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Radial Scars in Benign Breast-Biopsy Specimens and the Risk of Breast Cancer
JANUARY 2000, VOL 71, NO 1 REVIEWS
RESEARCH REVIEWS
NEEDLESTICK INJURIES AMONG HEALTH CARE WORKERS: A LITERATURE REVIEW C Porta, E Handelman, P McGovern American Association of Occupational Health Nurses Vol47 no 6 (1999) 237-243
T
his article offers the results of an extensive literature review about needle-stick injuries. Addressed are needlestick injury rates and trends, along with current scientific findings pertaining to safer needle devices and their effectiveness in decreasing needle-stick incidents.
Needle-stick injury rates and trends. The US Centers for Disease Control and Prevention estimates that 800,000exposure incidents occur annually. Determining the scope of needlestick injuries in the United States, however, is difficult for several reasons. First, national databases do not exist to track or tabulate data about needle-stick injuries. Second, the literature reviewed pertains to hospital sites and may not be representative of other health care settings. Third, researchers have used a variety of methods to evaluate needle-stick injury rates, making it difficult to compare individual findings and determine a standard needle-stick injury rate. Finally, many injuries are not reported. Research regarding underreporting indicates needlestick injury rates ranging from 21% to 95%.
Safer needle devices. MOR than 1,OOO US patents in the area of needle-stick prevention devices
have been issued since the early 1980s. Many studies report that use of safer devices is associated with radical improvements in safety and decreases in reported needle-stick injuries. Some literature, however, reports little or no improvement. Despite the limitations of these studies, they do offer generalizations about the use of safer devices. First, devices with passive mechanisms of action are recommended over those with active mechanisms of action. Devices with passive mechanisms require no action from the user; thus, they do not add a step to the user’s work procedure. Second, most of the studies focus on three basic devices: IV equipment, suture needles, and hollow bore needles. Of particular interest to perioperative nurses is the fact that suture needles harbor great potential for disease transmission. The good news is that blunt suture needles are associated with significant decreases in needle-stick injuries. The use of these needles, however, is limited to certain surgical procedures. Third, some studies have attempted to determine the cost-efficiency of using safer needle devices. The studies found that the direct purchasing costs related to safer needle devices are greater than those of traditional devices; however, a comparison of study findings requires the use of standard economic frameworks. Finally, the user’s satisfaction is critical to the success of safer needle devices. Dissatisfaction with the devices frequently results in users resorting to traditional devices. This is least 240 AORN JOURNAL
likely to happen when satisfaction among users is high. Greater satisfaction is related to the use of training periods that enable users to practice and gain confidence in using the new products. COnClUSlOn. Needle-stick injuries continue to pose a serious threat to perioperative nurses, as well as to other health care workers. Needleless IV needles and blunt suture needIes have been developed. Product substitution, however, is not sufficient to address the problem. The literature supports comprehensive injury prevention and control strategies, in addition to the use of safer devices. Critical to the success of these strategies and the introduction and use of safer devices is the involvement of the users. EDWINA A. McCONNELL RN, PnD, FRCNA NURSINGRESEARCH COMMIITEE
RADIAL SCARS IN BENIGN BREAST-BIOPSY SPECIMENS AND THE RISK OF BREAST CANCER T W Jacobs et a1 New England Journal of Medicine Vol340 (Feb 11,1999) 430-436
R
adial scars are benign breast lesions of uncertain clinical significance. This study explores the possible risks associated with radial scars in women with benign breast disease. The main characteristic of radial scars is a fibroelastotic core from which ducts and lobules radiate. These scars are usually incidental microscopic findings in breast tissue that are sometimes removed because of other possible abnormalities. Mammography examinations, however, have shown an
JANUARY ZOOO,VOL 7 1, NO 1
increased incidence of large radial scars. The similarity of radial scars to cancer and the findings of carcinoma in some scars have suggested the possibility of a relationship between radial scars and certain types of breast cancer. Other studies have not demonstrated this relationship because the controls were not suitable. This particular study was a case-control study within the Nurses’ Health Study, which is a long-term prospective evaluation of risk factors for breast carcinoma in women in the United States. Methods. The f i s t part of the Nurses’ Health Study began in 1976, when 121,701 female RNs born between 1921 and 1946 responded to a mailed questionnaire about their potential risk factors for breast cancer and their medical history. The second part of the Nurses’ Health Study included 1 16,671 female RNs born between 1946 and 1964. These nurses also responded to a mailed questionnaire and answered questions regarding past diagnosis of benign breast disease that required hospitalization or was confirmed by a breast biopsy. Eligible participants included RNs who had not received a diagnosis of cancer at the beginning of each two-year follow-up interval and who reported a diagnosis of benign breast disease. Nurses reporting a diagnosis of breast cancer after at least one year of reported benign breast disease were matched to four RNs (ie, the controls) who did not have cancer, were born the same year, and received the diagnosis of benign disease the same year. Participants provided permission
to obtain slides of biopsy tissue
for comparison. Slides were reviewed with no prior knowledge of whether the participant had cancer. Results. Among the 1,396 women with benign breast disease whose biopsy specimens were reviewed, 99 (ie, 7.1%) had radial scars identified. Women with radial scars were older and more likely to be menopausal. Participants with radial scars and subsequent breast cancer were more likely to have a family history of breast cancer. No relationship was found between the presence of radial scars and menarche, parity, age at birth of first child, or body mass index. Radial scars were present in 12.5% of the women with subsequent breast cancer and in 5.9% of the controls. Discussion. The results of this study demonstrate that the presence of radial scars almost doubles the risk of breast cancer, regardless of the histologic category of benign breast disease. Pathologists examining breast biopsy specimens should report the presence of radial scars in benign breast disease and note the size and number of the lesions. The researchers suggest that women should undergo regular clinical and mammography follow-up examinations recommended for other patients with benign breast lesions. The radial scars noted in this study were small lesions that were detected incidentally. Whether these results can be extrapolated to large radial scars detected by mammography is unresolved and requires further investigation.
