Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Abstract P5-13-12: Symptom burden, unmet need for assistance, and psychosocial adaptation among longer term breast cancer survivors

Introduction:

Advances have improved survival among breast cancer (BC) patients and 89% can expect >5 year survival. The price for this survival, however, may be physical and psychosocial symptoms that persist many years into the survivorship trajectory. Unmet needs for symptom management and the relationships between unmet needs, symptom burden, and psychosocial adaptation remain unclear. We examined these relationships among longer term BC survivors.

Method:

Eligibility included non-metastatic BC survivors diagnosed > 3 years prior and attendance at a survivorship-focused appointment. Nineteen common symptoms of disease and treatment were evaluated and participants reported unmet need for assistance for each symptom they experienced. Psychosocial adaptation was assessed through the Hospital Anxiety and Depression Scale (HADS).

Results:

103 primarily white (72%), middle aged (M=62.7 yrs) BC survivors were recruited. Participants were, on average, 11.4 yrs from diagnosis and most (78.2%) reported Stage I or II BC. Participants reported an average of 9.2 symptoms, most commonly fatigue (67%), joint pain (66%), weight gain (60%), decreased sexual drive (55%), and insomnia (52%). Participants reported an average of 2.8 unmet needs for assistance with symptoms, most commonly joint pain (29%), fatigue (25%), weight gain (23%), and difficulty with memory (21%). Overall levels of depressive (M=2.45) and anxiety (M=4.89) symptoms were low, and elevated depressive and anxiety symptoms were reported by 3% and 18% of the sample, respectively. Number of symptoms and anxiety were unrelated to any demographic, disease or treatment variables. Depressive symptoms and unmet needs were related younger age (p < .05) and depressive symptoms were further related to not having received radiotherapy (p < .05). Number of symptoms experienced and unmet needs were moderately related to both depressive (all r > 0.49, p < .001) and anxiety symptoms (all r > 0.31, p < .01).

Conclusion:

Among long term BC survivors symptoms are common, while unmet need and symptoms of anxiety and depression are more modest. However, both symptoms and unmet need are associated with symptoms of depression and anxiety and represent a potentially missed opportunity for improving outcomes among BC survivors.

Citation Format: Palmer SC, Blauch AN, Pucci DA, Jacobs LA. Symptom burden, unmet need for assistance, and psychosocial adaptation among longer term breast cancer survivors [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-12.

Abstract P4-10-11: Comparability of computerized and paper-pencil patient reported outcome (PRO) assessments – Does it matter how they are administered?

Introduction:

There is an increased need to monitor and intervene to assist breast cancer (BC) survivors overcome the long-term and late effects of treatment. Many institutions are moving toward computerized assessments (CA) of PROs such as symptoms and concerns in place of more traditional paper and pencil administration, but little work has been performed to demonstrate that these very different methods of administration produce comparable results. Our goal was to evaluate the outcomes produced by these methods by comparing two similar samples of breast cancer survivors, one of which completed a PROs assessment using paper and pencil (PP), the other of which was assessed using a computerized system that links to the patient portal in use at our facility. Data collection of the CA of PROs is ongoing.

Method:

Women were eligible if they had a confirmed diagnosis of Stage 0-III BC, were within one year of completion of primary therapy, and were scheduled for a survivorship-focused end of treatment visit. As this was a naturalistic cohort study, no randomization was undertaken. The PRO assessment covered 19 common long-term or late effects of treatment, inquiring about their occurrence and severity in the previous month. On the day of the visit, participants in the PP cohort were provided with the questionnaire packet to complete prior to meeting with their provider. The women who completed the CA were either already enrolled in the patient portal or enrolled at the time of recruitment and sent an online version of the same questionnaire. Reminder calls and/or emails were sent to the CA participants to improve compliance.

Results:

164 BC survivors completed the PP questionnaire, and 62 women completed the CA. Racial make-up, marital status, and education, were similar between groups. Women in the PP group were older than those in the CA group (55.45 vs. 51.23 yrs, p < 0/05) and those in the PP group were marginally more likely than those in the CA group to have been menopausal prior to treatment (50% vs. 35%, p = 0.05).

With respect to PROs, there were no significant differences between groups in either the proportion of women endorsing a given symptom/concern or in the mean severity rating for any symptom/concern. The five most commonly reported concerns did differ somewhat between groups, with PP reporting Fatigue, Insomnia, Hot Flashes, Aching Joints, and Memory Difficulties, respectively, and CA reporting Fatigue, Anxiety, Body Image Problems, Memory Difficulties, and a tie between Insomnia and Depression, respectively.

Conclusion:

The results of the PRO assessment can be assumed to be comparable whether the method of administration is either PP or computerized. Differences found between groups in the most commonly endorsed symptoms likely reflected differences in age and menopausal status.

Citation Format: Palmer SC, DeMichele A, Glanz K, Schapira M, Pucci DA, Blauch AN, Jacobs LA. Comparability of computerized and paper-pencil patient reported outcome (PRO) assessments – Does it matter how they are administered?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-10-11.

Abstract OT3-03-02: Assessment of cancer Concerns at the End of treatment (ACE): What do survivors need and want?

Discussion:

There are over 14 million cancer survivors in the United States today and this population will continue to grow. Not only are survivors at risk for recurrence, but increasingly complex treatments place them at risk for a range of long-term and late effects. Provision of survivorship care plans (SCPs) at an end of treatment (EOT) visit that includes referrals to appropriate resources may be assumed to improve the care provided to survivors. There are, however, few relevant studies examining the outcomes of providing patients with referrals to resources identified through the completion of patient reported outcomes (PROs) reported in the literature. Current research has focused on documenting the frequency with which SCPs are provided and the perceived usefulness of these documents. Such data are a necessary but an insufficient step in the creation of practice guidelines in part guided by PROs, or standards of care that support the provision of SCPs. This study will provide a comprehensive description of breast cancer (BC) survivors' symptom burden and other concerns, as well as health behaviors as they enter the survivorship phase of care. These items will be evaluated by data generated by a pre visit PROs questionnaire completed through the patient portal. Significant symptoms and concerns will be addressed during a clinical encounter at the EOT visit. It will also describe referrals triggered by these data.

Trial Design:

Quasi-experimental single-group design with historical controls. Our study describes patient-reported symptom burden, desire for assistance, quality of life (QoL) and health behaviors of BC survivors who have completed initial treatment using a web-based platform to collect PRO data. As well, it estimates differences in referral and uptake between participants and historical controls.

Eligibility Criteria:

Survivors must understand English, have internet access and a working email address, and be age 18 years or older within 1 year of completing initial treatment (chemotherapy, radiotherapy, and/or surgery). Participants may still be receiving hormonal or targeted therapy.

Specific Aims:

1) Describe physical and psychosocial PROs of BC survivors after completion of treatment so as to define targets and develop metrics for future intervention; 1A) examine diagnosis and treatment variables that moderate PROs; 2) determine provider satisfaction with a web based patient questionnaire that includes a summary of significant patient concerns; 3) estimate the impact of providing the summary of patient concerns on utilization of/referral to available services relative to historic controls.

Statistical Methods:

Parameter estimates with confidence intervals for concerns and desire for help. Bivariate associations between unmet needs and quality of life. Non-parametric comparison of referral patterns between ACE participants and historical controls.

Present Accrual and Target:

To date 107 BC survivors have consented to complete a self-report survey questionnaire prior to their scheduled EOT visit, 61 completed the survey, 28 pending a visit. Target 250.

