Ductal approaches to assessment and management of women at high risk for developing breast cancer

Projects from PSBHN Workshop – Sofia 2003

Announcement

To all participants in the programs of Dreyfus Health Foundation and subscribers to Communications for Better Health Digest

Dear friends,

Ten years have passed since the first Problem Solving for Better Health Workshop in Bulgaria. Since then, many workshops have been organized, and many projects implemented. We hope participants have learned as much we have learned from them during all the twenty workshops and follow-up workshops in the country.

If you feel you want to share your success stories and your experience, and if you have ideas about future collaboration, please write to our e-mail address - abh-psbh-bg@el-soft.com, or to 1, St. Kl. Ochridski Street, 5800 Pleven, Bulgaria, Room 271.

We look forward to hearing from you!

From the Board of Association for Better Health

NEWS

A follow-up workshop was held in Sofia on February 6^th, 2004 in Sofia. Project coordinators progress on projects prepared during the PSBHN workshop organized in Sofia in June 2003. Reports inluded:

· Providing information about diagnostic tests performed at the Center of Nuclear Medicine in Vratza - Mrs. Angela Mladenova

· Health education to help cancer patients cope with side effects of chemotherapy - Mrs. Aneta Alexieva

· Setting up a center to provide nursing staff with information about the postgraduate courses on oncopalliative care organized at the National Oncology Hospital - Mrs. Elena Christova

· Practical training for students of Sofia Nursing College to give palliative care - Mrs. Emilia Kikarina

· Setting up an information and education center at the Regional Oncology Hospital inVratza - Mrs. Karolina Kostova

· Providing cancer patients and their families with information about their rights and social benefits - Mrs. Maya Georgieva

· An educational program for patients with urostoma - Mrs. Petya Naidenova

· A program to decrease the number of cancer patients not registered for follow-up - Mrs. Yanka Zhivkova

· An educational program on safe sex for mental patients residing in a protected home in Sofia - Mrs. Roumyana Stoyanova

· Stress reduction in patients undergoing palliative treatment for lung cancer - Mrs. Valentina Kostova

· An educational program on maintenance of proper hygiene of tracheostoma - Mrs. Sinanitsa Stamatova

· Reduction of stress in medical staff with cancer disease - Mrs. Lenka Atanassova

· Educational program on the prevention of bed sores for families of patients with motor deficits - Mrs. Detelina Stancheva

A one-day training workshop for facilitators was organized in Pleven. Acting and future PSBH facilitators and PSBH activity coordinators participated from:

· Pleven - Assoc. Prof. Maria Alexandrova, Assoc. Prof. Angelika Velkova, Assoc. Prof. Maria Sredkova, Vice Rector for Research of Pleven Medical University, Mrs. Yanka Tzvetanova, Dr. Roumen Stoyanov, Mrs. Polya Zhivkova, Mrs. Makretta Draganova, Dr. Magdalena Balashkova, Mrs. Evgenia Dimitrova, Mr. Lyudmil Nikolov

· Stara Zagora – Mrs. Slava Rousseva

· Rousse – Dr. Plamen Panayotov, Mrs. Evelina Vankova

· Varna – Assoc. Prof. Lyudmila Angelova, Mrs. Gergana Momova

· Sofia – Mrs. Elena Christova, Mrs. Emilia Kikarina

· Gabrovo – Mrs. Nelly Todorova

During the workshop, under the guidance of Assoc. Prof. Vili Nisheva, training sessions were organized. Facilitation techniques and approaches were demonstrated and discussed. Future plans were discussed regarding the role of the PSBH program in Bulgaria.

A meeting was organized on March 16^th, 2004 in Gabrovo to discuss details about the June Gabrovo PSBHI –ІІ workshop in June 2004. Representatives of Gabrovo Regional Hospital, the Lung Disease Hospital, the Regional Health Center, Gabrovo Municipality, the Red Cross, the Union of Blind People, the Hygiene and Epidemiology Station, the Union of Disabled People took part in setting up priorities and establishing mechanisms of coordination to achieve better health for the population of Gabrovo and the region.

A PSBH workshop was held in Pleven on April 23-25, organized by Dreyfus Health Foundation, the Association for Better Health and Pleven Medical University. The workshop participants – students of three Medical Universities and five nursing colleges, were greeted by the Vice Rector for Academic work Assoc. Prof. Petyo Bochev.

