The value of serum carcinoembryonic antigen in predicting recurrent disease following curative resection of colorectal cancer.

UNLABELLED: Carcinoembryonic antigen (CEA) estimations are used to facilitate early diagnosis of recurrent disease after treatment for colorectal cancer. PURPOSE: This study was designed to determine the natural history of patients with normal and abnormal levels of CEA. METHODS: Patients undergoing potential curative resection of colorectal tumors (Dukes Stage A-C) entered a prospective, randomized trial comparing two follow-up regimens (to be reported separately) had CEA levels measured every 3 months for two years; then every 6 months for the next three years. In the study protocol, a rise in CEA was not an indication for investigation to determine recurrence unless there was also other evidence of recurrent disease. RESULTS: Three hundred eleven patients were followed for a median of 4.5 (range, 2-5) years. Recurrent disease developed in 98 (32 percent) patients, 57 of whom had an elevated CEA (sensitivity 58 percent), with a median lead time of six (range, 1-30) months from first abnormal CEA to diagnosis of recurrent disease by other means. The specificity, positive predictive value, and negative predictive value of CEA as an indicator of subsequent recurrent disease was 93 percent, 79 percent, and 83 percent, respectively. The sensitivity of CEA for predicting hepatic metastases was 80 percent, with a median lead time of eight (range, 1-30) months, compared with only 46 percent for sites of recurrent disease other than the liver. CONCLUSIONS: CEA was the first indicator of recurrent disease in 58 percent of all patients and in 80 percent of patients with liver metastases. The diagnosis of recurrent disease may be made several months earlier by investigating the first abnormal CEA level, although any benefit in terms of survival remains to be proven.

Attention-deficit hyperactivity disorder in adults.

It has been estimated that 30% to 70% of children who are diagnosed as having attention-deficit hyperactivity disorder (ADHD) will continue to show symptoms of the condition as adults. Since the prevalence of ADHD among school children may be 3% or more, its prevalence among adults may be 1% or 2%. The third revised edition of the Diagnostic and Statistical Manual (1987) of the American Psychiatric Association lists three essential features for the diagnosis of ADHD: "developmentally inappropriate inattention, impulsiveness, and hyperactivity." Other conditions associated with ADHD in adults include learning disabilities (or their sequelae), general anxiety disorder, drug and alcohol abuse, and dysthymic and cyclothymic disorders. Strong correlations have been found between ADHD and oppositional defiant and conduct disorders in children and an increased risk for antisocial disorders in adults. A combination of genetic, biologic, and environmental factors appears to be implicated in the etiology of ADHD. The management of adult ADHD requires a multimodal approach. The patient needs to be informed of the cause of his or her impulsive and often self-destructive behavior. Many patients will have learning difficulties that require evaluation and remediation by specialists in learning disabilities. Psychotherapy can help the patients resolve disturbances in perceptions of self and others and family therapy can address difficulties in the adult's relationships with family members. Pharmacotherapy of adult ADHD includes the use of central nervous system stimulants, such as methylphenidate, dextroamphetamine, and pemoline, of the tricyclic antidepressants imipramine and desimipramine, and of other antihypertensive, analgesic, and antimanic drugs.

When in vitro fertilization fails: a prospective view.

New reproductive technologies such as in vitro fertilization (IVF) offer much hope to infertile couples, yet the odds for success are not high. In this study we examine the experiences of a cohort of women undergoing IVF or a related technology at three points in time: before technological intervention, approximately one month after the first failed cycle, and six months later. We consider the women's expectations and experiences and discuss implications of the findings for social work practice.

Women's voices after pregnancy loss: couples' patterns of communication and support.

This paper reports results of a study of prenatal diagnosis patients who lost pregnancies. The women felt they shared much in common with their male partners and generally felt understood and supported by the men. However, many of the women also saw their responses to the loss as different from those of their male partners. A variety of coping patterns were adopted by the women in the face of these differences. Implications are considered for preventive efforts to minimize distress; treatment approaches to help couples who experience greater difficulties; and future research directions.

