Primary reconstruction of pelvic floor defects following sacrectomy using Permacol graft.

AIMS: The large pelvic floor defect following sacrectomy for sacral masses leaves the challenging problem of primary closure and herniation. We present the outcome of primary repair using Permacol, a biomaterial made of acellular porcine cross-linked dermal collagen and with similar tensile strength to polypropylene mesh. It is non-allergenic and possibly less likely than synthetic mesh to cause inflammation leading to small bowel adherence; fistula formation and graft extrusion. Following implantation, Permacol is colonized by host cells and resists degradation by host enzymes. METHODS: Three patients had sacrectomy with primary repair of pelvic floor defects between March 2004 and August 2005. Two had excision of sacral chordomas and one excision of a sacrococcygeal teratoma. Repair of the defect was carried out using the Permacol graft, suturing to the sacrum, anococcygeal raphe and ischial spines. Two suction drains were placed superficial to the mesh. RESULTS: All patients had gross en-bloc tumour resections and over a median follow-up period of 1year (range 8-25months), there were no complications related to primary repair. CONCLUSION: Primary closure of a large defect following sacrectomy using a Permacol graft, in our early experience seems to be convenient and safe without the development of herniation.

Initial study to assess the effects of topical glyceryl trinitrate for pain after haemorrhoidectomy.

BACKGROUND: Postoperative pain remains the most dreaded part of haemorrhoidectomy in the minds of both patients and doctors. It may delay patient discharge, recovery, and return to work. Glyceryl trinitrate has been used successfully in the treatment of anal fissures. We investigated its topical use in the management of pain after haemorrhoidectomy. METHOD: Twenty patients were entered into a double-blind trial and randomised into two groups. Group A (n = 10) applied glyceryl trinitrate ointment (0.2% twice daily) to the perianal area following surgery, and Group B applied a placebo ointment. They applied the ointment for up to 42 days after surgery, or until they felt it necessary to stop the treatment. Patients scored their daily anal pain using a visual analogue scale. Six weeks after surgery, patients were reviewed by an independent observer. RESULTS: The total pain score was calculated for each patient. The median score for Group A was 50.65; the median score for Group B was 73.50. There was no significant difference in pain scores between both groups, even when aberrant results were ignored. 20% of patients in each group complained that the ointment caused headache. CONCLUSION: The results suggest that topical glyceryl trinitrate ointment may not significantly reduce postoperative pain following haemorrhoidectomy. Meta-analysis would provide a more definitive answer.

Menarche, sexual practices, and pregnancy: model testing.

Rates of adolescent pregnancy and childbearing, while in slight decline in the United States since 1992, remain high enough to warrant significant national concern. Birth rates, however, remain particularly high for minority adolescents. One hundred fifty-two records of African American and Latina adolescents receiving prenatal care from nurse midwives at an inner city university clinic were reviewed to partially test a developmental maturity model of pregnancy using logistic regression. The relationships between age at menarche to sexual practices and age at first pregnancy were examined. Mean age of the sample was 16.5 years, mean age at menarche was 12.2 years, at first coitus was 14.6 years, and at first pregnancy was 15.6 years. Thirty percent of the girls were experiencing second pregnancies. Birth control use by the adolescents was inconsistent, with only 20 percent using birth control at first coitus. Multiple regression analyses produced a model explaining 50 percent of the variance in age at first pregnancy. The predictor variables in the model were age at first coitus, age at menarche, race/ethnicity, and use of birth control at first coitus. Further analyses indicate that for childbearing adolescents, age at first coitus is a classic intervening variable between age at menarche and age at first pregnancy. Early physiologic maturers appear to lack the psychological and cognitive maturity required to cope with their emerging sexuality resulting in early unprotected coitus and pregnancy. Findings provide guidance to healthcare providers for the development of interventions to prevent unplanned pregnancies.

Cardiovascular risk prevalence among diverse school-age children: implications for schools.