Citation Format: Jacobs LA, DeMichele A, Glanz K, Schapira M, Pucci DA, Blauch AN, Palmer SC. Assessment of cancer Concerns at the End of treatment (ACE): What do survivors need and want?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-03-02.

Abstract P3-08-07: Survivorship care planning – When is intervention most effective?

Introduction: Cancer survivors experience late and long-term effects, though post-treatment follow-up is generally focused on monitoring for disease recurrence. Survivors may hesitate to volunteer symptom concerns for fear of burdening their providers with ‘insignificant complaints.’ Survivorship care plans (SCPs) have been recommended by the IOM and mandated by the American College of Surgeons as a means of improving outcomes and enhancing communication between survivors and providers. To date, however, little research has evaluated the effect of SCPs on patient-reported outcomes, and less has examined the optimal timing of SCP interventions. This study examined symptom burden, quality of life (QoL), health concerns, use of SCP materials and differences by time since diagnosis in a pre-post quasi-experimental design.

Method: 139 breast cancer survivors completed assessments prior to and 3 months following a structured SCP visit at one of seven LIVESTRONG™ affiliated survivorship programs. Measures at both time points included global and individual symptom burden, QoL (SF-12), cancer-specific and general health worry, personal survivorship concerns, and family/genetic Survivorship Concerns. Patients also reported use of SCP materials for informational, decisional, and communication Support at follow-up. Subjects were grouped according to time since diagnosis into two categories: near term (≤ 24 months, n = 84), long term (> 24 Month, n = 55) survivors.

Results: Global symptom burden decreased following SCP intervention (p < .001). Participants reported decreased pain (p = .001), fatigue (p < .001), disturbance from hot flashes (p = .02), emotional concern (p = .02), and numbness/neuropathy (p = .006), and a trend toward decreased cognitive disturbance (p = .09). Near term survivors reported marginally greater decrease in global symptom burden relative to long term survivors (p = .08), and in the specific areas of cognitive difficulties (p = .05), fatigue (p = .006), and emotional concerns (p = .10). Although there were no differences over time in physical functioning on the SF-12, near term survivors reported worse mental health than long term survivors (p = .008).

Across groups, cancer-specific worry, general health worry, personal survivorship concerns, and family/genetics concerns did not change over time. However, near term survivors reported more cancer-specific worry (p = .03) and marginally greater family/genetics concern than long term subjects (p = .10). Near term survivors were also more likely to use their SCP documents for informational (p = .02) and decisional (p = .08) support following their SCP visit.

Discussion: Although limited by a quasi-experimental design, results suggest that SCPs may have a beneficial effect on symptom burden generally, with physical symptoms of pain, fatigue and neuropathy most responsive to care.. Much of the benefit appears to accrue to near term survivors. Moreover, near term survivors report more concerns relative to long term survivors, and are more likely to use SCP materials following visits. If these findings are replicated in better controlled studies, survivorship care will provide greater benefit in the first two years after completion of treatment.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-07.

Abstract P3-08-02: Breast cancer survivors’ outcomes and satisfaction following delivery of a survivorship care plan: Results of a multicenter trial

Introduction: Survivorship care plans (SCPs) have been suggested as a solution to the fragmentation of care and suboptimal outcomes experienced by the more than 13 million cancer survivors in the US. Provider and patient acceptance of SCPs is generally high, but trials to date have examined outcomes such as cancer-related distress rather than constructs more directly related to the purpose of SCPs, such as improving coordination of care, knowledge about survivorship issues, and perceived usefulness by patients. Moreover, little is known about processes by which SCPs are developed and delivered in practice – who is involved and the level of resources needed for implementation. This pilot study used a quasi-experimental, pre-test/post-test design to examine the process of delivering standardized SCPs and the outcomes achieved by post-treatment breast cancer survivors at seven cancer centers affiliated with the LIVESTRONG™ Survivorship Centers of Excellence Network.

Method: Outcomes were assessed prior to SCP delivery and 3 months following and included survivors’ use of and satisfaction with SCPs, perceived knowledge about survivorship care and potential late effects, and survivors’ assessment of the quality and coordination of survivorship care. Process variables included type of provider delivering the SCP and time required to complete and deliver the SCP.

Results: 139 breast cancer survivors completed baseline and follow-up measures and received a comprehensive, standardized SCP at a survivorship visit (Age M = 53.9 years, 3.4 years post-diagnosis, 90.6% Caucasian). Satisfaction with the SCP was high, with 90% of participants being at least ‘satisfied’ and 56% being ‘very’ or ‘extremely satisfied’. Perceived knowledge about survivorship care improved following SCP delivery (p < 0.001), as did survivor perception of quality of survivorship care received and coordination among providers (all p < 0.001). A trend toward improvement in satisfaction with the follow-up care provider was also noted (p = 0.11). Most participants (88%) reported reading their SCP carefully following delivery. In the 3 months following delivery, participants reported they most commonly used SCP materials to make decisions about appropriate exercise (69%), which tests to receive and when (65%), and to make dietary changes (65%), but only 23% shared the SCP with their primary care providers during that time frame. With respect to process, providers were predominately NPs and Pas (80%). Although implementation varied, time burden was consistently high (M = 72 minutes to prepare, M = 48 minutes to deliver).

Discussion: This is the first known study to demonstrate significant improvements in perceived knowledge regarding and perceived quality of survivorship care following receipt of a comprehensive SCP. Survivors were satisfied with their SCP, and most frequently reported using SCPs in making decisions regarding behavioral changes. Results warrant further consideration in a randomized controlled trial, and approaches that maximize efficiency are needed given the time burden of providers to provide an SCP. SCPs have been recommended for all cancer survivors and these data provide preliminary support for this recommendation.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-02.

Difficulties in implementing an organized screening program for breast cancer in Brazil with emphasis on diagnostic methods

INTRODUCTION

Breast cancer is the most common type of cancer among women, and the leading cause of cancer deaths worldwide. Among early detection methods, screening by mammography has been used in most developed countries as gold standard. The goal of this study was to evaluate the difficulties and opportunities in implementing breast cancer screening in Brazil, with an emphasis on the diagnostic methods used according to stage distribution.

METHODS

Between 2007 and 2009, 248 women were diagnosed with breast cancer in the Barretos region. Most of these were interviewed in their homes using a questionnaire with sociodemographic and preventive breast cancer screening questions. All other data were obtained from Barretos Cancer Hospital (BCH) medical records.

RESULTS

The screening program conducted by BCH was responsible for 46.1% of diagnosed cases, with 30.1% of these referred from the private system and 23.8% from the public system. Among asymptomatic women screened by the BCH Screening Program 70.8% had clinical stage 0-I disease, compared with 58.1% in the private and 50% in the public systems. Monthly breast self-examination was reported by 48.5% of the women. Clinical breast examinations were regularly performed by 88.9% of gynecologists in the private and 40.7% in the public health systems. Only 5.6% of the women reported difficulty in accessing mammography and this was most frequently due to fear of the disease or lack of knowledge about mammography in asymptomatic women.

CONCLUSION

This breast cancer screening program resulted in a substantial number of patients presenting with clinical stage (CS) 0-I disease. The success of this program was due to intensive community interventions, free mammography, and the availability of health care and mammography close to patients' homes.