PIP: To study women's emotional and coping response after loss of pregnancy, a group of 121 women who had participated in the National Institute of Child Health and Human Development collaborative Chorionic Villus Sampling and Amniocentesis Study and who had elective abortion or miscarriage were interviewed. The group was mainly white, married, university educated, and affluent. They lost their pregnancy at mean 13.7 weeks gestation. They were interviewed with a semi structured telephone interview at 1-2 and again at 6 months after the event. The quality of the marriage was judged by the Dyadic Adjustment Scale, and each women also completed a Partner Support Scale and the Profile of Mood States. The women's scores on partner support were close to the norm soon after the loss, but declined slightly (p = .03) at 6 months. Qualitative results of the interviews pointed out several differences in the experience between women and their partners: women experienced the pain, inconvenience, and physical recovery; women felt grief for a longer period, and they tended to express their feelings verbally. Women noted that men often either expressed less distress or were less verbal. Men's coping styles included intellectualizing and physical acting-out, e.g., purchasing a motorcycle. Descriptions of couples' coping patterns evidenced some struggle in achieving understanding after the loss. These interviews suggest that most couples who lose a pregnancy do not need therapeutic intervention from a mental health provider, but some may benefit by supportive follow-up, education about the impact of genetic disorders on families, and assistance on decisions about future pregnancies or dealing with the decision not to have children.

Genetic support groups and social workers as partners.

Collaborations with individual genetic support groups and with regional and national coalitions offer social workers the opportunity to expand their contributions to genetic services. Explored in this article are the current service contributions of genetic support groups, the potential impact of the national Alliance of Genetic Support Groups, and the opportunities for social workers to form mutually advantageous partnerships with genetic organizations. This expanded agenda for social work in genetic services also challenges the profession to translate the concept of partnership into action in the many other service areas in which social workers offer their skills.

A 1 and 6 month follow-up of prenatal diagnosis patients who lost pregnancies.

This paper reports results of an exploratory study of prenatal diagnosis patients who experienced voluntary terminations of pregnancy following the detection of an abnormality or spontaneous miscarriages. The 121 participants were part of the national collaborative Chorionic Villus Sampling and Amniocentesis Study. They completed semi-structured telephone interviews and mailed questionnaires at 1 month and 6 months after the pregnancy losses. Scores on the Profile of Mood States showed that mood levels improved significantly over time. However, there were some declines in loss-related support from partners and others. The persisting distress and difficulties of a minority highlight the variability in women's responses to pregnancy losses. Women who lost pregnancies later in gestation, showed the greatest mood disturbances at initial assessments, used professional mental health assistance after the loss, or reported less satisfactory loss-related support from significant others showed the greatest levels of mood disturbance at the six-month assessment. Follow-up contacts with patients who lose pregnancies should be used to inform women about the variation in possible grief reactions, to assess the extent of support the women are receiving from their partners and significant others, and to provide additional follow-up or referral of those experiencing the greatest distress.

PIP: Obstetrician-gynecologists from the University of Virginia in Charlottesville and Wayne State University/Hutzel Hospital in Detroit, Michigan, present an ethical justification for fetal intracardiac potassium chloride injection to bring about cardiac arrest prior to induction of labor. Some pregnant women do not become aware of fetal anomalies until the 2nd trimester. Some of these fully informed and capable women opt to terminate the pregnancy. Yet late 2nd trimester abortions sometimes result in the delivery of a live neonate. This poses an ethical dilemma for the physician who performed the abortion, the neonatologist, and the woman who chose to abort and affected fetus. Specifically, neonatologists intervene to save an aborted neonate. The physician ethicists propose that the individual rights of a woman (and the biological father, if available and involved) should protect her from interference from others in relation to a legal abortion. If injected intracardiac potassium chloride cardiac arrest killing the fetus indeed protects the choices of the woman and perhaps even an involved biological father from interference and coercive imposition of treatment, then intracardiac injection is justified. Injection has the same result as would the abortion process itself had extrauterine death occurred. In addition to protecting the woman's right to noninterference and prevention of coercive actions by other health care personnel, fetal intracardiac potassium chloride injection also prevents the psychological damage the woman and her family would most assuredly suffer if the abortus/neonate lives through the abortion. Fetal killing, be it by dilation and evacuation or direct intracardiac potassium chloride, poses significant stress to the involved health care workers. Physicians should perform this procedure only in the event there is high probability of an unjustified intervention by health personnel.

Genetic support groups in the delivery of comprehensive genetic services.

