Relationships between biophysical and psychosocial outcomes following minor stroke.

This descriptive correlational study examined relationships between mild stroke functional and psychosocial outcomes over the early post-discharge period among dyads of mild stroke patients (n=38) and their spousal caregivers (n=38). We measured patients' functional scores using the modified Rankin Scale; patients' and caregivers' quality of life (QoL) using Stroke Impact Scale and Short-Form 36 respectively, mood using the Beck Depression Inventory-II, and marital function scores using the Family Assessment Device. Spousal caregivers also completed the Bakas Caregiving Outcomes Scale as a measure of caregiver strain. The average age of stroke patients was 64 years and of spousal caregivers 58 years. All stroke patients were male; all spousal caregivers female. At three months post discharge, patient functional status scores had significantly improved from discharge (p=0.026) with a corresponding increase in QoL scores (p=0.012). Functional status was significantly correlated with patient perceptions of QoL at three months (r=.014, p=0.024) and spousal caregiver perceptions of physical domain QoL (r=.-.397, p=0.014). Spousal caregivers' mood at three months post discharge was strongly correlated with their perceptions of marital satisfaction (r=.578, p=0.000) and caregiver strain (r=-.620, p=0.000). In preparing patients for discharge following mild stroke, nurses must consider the psychological and social implications of the recovery process over time for both the patient with stroke and their spousal caregivers.

Optimal use of taxanes in metastatic breast cancer.

The role of taxanes in the treatment of breast cancer is becoming increasingly important. In clinical practice, the taxanes are now standard therapy in both early-stage and metastatic breast cancer. Since the 1990s, multiple randomized clinical trials have been evaluating the efficacy of taxanes in the treatment of metastatic breast cancer. These trials have included treatment with taxanes alone or in combination with other chemotherapeutic agents. Pre-existing published guidelines for the use of taxanes in the management of metastatic breast cancer are available. The mandate of the Alberta Cancer Board Provincial Breast Tumour Group Guideline Panel was to consider and adapt the recommendations of the existing guidelines and to develop de novo guidelines to account for current evidence. For this task, the panel used the ADAPTE process, which is a systematic process of guideline adaptation developed by the ADAPTE Collaboration.The recommendations formulated by the panel included the identification of taxane regimens that could be offered in anthracycline-naïve patients, anthracycline-pretreated or -resistant patients, and patients overexpressing the human epidermal growth factor receptor 2. Potential toxicities and benefits in terms of time to progression, progression-free survival, overall survival, and quality of life were also considered.

Squamous cell carcinoma of the pancreas.

Pancreatic malignancies can be subdivided into endocrine and non-endocrine processes. Of the non-endocrine tumours, ductal carcinoma is the most common, and the ductal carcinomas can be further subdivided into adenocarcinomas and squamous cell carcinomas. The adenocarcinomas constitute most of the non-endocrine pancreatic malignancies, and the treatment options for these, although limited in efficacy, are relatively well established. The squamous cell carcinoma pathology is a rare entity, and few reports of it are found in the literature. As a result, treatment options for squamous cell carcinoma of the pancreas are poorly understood. Here, we report the presentation of a 48-year-old woman with metastatic squamous cell carcinoma of the pancreas. The subsequent investigations, treatment, and outcome are described.

Women's Recovery from Sternotomy-Extension (WREST-E) study: examining long-term pain and discomfort following sternotomy and their predictors.

OBJECTIVE: To examine incision and breast pain and discomfort, and their predictors in women 12 months following sternotomy. DESIGN: Extension survey following participation in a clinical trial. SETTING: 10 Canadian centres. PATIENTS: Women (n = 326) who completed the Women's Recovery from Sternotomy Trial. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Pain and discomfort data (numeric rating scales) collected by standardised interview at 5 days, 12 weeks and 12 months following sternotomy. RESULTS: More patients reported having incision or breast discomfort (46.6%) than pain (18.1%) at 12 months postoperatively. No symptoms at 5 days postoperatively were significantly associated with symptom presence at 12 postoperative months. However, having incision pain and discomfort as well as breast pain and discomfort at 12 postoperative weeks was associated with incision pain (odds ratio (OR) = 3.26, 95% confidence interval (CI) 1.51 to 7.07), incision discomfort (OR = 4.87, 95% CI 3.01 to 7.88), breast pain (OR = 9.36, 95% CI 3.91 to 22.38) and breast discomfort (OR = 6.42, 95% CI 3.62 to 11.37), respectively, at 12 postoperative months. Increasing chest circumference was associated with having ongoing incision pain (OR = 1.12, 95% CI 1.03 to 1.21) and breast pain (OR = 1.10, 95% CI 1.00 to 1.22). Harvesting of bilateral internal mammary arteries (IMAs) was associated with having ongoing incision pain (OR = 4.71, 95% CI 1.54 to 14.3), while harvesting only the left IMA was associated with having ongoing breast pain (OR = 2.78, 95% CI 1.06 to 7.32) and breast discomfort (OR 1.80, 95% CI 1.02 to 3.19). CONCLUSIONS: Patients reported incision and breast pain and discomfort as long as 12 months post-sternotomy. Improved management of postoperative pain and discomfort up to at least 12 weeks following surgery may render reduced long-term pain and discomfort symptoms.