Utilization of Internet-based survivorship care plans by survivors of gynecologic cancers

5592

Background: Survivors of gynecologic cancers may be at risk for cancer-related late-effects, including fatigue, pain, second malignancy risk, and sexual side effects. The Institute of Medicine has recommended survivorship care plans (SCP) for all cancer survivors. Methods: A program for creation of SCP, OncoLife, is publicly accessible through OncoLink ( www.oncolink.org ), serving over 3.9 million pages/month to 385,000 unique IP addresses (August 2008). Users responding to 17 queries regarding demographics, diagnosis, and treatment receive comprehensive, individualized guidelines for future care. User data is maintained anonymously and securely, with IRB approval. Results: From May 2007-November 2008, 3,343 individuals completed OncoLife surveys. Survivors of gynecologic cancers represented 8% (n = 272; 58% ovarian, 24% endometrial, 19% cervical). Median ages at diagnosis of ovarian, endometrial, and cervical cancer were 50, 51, and 35 yrs, respectively, and median current ages 53, 55, and 47. Surgery was undergone by 98% of ovarian, 97% of endometrial, and 81% of cervical cancer survivors, and chemotherapy/ radiotherapy by 91%/12%, 51%/59%, and 67%/67%, respectively. Known genetic syndromes were reported by 13% of ovarian cancer survivors, compared to < 1% of endometrial/ cervix cancer survivors (p = 0.0006). Of all gynecologic cancer survivors, 53% reported being followed by an oncologist, 14% a primary care provider (PCP), and 27% both. Only 7% had received survivorship information previously. Conclusions: Most survivors of gynecologic malignancies have undergone multimodality treatment and may particularly benefit from SCP guidelines. Most do not receive follow-up care from both an oncologist and PCP, and few have received survivorship information. Gynecologic cancer survivors appear willing to use this tool; future iterations will focus on further individualization of guidelines, and improving access to underrepresented populations.

No significant financial relationships to disclose.

Renal artery aneurysms: a 35-year clinical experience with 252 aneurysms in 168 patients

OBJECTIVE

To define the relevance of treating renal artery aneurysms (RAAs) surgically.

SUMMARY BACKGROUND DATA

Most prior definitions of the clinical, pathologic, and management features of RAAs have evolved from anecdotal reports. Controversy surrounding this clinical entity continues.

METHODS

A retrospective review was undertaken of 168 patients (107 women, 61 men) with 252 RAAs encountered over 35 years at the University of Michigan Hospital. Aneurysms were solitary in 115 patients and multiple in 53 patients. Bilateral RAAs occurred in 32 patients. Associated diseases included hypertension (73%), renal artery fibrodysplasia (34%), systemic atherosclerosis (25%), and extrarenal aneurysms (6.5%). Most RAAs were saccular (79%) and noncalcified (63%). The main renal artery bifurcation was the most common site of aneurysms (60%). RAAs were often asymptomatic (55%), with a diagnosis made most often during arteriographic study for suspected renovascular hypertension (42%).

RESULTS

Surgery was performed in 121 patients (average RAA size 1.5 cm), including 14 patients undergoing unilateral repair with contralateral RAA observation. The remaining 47 patients (average RAA size 1.3 cm) were not treated surgically. Operations included aneurysmectomy and angioplastic renal artery closure or segmental renal artery reimplantation, aneurysmectomy and renal artery bypass, and planned nephrectomy for unreconstructable renal arteries or advanced parenchymal disease. Eight patients underwent unplanned nephrectomy, being considered a technical failure of surgical therapy. Dialysis-dependent renal failure occurred in one patient. There were no perioperative deaths. Late follow-up (average 91 months) was available in 145 patients (86%). All but two arterial reconstructions remained clinically patent. Secondary renal artery procedures included percutaneous angioplasty, branch embolization, graft thrombectomy, and repeat bypass for late aneurysmal change of a vein conduit. Among 40 patients with clearly documented preoperative and postoperative blood pressure measurements, 60% had a significant decline in blood pressure after surgery while taking fewer antihypertensive medications. Late RAA rupture did not occur in the nonoperative patients, but no lessening of this group's hypertension was noted.

CONCLUSION

Surgical therapy of RAAs in properly selected patients provides excellent long-term clinical outcomes and is often associated with decreased blood pressure.

Efficacy and durability of autogenous saphenous vein conduits for lower extremity arterial reconstructions in preadolescent children

OBJECTIVE

Limb length discrepancies (LLDs) in growing children may accompany extremity arterial occlusions. Revascularization with vein grafts has been questioned because of degenerative graft changes observed at other sites. This study was undertaken to define vein graft durability and efficacy in lower extremity revascularizations in preadolescent children.

STUDY DESIGN

Fourteen children (10 boys, 4 girls) with a mean age of 7.3 years (range, 2-11 years) who underwent 16 lower extremity revascularizations with greater saphenous vein grafts were subjected to follow-up with graft ultrasonography, ankle/brachial indices (ABIs) with and without exercise, and limb length determinations. A mean of 5.7 years elapsed between the onset of ischemia and operation. Arterial occlusions resulted from cardiac catheterizations (11), arteritis (1), dialysis cannulation (1), and penetrating trauma (1). Indications for operation included LLD (6), claudication (4), both LLD and claudication (3), markedly diminished ABIs with a potential for LLD (2), and a traumatic transection with hemorrhage (1). The reconstructions with 15 reversed and one in situ vein grafts included iliofemoral (11), femorofemoral (1), aortofemoral (1), femoropopliteal (1), popliteal-popliteal (1), and popliteal-posterior tibial (1) arterial bypass grafts.

RESULTS

Among patent grafts available for follow-up, 36% (5 of 14) remained unchanged, 50% (7 of 14) developed nonaneurysmal dilatation, and 14% (2 of 14) exhibited nonprogressive aneurysmal expansion. One graft became occluded, and one graft was lost to follow-up. Collectively, the grafts manifest an 11.2% expansion at an average of 10.7 years postoperatively. ABIs increased from 0.75 preoperatively to 0.97, at an average of 11.0 years postoperatively. LLDs were reduced from 1.66 to 1.24 cm, at an average of 11.4 years postoperatively.

CONCLUSION

Vein graft reconstructions of lower extremity arteries in preadolescent children are durable. They provide an efficacious means of restoring normal blood flow, and in 70% of children their preexisting LLDs were reduced.

Aneurysm rupture is independently associated with increased late mortality in those surviving abdominal aortic aneurysm repair

PURPOSE

The aim of this study was to define whether veterans who survived repair of ruptured abdominal aortic aneurysms (AAA) experienced late survival rates similar to those surviving repair of intact AAA.

METHODS

All veterans undergoing AAA repair in DRGs 110 and 111 during fiscal years 1991-1995 were identified using the Veterans Affairs (VA) Patient Treatment File (PTF). Late mortality was defined using VA administrative databases including the Beneficiary Identification and Record Locator System and PTF. Illness severity and patient complexity were defined using PTF discharge data that were further analyzed by Patient Management Category software. Veterans were followed up to 6 years after AAA repair.

RESULTS

During the study, 5833 veterans underwent repair of intact AAA while 427 had repair of ruptured AAA in all VA medical centers. Operative mortality was defined as that which occurred within 30 days of surgery or during the same hospitalization as aneurysm repair. For those undergoing repair of intact AAA, operative mortality thus defined was 4.5% (265/5833). Operative mortality was 46% (195/427) after repair of ruptured AAA. Overall mortality (including operative mortality) during 2.62+/-1.61 years follow-up was 22% (1282/5833) with intact AAA versus 61% (260/427) for those with ruptured AAA (P<0.001). Further analysis of survival outcomes was performed in patients who survived AAA repair (i.e., those who were discharged alive and lived 30 days or more after surgery). Of those who initially survived repair of ruptured AAA, 28% (65/232) died during follow-up versus 18% (1017/5568) who initially survived repair of intact AAA (odds ratio 1.74; 95% confidence limits 1.30-2.34; P<0.001). In those initially surviving AAA repair, stepwise logistic regression analysis revealed that increasing age, illness severity, patient complexity, as well as AAA rupture and aortic graft complications were increasingly and independently associated with late mortality. Mean survival time was 1681 days for those who survived >30 days and who were discharged alive after repair of ruptured AAA versus 1821 days for those who initially survived repair of intact AAA (P< 0.001).