International facilitators – Dame Sheila Quinn (UK), Mr. Paul Florea (Romania) and Assoc. Prof. Mariya Telishevska of Lviv Medical University (the Ukraine), and local facilitators – Mrs. Yanka Tzvetanova, Assoc. Prof. Angelika Velkova, Dr. Plamen Panayotov, Dr. Magdalena Balashkova, Mrs. Polya Zhivkova, Mrs. Evgenia Dimitrova, Mrs. Makretta Draganova and Mrs. Emilia Kikarina assisted the students to prepare the following plans of action:

· Health education on early diagnosis of gynecological problems - Eliz Ouzunova, Rousse Nursing College

· Drug abuse prevention for school children - Milena Ilieva, Rousse Nursing College

· Safety rules for clinical lab student technicians - Victoria Bacheva, Rousse Nursing College

· A program for social integration of people with mental disorders - Martin Yotzov, Varna Medical University

· Prevention and correction of minor spinal deformities in preschoolers - Desislava Mladenova, Sofia Nursing College

· Information for applicants for nursing colleges - Anelia Ivanova, Sofia Nursing College

· Training primary schoolchildren to give first aid - Alexandra Kamousheva, Sofia Nursing College

· Antismoking program for nursing college students - Nadezhda Lazarova, Veliko Turnovo Nursing College

· Antismoking program for nursing college students - Kamelia Todorova, Veliko Turnovo Nursing College

· Reduction of violence among middle school children - Maya Patrikova, Veliko Turnovo Nursing College

· Educational and rehabilitation program for overweight middle school children - Petya Nikolova, Veliko Turnovo Nursing College

· Teaching basic hygiene to children aged 2-3 years - Zhaklina Mineva, Veliko Turnovo Nursing College

· Organizing support groups for families of psychiatric patients - Stanimira Todorova, Dobrich Nursing College,

· Health education program for school children aged 10- 13 - Milena Lazarova, Varna Medical University

· Education on healthy diet for schoolchildren aged 12 - Teodora Marinova, Varna Medical University

· Antismoking program for children aged 10-14 - Boryana Christova, Varna Medical University

· Educational program on STIs and contraception for adolescents - Krum Krumov, Stara Zagora Medical Faculty

· Improving physical fitness of medical students - Georgi Marinov, Stara Zagora Medical Faculty

· Education on contraception for high school students - Galina Kisyova, Stara Zagora Medical Faculty

· Prevention of flat foot deformities in children aged 3-5 - Miroslava Nikiforova, Pleven Nursing College

· Education on exercise regimen for pregnant women - Ivalina Ilieva, Pleven Nursing College

· Educational programs for mothers on the dangers of treating children with antibiotics without prescription - Veselka Marinova. Pleven Nursing College

· Promotion of breast feeding - Irena Petkova, Pleven Nursing College

· Health education for pregnant women - Yana Parvanova, Pleven Nursing College

· Organizing support groups for lonely elderly people - Nikolay Alexov, Pleven Nursing College

· Health education for pregnant women - Gergana Georgieva, Pleven Nursing College

· Health education for pregnant women - Velichka Petkova, Pleven Nursing College

· Education on baby care for young couples - Galya Vladimirova, Pleven Nursing College

· Helping children from an orphanage to cope with school tasks - Christo Boyadjiev, Pleven Medical University

· Education on the dangers of drugs for high school students - Zlatina Georgieva, Pleven Medical University

· Education on prevention STIs and pregnancy for teenagers - Kalina Porozhanova, Pleven Medical University

· Education for patients with cardiac insufficiency - Rishab Kedia, an international student from India at Pleven Medical University

· Sex-education program for schoolchildren aged 12-13 - Velichka Simeonova, Pleven Medical University

· Anti-smoking program for pregnant women - Veronika Gincheva, Pleven Medical University

· Educating mothers on dangers of giving children antibiotics without prescription - Gergana Bacheva, Pleven Medical University

· Education on the effect of drugs, alcohol, nicotine and medicines on the fetus for high school girls - Boris Dashkov, Pleven Medical University