CD69 expression as an index of T-cell function: assay standardization, validation and use in monitoring immune recovery.

BACKGROUND: CD69 is a surrogate marker of T-cell responsiveness to mitogen and Ag stimulus and can be used as a measure of T-lymphocyte activation. Quantitative flow cytometric determination of CD69 expression on T lymphocytes has several advantages over traditional lymphocyte proliferation assays, but this method has not yet been standardized for clinical applications. METHODS: We qualified a commercially available assay using the manufacturer's procedures for measurement of T-cell response to a mitogen (PHA), superantigen (Staphylococcus endotoxin B; SEB) and Ca(2+) ionophore (phorbyl myristate acetate; PMA) with peripheral blood from healthy volunteers. Following this, we tested the usefulness of the assay in determining T-cell responses to PHA and SEB for six immunocompromised patients. RESULTS: Healthy volunteers showed 17-fold increases in T-cell CD69 Ab bound per cell (ABC) with PHA stimulation compared with the baseline. SEB was also an effective T-cell activating agent, increasing CD69 ABC by 5-fold, comparable with results obtained with PMA stimulation. PHA- and SEB-stimulated T-cell CD69 ABC for patients 100 days post-BM transplant were generally below 1 SD of that from healthy volunteers. SEB-stimulated T-cell CD69 expression was significantly depressed for CD8(+) T cells while CD4(+) T-cell responses to SEB were generally within 1 SD of the mean for healthy volunteers. DISCUSSION: These results suggest that quantitative measurement of CD69 surface expression by flow cytometry is a useful diagnostic tool for detailed assessment of T-lymphocyte and subset activation.

Inhaled nitrous oxide versus placebo as an analgesic and anxiolytic adjunct to peripheral intravenous cannulation.

The objective was to determine whether an inhaled 50:50 mixture of nitrous oxide and oxygen (N(2)O/O(2)) provides significant pain and anxiety relief during intravenous cannulation in healthy adults. The study was conducted at the ED of a military teaching hospital. Participants included adult volunteers aged 18 to 50 years. Excluded were those with allergy to N(2)O, anemia, cardiac disease, pregnancy, asthma, or bone marrow disorder. A prospective, randomized, double-blind, placebo-controlled crossover design was used comparing a 50:50 mixture of N(2)O/O(2) versus O(2). After recording baseline nonhatched 100mm visual analog scales (VAS) for pain and anxiety, subjects inhaled gas 1 for 120 seconds, followed by antecubital intravenous cannulation, discontinuance of gas and VAS rating of procedural pain and anxiety. After 15 minutes, the experiment was repeated with gas 2. Ten subjects would detect a 12mm difference in pain or anxiety with a standard deviation of 10 mm, an alpha error under 0.05 and a power over 80%. Differences between VAS were compared by matched 2-tailed t-test. Eleven subjects were enrolled. One withdrew because of dizziness while inhaling gas (N(2)O). The 10 remaining subjects reported significantly less pain (N(2)O/O(2) 14.5mm, SD 18; O(2) 34.3mm, SD 23.4; P < .01) and anxiety (N(2)O/O(2) - 7.9mm, SD 7.8; O(2) 6.0mm, SD 11.6; P < .02) when inhaling N(2)O/O(2) than when inhaling O(2) alone. N(2)O/O(2) provided significant pain and anxiety reductions during intravenous cannulation. Some patients may experience adverse perceptions while using N(2)O, limiting its utility. Further studies defining the role of N(2)O as an anxiolytic agent, efficacy in actual patients, and cost comparisons with intravenous conscious analgesia/sedation, are warranted.

