Paraneoplastic Manifestation of Primary Squamous Cell Cancer of the Thyroid Gland.

Paraneoplastic manifestation (PNM) of cancers is a non-metastatic, non-invasive systemic effect of malignancies due to chemokines and hormones produced by the primary neoplasm. Squamous cell cancers (SCCs) are known to present with PNM. Primary SCC of thyroid accounts for <1% of all thyroid malignancies and carries a very poor prognosis. We present a rare case of SCC arising from the thyroid gland who presented with fever, leukemoid reaction and hypercalcemia as part of PNM. A 67-year-old male patient presented with two months history of intermittent high-grade fever, weakness, loss of weight and appetite. Examination revealed a large (~10 cm) hard swelling over the right side of the neck. Investigations revealed neutrophilic leukocytosis, elevated C-reactive protein (CRP) and procalcitonin and hypercalcemia with a normal thyroid-stimulating hormone (TSH). The fever workup was negative for infection. Fine-needle aspiration cytology (FNAC) and core biopsy of the thyroid mass revealed malignant cells with squamous differentiation. An extensive search for possible other primary was ruled out by triple endoscopy. The combination of fever, neutrophilic leukocytosis, hypercalcemia and squamous malignancy was consistent with a diagnosis of PNM of SCC. A fluorodeoxyglucose-positron emission tomography (FDG-PET) CT scan showed a heterogeneously enhancing mass lesion in the right lobe of the thyroid with some retrosternal extension. He underwent total thyroidectomy with bilateral central compartment neck dissection. Final histopathology revealed moderately differentiated SCC of the thyroid. Concurrent chemoradiation was given. Despite continued chemotherapy, he succumbed to illness within six months of diagnosis. Primary SCC of thyroid (PSCCT) is a rare malignancy. It is a highly aggressive tumor having a poor prognosis with a median survival time of about 9-12 months and less clearly defined therapy due to its rarity. Paraneoplastic manifestation of PSCCT is known. As fever, leukemoid reaction and hypercalcemia can be a paraneoplastic manifestation, one should think of PSCCT.

"When Love Does not bear a Fruit": Patterns and Prevalence of Sexual Difficulties in Infertile Men and Women as Predictors of Emotional Distress.

BACKGROUND: Self-identity, sexuality, and subfertility have multidirectional effects on each other. Subfertility is known to alter sexual esteem, threaten identity, body image, sexual attractivness, coital pleasure, and sexual satisfaction. OBJECTIVE: This study aimed to evaluate sexual difficulties as predictors of infertility-specific stress in patients undergoing fertility treatments and to assess the profile of sexual dysfunctions in participants. STUDY SETTING AND DESIGN: This cross-sectional study was conducted in a tertiary hospital setup of a medical college. METHODS: Three hundred married men and women diagnosed with infertility participated. The psychological evaluation test, international classification of diseases (10th, CDDG), female sexual functioning index, and international index of erectile functioning were used as measures. STATISTICAL ANALYSIS: Data were analyzed using SPSS (version 15, Chicago, USA). Chi-square test was used for univariate analysis between stress and presence of sexual dysfunctions in men and women. Medians, quartile, and cutoff scores were used to profile the sexual issues in participants. RESULTS: Prevalence of sexual dysfunctions since marriage was higher in women (75%) than men (60%). Ninety-two percent of women and 86% of men experienced emergence of sexual difficulties after the couple started treatments. CONCLUSIONS: Sexual dysfunctions appear to be a consistent psychosocial concern for those awaiting conception. These appear to worsen during the treatments. Our findings suggest the need to sensitively approach and explore sexual anamnesis with the couple before recourse to medically assisted reproductive treatments. Psychological interventions for sexual issues in distressed patients before, during, and after treatments such as controlled ovarian hyperstimulation, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection are most needed.

Facial emotion recognition and its association with quality of life and socio-occupational functioning in patients with bipolar disorder and their first-degree relatives.

INTRODUCTION: Facial emotion recognition deficits (FERD) are common even in the remitted phase of bipolar disorder (BD). Research regarding FERD in first-degree relatives is inconclusive. This study aimed to assess the facial emotion recognition in remitted patients of bipolar disorder and first-degree relatives(FDR) in comparison with healthy controls. Correlation between FERD and quality of life and socio-occupational functioning was also assessed. METHODS: It was an observational, cross-sectional study done at a tertiary hospital in India. Study population (n = 75) included remitted patients of bipolar disorder (n = 27), first-degree relatives of BD patients (FDR) (n = 20) and healthy controls (HC) (n = 28). Facial emotion recognition, social and occupational functioning, and quality of life (QoL) was measured using Tool for Recognition of Emotions in Neuropsychiatric Disorders, Social & Occupational Functioning Assessment Scale and World Health Organization Quality of Life-Bref, respectively, in all the participants. RESULTS: The BD group did significantly worse in facial emotion recognition in comparison to FDR and HC groups (p < 0.001). Emotion recognition of fear, anger, surprise, and happy were most affected. FDR did not vary significantly from HC in facial emotion recognition. Lower scores on facial emotion recognition were associated with lower QoL in the social domain(p = 0.006) and poorer socio- occupational functioning scores (p = 0.01), but it was not significant within the BD group. CONCLUSION: FERD is seen in remitted patients of bipolar disorder but not in the first -degree relatives. FERD affects social quality of life and functioning. Poorer social functioning in remitted patients of bipolar disorder might be multifactorial and cannot be attributed solely to FERD.

