Reports of information and support needs of daughters and sisters of women with breast cancer.

The aim of this study was to describe the information and support needs of women who have primary relatives with breast cancer. The Information and Support Needs Questionnaire (ISNQ) was developed and revised from previous qualitative and pilot studies. The ISNQ addressed concepts of the importance of, and the degree to which, 29 information and support needs related to breast cancer had been met. The study sample consisted of 261 community-residing women who had mothers, sisters, or a mother and sister(s) with breast cancer. Data were collected using a mailed survey. In addition to the ISNQ, additional items addressed family and health history, breast self-care practices, perception of the impact of the relative's breast cancer and other variables. Also included were established and well-validated measures of anxiety and depression. The findings document women's priority information and support needs. The information need most frequently identified as very important was information about personal risk of breast cancer. Other highly rated needs addressed risk factors for breast cancer and early detection measures. Generally, the women perceived that their information and support needs were not well met. These findings illuminate needs of women for more information and support when they have close family relatives with breast cancer and opportunities for primary care providers to assist women in addressing their needs.

A smoking reduction and cessation program with registered nurses: findings and implications for community health nursing.

A smoking reduction and cessation program was implemented with registered nurses in 3 Canadian provinces. Nurses (n = 117) participated in either an 8-week group or self-directed program using a resource specifically designed for nurses. Questionnaires were administered prior to and at the end of the 8-week interventions and at 6 and 12 months postintervention. Statistically significant changes at 8 weeks in nurses' smoking practices were found on the number of nurses continuing to smoke, mean number of cigarettes smoked, and movement in the stage of behavioral change. Attrition and variation in patterns of quitting over the 12-month study period made assessing participants' longer term outcomes difficult. This study highlights the complexity of assisting nurses to quit smoking and of implementing and evaluating a program based on accepted community health models of practice.

Prognostic awareness and the terminally ill.

The authors rated patients who were in advanced stages of cancer and in their final few weeks of life on their level of awareness of their medical prognosis (N = 200, mean age = 71.0 years). The authors measured prognostic awareness with a semistructured interview, dividing patients into those acknowledging No Awareness, Partial Awareness, and Complete Awareness. The authors also administered a semistructured interview for depressive disorders, along with an assessment of various demographic and social support measures. Nineteen patients (9.5%) denied awareness of both their terminal prognosis and foreshortened life expectancy. Thirty-four patients (17%) were placed in the partial awareness category, with the remaining 147 patients (73.5%) reporting complete awareness. Depression was nearly three times greater among patients who did not acknowledge their prognosis, as compared with those who demonstrated partial or complete acknowledgment (chi2 = 7.094), P = 0.029). In addition to depression, male patients, older patients, and those having "intense social contact" were associated with lower ratings of prognostic awareness. Dying patients differ in respect to their capacity to acknowledge their prognosis. Prognostic disavowal is most likely to arise in patients with underlying psychological distress and emotional turmoil.

Will to live in the terminally ill.

BACKGROUND: Complex biomedical and psychosocial considerations figure prominently in the debate about euthanasia and assisted suicide. No study to date, however, has examined the extent to which a dying patient's will to live fluctuates as death approaches. METHODS: This study examined patients with cancer in palliative care. Will to live was measured twice daily throughout the hospital stay on a self-report 100 mm visual analogue scale. This scale was incorporated into the Edmonton symptom assessment system, a series of visual analogue scales measuring pain, nausea, shortness of breath, appetite, drowsiness, depression, sense of well-being, anxiety, and activity. Maximum and median fluctuations in will-to-live ratings, separated by 12 h, 24 h, 7 days, and 30 days, were calculated for each patient. FINDINGS: Of 585 patients admitted to palliative care during the study period (November, 1993, to May, 1995), 168 (29%; aged 31-89 years) met criteria of cognitive and physical fitness and agreed to take part. The pattern of median changes in will-to-live score suggested that will to live was stable (median changes <10 mm on 100 mm scale for all time intervals). By contrast, the average maximum changes in will-to-live score were substantial (12 h 33.1 mm, 24 h 35.8 mm, 7 days 48.8 mm, 30 days 68.0 mm). In a series of stepwise regression models carried out at 12 h, 24 h, and 1-4 weeks after admission, the four main predictor variables of will to live were depression, anxiety, shortness of breath, and sense of well-being, with the prominence of these variables changing over time. INTERPRETATION: Among dying patients, will to live shows substantial fluctuation, with the explanation for these changes shifting as death approaches.

Beyond convention: describing complementary therapy use by women living with breast cancer.