Human gammadelta(+) T lymphocytes have in vitro graft vs leukemia activity in the absence of an allogeneic response.

Refractory acute lymphoblastic leukemia (ALL) is often incurable, and relapse rates following allogeneic bone marrow transplantation (BMT) remain high. We have reported that patients who develop increased numbers of gammadelta(+) T cells soon after BMT are significantly less likely to relapse. We now show in seven donor/recipient pairs that donor-derived Vdelta1(+)CD4(-)CD8(-)gammadelta(+) T cells are activated and proliferate in response to recipient primary ALL blasts. In addition, these cells have been shown to bind and lyse the recipient ALL blasts. Separately, gammadelta(+) T cells proliferate poorly or not at all in mixed lymphocyte culture against HLA-mismatched unrelated stimulator cells. These observations suggest that allogeneic gammadelta(+) T cells could be an effective immunotherapeutic strategy against refractory disease without the risk of graft-versus-host disease.

Predicting and explaining cardiac rehabilitation attendance.

BACKGROUND: A variety of factors influence patients' health behaviour; these are patterns of practitioner practice, patient characteristics and availability of resources. OBJECTIVES: To examine patient-related factors (demographic, health, psychosocial characteristics) that may influence patients' attendance at cardiac rehabilitation programs and their subsequent behaviour change. PATIENTS AND METHODS: A prospective cohort design was used. Three hundred four acute myocardial infarction and/or coronary artery bypass graft surgery patients from a tertiary care centre in a Western Canadian city were enrolled to participate in telephone interviews at two weeks and again at approximately six months after their hospital discharge. Measures of self-efficacy and behaviour performance for cardiac health maintenance and role resumption, motivation and social support were used at both interview times. A survey focusing on factors influencing patients' choices to attend cardiac rehabilitation programs was also administered at the interview six months after discharge. RESULTS: Attendance at cardiac rehabilitation programs is not associated with patients' risk factor status, and elderly and rural-living patients are at particular risk for nonattendance. CONCLUSIONS: Systematic mechanisms to guide the appropriate referral of patients to this health care resource and administer secondary prevention initiatives to those with limited access to resources need to be a priority in cardiovascular health care.

Psychosocial components of cardiac recovery and rehabilitation attendance.

OBJECTIVE: To examine the relations between demographic factors, specific psychosocial factors, and cardiac rehabilitation attendance. DESIGN: Cohort, repeated measures design. SETTING: A large tertiary care centre in western Canada PATIENTS: 304 consecutive consenting patients discharged following acute myocardial infarction and/or coronary artery bypass graft surgery. MAIN OUTCOME MEASURES: The Jenkins self-efficacy expectation scales and activity checklists of behaviour performance for maintaining health and role resumption, modified version of the self-motivation inventory, and the shortened social support scale. RESULTS: Those who had higher role resumption behaviour performance scores at two weeks after discharge were significantly less likely to attend cardiac rehabilitation programmes. At six months after discharge, those who attended cardiac rehabilitation demonstrated higher health maintenance self-efficacy expectation and behaviour performance scores. Health maintenance self-efficacy expectation and behaviour performance improved over time. Women reported less social support but showed greater improvement in health maintenance self-efficacy expectation. Changes in self-efficacy scores were unrelated to-but changes in health maintenance behaviour performance scores were strongly associated with-cardiac rehabilitation attendance. CONCLUSIONS: Cardiac patients and practitioners may have misconceptions about the mandate and potential benefits of rehabilitation programmes. Patients who resumed role related activities early and more completely apparently did not see the need to "rehabilitate" while those who attended cardiac rehabilitation programmes enhanced their secondary prevention behaviours.

Rituximab: review and clinical applications focusing on non-Hodgkin's lymphoma.

Rituximab (Rituxan) was the first monoclonal antibody approved for cancer therapy and the first single-agent approved for therapy of lymphoma. When combined with CHOP, rituximab is the only drug that has been shown to improve survival of a subpopulation of patients with diffuse large cell lymphoma during the last three decades. It was approved by the FDA for the treatment of patients with relapsed or refractory low-grade or follicular, CD20-positive, B-cell non-Hodgkin's lymphoma in 1997. Rituximab is also being studied in many other B-cell malignancies alone and in combination with other agents. Furthermore, it is currently being evaluated in several nonmalignant diseases, such as autoimmune disorders. This review will focus on the role of rituximab in patients with non-Hodgkin's lymphoma.