"The Miracle Mothers and Marvelous Babies": Psychosocial Aspects of Surrogacy - A Narrative Review.

Surrogates are described in literature as true angels "who make dreams happen." On the other hand, surrogacy has also been surrounded by several psychosocial controversies. In this review, we have made an attempt to encapsulate this topic from the multiple perspectives of individuals who are involved in the surrogacy cycle. We present to the readers the various outlooks and dilemmas of the clinicians, patient parties contracting for surrogacy, the child born out of surrogacy, and the intricate role of the mental health professionals in surrogacy arrangements. The review also throws light upon the psychosocial issues in connection to the evolving Surrogacy practices in Indian and in the Western world.

Application of Mindfulness-Based Psychological Interventions in Infertility.

Living mindfully helps one gain a deeper understanding into realities of life. It enables people to witness suffering, desire, attachments, and impermanence without any fear, anxiety, anger, or despair. This is considered the hallmark of true psychological insight. As a skill, mindfulness can be inculcated by anyone. Mindfulness helps in attending, getting aware and understanding experiences in a compassion and open-minded way. Research suggests that applying mindfulness in daily life has been known to tame our emotional mind and enabled people to perceive things "as they are" without ascribing expectations, judgments, cynicism, or apprehensions to them. This review unravels the therapeutic power of mindfulness meditation in the context of infertility distress. It serves to integrate the evidence on the effectiveness of mindfulness-based psychological interventions to improve the emotional well-being and biological outcomes in Infertility.

Melancholic Versus Non-Melancholic Depression: a Prospective Study.

BACKGROUND: The binarian model views melancholia as a distinct depressive class, whereas the unitarian model views it as a more severe expression of depression. This study aims to investigate the sociodemographic, clinical, and course differences between melancholic and non-melancholic depression. METHODS: This prospective observational study was carried out at Kasturba Hospital, Manipal, India from November 2010 to September 2011. We recruited consecutive inpatients aged 18 to 60 years who have a diagnosis of depressive disorder (based on ICD-10), with or without any psychiatric or physical comorbidities. Patients were categorised into melancholia and non-melancholia using the CORE questionnaire, with scores of ≥8 indicating the presence of melancholic depression. In addition, patients were evaluated using the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Somatoform Symptom Checklist, Columbia Suicide Severity Rating Scale, Clinical Global Impression, and Presumptive Stressful Life Events Scale at baseline and at 1, 3, and 6 months. RESULTS: Of 87 inpatients with a diagnosis of depression, 50 met the inclusion criteria and 37 were excluded. Compared with patients with non-melancholic depression, patients with melancholic depression had higher depression score (30.8 vs 23.8, p < 0.001), had higher number of patients with psychotic depression (39.1% vs 7.4%, p = 0.007), had higher overall illness severity score (5.9 vs 4.8, p < 0.001), and had higher number of patients with suicidal ideation and suicidal behaviour. Regarding the course of melancholia, the number of melancholic patients decreased from 23 at baseline to eight at 1 month, three at 3 months, and three at 6 months. Scores of non-interactiveness, retardation, and agitation decrease significantly over 3 months. CONCLUSIONS: The construct and course of melancholia may be viewed as a part of depression, more in line with severe depression. Melancholia increases the risk for suicidal ideation and suicidal behaviour.

Role of Mental Health Practitioner in Infertility Clinics: A Review on Past, Present and Future Directions.

A large body of literature has emerged over the past four decades which highlights the need to address emotional needs in infertility and integrates psychological services within routine fertility care. Evidenced-based guidelines in most countries propagate that the mental health expert (MHP) plays a vital role as a team member in reducing the impact of infertility on the lives of patients, across all stages of treatment. In accordance with these global developments, inclusion of psychosocial care in fertility treatments is an upcoming trend in our nation. This review article brings forth the traditional role of MHP in infertility, compares patient-centered care with counseling, and elaborates on the guidelines on determinants of patient needs and suitability for structured psychological interventions. It also highlights the evidence-based studies on the application of psychotherapy in infertility.

Sociocultural Determinants of Infertility Stress in Patients Undergoing Fertility Treatments.