Using a descriptive survey design, 52 women living with breast cancer were interviewed to explore their use of complementary therapy and the relationships between complementary therapy use and key demographic variables and health beliefs. Sixty-seven percent of the women reported complementary therapy use, with meditation/relaxation therapies, vitamins and spiritual healing being the three most frequently reported treatments. Women using complementary therapies were more likely to have completed post-secondary education than women using only conventional medical treatment (chi 2 = 7.1, P = 0.008). Preferred decisional role was found to be significantly associated with the use of complementary therapies (chi 2 = 11.7, P = 0.003); women using complementary therapies preferred a more active/collaborative role in treatment decisions than women using only conventional medical treatment. No significant associations were found between complementary therapy use and beliefs about cause of cancer, treatments, satisfaction with health care providers, and perceived quality of life. The findings point to the pervasiveness of complementary therapy use by women living with breast cancer and contradict past research which has supported a distinct demographic profile of complementary therapy users and associated belief system.

Information needs of husbands of women with breast cancer.

PURPOSE/OBJECTIVES: To identify and measure the information needs of the husbands of women newly diagnosed with breast cancer and to determine the extent to which these needs are being met. DESIGN: Descriptive survey. SETTING: Five surgical inpatient units at four urban hospitals in Winnipeg, Manitoba, Canada. SAMPLE: 84 husbands of women recently diagnosed with breast cancer. METHOD: Subjects completed the Family Inventory of Needs--Husbands. MAIN RESEARCH VARIABLES: Information needs and extent to which these needs were met. FINDINGS: Husbands' highest ranked needs were those related to immediate care needs and communication issues. Their lowest ranked needs were those related to family relationship issues and their practical involvement in caring for their spouse. No differences existed between type of surgery (lumpectomy versus mastectomy) and number of needs and whether or not needs were met. However, husbands whose wives had undergone their first mastectomy reported approximately three times more unmet needs than husbands whose wives had undergone previous surgery for breast cancer. Husbands at greatest risk for not having their needs met were those whose occupational classification was listed as retired or laborers, those with less than a high school education, and those whose wives had only undergone one surgery for breast cancer. CONCLUSIONS: Results of this study provide a profile of the husbands' most and least important information needs and the degree to which these important needs were met. IMPLICATIONS FOR NURSING PRACTICE: With a clearer idea of the type of information important to husbands of women with breast cancer, intervention studies to determine how to best address these information needs can be designed.

Measuring the information needs of husbands of women with breast cancer: validity and reliability of the Family Inventory of Needs--husbands.

PURPOSE/OBJECTIVES: A two-phase study was undertaken to test the Family Inventory of Needs--Husbands (FIN-H), a tool designed to measure the information needs of husbands of women with breast cancer and the extent to which these needs are met. DESIGN: Methodologic survey. SAMPLES: Phase I: a panel of 6 husbands; phase II: 84 husbands of women with breast cancer. METHODS: Panel of expert ratings followed by pilot test of the two-part survey. FINDINGS: In phase I, husbands assessed the FIN-H for clarity, internal consistency, and content validity. All preset criteria were met. In phase II, internal consistency, test-retest reliability, and internal validity were assessed. Internal consistency estimates as measured by Cronbach's standardized alpha coefficients were 0.91 and 0.93. Test-retest correlations were 0.82 and 0.76 (p = 0.0001). Exploratory factor analysis suggested that the FIN-H consists of five factors. CONCLUSIONS: Initial results suggest that the FIN-H is reliable and valid. Further testing is needed to confirm these results. IMPLICATIONS FOR NURSING PRACTICE: Before nurses can address the information needs of husbands of women with breast cancer, use of a reliable and valid assessment tool is recommended.

Reliability of the Manitoba Mental Health Management Information System for Research.

OBJECTIVES: To determine the accuracy of data contained in Manitoba's Mental Health Management Information System (MHMIS) as compared with client charts and to determine which factors influence completeness and accuracy. METHODS: Data on diagnosis, open date and close date, demographic information, and contact information were obtained from client charts and compared with data extracted from the MHMIS. Semistructured interviews were conducted with individuals who contribute data to the MHMIS. RESULTS: Data on required demographic variables, primary diagnosis, and open and close dates are highly similar in the 2 sources. The correlation between data sources on the number of client contacts is also good. CONCLUSION: This study establishes the reliability of MHMIS data. MHMIS data, in combination with hospital abstracts and physician claims data, provide the information needed to serve as a psychiatric case register (PCR) and can be used for psychiatric epidemiology as well as for planning, monitoring, and evaluating mental health services.

Intensive use of mental health care.