· Education on prevention of STIs for schoolchildren aged 13-14 - Elitza Mileva,-Pleven Medical University

· Raising levels of physical activity among medical students - Tihomir Andreev, Pleven Medical University

· Health education for school children aged 12-13 on the dangers of drug use - Lalit Kumar, an international student from India at Pleven Medical University

· Organizing an antismoking campaign among young people - Victoria Gogosheva and Ivailo Nenov, Pleven Medical University

· Prevention of substance abuse among international students -Pleven Medical University - Sonali Vaid, an international student from India at Pleven Medical University

· Health education on the dangers of alcohol for children aged 13-15 - Sashka Gotzevska,an international student from Macedonia at Pleven at Pleven Medical University

· Improvement of hygiene at the students' hostel - Hermine Havaryan, Pleven Medical University

· Organizing a training program for medical students to give first aid – Gergana Gogosheva, Pleven Medical University

· A training program for medical students for health promotion activities – Vitalii Rizov, Pleven Medical University

Forthcoming events:

· On June 2^nd, 2004, a follow-up workshop will be held in Gabrovo for participants in the PSBHN June 2003 workshop in Stara Zagora;

· A PSBHI workshop is to be held in Gabrovo on June 3-5^th, 2004, organized by Dreyfus Health Foundation, the Association for Better Health, Pleven Medical University and Gabrovo Regional Hospital.

Further info We hope you can visit www.livebg.net/psbh-digest, where photos from workshops and some projects are placed.

For more information, please write to us at: abh-psbh-bg@el-soft.com

Ductal approaches to assessment and management of women at high risk for developing breast cancer

I.Nenov¹, G.Baitchev², V.Rizov¹, K.Iliev¹, V.Gogosheva¹

1 – Surgery circle in University School of Medicine - Pleven

2 - Department of surgical oncology MBAL-Pleven

Abstract: Ductal approach to breast cancer, encompassing nipple aspiration, ductal lavage and duct endoscopy, allows for assessment of breast ductal epithelial cells and their local microenvironment in a graded process of increasing invasiveness. Samples of ductal epithelial cells sufficient for cytological diagnosis may be safely collected, titers of individual proteins showing variation with breast cancer status may be measured, and abnormal pathology within the breast ducts may be directly visualized. However, the sensitivity and specificity of the ductal approach need further evaluation. Small quantities of nipple aspiration fluid available for analysis, and difficulties identifying and cannulating ducts remain important limitations of these techniques.

Projects from PSBHN Workshop – Sofia 2003

Providing information about diagnostic tests performed at the Center of Nuclear Medicine in Vratza

Mrs. Angela Mladenova

The project was started in July 2003 and completed in December 2003, in close collaboration with the Regional Oncology Center in Vratza, and especially of Dr. Valkanova, director of the Center of Nuclear Medicine. . The project team prepared information brochures for specialists referring patients for investigations and for patients visiting the center. A workshop was organized for the specialists. At the center, patients were given additional information on the investigation procedures carried there.

As a result, the number of referrals was increased by 22.8% as compared to the previous six-month period.

As an additional result, the level of competence of the team was raised, as well as the quality of services in general.

The project activities have been included in the daily routine of the center, and they continue after its completion.

Health education to help cancer patients cope with side effects of chemotherapy

Mrs. Aneta Alexieva

The project was started in September 2003 at the National Oncology Hospital, after informing the governing body and the clinic of chemotherapy staff about the activities planned. Brochures with information about antitumor therapeutic preparations and ways of alleviating their side effects were prepared with the assistance of Dr. Kirov and Assoc. Prof. Peicheva..

By the end of February 2004, 35 patients filled in questionnaires when staying for infusion procedures. Those questioned before the first procedure were more relaxed as compared to patients not exposed to the information program. Questionnaires filled in by patients during the treatment period itself also showed better tolerance to the preparations.

The project is considered successful and the activities will continue.

Setting up a center to provide nursing staff with information about the postgraduate courses on oncopalliative care organized at the National Oncology Hospital

Mrs. Elena Christova

The project was started in September 2003, by establishing contact with all oncology centers in the country and deciding upon contact persons for distributing information to specialists interested in taking postgraduate courses at the National Oncology hospital, which is also a training center for oncology and palliative care health professionals. A bulletin was prepared with information about the schedules of courses offered at the center.

