Lina Jandorf

THE MEASUREMENT OF FATIGUE: A NEW INSTRUMENT

Fatigue is a frequent medical symptom which has not been routinely measured. We present a 29-item fatigue assessment instrument, describe its psychometric properties, and use it to differentiate normal fatigue from fatigue related medical disorders. Differences in fatigue across a variety of medical disorders, the reproducibility of the fatigue instrument, and its convergent validity with other fatigue measures are also described.

Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. Racial disparities in CRC incidence and mortality have been well documented. In addition, lower rates of CRC screening among ethnic minorities have been reported. Therefore, we tested the effectiveness of a patient navigator (PN) in increasing compliance with CRC screening in a minority community health setting. Men and women aged 50 or older attending a primary care practice were enrolled if they had not had a fecal occult blood test within the past year, a sigmoidoscopy or barium enema within the past 3–5 years, or a colonoscopy within the past 10 years. Participants were randomly assigned either to receive navigator services (PN+) or not to receive navigator services (PN−). There were no demographic differences between the two groups. Within 6 months of physician recommendation, 15.8% in the PN+ group had complied with an endoscopic examination, compared with only 5% in the PN− group (P=.019). The PN+ groups also demonstrated higher rates of fecal occult blood test completion (42.1% vs. 25%, P=.086). Thus, a PN system successfully increases CRC screening rates among a predominantly minority population of low socioeconomic status.

A randomized controlled trial using patient navigation to increase colonoscopy screening among low-income minorities.

Organizational barriers play a key role in colorectal cancer (CRC) screening disparities in low-income minorities. This is a prospective, randomized trial to determine whether a patient navigator (PN) can help overcome the organizational barriers low-income minorities face in trying to obtain screening colonoscopy. Patients of average risk for CRC were referred by their primary care physician for screening colonoscopy. After the PN received the referral, patients were randomly assigned to either receive navigation (PN+) to screening colonoscopy or not receive navigation (PN-). We hypothesized that a PN would increase patient compliance with screening colonoscopy. A total of 21 patients were enrolled in the pilot study (PN+ = 13, PN- = 8); 54% of navigated patients completed screening colonoscopy versus 13% of nonnavigated patients (p = 0.058). Eighty-six percent of navigated patients had an excellent or very good colon prep; however, there was no difference in prep quality between groups ( p = 0.10). One-hundred percent of navigated patients were very satisfied with navigation services. A PN improves compliance with screening colonoscopy in low-income minorities. Larger studies are needed to evaluate what features of navigation are most effective in facilitating completion of screening colonoscopy.

A Program to Enhance Completion of Screening Colonoscopy Among Urban Minorities

BACKGROUND & AIMS Although colonoscopy is becoming the preferred screening test for colorectal cancer, screening rates, particularly among minorities, are low. Little is known about the uptake of screening colonoscopy or the factors that predict colonoscopy completion among minorities. This study investigated the use of patient navigation within an open-access referral system and its effects on colonoscopy completion rates among urban minorities. METHODS This was a cohort study that took place at a teaching hospital in New York. Participants were mostly African Americans and Hispanics directly referred for screening colonoscopy by primary care clinics from November 2003 to May 2006. Once referred, a bilingual Hispanic female patient navigator facilitated the colonoscopy completion. Completion rates, demographic factors associated with completing colonoscopy, endoscopic findings, and patient satisfaction were analyzed. RESULTS Of 1169 referrals, 688 patients qualified for and 532 underwent navigation. Two thirds (66%) of navigated patients completed screening colonoscopies, 16% had adenomas, and only 5% had inadequate bowel preps. Women were 1.31 times more likely to complete the colonoscopy than men (P = .014). Hispanics were 1.67 times more likely to complete the colonoscopy than African Americans (P = .013). Hispanic women were 1.50 times more likely to complete the colonoscopy than Hispanic men (P = .009). Patient satisfaction was 98% overall, with 66% reporting that they definitely or probably would not have completed their colonoscopy without navigation. CONCLUSIONS By using a patient navigator, the majority of urban minorities successfully completed their colonoscopies, clinically significant pathology was detected, and patient satisfaction was enhanced. This approach may help increase adherence with screening colonoscopy efforts in other clinical settings.

Correlates of colorectal cancer screening compliance and stage of adoption among siblings of individuals with early onset colorectal cancer

Concepts from the health belief, transtheoretical, and dual process models were used to examine how siblings of individuals diagnosed with colorectal cancer (CRC) before age 56 made decisions about CRC screening. Siblings (N = 504) were assessed for CRC screening practices and intentions, pros, cons, processes-of-change, perceived risk of CRC, perceived severity of CRC, preventability of CRC, cancer-related distress, and sibling relationship closeness. Physician and family recommendation and knowledge were also assessed. Fifty-seven percent of participants (n = 287) were compliant with CRC screening. Logistic regression indicated that perceived pros and cons, perceived risk, commitment to screening, health care avoidance, and sibling closeness were associated with screening compliance. Physician and family recommendation were also strong correlates. A similar set of factors was associated with stage of adoption of CRC screening.

