Taking responsibility for cancer treatment

One hundred and fourteen consecutive patients with early breast cancer were entered into a study on the psychological effects of involvement in treatment choice. All women were offered counselling throughout. One group of women (n = 34), were advised to undergo mastectomy, due to the nature or position of the tumour. These women fared less well psychologically when compared on a battery of measures, before and after surgery, with women who were involved in choosing their own treatment (n = 80). The latter group itself was randomly allocated into two groups for taking explicit responsibility for treatment choice, using a double-blind procedure. These were a Patient Decision Group (n = 41) and a Surgeon Decision Group (n = 39). Results support the hypothesis that over and above the benefits of receiving their preferred treatment, women can further benefit from taking explicit responsibility for their treatment choice.

A descriptive study of meaning of illness in chronic renal disease

AIM

To explore the subjective meaning of illness in a sample of renal patients.

BACKGROUND

Patients' illness representations, such as the meaning they attach to illness, may affect their coping and adaptation. Improved understanding in this area may therefore benefit patient care. Meaning of illness has not previously been explored in renal disease.

DESIGN AND METHODS

Cross-sectional survey (n=405) in a single regional renal unit in the North of England. Ethical approval was obtained and patients gave written consent. The instrument used was an eight-item schema, based on the work of Lipowski (1970, Psychiatry in Medicine 1, 91-102). Field notes regarding rationale for choice were recorded concurrently, then content analysed to enable identification of themes. The chi-square test (significance level P < 0.05) was used to analyse differences in selected meaning in older and younger patients; males and females; and patient groups (predialysis, haemodialysis and transplant).

FINDINGS

'Challenge' was selected by most patients (n=253, 62.5%), with similar results in all three patient groups. Slightly more older than younger patients selected 'challenge', although the difference was not statistically significant and older patients more commonly had a fatalistic interpretation of the option. More men selected 'challenge' than women. Those selecting 'challenge' and 'value' appeared to have a more positive outlook than other patients.

CONCLUSIONS

Patients had identifiable meanings for their illness, and these may be associated with their response to renal disease. The schema appeared to be comprehensive, but is in need of further refinement. Consideration of the possible influence of social desirability is necessary.

Comparative tolerability of drug therapies used to treat incontinence and enuresis

Drug therapy for incontinence and enuresis has met with varying degrees of success. Currently, there is no medication available that specifically targets the lower urinary tract without having untoward effects elsewhere in the body. Patients with urge incontinence are the most difficult group to treat. The agents most commonly used to treat urge incontinence, i.e. anticholinergics, musculotropics and tricyclic antidepressants, are limited in their effectiveness and have anticholinergic adverse effects. Other medications with theoretical treatment potential such as nonsteroidal anti-inflammatory drugs and calcium antagonists require more in depth clinical study before widespread use is appropriate. Although estrogen is well tolerated, its role in the treatment of incontinence in postmenopausal women may be limited. Medical treatment for stress incontinence is most successful in patients with a mild condition. Drugs with alpha-adrenergic activity alone or in combination with estrogen in postmenopausal women, are fairly effective and demonstrate few adverse effects at doses used to treat stress incontinence. Enuresis pharmacotherapy consists mainly of desmopressin and tricyclic antidepressants. Adverse effects are minimal with the doses commonly used. While the majority of patients improve with therapy, a significant portion relapse after treatment is terminated. Tolerability of a particular therapy depends on the effectiveness and adverse effects of the agent, the severity of incontinence and the general health of the patient. In general, patients are willing to accept a greater degree of inconvenience if a drug produces the desired effect. However, individualisation of therapy should be used to maximise compliance and outcome. Blinded, dose-titration studies are needed to better determine doses for optimum tolerability. Research into drugs specifically targeting the lower urinary tract may lead to more effective and well tolerated therapy for incontinence and enuresis.

A dual process model of perfectionism based on reinforcement theory

This article begins with a brief review of the current literature on the structure and measurement of perfectionism. It is concluded from this review that two major types can be distinguished, a normal/healthy form and a pathological form. These two forms are then defined as positive and negative perfectionism and related directly to Skinnerian concepts of positive and negative reinforcement. The positive/negative distinction is then further elaborated on in terms of approach/avoidance behavior, goal differences, self-concept involvement, emotional correlates, and the promoting environment. Finally, some of the more obvious theoretical and practical implications are briefly explored.

