CHICAGO—Adult survivors of childhood cancer are at increased risk of experiencing adverse general and mental health, activity limitations, and functional impairment, according to an article in the September 24 issue of The Journal of the American Medical Association (JAMA).

According to background information in the article, in general, children with aggressive tumors require more intensive cancer treatment, which predisposes them to an increased risk for certain illnesses. These could include neurocognitive dysfunction, cardiopulmonary toxicity, endocrine gland disorders, and a second malignancy.

Melissa M. Hudson, M.D., of St. Jude Children's Research Hospital and the University of Tennessee College of Medicine, Memphis, Tenn., and colleagues conducted a study to compare the health status of long-term survivors of childhood cancer and their siblings and to identify factors associated with adverse outcomes.

Health status was assessed in 9,535 adult participants of the Childhood Cancer Survivor Study (CCSS), a cohort of long-term (five years or more) survivors after treatment for cancer, leukemia, tumor, or similar illness diagnosed during childhood or adolescence between 1970 and 1986. A randomly selected cohort of the survivors' siblings (N=2,916) served as a comparison group. Six health status domains were assessed: general health, mental health, functional status, activity limitations, cancer-related pain, and cancer-related anxiety/fears. The first 4 domains were assessed in the control group.

The researchers found that survivors were significantly more likely to report adverse general health (2.5 times more likely), mental health (80 percent more likely), activity limitations (2.7 times more likely), and functional impairment (5.2 times more likely), compared with siblings.

"Important study findings include the general health as perceived by adults surviving childhood cancer is very good with only 10.9 percent reporting fair or poor health, long-term adverse effects in specific aspects of health were relatively common as reflected by 43.6 percent of the cohort reporting impairment in 1 or more of the health domains evaluated in the study, and factors associated with impaired health status included being female, not completing high school, having a household income less than $20,000, and having a diagnosis of bone tumor, central nervous system tumor, sarcoma, or Hodgkin disease," the authors write.

CHICAGO—Fitness-related variables derived from a treadmill test are useful for predicting a women's risk for death from cardiovascular disease, according to a study in the September 24 issue of The Journal of the American Medical Association (JAMA).

Cardiovascular disease claims the life of 1 of every 2 women in the United States, with most sudden deaths in women occurring in those with no previous symptoms, according to background information in the article. Identifying asymptomatic women who are at increased risk and who may benefit from aggressive primary prevention has the potential to reduce cardiovascular illness and death in women. It is controversial whether exercise testing should be used to screen asymptomatic women for cardiovascular risk. While several studies have found certain exercise test variables (e.g., reduced exercise capacity and ischemic ST-segment depression [an abnormal measurement on a electrocardiogram]) to be associated with increased mortality in healthy men, it is not known if these have similar prognostic value in women.

Samia Mora, M.D., M.H.S., of the Johns Hopkins Medical Institutions, Baltimore, and colleagues investigated the role of exercise treadmill testing in predicting cardiovascular and all-cause death in a group of asymptomatic women. The study included treadmill test data from the Lipid Research Clinics Prevalence Study (1972-1976) with follow-up through 1995. A total of 2,994 asymptomatic North American women, aged 30 to 80 years, without known cardiovascular disease, participated in the study.

During an average follow-up of 20.3 years, there were 427 (14 percent) deaths from any cause, including 147 cardiovascular deaths (34 percent of all deaths). Women with high levels of exercise capacity and high heart rate recovery (HRR) (ability of the heart rate to return to normal after peak exercise) had fewer all-cause and cardiovascular deaths during follow-up. They were also younger, reported more regular exercise, and had more favorable clinical and exercise test profiles compared with women who had lower exercise capacity or HRR. Failure to achieve target heart rate and ventricular arrhythmia were also predictors of poor prognosis. There was no increased cardiovascular death risk for exercise-induced ST-segment depression.

When the study population was divided into four groups based on the median values for exercise capacity and HRR, women who were below the median with respect to both exercise capacity and HRR had a 3.5-fold increased risk of cardiovascular death compared with women who were above the median for both variables, after controlling for cardiovascular risk factors.

CHICAGO—Hospitals that employ a higher proportion of nurses with education at the bachelor's degree or higher have lower rates of death for surgical patients, according to a study in the September 24 issue of The Journal of the American Medical Association (JAMA).

"Nurse understaffing is ranked by the public and physicians as one of the greatest threats to patient safety in U.S. hospitals," the authors write. "Nurses constitute the surveillance system for early detection of complications and problems in care, and they are in the best position to initiate actions that minimize negative outcomes for patients." The authors go on to describe the three types of programs from which registered nurses (R.N.s) in the U.S. receive their basic education: three-year diploma programs in hospitals, associate degree nursing programs in community colleges, and baccalaureate nursing programs in colleges and universities. The training has shifted from hospital-based diploma programs to associate and baccalaureate degrees in the past 50 years, according to the authors.

Linda H. Aiken, Ph.D., R.N., from the University of Pennsylvania, Philadelphia, and colleagues analyzed outcomes data for 232,342 general, orthopedic, and vascular surgery patients discharged from 168 non-federal adult Pennsylvania hospitals between April 1, 1998 and November 30, 1999. The researchers also surveyed more than 10,000 Pennsylvania nurses in 1999 through a questionnaire sent to the nurses' homes. The researchers examined the association between the educational attainments of nurses across hospitals and both deaths within 30 days of hospital admission and deaths within 30 days of admission among patients who experienced serious complications.

"The proportion of hospital R.N.s holding a bachelor's degree or higher ranged from zero percent to 77 percent across the hospitals," the authors report. "After adjusting for patient characteristics and hospital structural characteristics (size, teaching status, level of technology), as well as for nurse staffing, nurse experience, and whether the patient's surgeon was board certified, a 10 percent increase in the proportion of nurses holding a bachelor's degree was associated with a five percent decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue [deaths in patients with serious complications]."

"Our findings indicate that surgical patients cared for in hospitals in which higher proportions of direct-care R.N.s held bachelor's degrees experienced a substantial survival advantage over those treated in hospitals in which fewer staff nurses had BSN (bachelor's degree) or higher degrees," the authors state. "Similarly, surgical patients experiencing serious complications during hospitalization were significantly more likely to survive in hospitals with a higher proportion of nurses with baccalaureate education."

CHILDHOOD CANCER SURVIVORS FACE CONSIDERABLE HEALTH EFFECTS IN ADULTHOOD - BUT POSITIVE ATTITUDE PREVAILS