Results as of February 2004: in September 2003, an extraordinary course was organized on demand, attended by 28 nurses. By the end of December, applications for postgraduate courses in 2004 were submitted, exceeding those for the previous year nearly three times (278%).

Practical training for students of Sofia Nursing College to give palliative care

Mrs. Emilia Kikarina

The project was approved by the college director Assoc. Prof. Manolov, and a contract was made with Medibul Hospice in Sofia.

The plan of action was presented to the instructors in the nursing department, and the topics for the practical training were discussed and decided upon.

The training itself was integrated in the schedule for practical training of 10 student nurses during the 5^th semester, who chose to participate in it after a lecture course on nursing care entitled “Nursing care for terminal patients.

Meetings were organized with the staff and managers of two hospices in Sofia – Mrs. Donka Paprikova and Mrs. Daniela Tosheva. The training sessions were carried out at the hospices for three weeks, 6 hours daily, as part of the course in nursing care.

The project was presented at a conference which took place in Sofia in February and was organized by the National Association of Palliative Care and the Open Society Fund, to inform teachers of nursing colleges about the project activities and results. Teachers representing all colleges agreed upon the necessity for introducing palliative care nursing into the curriculum for student nurses thus giving an opportunity to students to acquire the knowledge and skills to give palliative care.

Results: four of the student nurses included in the group have stated they were willing to work in hospices for terminal patients in Sofia.

Setting up an information and education center at the Regional Oncology Hospital inVratza

Mrs. Karolina Kostova

The main objective of the project team was, by providing information to reduce the stress among patients newly registered for follow up and reduce the number of those who refused treatment for cancer diseases.

The project was started in June 2003, after its presentation to the Medical Advisory Board of the Clinic. The objectives were approved and a team was built.

Together with the clinical psychologist, a questionnaire was prepared for the patients and their families. After processing the answers the team was able to identify their needs, namely more information about the disease, its prognosis and methods of treatment.

Patients with depression are invited to therapeutic sessions with the clinical psychologist, and the social worker pays regular visits to patients and gives them information about the social benefits they can apply for. If necessary, the patients are assisted to prepare the documents for the social services.

COLOPLAST Company presented an educational video and consumables for patients with colostoma.

Meetings were organized attended by in-patients and discharged patients who felt better after therapy, and a support group was set up for which future plans were made. Patients were really appreciative of the meetings and eager to participate in them.

Many other activities were carried out by the nursing staff: posters with educational materials were hung up in all the wards, and leaflets were produced with information about radiotherapy and chemotherapy and their side effects.

The results so far are very good and encouraging according to the feedback information from questionnaires and overall impressions of the medical staff from talks to patients and their families.

In June 2004, there will be another meeting of the support group with in-patients, a representative of La Roche Company will give a lecture on antiemetic drugs, and will also sponsor the meeting.

The team has prepared a new questionnaire to allow for gathering more detailed feedback information from patients concerning activities like meetings, talks and others. This will serve as a basis for continuation of the project after its completion.

Providing cancer patients and their families with information about their rights and social benefits

Mrs. Maya Georgieva

The project was started in July 2003, after informing the management of the Oncology Hospital and staff of the palliative care ward. A team, including nurses, a clinical psychologist and a social worker was built.

Questionnaires were prepared to assess the patients’ needs for social support, and leaflets were provided with information about what benefits they can apply for.

The inquiry also included members of patients’ families. Consultations were offered regarding financial support and relief devices (wheel chairs, anti-decubital mattresses etc). Feed back information was collected from patients and their families. The level of satisfaction of patients was measures.

The number of who applied for support and relief devices has increased though some difficulties occurred in getting feed back information, and refusal of help on behalf of families of patients whose condition got worse in the course of the program. Despite the difficulties, the project team plans to continue with the activities.

Educational program for patients with urostoma

Mrs. Petya Naidenova

The project was started in July 2003 in the Urology Clinic of the National Oncology Hospital in Sofia, with the support of the head of clinic and participation of five nurses.

Within the postoperative hospital stay, individual training was carried on proper handling of the urostoma with each patient. The team was assisted by CONVATEC – Bulgaria: the company provided brochures, which demonstrated maintenance of urostoma to avoid complications. The firm also provided the team with teaching videos.