Integrating clinical quality improvement strategies with nursing research.

Bridging the research-practice gap has been a focus of concern for nursing and other health care disciplines. The challenge in linking research and practice is for practitioners to use consistently the best available evidence in their clinical practice and for researchers to engage in clinically relevant research that provides practitioners with the evidence to do so. The authors of this article advocate that blending Clinical Quality Improvement (CQI) strategies with research methodology is a means of bridging the research-practice gap. The process of blending CQI strategies and nursing research is described in this article.

Gender and short-term recovery from cardiac surgery.

BACKGROUND: There has been a lack of agreement regarding whether women have poorer outcomes than men following cardiac surgery. OBJECTIVES: To examine the effect of gender on early recovery from cardiac surgery. METHOD: Using a prospective descriptive design, 60 men and 60 women who had coronary artery bypass and/or valve surgery completed the study by participating in interviews in the immediate preoperative period and monthly through the third postoperative month. Measures of life quality, life satisfaction, expected/perceived recovery, functional status, global health status, and social support were examined. RESULTS: Preoperatively, women were more functionally limited (p = 0.019), and reported lower life satisfaction (p = 0.001) and social support (p = 0.006), than men. At 3 months postoperatively, there were few significant differences in outcome measures though women continued to report lesser social support (p = 0.002); women realized significantly greater improvement than men in functional status (p = 0.008); and neither age nor gender consistently predicted recovery. CONCLUSIONS: Recent studies focusing on gender differences in cardiac surgery recovery indicate fewer differences between men and women than once thought. However, the differences identified in this study (women's significantly greater improvement in functional status, lesser social support, and differences in the nature of work to which women return following their surgery) warrant concern and attention in clinical practice.

Mouse transporter protein, a membrane protein that regulates cellular multidrug resistance, is localized to lysosomes.

Mouse transporter protein (MTP), a small, highly conserved mammalian intracellular membrane protein with four putative transmembrane domains, has been implicated in the transport of nucleosides and/or related molecules across intracellular membranes. The production of recombinant MTP in Saccharomyces cerevisiae alters sensitivity of yeast cells to a heterogeneous group of compounds (e.g., antimetabolites, antibiotics, anthracyclines, ionophores, and steroid hormones) by changing the subcellular compartmentalization of these drugs, suggesting that MTP functions similarly in higher organisms. The present study was undertaken to define the intracellular location of MTP in mammalian cells. Native MTP was not detected by indirect immunofluorescence in cell types that expressed MTP mRNA; therefore, a hemagglutinin (HA) epitope-tagged version of MTP was produced in cultured BHK21 cells by transient transfection, and its distribution within cells was determined by confocal microscopy using antibodies directed against the HA epitope and various organellar proteins. Antibodies directed against HA-MTP colocalized with antibodies against late endosomal and lysosomal proteins but not with antibodies against either Golgi or early endosomal proteins. Analysis of subcellular fractions from rat liver by immunoblotting with antibodies directed against MTP demonstrated the presence of a MTP-like protein in Golgi- and lysosome-enriched membranes but not in mitochondria. These results indicate that MTP resides in late endosomes and lysosomes, a finding that is consistent with the proposed role for MTP in the movement of a variety of small molecules across endosomal and lysosomal membranes. MTP shares a number of characteristics with other lysosome-associated proteins. We, therefore, propose that it be redesignated murine lysosome-associated protein transmembrane 4.

Cardiac rehabilitation: the forgotten intervention.

OBJECTIVE: To examine the influence of cardiac patients' demographic and health characteristics on physicians' cardiac rehabilitation (CR) referral practice and patients' attendance at such programs. DESIGN: A retrospective, systematic review of consecutive health records. SETTING: A tertiary care centre and the two associated CR programs in a Western Canadian city. PATIENTS: One thousand, three hundred and twenty-eight adult patients (21 years of age or older) discharged following acute myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA) and/or coronary artery bypass graft surgery between September 1, 1996 and August 31, 1997. MAIN RESULTS: There were 1245 surviving patients. Evidence of attendance at a CR program was 28.4%, while auditable evidence of referral to a CR program was 23.9%. Stepwise logistic regression revealed that ability to speak English (OR 9.56) living in a city (OR 3.97) and current smoking (OR 1.51) were associated with an increased likelihood, whereas having a history of chronic obstructive pulmonary disease or asthma (OR 0.53), being 70 years of age or older (OR 0.42), having a current admission for PTCA (OR 0.32) and having a history of neurological or cognitive impairment (OR 0.26) were associated with a decreased likelihood of CR attendance. Sex, nature of coronary artery disease risk factors, incidence of postevent complications and pre-event cardiac status (including New York Heart Association status and number of previous events) were not associated with patients' CR attendance. CONCLUSIONS: This study suggests that there is an inconsistent and poorly documented approach to referral of patients to CR programs for reasons that remain unclear. These findings provide a foundation for development and testing of enhanced referral mechanisms and of innovative means to provide rehabilitation services to patients who are at risk for not being referred to or attending CR programs.