CONCLUSIONS

In addition to higher postoperative mortality rates with ruptured AAA, mortality during follow-up for survivors of AAA repair was also greater for those who survived repair of ruptured AAA. The toll taken by ruptured abdominal aortic aneurysms did not end in the immediate postoperative period.

Impact of chronic obstructive pulmonary disease on elective and emergency abdominal aortic aneurysm repair

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is associated with abdominal aortic aneurysm (AAA) expansion and is considered by some to be a relative contraindication to conventional aortic surgery. This study was undertaken to determine if COPD increases operative death, morbidity, intensive care unit (ICU) length of stay (LOS), and hospital LOS, after AAA repair.

METHODS

Data from national administrative records supplemented with laboratory data previously obtained for a system-wide study were analyzed in a retrospective review of 1053 consecutive patients (264 with and 789 without COPD) undergoing operation for intact or ruptured AAAs in Veterans Administration Hospitals from 1997 to 1998. Bivariate comparisons and multivariate regression were used to evaluate the impact of COPD on the number of days of ventilation, ICU LOS, total hospital LOS, and death, while controlling for other known risk factors, including acute myocardial infarction, renal failure, and age.

RESULTS

The mortality rate in elective aneurysm patients did not differ (P =.99) between patients with (3.7%) or without COPD (3.7%). However, elective AAA repair was associated with longer hospital LOS (14.4 vs 12.3 days, P =.01), longer ICU LOS (6.5 vs 5.4 days, P =.01), and a higher incidence of requiring 96 hours or more ventilation (6.9% vs 3.6%, P =.02) in patients with COPD. Ruptured AAA affected 4.9% of patients and was strongly associated with COPD (P =.02); however, COPD did not result in a statistically significant increase in death (P =.25).

CONCLUSIONS

Although COPD does not appear to increase operative death, it is associated with an increased risk of rupture. Elective repair of AAA should not be deferred in patients with COPD despite their higher LOSs and need for postoperative ventilation.

Major lower extremity amputation in Veterans Affairs medical centers

Our objective was to assess outcomes for 8696 patients who underwent 9236 above- (AKA) and/or below-knee (BKA) amputations during a 4-year period for disorders of the circulatory system. Veterans Affairs (VA) Patient Treatment File (PTF) data were acquired for all patients in Diagnosis Related Groups (DRGs) 113 and 114 hospitalized in VA medical centers (VAMCs) during fiscal years 1991-1994. Data were further analyzed by Patient Management Category (PMC) software, which measured illness severity, patient complexity, and relative intensity score (RIS), a measure of resource utilization. The results of this analysis showed that mortality and morbidity rates remain high after AKA and BKA. Differing amputation practice patterns found in this study warrant further investigation.

Issues related to the use of genetic material and information

PURPOSE/OBJECTIVES

To review issues regarding the use of genetic materials and information.

DATA SOURCES

Professional literature, regional and federal legislation.

DATA SYNTHESIS

An analysis is provided of the relationship among advances in genetic technology, use of genetic material and information, and the development of laws that protect the interests of donors, researchers, and insurers. Rapid technological achievements have generated complex questions that are difficult to answer. The Human Genome Project began and the scientific discoveries were put to use before adequate professional and public debate on the ethical, legal, social, and clinical issues. The term "proper use" of genetic material and information is not defined consistently. An incomplete patchwork of protective state and federal legislation exists.

CONCLUSIONS

Many complicated issues surround the use and potential misuse of genetic material and information. Rapidly advancing technology in genetics makes it difficult for regulations that protect individuals and families to keep pace.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses need to recognize their role as change agents, understand genetic technology, and advocate for patients by participating in the debate on the proper use and prevention of misuse of genetic material and information.

An analysis of the concept of risk

The meaning of the word "risk" has changed throughout history. Once a neutral term, risk has come to represent a combination of probability and something adverse or dangerous. Phenomena that were previously referred to as hazards, dangers, or uncertainties are now labeled as risks. Although risk touches every aspect of health and human welfare, the dimensions of risk as conceptualized in the fields of epidemiology, nursing science, medical science, and lay health are qualitatively different. Risk has not been examined as a concept in nursing literature or research, although risk and related terms are defined in a few nursing textbooks. Using the evolutionary method of concept analysis, risk is examined as a concept. This analysis was undertaken to define and clarify the concept and dimensions of risk as they relate to risk for disease. A sound understanding of risk as a concept is critical for developing an empirical knowledge base in nursing and directing nursing research examining issues related to risk for developing diseases such as cancer.

Outcomes after abdominal aortic aneurysm repair: comparison of mortality defined by centralized VA Patient Treatment File data versus hospital-based chart review

BACKGROUND

Outcomes after abdominal aortic aneurysm (AAA) repair have been reported by individual Veterans Affairs medical centers (VAMCs) and for the entire VA patient population.

PURPOSE

This study was done to determine whether outcomes defined using VA Patient Treatment File (PTF) data were comparable to those defined by direct chart review in those undergoing repair of intact AAA.

METHODS

Focused chart review was performed in all veterans undergoing such AAA repair in a sample of VAMCs (n = 5) for separate 1-year periods during fiscal years (FY) 1991-1993. A previous report of outcomes after AAA repair for all veterans in DRGs 110 and 111 during FY 1991-1993 was based on PTF data that were further analyzed by Patient Management Category (PMC) software. Outcomes after AAA repair were defined in a similar fashion using PTF data and PMC analysis in the same sample VAMCs for which direct chart review data were available. Outcomes defined by chart review were then compared to those based on PTF data.

RESULTS

Three of the 69 patients undergoing repair of intact AAA for which chart review data were available were assigned to DRGs other than 110 and 111 and, by definition, were not included in the PTF-derived database. Nine of 10 additional patients undergoing chart review were not identified as having undergone AAA repair by PMC software: 7 had procedure codes 39.25 instead of more standard AAA repair codes 38.34 or 38.44. Two additional patients with codes 38.64 or 38.66 were not identified as having undergone AAA repair by PMC software. The 10th patient not included in the PTF-derived database underwent additional operative procedures. Of the 13 patients missed by the combined PTF and PMC outcome analyses but identified by chart review, none died or had cardiac complications. One of these 13 patients had pulmonary complications based on chart review and PTF but was excluded by PMC analysis. There remained a total of 56 patients at the five sample VAMCs common to the PTF-derived and chart-derived databases identified as having undergone repair of intact AAA. There were two in-hospital deaths in these patients, and both were identified by each approach to outcome assessment. Four of these 56 patients had postoperative cardiac complications (ICD-9-CM code 997. 10) which were identified by both PTF and chart review. Postoperative pulmonary complications (ICD-9-CM code 997.30) were present in 4 of the 56 cases and were also identified by both PTF-based and chart-based outcome analyses.