OBJECTIVE: To describe the profile of the intensive use of mental health services over a 4-year period in a population of 1.1 million people. METHODS: Data obtained from computerized hospital separation records and physician reimbursement claims were combined to form patient-based histories of mental health care utilization. Users of mental health services in a 24-month period were hierarchically classified as having a psychotic disorder (ICD-9-CM 295-299) or a nonpsychotic disorder (ICD-9-CM 300-301, 306-309, 311). Intensive use was defined as 12 or more contact months or a minimum of 2 episodes of therapy in the 24-month period. The cohort of intensive users were followed over the subsequent 24-month interval to describe the persistence of intensive use. RESULTS: In the initial observation periods, intensive users constituted 27.4% of individuals in treatment for psychotic disorder and 4.4% of persons in treatment for nonpsychotic disorder. These 2 groups, which represent 7.4% of all users of mental health care, were responsible for 53% of physician services, 72.7% of contacts with psychiatrists, and 64.4% of acute psychiatric bed days in the initial period. In the follow-up period, intensive use status was replicated by 44.6% of the cohort. CONCLUSIONS: The diagnostic and therapeutic characteristics of intensive users of mental health services are heterogeneous. There is substantial persistence of intensive mental health service use over time.

Population health and health care use: an information system for policy makers.

University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design a population-based health information system (POPULIS). Decision-makers can use this system to make critical comparisons across regions of residents' health status, socioeconomic risk characteristics, and use of hospitals, nursing homes, and physicians. Policy makers have found this information system useful in providing answers to questions they are often asked: Which populations need more physician services? Which need fewer? Are high-risk populations poorly served or do they have poor health outcomes despite being well served? Does high utilization represent overuse or is it related to high need? Three commentaries follow.

A population-based health information system.

The authors introduce the Population Health Information System, its conceptual framework, and the data elements required to implement such a system in other jurisdictions. Among other innovations, the Population Health Information System distinguishes between indicators of health status (outcomes measures) and indicators of need for health care (socioeconomic measures of risk for poor health). The system also can be used to perform needs-based planning and challenge delivery patterns.

Utilization of physician resources for ambulatory care.

This article describes the utilization of ambulatory physician services by Manitoba residents during the fiscal year 1991/1992. Care was assigned to the patient's residence in one of eight administrative regions, whether the care was received in or out of the region of residence. Disparities in physician supply across regions did not correspond with differences in the use of services: the Winnipeg region had twice as many physicians per 1000 residents as the largely rural non-Winnipeg regions and was home to most specialists. With their rich supply of physicians, particularly specialists, Winnipeg residents had somewhat higher contact rates (16%), and the province spent 26% more per resident providing physician services, despite the fact that our indicators of health status and socioeconomic risk suggest no increased need for physician services among Winnipeg residents. Despite the concentration of physicians in Winnipeg, there was remarkably good access to physicians across the province, with 78% or more of the residents in every region making at least one contact with a physician during the year. The differences in use between Winnipeg and non-Winnipeg residents were almost entirely accounted for by intensive users, (individuals making eight or more visits per year). Although residents 75 years of age and older (6% of the population) made twice as many visits per capita compared to younger adults, their actual demand on the system was small, accounting for just less than 10% of expenditures on physician services. Population-based health information provides important insight for needs-based planning of physician services.

Should antibiotic prophylaxis be used routinely in clean surgical procedures: a tentative yes.

BACKGROUND: The incidence of surgical site infection (SSI) after clean surgical procedure has traditionally been regarded as too low for routine antibiotic prophylaxis. But we now know that host factors may increase the risk of SSI to as high as 20%. We assessed the value of prophylactic cefotaxime in patients stratified for risk of SSI in a randomized double-blind trial. METHODS: Patients admitted for clean elective operations were enrolled, stratified for risk by National Nosocomial Infection Survey criteria, and randomized to receive intravenous cefotaxime 2 gm or placebo on call for operation. They were followed for 4 to 6 weeks for SSI diagnosed by Centers for Disease Control and Prevention criteria. RESULTS: Analysis of 775 patients showed that the 378 evaluable patients who received cefotaxime had 70% fewer SSI than those who did not--Mantel-Haenszel risk ratio (MH-RR) 0.31; 95% confidence intervals (CI) 0.11 to 0.83. Benefit was clear in the 616 low risk patients--0.97% versus 3.9% SSI (MH-RR 0.25, CI 0.07 to 0.87, p = 0.018), but only a trend was seen in 136 high risk patients--2.8% versus 6.1% SSI (MH-RR 0.48, CI 0.09 to 2.5). CONCLUSIONS: The results indicate clear benefit for routine antibiotic prophylaxis in clean surgical procedures. High risk patients need more study.

Hypnotizability and mental imagery.

Two studies investigated the relationship between mental imagery and hypnotizability, with the imagery measures administered in a hypnotic context. The correlation of hypnotizability with vividness of imagery was significant in one study, but not in the other; both correlations were significantly lower than that obtained between hypnotizability and absorption, assessed in the same samples. The correlations with control of visual imagery, and with various measures of the vividness of motor imagery, were even lower and rarely significant. Except for an aggregate index of motor imagery, a search for significant nonlinear relationships with hypnotizability yielded nothing that was consistent across studies. Future studies of imagery and hypnotizability should make use of better measures of vividness of mental imagery and consider the relevance of aspects of imagery other than vividness.