Cardiovascular risk reduction programs in school-aged populations must be based on accurate assessments of risk. This cross-sectional, descriptive study presents the prevalence of cardiovascular risk with respect to blood pressure, obesity, and fitness in 4th, 5th, and 6th grade children. School nursing research assistants conducted 358 interviews and clinical risk assessments with children and their parents. A total of 180 children (53%) were found to have one or more cardiovascular risk factors. Our findings of a high level of risk illustrate the need for school nurses to take a leadership role to reduce risk and foster "heart-healthy" school environments.

Southeast Asian refugee children: violence experience and depression.

The United Nations High Commission for Refugees (UNHCR) reports that there were approximately 8.2 million refugees world wide in 1980. Estimates today place the number of refugees to be at least 44 million. Although most refugees remain within the boarders of their homelands, others who are granted asylum immigrate to host countries. The largest number of refugees to enter the United States during the past 20 years are from Southeast Asia, following the end of the Viet Nam War in 1975. The majority of immigrating Southeast Asian refugees were children and adolescents. Empirical study of refugee children, who are known to have experienced catastrophic violence during war, escape from homelands and in camps of asylum, is relatively scarce. Some studies that have addressed this issue document association between violence experience, depression and post traumatic stress disorder. Even so, the findings are not always clear. The purpose of this paper is to document the frequency of pre-migration and post-migration violence experiences reported by Southeast Asian refugee children in the U.S. and their relationship to depression. This study also addresses the emotional impact of violence experiences as described by the children. Previous studies have often neglected this important variable in accounting for variations in children' 5 mental health status. Nurses, internationally, will want to consider the multiple facets of violence experience when assessing children who may be at high risk for psycho-social adaptation problems following resettlement.

Social role quality and psychological well being in employed black and white midlife women.

This study examined relationships among job, partner, and parent role quality and psychological well being in midlife black (n = 51) and white (n = 56) women employed in occupations varying by socioeconomic status (SES). Oversampling for black women ensured balanced occupational representation, allowing investigation uncontaminated by SES. Instruments included Baruch and Barnett's Rewards and Concerns Scales, Bradburn Affect Balance Scale, and Center for Epidemiological Studies Depression Scale (CES-D). Better well being scores were reported by black women than whites, and by professionals than non-professionals. However, when race, occupational group, and menopausal status were held constant in a multiple regression analysis, partner role quality was significantly related to both well being scores, parent role quality was related to life satisfaction only, and job role quality was not related to either. Nurses in the workplace can help women identify problematic aspects of their multiple social roles, and facilitate resolution of problems to improve worker health.

Karydakis operation for sacrococcygeal pilonidal sinus disease: experience in a district general hospital.

Asymmetrical excision of sacrococcygeal pilonidal sinus has been shown to be associated with low recurrence rates. We report our experience with an asymmetric technique--the Karydakis operation. Of 28 patients who had the operation over a 4-year period, no recurrences were observed in 27 patients available for follow-up (median follow-up 3 years). Three patients had complications requiring surgical intervention. The operation is easy to teach and learn and is worth considering by both specialist and non-specialist surgeons.

Standardizing faculty evaluation of nurse practitioner students by using simulated patients.

Biases related to variations among patients and settings may be reduced by having faculty evaluate the clinical skills of students as they interact with simulated patients. The Student Clinical Performance Scale is a rating scale developed to standardize assessment of videotaped simulated patient encounters with family nurse practitioner students. In a pilot study of faculty interrater reliability, correlation coefficients for independent scoring by faculty pairs using the Student Clinical Performance Scale varied widely among six case studies, and several scenario- and faculty-related factors served as systematic sources of faculty variability. The findings demonstrate the importance of a rigorous approach to developing and testing instruments that guide measurement of clinical competence. The use of simulated patients to evaluate nurse practitioner students provides opportunities to assess a wide range of attributes and holds promise for assessing advanced clinical skills in controlled educational environments.

Southeast Asian refugee women and depression: a nursing intervention.

