Christopher S. Wendel

Health-Related Quality of Life Among Long-Term Rectal Cancer Survivors With an Ostomy: Manifestations by Sex

PURPOSE Intestinal stomas can pose significant challenges for long-term (> or = 5 years) rectal cancer (RC) survivors. Specifying common challenges and sociodemographic or clinical differences will further the development of tailored interventions to improve health-related quality of life (HRQOL). PATIENTS AND METHODS This was a matched cross-sectional study of long-term RC survivors conducted in three Kaiser Permanente regions. The mailed questionnaire included the modified City of Hope Quality of Life-Ostomy (mCOH-QOL-Ostomy) and Medical Outcomes Study 36-Item Short-Form Health Survey, version 2 (SF-36v2). Groups surveyed were permanent ostomates (cases) and those who did not require an ostomy (controls). RC survivors were matched on sex, age, and time since diagnosis. Comparisons between groups used regression analysis with adjustment for age, comorbidity score, history of radiation therapy, income, and work status. RESULTS Response rate was 54% (491 of 909). Cases and controls had similar demographic characteristics. On the basis of the mCOH-QOL-Ostomy, both male and female cases had significantly worse social well-being compared with controls, while only female cases reported significantly worse overall HRQOL and psychological well-being. For younger females (< age 75 years), ostomy had a greater impact on physical well-being compared with older females. Based on the SF-36v2, statistically significant and meaningful differences between female cases and controls were observed for seven of the eight scales and on the physical and mental component summary scores. CONCLUSION Men and women report a different profile of challenges, suggesting the need for targeted or sex-specific interventions to improve HRQOL in this population. This may include focus on physical HRQOL for female ostomy survivors younger than age 75.

Correlation of oesophageal acid exposure with Barrett's oesophagus length

BACKGROUND Gastro-oesophageal reflux disease (GORD) plays a major role in the development of Barretts oesophagus. However, it has yet to be elucidated what factors determine the length of Barretts mucosa in each individual patient. AIMS To determine if there is a correlation between oesophageal acid exposure and the length of Barretts mucosa. We also compared the extent of oesophageal acid exposure between patients with short segment (SSBE) and long segment (LSBE) Barretts oesophagus. METHODS Twenty seven patients with Barretts oesophagus were recruited prospectively into the study from the outpatient gastroenterology clinic at the Southern Arizona VA Health Care System. Diagnosis of Barretts oesophagus and its anatomical characteristics were determined during upper endoscopy. Ambulatory 24 hour oesophageal pH monitoring assessed the extent of oesophageal acid exposure. RESULTS There was a significant correlation between per cent total time pH less than 4 and length of Barretts mucosa (r=0.6234, p=0.0005). In addition, there was a significant correlation between per cent upright and supine time pH less than 4 and length of Barretts mucosa (r=0.5847, p=0.0014 andr=0.6265 p=0.0006, respectively). Patients with SSBE had significantly less oesophageal acid exposure than patients with LSBE, in terms of both per cent total time and per cent supine time pH less than 4 (p<0.05). CONCLUSIONS The length of Barretts mucosa correlated with the duration of oesophageal acid exposure. Patients with LSBE experienced significantly more oesophageal acid exposure than patients with SSBE. Duration of oesophageal acid exposure appears to be an important contributing factor in determining the length of Barretts mucosa.

Assessment of oesophageal motor function in patients with dysphagia or chest pain: the Clinical Outcomes Research Initiative experience

Background : Available prospectively acquired data on the distribution of oesophageal motor abnormalities in patients being evaluated for non‐cardiac chest pain and/or dysphagia are relatively scarce.

Demographic and clinical factors related to ostomy complications and quality of life in veterans with an ostomy.

PURPOSE The purpose of this study is to describe demographic, clinical, and quality-of-life variables related to ostomy complications (skin irritation, leakage, and difficulty adjusting to an ostomy) in a veteran population in the United States. DESIGN The original study employed a descriptive crosssectional study using a mixed method design. This secondary analysis used the quantitative data collected. SAMPLE AND SETTING Two hundred thirty-nine veterans with intestinal ostomies from 3 Veterans Administration hospitals participated in the study. METHODS Instruments used for this investigation included the City of Hope Quality of Life: Ostomy Instrument. Demographic and medical history data were collected from the survey, the Veterans Administration health information system, and the Tumor Registry database. A self-administered survey questionnaire (mCOH-QOL-Ostomy) was mailed to each participant. RESULTS The severity of skin irritation, problems with leakage, and difficulty adjusting were significantly related to demographic, clinical, and quality-of-life domains. Univariate analyses showed that age, income, employment, preoperative care (stoma site marking and education), having a partner, ostomy type, reason for ostomy, time since surgery, total quality-of-life scores and scores on all 4 domains of quality of life were related to the severity of these ostomy complications. Age was inversely related to severity of all 3 ostomy complications (skin irritation, leakage, and difficulty adjusting). Having an ileostomy, rather than a colostomy, was associated with higher severity of skin irritation. Having had the stoma site marked preoperatively was associated with less difficulty adjusting to an ostomy, and having had preoperative ostomy education was associated with less severe problems with skin irritation and leakage. Severity of each ostomy complication predicted total quality-of-life scores. Difficulty adjusting to the ostomy was related to all 4 quality-of-life domains (physical, psychological, social, and spiritual). CONCLUSIONS This study found important relationships between demographic and clinical factors and ostomy complications. Skin problems, leakage, and difficulty adjusting predicted total quality of life scores and domains. Establishing relationships among ostomy complications and demographic, clinical factors, and quality of life can enhance identification of patients at risk for the development of complications and is an important first step in identifying the development of effective interventions to reduce the negative impact of complications for people with ostomies. Further study of predictors and outcomes of ostomy complications is needed to improve care.

