To identify factors linked with emotional and behavioural problems in school age (6-to 17-year-old) children of women with breast cancer. Reports of children's emotional and behavioural problems were obtained from patient mothers, their healthy partners, the children's teacher and adolescents using the Child Behaviour Checklist and Mental Health subscale of the Child Health Questionnaire. Parents reported on their own level of depression and, for patients only, their quality of life. Family functioning was assessed using the Family Assessment Device and Cohesion subscale of the Family Environment Scale. Using a cross-sectional within groups design, assessments were obtained (N ¼ 107 families) where the patients were 3 -36 months postdiagnosis. Risk of problems in children were linked with low levels of family cohesion, low affective responsiveness and parental over-involvement as reported by both child and mother. Adolescents reported family communication issues, which were associated with externalising behaviour problems. Maternal depression was related to child internalising problems, particularly in girls. Whether the mother was currently on or off chemotherapy was not associated with child problems nor was time since cancer diagnosis. These findings held across child age. Where mothers have early stage breast cancer, a substantial minority of their school-aged children have emotional and behavioural problems. Such cases are characterised by the existence of maternal depression and poor family communication, rather than by the mother's treatment status or time since diagnosis. Targeted treatments, which focus on maternal depression and family communication may benefit the children and, through improved relationships, enhance the patients' quality of life.
When mothers have breast cancer, a substantial minority of their adolescent children have psychological and stress response-related problems linked with poor family functioning. These results argue in favour of a family-oriented approach to psychological support of breast cancer patients.
Congestive heart failure (CHF) has become an increasingly expensive and prevalent condi¬ tion in the United States. Patients with advanced or unstable CHF often have multiple comorbidities and are expensive and difficult to treat. Humana Inc., one of the largest health plans in the U.S., and Cardiac Solutions, a cardiac disease management company, initiated a heart failure disease management program nationally for Humana's Medicare risk members in 1996. Utilizing the Cardiac Solutions MULTIFIT® system, specialized disease managers managed 1,915 patients who had had at least one prior admission for CHF. Medical resource utilization was substantially reduced during the time that patients were on the Cardiac So¬ lutions program. The patients' hospital admissions for all diagnoses dropped 60%, and total hospital days were reduced 58% in the first 13 months. Inpatient costs for CHF admissions dropped 78%, while inpatient costs for all other admissions fell by 50%. Total costs for all conditions dropped 55% (before disease management fees) from prior levels. Patients for whom data are available (431 patients) reduced their sodium intake by 20% from 3,023 mg at program onset to 2,406 mg within the next 3-4 months. Two hundred fifty-nine (259) patients experienced a 15% overall improvement in functional status, from 14.2 to 16.3, utilizing the Duke Activity Status Index. Assessments of 2,442 patients indicated that the weighted aver¬ age New York Heart Association classification score improved by 3.2%, with more than 90% of all patients maintaining or improving their status. The management of care for heart fail¬ ure extends to the conditions that predispose to and accompany heart failure. An approach to heart failure that addresses the patient with disease rather than the disease in the patient is not only more likely to achieve overall better clinical results, but greater'financial savings.Congesti ve heart failure has become a per-ure nationally, with 400,000 new cases diagnicious, expensive, and growing problem nosed each year.1 Heart-failure prevalence inin the United States. There are an estimated 4.7 creases significantly with age, and the disease million individuals with congestive heart fail-is the number one reason for hospital admis-
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