CONCLUSIONS

All deaths as well as cardiac or respiratory complications identified by chart review at the study hospitals were also affirmed by the PTF. Due to study methodologies (which restricted analysis to those in DRGs 110 and 111 and which included secondary analyses of PTF data by PMC software), 19% of patients who underwent repair of intact AAA identified by hospital-based chart review were excluded from the PTF-based outcome analysis. Outcomes defined using large databases such as the VA PTF may be comparable to those defined by chart review if study methodologies permit. Discrepancies in outcome assessment between direct chart review and large database analysis in the present study were due to methodologies used, not to deficiencies, per se, in PTF data.

Outcomes after lower-extremity reconstruction in DRGs 478 and 479

PURPOSE

To assess outcomes for 21,261 patients in DRGs 478 and 479 hospitalized in Veterans Affairs Medical Centers (VAMCs) during fiscal years 1991-1994. DRGs 478 and 479 contain patients undergoing a variety of vascular procedures including lower-extremity arterial reconstruction.

METHODS

VA Patient Treatment File (PTF) data were analyzed using Patient Management Category (PMC) software which defined illness severity, patient complexity as defined by PMC count, and calculated resource intensity scale (RIS), a measure of resource utilization, for each admission.

RESULTS

In-hospital mortality rate was 3.16% (671/21,261) for all patients. Mortality did not differ between the 14,155 patients who underwent extremity arterial reconstruction (3.22%) and the remaining patients (3.03%). The incidence of ICD-9-CM-coded complications was 20.4% after limb revascularization versus 12.8% for remaining patients (P < 0.001). Length of stay (LOS) was 18.6 +/- 17.6 days with versus 10.3 +/- 14. 5 days without limb revascularization (P < 0.001). As defined in this study, patients who underwent limb revascularization were older (64.1 +/- 9.6 vs 62.2 +/- 11.0, P < 0.001); had higher illness severity scores (3.63 +/- 1.60 vs 2.72 +/- 1.72, P < 0.001); were more complex (had higher PMC count: 2.59 +/- 1.35 vs 2.54 +/- 1.34, P = 0.016); and required utilization of more resources (had higher RIS: 2.16 +/- 0.81 vs 1.68 +/- 0.76, P < 0.001) than remaining patients. Logistic regression analysis limited to those undergoing extremity revascularization revealed that age, presence of complications, patient complexity, illness severity, and acute arterial thromboembolism were increasingly and independently associated with greater in-hospital mortality. The logistic regression model also showed that the type of arterial reconstruction was related to in-hospital mortality: arterial bypass (ICD-9-CM 39.29) was associated with lower mortality. Outcomes were defined for the subgroup (n = 7,728) undergoing arterial bypass (ICD-9-CM 39.29) who were assigned to Patient Management Category 4101, 4113, or 4141: Mortality rates were 2.26, 2.19, and 5.03% for those undergoing elective bypass (n = 3003), urgent bypass (n = 3,513), and bypass for gangrene (n = 1212), respectively. Octogenarians did not experience higher mortality rates after elective bypass ¿1.4% (1/73) vs 2.3% (67/2,930), n.s., but experienced higher mortality rates after urgent bypass ¿8.6% (8/93) vs 2.0% (69/3,420), P < 0.001 and after bypass for gangrene ¿11.6% (5/43) vs 4.8% (56/1,169), P < 0.045.

CONCLUSIONS

Outcomes for patients in DRGs 478 and 479 who underwent extremity revascularization differed from those who did not. Outcomes varied by the type of arterial reconstruction and its urgency and indication and within selected subpopulations (i.e., octogenarians). DRG-based reimbursement would not be sensitive to these clinically important factors which have a major impact on outcomes and resource utilization.

Pulmonary embolism in Veterans Affairs Medical Centers: is vena cava interruption underutilized?

Veterans with venous thrombosis or pulmonary embolism (PE) were evaluated using Veterans Affairs patient treatment file (PTF) data from fiscal years 1990-1995, inclusive, to define outcomes for those with PE. The specific aims of the study were to define how often those with PE underwent vena cava interruption (VCI) and whether VCI affected in-hospital mortality rates. Outcomes were defined using PTF data and Patient Management Category (PMC) software for 26,132 veterans discharged from all Veterans Affairs Medical Centers (VAMCs) with venous thromboembolism, which included a subset of 4,882 patients identified by both PTF data and PMC software to have PE. PMC software also generated measures of illness severity, patient complexity (PMC count), and resource utilization (called resource intensity scale) for each hospital admission. The in-hospital mortality rate for those with PE was 15.9 per cent (775 of 4882). Only 157 VCIs were performed in those with PE which constituted 3.2 per cent of the latter group. Those with PE who had VCI experienced a 13.4 per cent unadjusted in-hospital mortality rate (21 of 157) versus a 16 per cent unadjusted mortality rate without VCI (754/4725; not significant). In a logistic regression model of in-hospital mortality in those with PE, increasing age and illness severity were directly related to mortality, whereas VCI was independently associated with reduced mortality. The odds of death were reduced by 0.482 (0.287-0.807, 95% limits) for patients with PE who underwent VCI (P<0.005). Utilization of VCI varied among VAMCs: the hospital rates that VCI were performed in those with PE ranged from 0 to 16.7 per cent. Mortality associated with PE was substantial in VAMCs, and VCI was independently associated with reduced in-hospital mortality. The low percentage of veterans with pulmonary embolism who underwent VCI was surprising. VCI may be underutilized in veterans with PE.

The individual, the family, and genetic testing

Genetics plays a role in every disease, yet few health care providers understand basic genetic principles or the science underlying the genetic testing process. An understanding of the science behind genetic advances is necessary, and it is equally important for health professionals to have an understanding of the complex nature of genetic testing for individuals and their families. Much of the debate about the psychological effects of genetic testing has occurred in the absence of empirical data on diseases for which predictive testing has only recently emerged. This article will review selected literature on genetic testing and its implications for the individual and the family. The responses of families and individuals to the diagnosis of a genetic disease will be reviewed, and Huntington disease will be used as the paradigm for examining issues related to genetic testing for adult-onset cancers. Literature addressing the response to genetic susceptibility for adult-onset cancers and the implications of testing children also will be explored. Finally, identification of emerging issues relevant to genetic screening will provide a framework for identifying needed nursing research in genetic testing for adult-onset cancer risk.

Health status in veterans undergoing noninvasive lower extremity arterial evaluation

The health status of outpatients (n = 299) undergoing lower extremity arterial Doppler studies (LES) in a Veterans Affairs Medical Center-based vascular laboratory was assessed from 9/95 through 6/96 using the SF-36 Health Survey. The purpose of this study was to compare health status of these outpatients to national norms and to determine whether Doppler-derived ankle/brachial indices (ABI) correlated with the eight health concepts measured by the SF-36 Health Survey. Physical functioning (PF), role limitations by physical illness (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations by emotional illness (RE), and mental health (MH) were more impaired in study patients (65.9 +/- 9.6 years of age) undergoing LES than national norms for males >/=65 years old (P < 0.0001). In fact, each health concept was below the 25th percentile of the national norms. PF was 33.4 +/- 22.4 for outpatients compared to the national norm of 65.8 +/- 28.3. Physical functioning was the only SF-36 health concept defined above which correlated with lowest ABI (r = 0.15; P = 0.012), adjusting for age but not comorbidities. Veterans undergoing only carotid duplex during the study period (n = 169) were compared to the veterans undergoing only LES (n = 251) during the study. PF, RP, BP, GH, VT, SF, and RE were significantly more impaired in those undergoing only LES compared with carotid duplex (P < 0.05). Veteran outpatients referred to a vascular laboratory have broad-based and profound impairments in health status. In addition, only physical functioning correlated with ABI, a measure of lower extremity arterial disease severity.