Globally, conflicts continue to result in large numbers of refugees and displaced persons, the majority are women. At present, there is scant literature on the mental health status of refugee women following resettlement in countries that grant asylum. We do know that adaptation following migration is a complex cultural, psychological and social process. Some studies have suggested a high prevalence of depression symptoms related to premigration and post-migration experiences. The purpose of this paper will be to describe the mental health status of Southeast Asian (S.E.A.) refugee women in the United States, before home visit interventions by school nurses and bilingual teachers, and at 10, 20 and 33 weeks following the intervention. A comparison group of S.E.A. refugee women, who did not receive the intervention, were evaluated for mental health status on two occasions ten weeks apart. The identified needs and problems identified by the women, the interventions implemented by the school nurses and the success of the interventions will also be discussed. The underlying problem for the majority of women was poverty and social isolation. The study demonstrates that indeed, refugee women in the U.S., are experiencing needs and problems related to basic survival issues in multiple areas of their lives. The findings suggest that home visit interventions by nurses may be a valuable means of reducing depression in S.E.A. refugee women.

The effects of violence on health and adjustment of Southeast Asian refugee children: an integrative review.

Public health nurses have historically been on the front line in meeting the needs of refugees in their practice communities. Little nursing research has been focused on the needs of refugees, however. The purpose of this integrative literature review was to clarify research focused on the needs of one refugee group, southeast Asian. The integrating factors reviewed were the instruments used, sampling procedures, statistical methods, and clarification of independent and dependent variables. Power analyses were computed on three of the studies to critique further the appropriateness of sample size. Findings indicate that premigration experiences, especially violence, play an important role in health status and adaptation after settling in the United States. Since health problems are often manifested in cultural ways different from Western norms, public health nurses would benefit from continued research clarifying the needs of individuals from other cultures.

Radical excision of sacrococcygeal tumours.

Large sacrococcygeal tumours are rare and remain a difficult management problem. Chordomas are one of the most common tumours in this region and may account for 30-40 per cent of postrectal tumours. Four patients aged between 22 and 66 years, three with chordomas and one with a schwannoma, are described. Each was managed by a combined general and neurosurgical approach. Major radical excision of the tumour involving high amputation of the sacrum and lower sacral nerve root division was performed. These large lesions can be radically excised with limited postoperative morbidity and excellent preservation of neurological function, including sphincter control, provided that one S2 nerve root is left intact.

Cardiovascular risk stability: from grade school to high school.

School-based, cardiovascular risk reduction programs have increased dramatically over the past decade. Though a wide range of evaluation plans have been implemented, limited longitudinal data are available to estimate the effectiveness of these risk reduction programs. The purposes of this study were to describe the stability of risk factors, the changes in cardiovascular risk from grade school to high school, and the differences in risk between gender. The sample (N = 195) of high school students was developed from three cohorts of elementary school students who participated in a risk reduction program in the sixth grade. Three to six years had elapsed since the students participated in the risk reduction program, thus providing a longitudinal view of participants' risk. Subject risk for obesity and high cholesterol level was stable although significant changes were noted for heart rate recovery and blood pressure. The only gender difference in risk was for elevated cholesterol level among female students. Nursing implications are presented.

Fitness and absenteeism among hospital workers. Clarifying the connection.

A total of 48% of hospital workers rated poor to below average in fitness. Administrative and clericals had the lowest fitness rating, while technical and paraprofessionals were the most fit. Illness absence days ranged from 0 to 39 in a 6 month period, with professionals absent the greatest number of days. Gender, income, and ethnicity explained 50% of the variance in the fitness results. Demographic and social characteristics potentially may confound fitness program outcome, including absenteeism.

Quality of life nursing care. An experimental trial in long-term care.

The study supports the idea that institutionalized elders' quality of life can be enhanced without increasing the cost of nursing care. By increasing resident choice and control over daily activities, well-being is enhanced despite a declining health status. Staff attitudes toward resident control and choice can be positively affected by implementing the Quality of Life Nursing Care Model.

Patient classification in home health care: are we ready?

This longitudinal descriptive study retrospectively profiled the acutely ill patient in home health care and explored the utility of using patient record data in predicting agency resource use and patient outcome. The findings suggest that those variables traditionally relied on for reimbursement qualification and as components of patient-classification schemes may not be wholly adequate to explain resource use and patient outcome in the home health setting. Professional nursing judgment of the patient's prognosis was found to be the most sensitive variable predicting outcome. Selected diagnoses and self-care capacity of the patient were the major predictors of resource use. Suggestions are offered for further studies that may move public health nursing more quickly toward the development of consistent and accurate home health care case mix measures.