Perceived disadvantages and concerns about abuses of genetic testing for cancer risk: differences across African American, Latina and Caucasian women

Participation in genetic testing for cancer risk is low among women of medically underserved ethnic groups and this is due, in part, to genetic testing attitudes, specifically perceived disadvantages of genetic testing and concerns about possible abuses of genetic testing. The goals of the current study were to: (a) explore genetic testing attitudes, and (b) determine the extent to which ethnicity, awareness of genetic testing, and medical mistrust are associated with genetic testing attitudes. African American, Latina, and Caucasian women (N=273) completed an interview assessing sociodemographic information, genetic testing awareness, medical mistrust, and genetic testing attitudes. Latina participants more strongly agreed with disadvantages of testing than the other ethnic groups. Both Latina and African American women more strongly concurred with concerns about testing abuses compared to Caucasian women. In hierarchical linear regression analyses, Spanish language preference and medical mistrust were the only significant predictors of perceived disadvantages and medical mistrust was the only significant predictor of abuse concerns. These findings support the importance of identifying genetic testing attitudes that may be culturally specific in order to promote culturally competent care by genetic risk professionals.

A simplified, noninvasive stool DNA test for colorectal cancer detection.

BACKGROUND:As a noninvasive colorectal cancer (CRC) screening test, a multi-marker first generation stool DNA (sDNA V 1.0) test is superior to guaiac-based fecal occult blood tests. An improved sDNA assay (version 2), utilizing only two markers, hypermethylated vimentin gene (hV) and a two site DNA integrity assay (DY), demonstrated in a training set (phase 1a) an even higher sensitivity (88%) for CRC with a specificity of 82%.AIM:To validate in an independent set of patients (phase 1b) the sensitivity and specificity of sDNA version 2 for CRC.METHODS:Forty-two patients with CRC and 241 subjects with normal colonoscopy (NC) provided stool samples, to which they immediately added DNA stabilizing buffer, and mailed their specimen to the laboratory. DNA was purified using gel-based capture, and analyzed for hV and DY using methods identical to those previously published.RESULTS:Using the same cutpoints as the 1a training set (N = 162; 40 CRCs, 122 normals), hV demonstrated a higher and DY a slightly lower sensitivity, for a combined sensitivity of hV + DY of 86%. Optimal cutpoints based on the combined phase 1a + 1b dataset (N = 445; 82 CRCs, 363 normals) yielded a CRC sensitivity of 83%. The vast majority of cancers were detected regardless of tumor stage, tumor location, or patient age. Assay specificity in the phase 1b dataset for hV, DY, and hV + DY was 82%, 85%, and 73%, respectively, using the phase 1a cutpoints. Optimal cutpoints based on the combined phase 1a + 1b dataset yield a specificity of 82%.CONCLUSIONS:This study provides validation of a simplified, improved sDNA test that incorporates only two markers and that demonstrates high sensitivity (83%) and specificity (82%) for CRC. Test performance is highly reproducible in a large set of patients. The use of only two markers will make the test easier to perform, reduce the cost, and facilitate distribution to local laboratories.

Sleep disturbance in chronic fatigue syndrome

Sleep and fatigue characteristics were evaluated in 72 patients who met major criteria for the chronic fatigue syndrome (CFS), 57 multiple sclerosis (MS) patients preselected for fatigue complaints, and 40 healthy controls. Using previously validated rating scales, CFS patients had significant elevations in fatigue and sleep disturbance compared to the MS and healthy control groups. To confirm these subjective measures, polysomnography was carried out in a subgroup of CFS patients who included sleep disturbance as one of their symptoms on initial clinical interview. In 10 of 16 (62.5%) polysomnography revealed clinically significant and potentially treatable sleep abnormalities. Their sleep disorders included periodic movement disorder (4), excessive daytime sleepiness (3), apnea (2), and narcolepsy (1). We conclude that subjective sleep disturbance is common in CFS and some CFS patients may have objective sleep disorders.

Failure to differentiate bipolar disorder from schizophrenia on measures of neuropsychological function

30 inpatients diagnosed with schizophrenia were compared to 35 inpatients with bipolar affective disorder, manic type, on a large group of neuropsychological measures. Separate factor analyses were performed on measures of verbal, spatial, and speed variables in order to generate summary scales. Controlling for the effects of age, education, sex, duration of illness, number of previous hospitalizations, and medications at time of testing, there were no significant differences between diagnostic groups on the three factors or on individual test variables. Patients on medication performed more poorly on speed variables than those off medication. These findings call into question the notion of differential patterns of cognitive deficit among psychotic diagnoses.

Insight in first-admission psychotic patients

BACKGROUND The prevalence of insight was examined longitudinally in psychotic patients with schizophrenia (n = 86), bipolar disorder (n = 52), major depressive disorder (n = 35) and other psychoses (n = 16). METHOD Before discharge and at 6-month follow-up, insight in first-admission patients from 10 facilities in Suffolk County, New York was rated as part of a modified Hamilton Depression Scale. RESULTS Initially, 80% of depressives but approximately half with other diagnoses manifested insight. At follow-up, most patients demonstrated insight except for the schizophrenic patients. After controlling for diagnosis, significant correlates of baseline insight were being married, hospitalized in a community or academic facility, intelligence and negative symptoms. At follow-up, after controlling for diagnosis and baseline insight, prior treatment was predictive. This finding held for schizophrenic patients separately. CONCLUSION Lack of insight is more prevalent in schizophrenia and improves over time. The components of prior treatment leading to better insight should be explored.