The psychological unconscious. Found, lost, and regained.

In response to Greenwald's article on contemporary research on unconscious mental processes, the authors address three issues: (a) the independence of much recent research and theory from psychodynamic formulations; (b) the broad sweep of the psychological unconscious, including implicit perception, memory, thought, learning, and emotion; and (c) the possibility that the analytic power of unconscious processing may depend both on the manner in which mental contents are rendered unconscious and the manner in which they are to be processed.

Absorption, openness to experience, and hypnotizability.

Absorption, a correlate of hypnotizability, is conceptually related to openness to experience. Study 1 found no evidence that gender moderated the correlation between absorption and hypnotizability, or of nonlinear trends. Study 2 showed that openness was factorially complex, and that absorption was related to imaginative involvement, but not to social-political liberalism. Study 3 found small quadratic trends in the relations between these variables and hypnotizability; hypnotizability was related to imaginative involvement, but not liberalism. Study 4 confirmed differential correlations between absorption subscales and hypnotizability but failed to confirm the nonlinear trends. Implications for future studies of the correlates of hypnotizability, and for the nature of the "fifth factor" in personality structure, are discussed.

Conditioning in the unattended left ear.

Two experiments demonstrated that a conditioned emotional response can both be established and arouse responses without awareness in a dichotic paradigm. Right handed male subjects performed a complex verbal task presented to the right ear, while patterns of musical notes were presented to the left ear. For experimental subjects, one of the patterns was always followed by an aversive noise in the left ear; the noises were presented at random times to control subjects. In Study 1, latency of skin potential response to the noise decreased among experimental subjects relative to control subjects, indicating that the critical tone pattern was acting as a CS. Subject awareness was determined through both recall and recognition procedures, and only unaware subjects were used. Study 2 demonstrated the effect more powerfully by showing conditioned responses among experimental subjects on interpolated CS-alone trials and a lack of reportable awareness among all subjects.

A coded study of antitumor immunity to human lung cancer assayed by tube leukocyte adherence inhibition.

The present study was undertaken to evaluate the specificity of antitumor immunity to human lung cancer, measured by an in vitro assay--tube leukocyte adherence inhibition (LAI). We standardized and monitored the putative tumor antigen activity of the extracts by testing leukocytes from controls and patients with lung cancer in the Montreal General Hospital. A specific antitumor response to a lung cancer antigen was detected with coded leukocytes from 56% (20 out of 36) of patients with epidermoid lung cancer. By contrast, 4% (2 out of 53) of patients with inflammatory lung disease and none of 46 other patients with cancer metastatic to the lung or with other diagnoses had an LAI-positive result. The LAI response was inversely related to the extent of cancer: 80% (8 of 10) with Stage I, 66% (2 of 3) with Stage II, 54% (6 of 11) with localized Stage III, and 33% (4 of 12) with widespread Stage III were LAI positive. Leukocytes from patients with epidermoid, adenocarcinoma, or small cell lung cancer reacted to a common tumor antigen shared by extracts of epidermoid and small cell lung cancer. This study with coded samples from a remote hospital confirms the results of other investigators that the LAI measures an antitumor immune response to human organ-specific neoantigens.

A computerized tube leukocyte adherence inhibition assay to detect antitumor immunity in early human cancer: a review of two years' experience.

A 2-year experience with a computerized in vitro assay of leukocyte adherence inhibition (LAI) indicated that patients with cancer of either the colorectum, stomach, pancreas, breast, or lung expressed antitumor immunity to an organ-type specific neoantigen. About 1% of the 1,299 control subjects with benign or malignant disease had a positive LAI assay and 2.5% of patients with inflammatory disease of the colorectum, stomach, pancreas, or lung had a positive LAI assay when tested against tumor extracts of the same organ. Of the 351 patients with cancer of either the colorectum (111), stomach (40), pancreas (28), lung (57), or breast (116) who harbored a microfocus of cancer, 80% or more were LAI positive. As the stage of the cancer advanced, fewer patients were LAI positive. Nine of 45 patients (20%) with colon adenomas had a positive LAI response to colon cancer antigen and 17 of 204 patients (8%) with benign breast disease reacted to the breast cancer antigen. Our results suggested that the leukocytes of some of the LAI-positive patients with either colon adenomas or benign breast disease were responding to an organ-specific neoantigen. Whether the acquisition of a cell surface tumor antigen by the colon adenomas and the dysplastic lesions of the breast implies an irretrievable step to ultimate malignancy is unknown. Most patients exhibit a vigorous antitumor immune response when the cancer exists as a microfocus, and some even before the neoplasm has acquired the capacity to invade.