The influence of the cardiac surgery patient's sex and age on care-giving received.

Care-giving research has predominantly focused on the care-givers of those with long-term illness and the elderly. Little attention has been given to examining care-giving from the perspective of the person receiving the care, differentiating how the sex or age of the person may influence the care received, or examining care-giving in the context of shorter term situations where the patient is expected to recover. The purpose of this study was to examine the characteristics of the informal care-givers of cardiac surgery patients from three hospitals in one Canadian province and the effect of patient characteristics (sex, age) on their experience of receiving that care. A prospective, non-randomized design, was used to examine the short-term recovery from cardiac surgery of 120 subjects (60 men, 60 women). Patients were interviewed preoperatively and then at monthly intervals through the third postoperative month. The findings from this study suggest that the patterns of informal care-giving noted in the chronic care literature are also present in the short-term care of post-surgical cardiac patients. The burden of care-giving continues to rest predominantly on women. Female patients relied on their spouses for help less frequently than did male patients and their care-givers were more frequently employed outside the home and in lower status jobs than were the care-givers of male patients. 30% of care-givers were reported to have a health problem of their own to manage while caring for the recovering patient. Patients who were male or who were < 65 years of age had higher social support scores than did patients who were female or who were > or = 65 years of age. These findings suggest that the cardiac patient's sex affects the availability of home-based care. In addition, care-givers may themselves be patients in need of care. Further research is needed to examine the receipt of home-based care-giving, particularly for female patients.

Warrantable evidence in nursing science.

Consensus among nurse scholars has not been reached regarding suitable qualities for accepting or rejecting the evidence arising from various world views. The authors' purpose in writing the paper is to describe the qualities or warrants for evaluating scientific findings (the 'evidence') of different research perspectives. The warrantable evidence pertinent to post-positivist, interpretivist, critical social theorist, and feminist perspectives are described and common warrants are suggested. Three warrants common to these scientific perspectives are proposed: (a) scrutiny and critique of methodological rigor and findings by the scientific community; (b) corroboration and intersubjectivity; and (c) scope of the evidence. The identification of common warrantable evidence will assist nurses in developing some core values regarding the constituents of good science or good scholarship even in the face of pluralism in nursing science approaches.

Short-term recovery from cardiac surgery in women: suggestions for practice.

OBJECTIVE: To examine the effect of sex on short-term recovery from cardiac surgery. DESIGN: Prospective, nonrandomized design. Men and women undergoing elective cardiac surgery were interviewed in the immediate preoperative period and monthly by telephone through the third postoperative month. SETTING: Subjects were recruited from three cardiac surgery referral centres in western Canada. PATIENTS: One hundred and thirty-two consecutive patients entering the hospital for coronary artery bypass and/or valve surgery were recruited. Inclusion criteria required that subjects be able to communicate effectively and to live independently. One hundred and twenty subjects completed the study--60 men and 60 women; 30 of each sex group were less than 65 years of age and 30 were 65 years and older. MAIN RESULTS: Women were more functionally impaired, had less social support and reported lower life satisfaction than men preoperatively. There were no significant differences between the sexes in the outcome measures three months postoperatively, and neither age nor sex consistently predicted outcome at the three-month end-point. Sex-specific issues reflect the social circumstances from which women entered the process of having their heart disease diagnosed and undergoing cardiac surgery. CONCLUSIONS: Findings support recent conclusions that there are few differences between men and women in the recovery from cardiac surgery; however, the existing differences warrant serious consideration for changes in current clinical practice. Sex differences included women's poorer preoperative functional status, lesser social support and differences in the nature of work women return to following their surgery.