Records are kept of all patients after discharge from hospital. Of the nine patients, two passed away, and in seven no complications occurred.

A program to decrease the number of cancer patients not registered for follow-up

Mrs. Yanka Zhivkova

The project was started in July 2003, at the Sofia Regional Follow-up Center. Letters were distributed to all heads of regional hospitals that refer patients to the center.

Brochures were prepared and distributed to the specialists, and information about the registration on the follow-up process and was spread to reach patients in the regional hospitals.

Information was collected to asses the percentage of patients registered for follow up during a previous period in 2002, and percentages were as follows: Sofia region - 11%, Kyustendil region - 9%, Pernik region - 14%. Six months after the program was started, the percentages of patients not registered for follow-up were reduced to 8% (Sofia), to 9% (Kyustendil ) and 10% (Pernik).

The final results will be known in July 2004.

An educational program on safe sex for mental patients residing in a protected home in Sofia

Mrs. Roumyana Stoyanova

The project was started in June 2003, with building a team and a network for collaboration.

The patients were invited to and participated in training and assessment sessions, including presentations, video demonstrations, discussions, individual talks, psychodrama, group work, and discussions on information brochures, psychological testing and other group activities.

Thanks to the intelligible teaching materials and aids, the project has contributed to introduce safer sex practices among these patients and improve their life-quality. Moreover, patients and their families were provided with the information where, when, how and whom to contact if they needed advice and support.

The team plans to include more people in the group and reaching more under-privileged people with special needs in such programs.

Stress reduction in patients undergoing palliative treatment for lung cancer

Mrs. Valentina Kostova

The project was started in September 2003, at the brochology consulting room of the National Oncology Hospital in Sofia. A team of nurses was built, and Dr. Shindov was invited to participate as a consultant in the preparation of the information brochure for the patients.

During individual talks with patients several days before endobronchial laser recanalisation, the nurses talked to them about the benefits of the procedure. During the procedure itself, a nurse was present to support the patient.

The stress level in the patients was assessed by using a questionnaire, filled after the second procedure by patients treated in the period between September 2003 and January 2004.

Results: stress levels were reduced by more than 50% as compared to that the project activities will continue till September 2004.

An educational program on maintenance of proper hygiene of tracheostoma

Mrs. Sinanitsa Stamatova

The project was started in September 2003 at the Head and Neck Clinic of the National Oncology Hospital in Sofia.

The training program for the 29 patients included

· Presentation of contents of an information brochure;

· Presenting a video with demonstration of proper techniques for the maintenance of hygiene of the tracheostoma canula

· Two practicing sessions under the guidance of a nurse

The projrct was carried out by the nurses in the clinic. The video was made with the support of Mr. Alexandrov of the Information Center, Ministry of Defense.

Results: all 29 patients have acquired skills for proper maintenance of the tracheostoma without assistance.

Reduction of stress in medical staff with cancer disease

Mrs. Lenka Atanassova

The project was started at the National at the National Oncology Hospital in June 2003, and the team included two cardiologists, a psychologist and a nurse. The target group of ten persons was selected on a volunteer basis. The program included individual talks and discussions, and when necessary, some of them were referred to a specialist.

The assessment of stress levels before and after the program showed a considerable decrease. The results achieved by the end of December 2003 have encouraged the team to continue with the project, adding more activities and with a larger group of participants.

Educational program on the prevention of bed ulcvers for familieas of patients with motor deficit

Mrs. Detelina Stancheva

The project was started in June 2003. For the period of six months, 68 patients with bed ulcers were examined by a surgeon in their homes in Pleven region.

Forty-six of these patients were assisted to apply for and get financial support and relief devices - anti-decubital mattresses and cushions, wheel chairs, walking sticks, crutches, chemical toilets, walkers. Each patient/family got instructions how to use the devices.

All patients and their families were also provided with instructions concerning individual diet and hygiene, and when it was necessary, patients were examined by a specialist (the team included an oncologiost, a surgeon, a neurologist, an orthopedist and a physiotherapist). Treatment in the home for bed ulcers was carried out for twelve patients, and three were admitted for treatment at the surfgery clinics of the University Hospital in Pleven. Seventeen patients were referred for assessment by a specialised board, so as to have access to additional financial support from social services.