Carotid surgery in octogenarians in Veterans Affairs medical centers

The purpose of this study was to define outcomes after carotid surgery in octogenarians in the Veterans Affairs health care system. During fiscal years 1991-1994, 9152 patients in DRG 5 underwent extracranial vascular surgery procedures in Veterans Affairs medical centers. Those >/=80 years of age constituted 2.1% (n = 195) of such patients. In-hospital mortality rates were 1.03% (92/8957) in those <80 versus 3.08% (6/195) in those >/=80 years old (P = 0.018). Of those >/=80, 11.8% (23/195) had an ICD-9-CM-coded complication during hospitalization versus 11.2% of those <80 (1004/8957, NS). Surgical complications of the central nervous system (CNS) were present in 0.51% of octogenarians (1/195) and in 0.93% of those younger (83/8957, NS). Myocardial infarction (MI) occurred in 1.0% (2/195) of octogenarians and 0.74% (66/8967) of younger patients (NS). Patient Management Category software was used to define illness severity and resource intensity scale (RIS, a measure of resource utilization). Logistic regression analysis showed that age, illness severity, MI, and surgical complications of the CNS were associated with greater likelihood of mortality after extracranial vascular surgery. When the dichotomous variable "octogenarian status" was substituted for the continuous variable "age," in this model, there was no significant association of octogenarian status per se with mortality, though the association of illness severity, MI, and CNS complications with mortality persisted. Illness severity was greater for octogenarians (2.03 +/- 1.36) versus those younger (1.84 +/- 1.13, P < 0.05). RIS was 2.57 +/- 0.57 in octogenarians versus 2.47 +/- 0.48 for younger patients (P < 0.015). Length of stay (LOS) was a mean of 3.2 days longer for octogenarians (P < 0. 001). The risk of postoperative CNS complications was not higher in octogenarians. Mortality, resource utilization, and length of stay were, however, greater for octogenarians, but so was illness severity. Though mortality rates were greater for octogenarians in DRG 5, illness severity, MI, and postoperative CNS complications had greater impact on mortality after extracranial vascular surgery than octogenarian status per se.

Personal knowing in cancer nursing

Nursing practice involves the use of different types of knowledge. This article provides an analysis of personal knowing, one type of nursing knowledge. It uses an example from the cancer nursing literature that reflects the creative and expressive dimensions of personal knowing. The author discusses the social/political process used to determine the validity of this way of knowing and comments on the invaluable contribution that the practice of personal knowing and all types of nursing knowledge lend to the discipline of nursing and to the art and science of cancer nursing.

The baccalaureate degree in nursing as an entry-level requirement for professional nursing practice

The education of professional nurses must take place in institutions of higher learning with a bachelor of science in nursing degree required for beginning professional practice. Nurses educated in these academic settings should be socialized as professionals with a philosophical and value system that is compatible with this role. This education should be flexible, diverse, and directed toward providing the nurse with a solid base for general, professional nursing practice. Nursing as a profession is a social institution and must present itself as a strong, unified profession to survive the inevitable changes occurring on the health care front. By tracing the evolution of the entry-into-practice dilemma, a systems archetype and two mental models that currently drive nursing and jeopardize its potential to meet the demands of the emerging health care market are identified. The authors offer a high-leverage solution to the entry-into-practice dilemma that they believe will strengthen the nursing profession.

Hereditary nonpolyposis colon cancer: genetic basis, testing, and patient-care issues

PURPOSE/OBJECTIVES

To describe the general mechanisms of cancer development and the specific genetic basis for hereditary nonpolyposis colon cancer (HNPCC); to discuss methods of genetic testing, surveillance, and management guidelines; and to review relevant psychosocial issues.

DATA SOURCES

Published papers, research reports, and books.

DATA SYNTHESIS

Colorectal cancer is one of the most common neoplasms in humans and perhaps the most frequent form of hereditary neoplasia. HNPCC has an autosomal dominant pattern of inheritance with variable but high penetrance estimated to be about 90%. HNPCC underlies 0.5%-10% of all cases of colorectal cancer.

CONCLUSIONS

An understanding of the mechanisms behind the development of HNPCC is emerging, and genetic presymptomatic testing, now being conducted in research settings, soon will be available on a widespread basis for individuals identified at risk for this disease. Complex medical, nursing, legal, ethical, and psychosocial issues demand oncology nurses' attention and understanding.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses in all settings play an integral role assisting patients in (a) understanding their genetic risk status and the implications of genetic testing, (b) making decisions regarding HNPCC genetic predisposition testing, and (c) understanding the meaning of DNA test results. Nurses also may assist patients in understanding and complying with recommended surveillance and management issues.

At-risk for cancer: genetic discrimination in the workplace

PURPOSE/OBJECTIVES

To discuss the complexity of issues related to genetic discrimination in the workplace against individuals identified as at risk for cancer.

DATA SOURCES

Professional literature; local and national laws.

DATA SYNTHESIS

A brief historical perspective on genetic discrimination is provided. Employment discrimination, insurance, job retention, and hiring issues facing cancer survivors and individuals genetically identified as at risk for cancer are discussed. State and federal initiatives that deal with these issues are examined, and strategies are proposed to prevent issues relating to genetic discrimination.

CONCLUSIONS

Genetic discrimination, in all of its forms, is likely to emerge as a major challenge in the next century.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses must recognize new opportunities, assume new roles, and ready themselves for the challenges associated with this new kind of oncology nursing practice and the reality of genetic testing and disclosure.

Outcomes after abdominal aortic aneurysm repair in those > or =80 years of age: recent Veterans Affairs experience

During fiscal years 91-95, 6260 patients underwent 6269 abdominal aortic aneurysm (AAA) repairs in Veterans Affairs Medical Centers. Those > or =80 years old comprised 3.7% (n = 231) of the patients. A total of 5833 patients underwent repair of nonruptured AAA: mortality was 4.1% (228/5627) in those <80 and 8.25% (17/206) in those > or =80 years old (p < 0.009). Logistic regression analysis indicated age > or =80 was independently associated with higher mortality (odds ratio 1.834:1, 95% bounds 1.117-3.012). Octogenarian status (defined as > or =80 years of age), however, had a less important association with in-hospital death than did surgical complications of the heart or genitourinary tract, postoperative hemorrhage, septicemia, respiratory insufficiency, myocardial infarction (MI), acute renal failure, surgical complications of the central nervous system (CNS), aneurysm rupture, postoperative shock, or disseminated intravascular coagulation (DIC), in ascending order of importance. Only 5.9% (n = 25) of the 427 patients undergoing repair of ruptured AAA were > or =80 years old. In those > or =80 undergoing repair of ruptured aneurysms, mortality was 48% which did not differ from the 45% mortality in those <80 (NS). The likelihood that one would be operated for rupture was statistically greater (1.66:1) for those > or =80 years (p < 0.025). Length of stay (LOS) for those > or =80 undergoing AAA repair was longer being 22.3 +/- 14.8 days versus 18.3 +/- 13.2 days for younger patients (p < 0.001). Mortality and LOS after AAA repair were statistically greater for those > or =80 years of age. Severity of illness, however, was also greater for octogenarians. Patient Management Category (PMC) software defined illness severity was 4.06 +/- 1.22 in octogenarians versus 3.84 +/- 1.13 for those younger (p < 0.005). Though age > or =80 was independently associated with increased mortality, selected elderly patients could benefit from AAA repair.