The family impact of childhood atopic dermatitis: the Dermatitis Family Impact Questionnaire

Little information is available about the effect of childhood atopic dermatitis (AD) on family function. The aim of this study was to identify the areas of family life most affected and their perceived importance. Intensive qualitative interviews with 34 families were conducted and 11 basic problem areas were identified. A detailed questionnaire was prepared, part of which addressed the perceived importance of particular issues using the framework of multi-attribute utility theory. The results from using this questionnaire in 41 families were analysed and a shorter 10-question one-page Dermatitis Family Impact (DFI) questionnaire designed (maximum score = 30). In affected families the mean DFI score was 9.6 +/- 7.0 (range 0-27, n = 56) and in unaffected families the mean score was 0.4 +/- 0.9 (range 0-3, n = 26, P < 0.0001). The DFI could potentially be used as an extra measure in clinical studies, or to help guide appropriate management of AD.

Meaning of illness for women with breast cancer

The meaning that women with breast cancer ascribe to their disease may well have an impact on the effectiveness of coping strategies used to come to terms with breast cancer. Health care professionals need to know what meanings women with breast cancer are ascribing to their disease if they are to identify maladaptive coping strategies and ensure that women receive the support that they need in order to promote physical and psychological recovery. This study involved assessing meaning of illness for a group of women with breast cancer at two points in time, the time of diagnosis and a mean of 21 months from diagnosis. The eight meanings of illness devised by Lipowski were depicted by the following words: challenge, enemy, punishment, loss, strategy, relief, weakness and value. The most popular choice of meaning for the women was challenge, although some women's choices indicated that maladaptive coping strategies were being used. The implications of the study for nurses and other health care professionals are discussed.

Ovarian tumors of low malignant potential. Correlation of DNA index and S-phase fraction with histopathologic grade and clinical outcome

BACKGROUND

DNA ploidy and/or S-phase fraction have been used as biologic predictors of aggressive behavior in a variety of solid tumors, including ovarian carcinomas. Recently, attention has focused on borderline lesions to determine if flow cytometry plays a role in separating potentially aggressive tumors from those which will pursue a more innocuous course.

METHODS

Paraffin-embedded tissue from 42 tumors with low malignant potential (LMP) were analyzed by flow cytometry (FC) to determine the DNA index (DI) and S-phase fraction (SPF). These result were then correlated with conventional pathologic parameters (size, nuclear grade, architecture, and mitotic index) and with clinical parameters (stage and age). Statistical analysis was carried out using the Fisher's Exact and Kruskal-Wallis tests.

RESULTS

Thirty-five cases (83.3%) were diploid, while 7 cases (16.7%) showed aneuploid stemlines, with a mean DI of 1.2 (range: 1.1-1.4). The mean SPF was 3.5% for the diploid tumors and 4.5% for the aneuploid tumors. Serous tumors comprised 74% of our cases; the remainder were either mucinous or endometrioid tumors. Complex solid architectural patterns were found in 29 tumors whereas high nuclear grade was seen in 24. A mitotic rate (MR) of 0-3/10 high power fields was seen in 29 tumors (69%), with only 5 having 10 or more mitotic figures. Aneuploidy statistically correlated with higher stage (P < 0.009). Marginal correlation was seen with a larger tumor size (P = 0.06). SPF showed a direct linear correlation with MR (P < 0.001). Also, smaller SPF's were seen in the serous tumors versus the mucinous and endometroid group (P < 0.05). Two patients with diploid and one patient with aneuploid stemlines had recurrent disease during the follow-up period.

CONCLUSIONS

DI and SPF correlated with some of the histologic parameters we evaluated. DI and SPF, however, could not predict which tumor(s) would behave in a more aggressive fashion.