CHILDREN’S PREOPERATIVE COPING AND ITS EFFECTS ON POSTOPERATIVE ANXIETY AND RETURN TO NORMAL ACTIVITY L L LaMontagne et a1 Nursing Research Vol45 (MaylJune 1996) 141-147
P
erioperative nurses often face the challenge of dealing with anxious pediatric patients. Although we have recognized the importance of helping children cope with the stressful surgical experience, little is known about how this coping influences patient outcomes. The purpose of this study was twofold: determine whether the relationships found previously between coping and its antecedents (eg, age, information given, locus of control) would be replicated with a sample of children undergoing major, rather than minor, elective surgery and test a model that relates coping to two different postoperative outcomes (ie, anxiety and return to normal activities). Creating a model. Researchers reviewed theories on stress and coping, as well as research conducted on children undergoing minor surgery. The study was grounded on Lazarus’ theory of stress and coping, which describes coping as the process used to alter, manage, or tolerate a disturbance in a personal or situational relationship. Previous research has found that children vary in their method of coping with stress, such as that caused by upcoming surgery. The use of MARYANNE K. COUGHLIN avoidance is associated with RN, MBA, CNOR external locus of control. NURSN I G RESEARCH COMM~EE Children who receive more 242 AORN JOURNAL
RESEARCH REVIEWS
NEEDLESTICK INJURIES AMONG HEALTH CARE WORKERS: A LITERATURE REVIEW C Porta, E Handelman, P McGovern American Association of Occupational Health Nurses Vol47 no 6 (1999) 237-243
T
his article offers the results of an extensive literature review about needle-stick injuries. Addressed are needlestick injury rates and trends, along with current scientific findings pertaining to safer needle devices and their effectiveness in decreasing needle-stick incidents.
Needle-stick injury rates and trends. The US Centers for Disease Control and Prevention estimates that 800,000exposure incidents occur annually. Determining the scope of needlestick injuries in the United States, however, is difficult for several reasons. First, national databases do not exist to track or tabulate data about needle-stick injuries. Second, the literature reviewed pertains to hospital sites and may not be representative of other health care settings. Third, researchers have used a variety of methods to evaluate needle-stick injury rates, making it difficult to compare individual findings and determine a standard needle-stick injury rate. Finally, many injuries are not reported. Research regarding underreporting indicates needlestick injury rates ranging from 21% to 95%.