A novel protamine variant reversal of heparin anticoagulation in human blood in vitro

PURPOSE

Protamine reversal of heparin anticoagulation during cardiovascular surgery may cause severe hypotension and pulmonary hypertension. A novel protamine variant, [+18RGD], has been developed that effectively reverses heparin anticoagulation without toxicity in canine experiments. Heretofore, human studies have not been undertaken. This investigation hypothesized that [+18RGD] would effectively reverse heparin anticoagulation of human blood in vitro.

METHODS

Fifty patients who underwent anticoagulation therapy during vascular surgery had blood sampled at baseline and 30 minutes after receiving heparin (150 IU/kg). Activated clotting times were used to define specific quantities of [+18RGD] or protamine necessary to completely reverse heparin anticoagulation in the blood sample of each patient. These defined amounts of [+18RGD] or protamine were then administered to the heparinized blood samples, and percent reversals of activated partial thromboplastin time, thrombin clotting time, and antifactor Xa/IIa levels were determined. In addition, platelet aggregation assays, as well as platelet and white blood cell counts were performed.

RESULTS

[+18RGD] and protamine were equivalent in reversing heparin as assessed by thrombin clotting time, antifactor Xa, antifactor IIa levels, and white blood cell changes. [+18RGD], when compared with protamine, was superior in this regard, as assessed by activated partial thromboplastin time (94.5 +/- 1.0 vs 86.5 +/- 1.3% delta, respectively; p < 0.001) and platelet declines (-3.9 +/- 2.9 vs -12.8 +/- 3.4 per mm3, respectively; p = 0.048). Platelet aggregation was also decreased for [+18RGD] compared with protamine (23.6 +/- 1.5 vs 28.5 +/- 1.9%, respectively; p = 0.048).

CONCLUSIONS

[+18RGD] was as effective as protamine for in vitro reversal of heparin anticoagulation by most coagulation assays, was statistically more effective at reversal than protamine by aPTT assay, and was associated with lesser platelet reductions than protamine. [+18RGD], if less toxic than protamine in human beings, would allow for effective clinical reversal of heparin anticoagulation.

Effect of the Asymptomatic Carotid Atherosclerosis Study on carotid endarterectomy in Veterans Affairs medical centers

OBJECTIVE

To examine the effect of the Asymptomatic Carotid Atherosclerosis Study on the volume of carotid endarterectomies (CEAs) performed in Veterans Affairs medical centers.

DESIGN

The data were retrospectively extracted from the Veterans Affairs Patient Treatment File for all patients undergoing CEA using the International Classification of Diseases, Ninth Revision, Clinical Modification procedural code 38.12. Data were classified into patient management categories to identify complications and to quantify the severity of illnesses and comorbidities.

SETTING

All 172 US Veterans Affairs medical centers.

PATIENTS

Veterans undergoing CEA during fiscal years 1993 through 1995.

MAIN OUTCOME MEASURES

Procedural volume, mortality, and morbidity.

RESULTS

There was a 43.4% increase in the volume of CEAs performed in fiscal year 1995 despite a 4.6% decrease in the served inpatients and an 8.8% decrease in the inpatient surgical procedures. The monthly volume of CEAs increased (P < .001, r2 = 0.78) at the onset of the fiscal year (October 1994) immediately after the Asymptomatic Carotid Atherosclerosis Study clinical advisory. The volume of CEAs increased in every region of the country for all nonpsychiatric hospital classifications and for almost every surgeon subspecialty. Despite the increased volume, the operative mortality rate, the International Classification of Diseases, Ninth Revision, Clinical Modification--and patient management categories--based complication rates, and the patients' comorbidity and severity of illness indexes all remained unchanged.

CONCLUSION

The dramatic increase in CEAs following the Asymptomatic Carotid Atherosclerosis Study clinical advisory suggests that the conclusions of the trial have been accepted by the medical community throughout the Veterans Affairs medical centers.

Differential clinical workloads among faculty at a major academic health center

OBJECTIVE

The authors analyzed patient care (1981-1995) and financial data (1991-1996) to determine if differential workloads existed at a major academic health center.

SUMMARY BACKGROUND DATA

Academic health centers differ markedly from community-based medical centers, but they are required to compete with others who have a more circumscribed mission and a responsibility for providing less complex care. Changes in health care systems may lessen incentives to generate clinical revenue and may adversely affect educational and research programs.

METHODS

Patient care data at the University of Michigan Health System were analyzed by discipline for level of activity from 1981 to 1995 and were compared to professional and institutional financial data from 1991 to 1995.

RESULTS

Surgeons represented 11% of the total full-time physicians throughout the period of the study (94 of the 836 Medical Center physicians, 1995). They accounted for 33% of hospital admissions (11,616 of 35,101) and 16% of outpatient visits (92,364 of 568,738). Since 1981, surgeons experienced a 249% increase in total operative workload (6799-16,909 procedures), representing a 30% increase in operations/surgeon (138-180 operations). Surgical efforts in 1995 accounted for 29% of the total professional fee revenue and $240 million of the $512-million University of Michigan Hospital revenue.

CONCLUSIONS

Surgeons had a greater collective and individual responsibility than did nonsurgeons for clinical activity and the financial viability of the academic health centers studied. Many proposals for financing health care delivery systems have the potential to exacerbate this differential. Restructuring of academic health centers must address this fact, lest their academic mission and scholarly activity be compromised.

The oncology clinical nurse specialist in a post-master's nurse practitioner program: a personal and professional journey

PURPOSE/OBJECTIVES

To examine the evolution of the advanced practice role in oncology nursing and the authors' educational experiences and role transitions as they progressed through a post-master's nurse practitioner (NP) certificate program.

DATA SOURCES

Professional literature and personal experiences of two experienced oncology clinical nurse specialists (CNSs).

DATA SYNTHESIS

Despite historical differences between CNS and NP roles, the authors did not subtract or detract from their CNS roles but added new skills to their established roles.

CONCLUSIONS

Skills that define both the NP and CNS roles must be maintained to effectively meet the current healthcare needs of patients with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Many CNSs are returning to school to obtain their NP credentials. Although assimilating new skills and knowledge into an already established professional identity was a challenging undertaking, the authors viewed the experience as essential in preparing them to meet the demands of the changing healthcare environment.

Hepatic metabolic response to injury and sepsis

BACKGROUND

Experimental reports have indicated that hepatic oxidative and synthetic metabolism may become depressed in sepsis. Because the mechanism of infection-related liver dysfunction has not been established, further study of these functional alterations could contribute to the therapeutic management of septic organ failure syndromes. However, recently controversy has arisen over the existence of these derangements that must be reconciled before further progress in this field can be made.

METHODS

Splanchnic balance studies for the measurement of glucose output and oxygen consumption were used to assess hepatic function in fasted normal volunteers (n = 18), injured patients (n = 10), and patients with sepsis (n = 18). The liver's contribution to splanchnic metabolism was estimated from a comparison of splanchnic oxygen utilization in response to increases in the liver-specific process of glucogenesis. In addition, in vivo liver albumin production was determined by using the [14C] carbonate technique.

RESULTS

Glucose output after injury and sepsis was increased by 12.8% and 76.6%, respectively, compared with controls. On the basis of substrate balance studies, gluconeogenesis was estimated to account for 46%, 87%, and 93%, respectively, of splanchnic glucose output in each of the three groups. In patients with sepsis glucose output was also noted to be linearly related to regional oxygen consumption, indicating that these processes were coupled and increases in the respiratory activity of the splanchnic cellular mass could be accounted for by increases in new glucose output and gluconeogenic substrate clearance. The mean albumin synthetic rate increased during injury and sepsis by 22% and 29%, respectively, compared with normal volunteers.