Information needs and sources of information for women with breast cancer: a follow-up study

This paper reports a study which examined the specific information needs and sources of information for 105 women with breast cancer at two time points, the time of diagnosis and a mean of 21 months from diagnosis. At diagnosis the priority information needs concerned survival issues. Further from diagnosis survival issues were still a concern, but information about the risk to family members of getting breast cancer showed a significant increase in importance. Information about sexual attractiveness was ranked last at both the newly diagnosed and follow-up stages. Information sources at the time of diagnosis centred around the specialist breast care service, while further from diagnosis few professional or voluntary sector sources were utilized, with women receiving most of their information from media sources such as women's magazines. The relevance of these findings for nurses and other health care professionals is discussed.

Treatment decision making in women newly diagnosed with breast cancer

The purpose of this study was to explore the hypothesis that women with breast cancer had specific preferences about the degree of control they wanted over treatment decision making. One hundred fifty women, newly diagnosed with breast cancer, were interviewed and their preferences for participation in treatment decision making were established using a measurement tool designed to elicit decision-making preferences (Degner LF, Sloan JF. Decision making during serious illness: What role do patients really want to play? J Clin Epidemiol 1992;45:944-50). Two hundred women with benign breast disease served as a descriptive comparison group. Unfolding theory (Coombs CH. A theory of data. New York: John Wiley & Sons, 1964) provided a means of analyzing the data so that the degree of control preferred by each woman could be established. The majority of the newly diagnosed women preferred to play a passive role in treatment decision making, leaving the decision-making responsibility to their physician, whereas the benign control group preferred a collaborative role in which joint decisions could be made between the patient and the physician. The implications of the results for patient participation are discussed.

Factors associated with sexual functioning in women following spinal cord injury

Research into sexuality following spinal cord injury (SCI) has tended to concentrate on male experiences and the physical capabilities for sexual intercourse. The sexuality of women following SCI has only recently been addressed and studies are limited to small numbers and the use of non-standardised measures. The present investigation utilised standard measures of affective state and body satisfaction together with pre and post-injury questionnaire information of sexual dysfunction, feelings about sex and importance of sexual activity in a group of 85 women with SCI. Sexual dysfunction increased significantly post-injury, whilst feelings about sex and it's importance were unaffected. Sexual dysfunction and the importance of sex were inversely correlated. General and Head satisfaction estimates were not significantly different to control samples, whilst Body Satisfaction was increased for women with disabilities. None of the body satisfaction measures were related to the sexual functioning measure. General dissatisfaction was associated depression. Both anxiety and depression were experienced by the same individuals, and anxiety related to current sexual dysfunction. Qualitative data supported previous findings concerning the effects of social and attitudinal barriers on sexual functioning.

Conflicting attitudes to corneal and organ donation: a study of nurses' attitudes to organ donation

The demand for transplantable organs and tissues is steadily increasing and action is necessary to improve the organ and tissue donation rates. Previous research has suggested that nurses have a substantial influence on the rates of donation in the clinical area. Nurses (N = 150) were asked to complete a number of measures to assess positive and negative attitudes towards cadaveric organ donation, with 112 (74.6%) responding. The findings identified conflicting attitudes particularly in relation to corneal donation; 25% of the respondents would not donate their corneas. Reasons given included fear of disfigurement, religious factors such as the need to see into the next life, and dislike of the thought of donation of eyes but without knowing why. The majority of the respondents were in favour of donation generally and many carried or had signed donor cards. Nurses are usually the professionals who have the most contact with the patient in the clinical and are therefore able to identify potential donors. It seems likely that nurses with conflicting attitudes to donation are less likely to undertake the emotional costs involved when relatives of potential donors are approached re donation, than those who have more positive attitudes.

