05). This suggests that some variantof the triple A Syndrome (achalasia, alacrima, andadrenocortical insufficiency) may exist in adultpatients with achalasia as well.     

Mediated priming in younger and older adults

This paper reports the result of a lexical decision experiment in which the primes were either directly related to their targets, mediated, or unrelated. Mediated primes are indirectly related to their targets through a single connecting link (e.g., PASTURE-COW-MILK). Older and younger adult subjects responded to each letter string in a continuous lexical decision task, deciding whether each string was a word or a nonword. The results indicated that both younger and older subjects benefited from the mediated primes, as well as from the directly related primes. The results are discussed in relation to issues of age changes in processing speed.     

A prospective study of the use of a dobutamine stress test to identify outcome in patients with sepsis, severe sepsis, or septic shock

OBJECTIVE: To more clearly define the relationship between an oxygen flux test, oxygen supply dependency, and outcome in patients with sepsis, severe sepsis, or septic shock. DESIGN: Prospective, interventional clinical trial. SETTING: A teaching hospital general intensive care unit in London, UK. PATIENTS: A total of 36 patients with sepsis, severe sepsis, or septic shock were studied during a 10-month period. INTERVENTIONS: After resuscitation, patients were given an intravenous infusion of dobutamine at 10 microg/kg/min for 1 hr. Cardiac and respiratory variables were measured before the infusion and then while the infusion was in progress. Any patient who was able to increase his or her oxygen consumption by >15% was designated a responder to the test. MEASUREMENTS AND MAIN RESULTS: Hemodynamic, oxygen transport, and lactate measurements were made at baseline and after 1 hr of the dobutamine infusion. All patients were then followed up until hospital discharge. Responders to this test had a hospital mortality of 14%, whereas nonresponders had a mortality of 91% (p<.01). The responders were characterized by being younger (p<.05), having higher Acute Physiology and Chronic Health Evaluation III scores (p<.05), and having a greater requirement for inotropic support (p<.05). After the test, the responders had significantly higher oxygen delivery (p<.01) and oxygen consumption (p<.05) than the nonresponders, as well as a significantly greater temperature increase as a result of the infusion (p<.05). The nonresponders were unable to increase either oxygen delivery or oxygen consumption to the dobutamine. This test was highly predictive of outcome (p<.0001). The identification of an increase in both oxygen delivery and oxygen consumption (oxygen supply dependency) was not associated with a poor outcome. CONCLUSION: A dobutamine oxygen flux test provides evidence of the intrinsic function of cells. The inability of these cells to increase oxidative metabolism during sepsis, as indicated by the dobutamine test, is associated with a high mortality.