CONCLUSIONS

These studies cast doubt on the commonly held notion that tissue respiratory dysfunction may occur during sepsis. On the contrary, hepatic function is accelerated during hyperdynamic sepsis, and evidence indicating oxidative or synthetic functional depression is lacking.

Incorporating midmanagement skills in an oncology CNS program

Today's health care system requires that CNSs be prepared to manage care within complex organizations as well as deliver expert care to individuals and their families. The integration of midmanagement preparation with clinical knowledge and skills is critical. In this paper, we (1) review the literature pertaining to the role of oncology CNS and management preparation, (2) describe the program at the University of Pennsylvania School of Nursing, and (3) identify the management content that was added to strengthen the theoretical and clinical components of the program and to prepare our graduates in assuming leadership positions.

Effects of lumbar sympathectomy on canine transcutaneous oxygen tension

Augmentation of cutaneous blood flow by postganglionic lumbar sympathectomy may not reflect an increase in nutritive vascular supply to the dermal tissues. Transcutaneous oxygen tension (TcPO2) was compared with radionuclide microsphere determination of dermal microcirculation in a hind limb sympathectomy model in 20 dogs. After 90 minutes the TcPO2 was greater in the sympathectomized limbs than in the contralateral limbs (125 mm Hg versus 114 mm Hg, p < or = 0.05). In contrast, microsphere-determined paw dermal capillary flow declined in sympathectomized limbs (4.9 ml/min/100 gm versus 11.8 ml/min/100 gm, p < or = 0.05). Decreases in the TcPO2/venous PO2 ratio correlated with sympathectomy-induced increases in total limb blood flow (r = 0.60; p < or = 0.001), reflecting less efficient oxygen extraction. These observations confirm the lack of enhancement of tissue oxygen delivery by sympathectomy because of the associated dilation of cutaneous arteriovenous shunts.

Preparing clinical preceptors to teach master's-level students in oncology nursing

This article reports the development of a structured program for clinical nurse specialists who served as clinical preceptors for graduate students in an oncology nursing program. A needs assessment of clinical preceptors was completed, and a program for the preceptors was developed based on the learning needs identified. In addition to the program, a Manual for Clinical Preceptors was developed. The benefits of this program include networking; positive working relationships among the preceptors, faculty, and students; potential job opportunities for students; potential applicants from the clinical agencies; and, ultimately, improved care for patients with cancer and their families. The authors conclude that administrators should support efforts to nurture and recognize the personnel in the clinical agencies.

Clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional versus diagnostic procedures

The purpose of this report is to define the clinical characteristics and outcome of surgical management of vascular complications after interventional cardiac catheterization and to contrast them to those after diagnostic cardiac catheterization. From October 1985 to December 1989, 101 patients were treated for 106 vascular complications after 1866 interventional and 5046 diagnostic cardiac catheterizations at the University of Michigan Medical Center. Interventional catheterizations resulted in 69 vascular complications in 64 patients (frequency 3.4%). The most common interventions included coronary angioplasty (34), of which 10 required percutaneous partial cardiopulmonary bypass, intraaortic balloon pump placement (14), and aortic valvuloplasty (11). Interventional catheter-related complications included hemorrhage (33), arterial thrombosis (18), pseudoaneurysm formation (12), catheter embolization (2), thromboembolism (2), as well as arteriovenous fistula, pseudoaneurysm, and arterial dissection (1 each). Fifteen of these 69 patients (24%) had suffered acute myocardial infarction just before their catheterization. Surgical repair was performed under local anesthesia in 70% of patients. Major vascular reconstructions were required in 9% of patients. Three percent of the involved lower extremities had to be amputated because of complications occurring after arterial puncture. Eight percent of the patients incurring vascular complications after interventional procedures died after operation. Diagnostic catheterizations resulted in 37 vascular complications in 37 patients (frequency 0.7%). In contrast to diagnostic cardiac catheterization, vascular complications after interventional cardiac catheterization occurred more frequently, were most often due to hemorrhage at the vascular access site, and occurred in high-risk, critically ill patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of endometriosis with the GnRH agonist nafarelin acetate

Additional details of a multicenter study of nafarelin acetate with particular attention to a unique endometriosis scoring system utilized are reviewed. Additional information regarding the relapse of symptoms of 10 patients treated with nafarelin and danazol during a 6- to 12-month follow-up interval is described. Transient decreases in leukocytes previously reported by other investigators were observed in 3 of 8 patients, but appear to represent a laboratory artifact.

Hepatic parenchymal oxygen tension following injury and sepsis

Hepatic blood flow and splanchnic oxygen consumption were measured in 16 injured (n = 6) or septic (n = 10) patients and compared with values in 16 normal volunteers. Sepsis and injury appeared to stimulate an increase in blood flow and oxygen utilization, with the highest levels observed in the septic group. Patients with sepsis exhibited a 72% and 60% increase in hepatic blood flow and splanchnic oxygen consumption, respectively, compared with normal volunteers. Application of these data to the Krogh-Erlang tissue model indicates that despite an increase in oxygen delivery to the splanchnic bed during sepsis, it becomes more sensitive to hypoxic/ischemic events compared with other patient groups. This is indicated by a reduced centrilobular and increased critical oxygen tension. The major factor responsible for this is the regional hypermetabolism present in sepsis. This analysis emphasizes the critical importance of maintaining oxygen transport in critically ill patients with sepsis.

Hepatic blood flow and splanchnic oxygen consumption measurements in clinical sepsis

In an effort to characterize the hemodynamic response of the liver to sepsis, hepatic blood flow (HBF) was measured in 10 normal volunteers and compared with that of 9 patients with sepsis. Flow was determined according to two different indicators and three methods of analysis including indocyanine green dye clearance (HBFICG), galactose clearance (GC), and galactose clearance with splanchnic galactose gradient measurement (HBFGG). For normal subjects, these three analytic methods provided essentially identical results (HBFICG = 0.74 +/- 0.18, GC = 0.72 +/- 0.14, and HBFGG = 0.76 +/- 0.16 L/min-m2). With hepatic venous sampling, HBF in patients with sepsis was significantly higher than normal levels (HBFICG = 1.28 +/- 0.50 and HBFGG = 1.17 +/- 0.52 L/min-m2) (p less than 0.025), but HBF by the GC technique (0.89 +/- 0.41 L/min-m2), which uses peripheral venous sampling, was not significantly increased because of reduced splanchnic galactose extraction, which appears to be characteristic of sepsis. Thus HBF estimates based on peripheral venous sampling must be interpreted with caution in view of the reduced extraction fraction in sepsis. HBF in clinical sepsis tends to increase in response to this inflammatory stress.

Management of multiple enterocutaneous fistulas

Enterocutaneous fistulas present a difficult management problem in the intensive care unit. Although some patients require surgical intervention for fistula control, key elements to good clinical management include mechanical control and vigorous nutritional support. This approach includes eradication of malnutrition, support of the hypercatabolic state, and maintenance or replacement of protein loss from fistula drainage. Good mechanical control involves integument protection and a mechanism of drainage collection. The patient we describe taxed the ingenuity and creativity of all those concerned with his care. Modification of a previously described technique to protect surrounding skin and collect fistula output served as a simple and inexpensive approach to eliminate infection potential, improve the patient's comfort, and decrease the nursing time that would have been required for frequent, complex dressing changes.