Cardiovascular risk assessment in school-age children: a school and community partnership in health promotion.

There is little doubt that the primary prevention of cardiovascular disease is a pediatric problem that nursing must address. Cardiovascular health-promotion activities for children have generally used an ecologic model, providing community-based education programs in the schools. The purpose of this study was to identify changes in cardiovascular risk among sixth-grade cohorts over eight years. Four variables known to be associated with such risk--weight (obesity), pulse rate recovery index, blood pressure, and total cholesterol level--were measured on 4900 students, and changes in their prevalence were analyzed. The data presented in this paper were compiled from a screening program conducted by a local health department in partnership with a school district's health-education program. Although the school-based health-education program has been in existence for eight years, the prevalence of cardiovascular risk in sixth-grade students has not declined, suggesting the need for nurses to target the children at risk, and address more directly the motivational and affective domains in addition to cognitively focused programs.

Life style and patterns of health and social behavior in high-risk adolescents.

This article examines the life style of young people aged 14 to 19 years to describe the interrelations among social and health-related modes of behavior. The data were derived from a national survey, conducted from 1984 to 1986, of 2,787 respondents using consolidated health services for high-risk youths. A broad range of health habits, risk behaviors, and social activities are examined, including leisure activities, social relations, sexual behavior, substance use behavior, violent social behavior, seat belt use, dental hygiene, sleep behavior, weight, and preventive medical care. Factor analysis and multidimensional scaling are used to determine the empirical patterns among these behaviors. The analyses show two major modes of behavior, health-promoting and health-compromising, while a third pattern can be interpreted as group or social activity. Implications of these life-style distinctions are discussed in relation to health promotion.

Quadrantic excision and axillary node dissection without radiation therapy: the long-term results of a selective policy in the treatment of stage I breast cancer.

The results of a selective policy of conservative surgery without radiation over a 14-year period with a minimum 5 year follow-up indicates that routine postoperative radiotherapy can be safely omitted in certain cases. Eighty-one patients were studied, the overall survival at 5 years and 10 years was 88% and 73% respectively. The risk of local recurrence within the treated breast or axilla was 10% at 5 years and 11% within the total follow-up period. Most (91%) local recurrences were noted within 5 years. The rate of dying from breast cancer did not change over 10 years of follow up. The risk of recurrence was significantly higher in younger (less than 46 years) patients (P less than 0.05) and premenopausal patients (P less than 0.005) compared with older, post menopausal patients. The risk of dying from breast cancer was also significantly greater in the younger premenopausal women. At 10 years the rate of dying from breast cancer was unchanged from that seen soon after diagnosis. In postmenopausal patients with tumours less than 2 cm and uninvolved axillary nodes after pathological assessment, radiotherapy can be safely omitted. In these patients there is a low risk of local recurrence (10%), similar to that reported following segmental mastectomy and radiation.

Risk factors and clinical data related to oestrogen receptor status in women presenting with breast cancer.

Oestrogen receptor (ER) content was measured in 257 patients presenting with 'operable' breast cancer. Difference in age, menopausal status, parity, age at first pregnancy, breast feeding habit and details of past and family history were compared with oestrogen receptor status. The symptoms and their duration together with the extent of the disease both clinically and pathologically were also compared with receptor status. Association both for increasing age and postmenopausal status was found when oestrogen receptors were present in the primary tumours in significant quantities. No separation between the effect of age and menopausal status on oestrogen receptor status could be distinguished. No relationship was demonstrated between oestrogen receptor status and the other clinical and pathological factors examined.

Radical neck dissection for squamous cell carcinoma of the head and neck: early and long-term results of treatment.

An account is given of the use of radical neck dissection in a consecutive series of 147 patients treated during the years 1967-76 in the Head and Neck Unit of the Royal Marsden Hospital. The majority had received previous treatment principally by irradiation to full dosage, some by previous surgery, and a minority by induction cytotoxic chemotherapy. The 5-year determinate survival results for surgical salvage are 28.03%, and 20.5% at 10 years. Prevention of recurrent cancer in the neck was achieved in 70% of all those who later succumbed to their disease.