The omeprazole test is as sensitive as 24‐h oesophageal pH monitoring in diagnosing gastro‐oesophageal reflux disease in symptomatic patients with erosive oesophagitis

Ambulatory 24‐h oesophageal pH monitoring and a short course of high dose omeprazole can be used as diagnostic modalities for GERD. However, comparative studies of the diagnostic accuracy and reliability of both strategies have not been performed.

Failure of oesophageal acid control in candidates for Barrett's oesophagus reversal on a very high dose of proton pump inhibitor

Normalization of oesophageal acid exposure using high dose proton pump inhibitors in patients who are candidates for ablation therapy has been suggested to be essential for successful Barretts reversal. However, the success rate for achieving pH normalization has not been determined.

Omeprazole 40 mg once a day is equally effective as lansoprazole 30 mg twice a day in symptom control of patients with gastro‐oesophageal reflux disease (GERD) who are resistant to conventional‐dose lansoprazole therapy—a prospective, randomized, multi‐centre study

Comparative studies of omeprazole and lansoprazole are scarce and even scarcer are comparisons of higher doses. Most of the comparative studies have assessed the effect of the two proton pump inhibitors (PPIs) on gastric acid secretion or gastric pH. Few studies have compared clinical end‐points such as oesophageal healing and symptom control.

Barriers to Use of Electronic Adherence Monitoring in an HIV Clinic

OBJECTIVE: To evaluate barriers to Medication Event Monitoring System (MEMS) measurement of adherence to combination antiretroviral therapy in an HIV clinic. DESIGN: Descriptive, cross-sectional study measured MEMS adherence to one antiretroviral for one month. SETTING: HIV clinic in a Veterans Affairs Medical Center. PARTICIPANTS: Sixty-four men on a stable antiretroviral treatment regimen. MAIN OUTCOME MEASURES: Decanting (removing >1 dose at a time) before and during monitoring over a 30-day observation period was used to determine the qualitative impact of MEMS on adherence. The adherence index was the proportion of prescribed doses not missed. RESULTS: Subjects were primarily white (73%) with mean CD4+ count 408 cells/mm3, log viral load 1.81 copies/mL, and duration of antiretroviral therapy 5.5 years. Twenty-seven (42%) had some decanting routine established prior to monitoring; 12 (44%) of these patients used daily decanters and 15 (56%) used weekly pillboxes. Of those who decanted prior to the study, 10 (37%) did not stop decanting during monitoring, 14 (52%) stopped decanting only the capped medication, and three (11%) stopped decanting all antiretrovirals. Other adherence strategies did not accommodate MEMS. Eight (13%) subjects said MEMS made adherence more difficult, six (9%) said MEMS was a reminder to adhere, and two (3%) mentioned both. Two subjects attributed skipped doses or time changes to the MEMS cap. The majority who refused to participate used pillboxes. CONCLUSIONS: Personal adherence strategies incompatible with MEMS are common in persons on complex treatment regimens. Although MEMS data on decanters underestimate adherence, excluding decanters erodes applicability of descriptive measures. MEMS use may have affected adherence behavior. Measures in conjunction with MEMS should include self-reported adherence and decanting assessment.

Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: A meta-analysis comparing successful versus failed percutaneous intervention for chronic total occlusion

Chronic total occlusions (CTOs) represent the most complex and challenging coronary lesions for percutaneous coronary intervention (PCI). PCI for a CTO is a high‐risk procedure and the long‐term benefits of a successful percutaneous CTO recanalization over the medical management (as a result of failed PCI) are not clear, as the studies have shown conflicting results in the past. The goal of this analysis was to clarify this issue by performing a meta‐analysis of the available literature.

Factors affecting diabetes knowledge in Type 2 diabetic veterans

Aims/hypothesisTo describe the clinical, psychological and social factors affecting diabetes knowledge of veterans with established Type 2 diabetes.MethodsWe conducted an observational study of 284 insulin-treated veterans with stable Type 2 diabetes. All subjects completed the University of Michigan Diabetes Research and Training Centre Knowledge Test, the Diabetes Care Profile, the Mini-Mental State Examination, the Geriatric Depression Scale, and the Diabetes Family Behaviour Checklist. Stepwise multiple linear regression was used to develop a model for the diabetes knowledge score based upon clinical and psychosocial variables.ResultsOne hundred eighty subjects were evaluated in a derivation set. The mean age ± SD was 65.4±9.6 years, 94% were men, and 36% were members of a minority group. Performance on the diabetes knowledge test was poor (64.9±15.3% correct). Self-perceived understanding of all management objectives explained only 6% of the variance in the knowledge scores. Multivariate analysis showed that age, years of schooling, duration of treatment, cognitive function, sex, and level of depression were independent determinants of the knowledge score. When the model was applied to 104 subjects in a validation set, there was a strong correlation between observed and predicted scores (r=0.537; p<0.001).Conclusions/interpretationStable, insulin-treated veterans have major deficiencies in diabetes knowledge that could impair their ability to provide self-care. A multivariate model comprised of demographic variables and psychosocial profiling can identify patients who have limited diabetes knowledge and be used to assess individual barriers to ongoing diabetes education.