An leaflet with information on prevention and treatment for decubital ulcers was printed and distributed. Brochures containing information on services provided by the Ministry of Labor and Social Welfare and the National Union of Disabled people was copied and distributed to ensure easier access to services and support for disabled people.

An intervention program to reduce frequency of risk factors and to prevent late complications in hypertensive patients

Lilyana Mihailova

Arterial hypertension is one of the most frequent cardiovascular diseases and socially significant health problems of the population of Bulgaria. It is a significant independent, and with a high prevalence secondary risk factor, a major determinant of cerebrovascular disease, one of the three most important causes of ischemic heart disease, and a significant predictor of peripheral vessels disease.

The risk factors constellation of Bulgarian population is favorable for the large spread of high blood pressure. A higher prevalence of hypertension and its complication has been observed among rural population. The presented intervention program aimed at achieving better health and preventing late complications among hypertensive patients aged 20 to 79 years living in the village of Opanetz, Pleven region. We wanted to reduce the systolic blood pressure by 10 mm Hg and the diastolic blood pressure – by 5 mm Hg permanently and in all the patients.

The project team included a nurse-coordinator, the general practitioner and the nurse working in the village, a cardiologist and several cardiologists observing the hypertensive patients on a regular basis. The program was carried out in the GP’s consulting room, at patients’ homes and at the local house of culture.

The program was directed to 320 hypertensive patients with high blood pressure registered at the local GP’s consulting room, and their families. Scientific observation and laboratory tests were performed on a study group of 100 patients. The group was randomly selected keeping the sex and age distribution of the entire hypertensive population.

To examine the risk factors distribution and the health problems of the group a cross-sectional epidemiological study was carried out. It included an explorative interview, review of medical records and some laboratory tests. The patients were interviewed about the most important risk factors of hypertension and its complications, using a standardized interview. Anthropometric measurements were performed and body mass index (BMI) was calculated to determine the obesity grade of patients. The study confirmed that age, genetic predisposition, gender, high daily salt intake, high alcohol consumption, imbalanced nutrition and obesity are independent significant risk factors of hypertension and its complications. Two thirds of the study group ate at least 500g bread daily, and 50% preferred white bread. About 85% of the respondents reported low consumption of fresh fruit and vegetables. Only 11% did not add salt to the food. Increased level of stress was typical for 80% of the sample and 72% stated that they were not satisfied with their lives in general. BMI was higher in 56 women and 32 men. Wrong self-assessment of personal weight was observed in 21 hypertensive patients with obesity who evaluated their body weight as normal. That puts serious obstacles to the initiation of an intervention program aiming at reducing the body weight because of the underestimation of personal risk of complications.

Medical documentation review revealed that despite the long period of hypertension (more than 15 years) in 50% of the study group, the treatment started at a rather late stage of the disease. Diabetes Mellitus was found in 11 of the patients, serious cardiovascular complications developed 67 of them, and 62 had retinopathy.

The goals of the intervention program were determined on the basis of study findings, and standardized procedures for the medical team were developed in order to improve the quality of care for hypertensive patients. Lecture on hypertension and its complications was prepared by the cardiologist and broadcasted on the local radio. All hypertensive patients and their families participated in a lecture course delivered by the GP and the medical team members on risk factors, diet and appropriate life styles in view of the disease. The village council and Meditech Company helped to organize standardization of all personal blood pressure devices of the patients. The medical team prepared individual cards for registering the blood pressure and treatment, and patients were trained how to use it. In two practical sessions with the coordinator of the project and the local nurse, the patients were trained to measure their blood pressure at home. In December 2003, the acquired health knowledge and behavioral change achieved by patients in the study group were studied using a questionnaire. Blood pressure was checked assess the actual change after the intervention.

The results showed an average decrease of systolic blood pressure of 5.7 mm Hg in men, and 4.7 mm Hg in women, and a decrease of diastolic blood pressure of 3 and 4 mm Hg respectively. The achieved reduction of both systolic and diastolic blood pressure in a six-month period is sound come to prove that a complex intervention program to change life-style and improve the medical care for hypertensive persons possesses significant possibilities to improve health of patients and to reduce late complications.