Safer needle devices. MOR than 1,OOO US patents in the area of needle-stick prevention devices
have been issued since the early 1980s. Many studies report that use of safer devices is associated with radical improvements in safety and decreases in reported needle-stick injuries. Some literature, however, reports little or no improvement. Despite the limitations of these studies, they do offer generalizations about the use of safer devices. First, devices with passive mechanisms of action are recommended over those with active mechanisms of action. Devices with passive mechanisms require no action from the user; thus, they do not add a step to the user’s work procedure. Second, most of the studies focus on three basic devices: IV equipment, suture needles, and hollow bore needles. Of particular interest to perioperative nurses is the fact that suture needles harbor great potential for disease transmission. The good news is that blunt suture needles are associated with significant decreases in needle-stick injuries. The use of these needles, however, is limited to certain surgical procedures. Third, some studies have attempted to determine the cost-efficiency of using safer needle devices. The studies found that the direct purchasing costs related to safer needle devices are greater than those of traditional devices; however, a comparison of study findings requires the use of standard economic frameworks. Finally, the user’s satisfaction is critical to the success of safer needle devices. Dissatisfaction with the devices frequently results in users resorting to traditional devices. This is least 240 AORN JOURNAL
likely to happen when satisfaction among users is high. Greater satisfaction is related to the use of training periods that enable users to practice and gain confidence in using the new products. COnClUSlOn. Needle-stick injuries continue to pose a serious threat to perioperative nurses, as well as to other health care workers. Needleless IV needles and blunt suture needIes have been developed. Product substitution, however, is not sufficient to address the problem. The literature supports comprehensive injury prevention and control strategies, in addition to the use of safer devices. Critical to the success of these strategies and the introduction and use of safer devices is the involvement of the users. EDWINA A. McCONNELL RN, PnD, FRCNA NURSINGRESEARCH COMMIITEE
RADIAL SCARS IN BENIGN BREAST-BIOPSY SPECIMENS AND THE RISK OF BREAST CANCER T W Jacobs et a1 New England Journal of Medicine Vol340 (Feb 11,1999) 430-436
R
adial scars are benign breast lesions of uncertain clinical significance. This study explores the possible risks associated with radial scars in women with benign breast disease. The main characteristic of radial scars is a fibroelastotic core from which ducts and lobules radiate. These scars are usually incidental microscopic findings in breast tissue that are sometimes removed because of other possible abnormalities. Mammography examinations, however, have shown an
JANUARY ZOOO,VOL 7 1, NO 1
increased incidence of large radial scars. The similarity of radial scars to cancer and the findings of carcinoma in some scars have suggested the possibility of a relationship between radial scars and certain types of breast cancer. Other studies have not demonstrated this relationship because the controls were not suitable. This particular study was a case-control study within the Nurses’ Health Study, which is a long-term prospective evaluation of risk factors for breast carcinoma in women in the United States. Methods. The f i s t part of the Nurses’ Health Study began in 1976, when 121,701 female RNs born between 1921 and 1946 responded to a mailed questionnaire about their potential risk factors for breast cancer and their medical history. The second part of the Nurses’ Health Study included 1 16,671 female RNs born between 1946 and 1964. These nurses also responded to a mailed questionnaire and answered questions regarding past diagnosis of benign breast disease that required hospitalization or was confirmed by a breast biopsy. Eligible participants included RNs who had not received a diagnosis of cancer at the beginning of each two-year follow-up interval and who reported a diagnosis of benign breast disease. Nurses reporting a diagnosis of breast cancer after at least one year of reported benign breast disease were matched to four RNs (ie, the controls) who did not have cancer, were born the same year, and received the diagnosis of benign disease the same year. Participants provided permission
to obtain slides of biopsy tissue
for comparison. Slides were reviewed with no prior knowledge of whether the participant had cancer. Results. Among the 1,396 women with benign breast disease whose biopsy specimens were reviewed, 99 (ie, 7.1%) had radial scars identified. Women with radial scars were older and more likely to be menopausal. Participants with radial scars and subsequent breast cancer were more likely to have a family history of breast cancer. No relationship was found between the presence of radial scars and menarche, parity, age at birth of first child, or body mass index. Radial scars were present in 12.5% of the women with subsequent breast cancer and in 5.9% of the controls. Discussion. The results of this study demonstrate that the presence of radial scars almost doubles the risk of breast cancer, regardless of the histologic category of benign breast disease. Pathologists examining breast biopsy specimens should report the presence of radial scars in benign breast disease and note the size and number of the lesions. The researchers suggest that women should undergo regular clinical and mammography follow-up examinations recommended for other patients with benign breast lesions. The radial scars noted in this study were small lesions that were detected incidentally. Whether these results can be extrapolated to large radial scars detected by mammography is unresolved and requires further investigation.
CHILDREN’S PREOPERATIVE COPING AND ITS EFFECTS ON POSTOPERATIVE ANXIETY AND RETURN TO NORMAL ACTIVITY L L LaMontagne et a1 Nursing Research Vol45 (MaylJune 1996) 141-147
P
erioperative nurses often face the challenge of dealing with anxious pediatric patients. Although we have recognized the importance of helping children cope with the stressful surgical experience, little is known about how this coping influences patient outcomes. The purpose of this study was twofold: determine whether the relationships found previously between coping and its antecedents (eg, age, information given, locus of control) would be replicated with a sample of children undergoing major, rather than minor, elective surgery and test a model that relates coping to two different postoperative outcomes (ie, anxiety and return to normal activities). Creating a model. Researchers reviewed theories on stress and coping, as well as research conducted on children undergoing minor surgery. The study was grounded on Lazarus’ theory of stress and coping, which describes coping as the process used to alter, manage, or tolerate a disturbance in a personal or situational relationship. Previous research has found that children vary in their method of coping with stress, such as that caused by upcoming surgery. The use of MARYANNE K. COUGHLIN avoidance is associated with RN, MBA, CNOR external locus of control. NURSN I G RESEARCH COMM~EE Children who receive more 242 AORN JOURNAL