The information needs of women newly diagnosed with breast cancer

Nurses can play a key role in patient education, including providing patients with useful and appropriate information. Rather than focusing on the process of education or information giving by nurses, this study places emphasis on the content of that information by taking the patients' perspective and asking the patients themselves what particular types of information are perceived as important at a specific point in time. The aim of the study was to explore what particular types of information were important to women newly diagnosed with breast cancer; to enable nurses and other health care professionals to utilize their time as effectively as possible and provide a high-quality service to individuals in their care. Women with breast cancer (a mean of 2.5 weeks from diagnosis) were interviewed and asked to compare items of information. The items of information were presented in pairs and the women stated a preference for one item in that pair. Thirty-six pairs were presented in total. The analysis involved the use of a Thurstone scaling model, which allowed rank orderings, or profiles of information needs, to be developed, reflecting the perceived importance of each item. Information about the likelihood of cure, the spread of the disease and treatment options were perceived as the most important items of information at the time of diagnosis. Other information needs, in order of descending priority, included information about the risk to family, side-effects of treatments, impact on family, self-care, effect on social life and sexual attractiveness. Profiles of information needs were produced to take account of differences in age, level of education and social class.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients' perceptions of magnetic resonance imaging

There are several anxiety-related reactions associated with magnetic resonance imaging (MRI). Patients who experience such reactions may disrupt the examination or move so much that images are degraded. These experiences may also influence patients' perceptions of the quality of their care. The objective of this study was to further assess the subjective experiences of patients undergoing MRI in an attempt to identify those patients likely to have problems and factors affecting their experiences. Five hundred consecutive patients undergoing MRI were surveyed using questionnaires before and immediately after imaging. Anxiety was measured using the state anxiety component of the state-trait anxiety inventory. All patients exhibited some degree of pre-imaging anxiety. This was particularly associated with a previous 'unpleasant' imaging experience. Patients who experienced problems during MRI had pre-imaging anxiety levels equivalent to patients about to undergo surgery, were more likely to react badly when first seeing the scanner and were more likely to leave the MRI unit with even greater feelings of anxiety than when they arrived. In contrast to previous studies, anxiety was not associated with either the patient's understanding of the procedure or the duration of the examination. Several features have been identified which could improve the patient's experience (e.g. better information sheet). Awareness of MRI-related anxiety should also be considered when assessing the impact of MRI on outcome for the patient.

Continuing professional education: identifying the characteristics of an effective system

The need for a functioning system of continuing professional education (CPE) in nursing, midwifery and health visiting has received increased attention in recent years. However, whilst the literature describes a number of benefits, detailed empirical studies have been limited. There is, in particular, a dearth of information on nurses' perceptions of the important components of a CPE programme. Using the results of a recent evaluation of the Welsh National Board's Framework for Continuing Education, this paper highlights a number of key issues identified by practitioners, educators and managers throughout Wales. Using a structure-process-outcome model, attention is focused on the outcomes of CPE and the structure and process variables which facilitate or inhibit success. The results indicate a strong commitment to the principles of CPE and identify a complex range of perceived benefits. Potential barriers inhibiting both the uptake of CPE and the achievement of subsequent change are discussed and the need to create an equitable, well-resourced system is stressed.

Starting up stress thallium cardiac imaging services

This paper presents an evaluation of alternative methods for a hospital to establish stress thallium cardiac imaging services at a group of physicians' office. Volume-cost-profit analysis, break-even analysis and capital budgeting techniques were used to determine the most feasible method from a financial perspective without sacrificing quality of services. The main focus of this evaluation centers upon three alternative methods of procuring an imaging camera: (1) purchasing a new camera, (2) purchasing used equipment, or (3) leasing a new camera. Budgeted income statements were constructed using relevant revenue and cost information for each alternative. The payback period, net present value and the internal rate of return for each method of procuring a camera was computed. In addition, the break-even point was also determined for each alternative. After the analysis was completed, it was concluded that the method of choice, without sacrificing quality of service delivery, was that of purchasing a used camera.

Judo as a possible cause of anoxic brain damage. A case report

The rules of judo provide for strangulation techniques in which the blood supply to the brain is blocked by pressure on the carotid arteries; such techniques produce anoxia and possible unconsciousness if the victim fails to submit. A case is presented of a patient with signs of anoxic brain damage, with psychometric investigation showing memory disturbance consistent with a left temporal lobe lesion. This patient had been frequently strangled during his career as a judo player; it is suggested that such frequent strangulation was the cause of the damage. Such an observation indicates the need for caution in the use of such techniques.