This research sought information about the services provided by genetic support groups, their members' experiences in obtaining genetic and related services, and members' recommendations for improving services. Results from a survey of 43 directors of genetic support groups showed that these organizations not only provide their members with a wide range of informational and supportive services but also address the need for education of both the public and health professionals about genetic disorders. A second survey of 931 members of genetic support groups found that, although they obtained genetic information from a variety of professional and informal sources, many of them experienced barriers to obtaining sufficient genetic information. Respondents called for professionals to improve their interpersonal skills in working with clients and to assist families in obtaining a wider variety of services. On the basis of these findings, a service model and priorities are proposed to bring together genetic specialists, community professionals, and genetic support groups for the delivery of comprehensive services to individuals and families with genetic disorders.

Challenges for social work as a core profession in cancer services.

Social work's claim to be a core profession in cancer services carries the challenge to articulate the basis for that central position. In answer to that challenge, this paper considers the essentially psychosocial nature of cancer and the usefulness of empowerment as a practice premise for conceptualizing social work in oncology. Specific responsibilities are suggested for practitioners at the levels of clinical service, organizational and political action, and writing and research.

A professional partnership with genetic support groups.

Voluntary, lay genetic support groups have become important providers of supportive, educational, and social services for clients and families who face genetic disorders. A survey of 88 persons representing genetic support groups confirms that these organizations are providing their members with information and assistance about not only the genetic aspects of the disorders but also problems of daily living. Respondents noted that professionals frequently refer patients to their groups and that many of the groups have professionals working directly with them as guest lecturers, consultants, and advisory board members. At least 20% cited a lack of genetic counseling services for members of their groups as a serious problem and called for greater sensitivity to emotional concerns in the timing and delivery of genetic counseling by professionals. Respondents called for greater collaboration between the voluntary organizations and professionals but underscored the unique benefits of empathy and support from one's peers.

Challenges in developing health promotion services for the chronically ill.

A health promotion perspective and the involvement of voluntary agencies are both becoming increasingly important in the development of services for the chronically ill. A multidisciplinary model of health promotion for this population is presented that highlights the importance of self-care education and the contributions of social workers, health educators, and other community health professionals in the development and delivery of such a program.

Extending the boundaries of life: implications for practice.

Recent advances in medical technology are confounding traditional definitions of life and death and even of who is a person. This article considers the implications of these developments for social workers and presents a technique for helping clients make decisions in the face of ethical dilemmas created by new medical technologies.

Hospital social workers and self-help groups.

Self-help has developed into a significant trend in health care, and the relationship between professional services and self-help has begun to be explored. This article describes a survey that investigated hospital social workers' involvement with self-help groups and reports the need for a dual focus on research and clinical training to prepare social workers for the practice challenges presented by the self-help movement.

Prenatal diagnosis: the experience in families who have children.

Recent investigations have documented the potentially stressful nature of prenatal diagnostic testing but no systematic attention has been paid to the particular experiences of women who already have other offspring in the home. Some evidence suggests an alteration of parent-child relationships. Further support for need to inquire into this issue can be found in the extensive literature concerned with children's reactions to death and bereavement, as well as to miscarriage. Results are presented from a study of the experiences of families in which mothers used prenatal diagnostic testing. The sample consisted of 112 women drawn from an outpatient population receiving prenatal testing and their 175 living offspring who were 4 years old or older. Over two thirds of the mothers indicated they had told at least one child in the family about the testing, and children's reactions were characterized as very interested, with low to moderate levels of anxiety, worry, or confusion about the testing. More extreme, worrisome reactions were the exception. In a few cases children were reported to have been concerned about the possibilities of harm to the mother and about abortion. Some of the preschool age children seem to have been frightened by overly graphic descriptions of the procedure itself. A few mothers also voiced concerns that as a result of knowing about the testing their children might become frightened and feel less secure about their own imperfections.

Pregnancy termination for genetic indications: the impact on families.

Results are presented from a study of the experiences of families in which mothers terminated a pregnancy following detection of a serious defect in the fetus. Responses indicate that even very young children and those sheltered from knowledge of the event showed reactions to their parents' distress and maternal absence. Younger children may experience particular difficulties in coping with complete information about such a complex decision. Recommendations are made for social work service before, during, and after hospitalization for the pregnancy termination.