Subjective experiences of magnetic resonance imaging

Clinical experience with the new technology of magnetic resonance imaging (MRI) has indicated that the procedure may produce anxiety in a number of patients, to the extent that occasionally a patient may be unwilling to undergo the procedure. A study of patients' subjective experiences of MRI was therefore conducted and these were compared with those of patients undergoing computed tomography (CT). Initial interviews with 15 MRI and 15 CT patients led to the development of a questionnaire which was administered to a further 40 patients in each setting. No significant differences were found between those factors identified as unpleasant in MRI and those of CT, with the exception of the confined space of MRI; 40% of the MRI patients found this unpleasant by comparison with only 15% of the CT patients. Principal components analysis of the concerns expressed suggested three factors, to do with the machine itself, the environment of the machine, and the social interactions involved. Patients finding the procedures unpleasant tended to be those with high initial levels of anxiety, little experience of diagnostic procedures, and believing themselves to have cancer.

The effect of minimal interventions by general practitioners on long-term benzodiazepine use

Seventy one long-term users of benzodiazepines were asked by their general practitioners in a letter or short interview to reduce their medication. Twenty two patients were successful in giving up or reducing their consumption to less than 100 tablets per annum. There were no clear predictors of success in terms of patient characteristics, duration of drug use, type of benzodiazepine, reason for drug use or strategy employed to reduce medication. However, patients who were successful at reducing their medication had a significantly lower mean baseline drug consumption than unsuccessful patients. The implications of this study are that a proportion of long-term users who are not in current crisis, especially those with relatively low consumption, can reduce or stop benzodiazepine treatment with minimal difficulty.

Threat and loss in breast cancer

The psychological well-being of forty-four breast cancer patients was assessed shortly before and after surgery, and at three and twelve months post-operatively. Regression analysis revealed type of treatment, control over treatment and concern for appearance as significant predictors of nature of subsequent mood state. Results are discussed with reference to the theoretical position that type of severe life event can predict the nature of ensuing psychological disorder.

The experience of opioid abstinence: the relevance of motivation and history

Questionnaire measures relating to a recent episode of unmodified heroin withdrawal (the target episode) were obtained from 70 subjects. The duration of the target episode, but not reported distress during the episode, correlated with the amount of heroin consumed in the previous 3 months. Data from scales measuring motivation during the target episode were factor analysed and two factors emerged, one relating to motivation concerning private affairs and the other relating to motivation derived from public sources. High scores for private affairs motivation were correlated with success in the target episode whilst there was a trend for public affairs based motivation to be associated with failure. Private affairs motivation was negatively correlated with length of heroin use but positively correlated with the number of coping strategies employed in withdrawal. The implications of these findings for the treatment of heroin users are discussed.

Functional analysis in applied psychology

Various clinical problems in recent years have been described under the general heading of 'functional analyses'. The present paper considers the background to the notion of a functional analysis and some of the differences between functional analysis and more traditional approaches. The processes involved in producing such analyses of the origin and maintenance of clinical problems are outlined, using a clinical case as an illustration. It is suggested that, amongst the features highlighted by such analyses, feedback loops will often be apparent, and that these may provide particularly valuable targets for intervention. Moreover it appears that the use of such analyses transcends, at least to some extent, the type of problem or client (in being applicable to institutional or individual problems) and in particular that the use of functional analyses transcends theoretical biases of the clinician. In this respect it provides a potential common ground for workers of different orientations.

Analysis of tobacco and smoke condensate for penicillic acid

Gas chromatographic analyses of smoke condensate from commercial, unfiltered cigarettes spiked with penicillic acid (500 or 1,000 ppm), a reported carcinogenic substance from certain fungi, indicated approximately 3% of unchanged compound was transported in the smoke. Analysis of tobacco on which either Aspergillus ochraceus or Penicillium cyclopium was grown revealed microgram quantities of the compound. Small amounts of the material were also found in moldy tobacco from commercial storage. The results of these investigations suggest that fungi may be a source of carcinogenic compounds in tobacco and tobacco smoke.

Simple micromethod for detecting antifungal activity

A bioassay that can be carried out on thin-layer chromatograms is described for rapid detection of antifungal or general cytotoxic activity with microquantities of test compound.