INTRODUCTION: Involuntary childlessness is a distressing condition that has considerable social implications in developing nations. AIM: The present study aims to investigate the less known sociocultural determinants of infertility stress in patients undergoing assisted conception and reproductive treatments. METHODS: This cross-sectional research was conducted on 300 men and women with primary infertility. The profile of sociodemographic variables, clinical variables, and sociocultural variables was collected using a locally devised questionnaire. Infertility stress was assessed using the psychological evaluation test. STATISTICAL ANALYSIS: Research data were analyzed using SPSS 15. Chi-square test is used for univariate analysis. Multiple logistic regression with enter method is used to examine the association between infertility stress and sociocultural variables. RESULTS: The findings suggest that in both men and women, low spousal support, financial constraints, and social coercion in early years of marriage predicts infertility distress. Peer-support neither predicts nor protects against distress. DISCUSSION: Family acceptance and social security for infertility is low. Stigma, concealment, and discrimination among men are reported to be high. Distress is three times greater in women with overinvolved family members who had unrealistic expectations from treatments. Taking continuous cycles of fertility treatments seems unaffordable for most patients. Subfertile individuals were socially perceived to be deprived, blemished, incomplete, and sexually incompetent. CONCLUSION: Data from this investigation, provides a glimpse into sociocultural aspects of infertility. The findings may be useful for identifying targets for individual and family-focused psychological interventions for distress reduction in infertility.

Illness Cognitions, Anxiety, and Depression in Men and Women Undergoing Fertility Treatments: A Dyadic Approach.

BACKGROUND: Emotional response to infertility is mediated by numerous interrelated psychological variables such as personality, health perceptions, cognitive appraisals, coping, and social support. While men and women respond to infertility differently, illness cognitions are a vital component of their emotional adjustment. The aim of this study is to compare the infertile men and women undergoing fertility treatments on perceived distress, helplessness, acceptance, benefits, anxiety, and depression. MATERIALS AND METHODS: Eighty-one infertile couples, undergoing intrauterine insemination participated in the study. They were assessed on the presence of infertility distress using the fertility problem inventory, for psychiatric morbidity using the Mini International Neuropsychiatric Interview, for affective disturbances using the Hamilton Anxiety and Depression scales, and for illness cognitions using the Illness Cognition Questionnaire. STATISTICAL ANALYSIS: Data are analyzed using SPSS version 15. The paired sample t-test is performed for assessing differences on normally distributed data. The Wilcoxon Signed-Rank test is performed for assessing differences in medians obtained on data that was skewed. RESULTS AND DISCUSSION: Infertile women (wives) were more emotionally distressed, anxious, and depressed than men (husbands). Gender-wise differences were found for perceptions of helplessness and acceptance of infertility. Infertility was perceived to be a nonbeneficial event for both partners investigated. CONCLUSION: Negative cognitions and affective disturbances may contribute to higher treatment burden in couples seeking-assisted conception. The present study suggests that psychosocial intervention for couples plays a central role and should be integrated within the conventional treatments for infertility.

Outcomes of Structured Psychotherapy for Emotional Adjustment in a Childless Couple diagnosed with Recurrent Pregnancy Loss: A Unique Investigation.

Losing a much-awaited pregnancy and an unborn child, time and again is known to be a painful experience in recurrent miscarriage or pregnancy loss (RPL). Literature on psychological consequences of RPL is abundant. Nonetheless, application of psychological intervention in RPL remains to be an overlooked area. Using a repeated measures design and standardized psychological measures, this case study assessed the outcomes of mindfulness-based therapy administered with routine fertility treatment in a couple with the history of recurrent miscarriages and secondary infertility. Data analysis was done using clinically significant change and analysis of graphic trends. Psychotherapy helped the couple initiate a meaningful discourse with the stress following miscarriage, uncertainty of pregnancy, and fertility-related emotional struggles by mindfully transforming stressors into less painful experiences. Control studies on applications of such therapies are needed to provide definitive answers to "what works, for whom, when, and how," with distressed patients experiencing RPL.

Video assisted patient education improves compliance with follow up and depression scores in Inflammatory Bowel Diseases.

OBJECTIVES: Patients with inflammatory bowel diseases (IBD) have to deal with a poor quality of life (QOL) and psychomorbidity resulting from an incurable illness. We aimed to study the effect of patient education on QOL, compliance, anxiety and depression in IBD. METHODS: Patients were prospectively enrolled over two years beginning July 2014 and divided into an interventional and usual care group. Both received the standard of care, but the former in addition received an 8 min session of video-assisted education. Compliance to drugs was defined as drug intake of > 80% of the prescribed dose, and adherence to scheduled follow up visits were also compared. Self-administered questionnaires namely Short IBD questionnaire (SIBDQ), Beck Anxiety and Depression Inventory (BAI, BDI-II), Hospital Anxiety and Depression Scale (HADS) were used to assess QOL, anxiety and depression respectively at baseline, 6 months and 1 year. RESULTS: Of the 91 patients enrolled, 84 [92.3%; male = 66 (78.57%)] completed the follow up. Significantly more patients were compliant to follow up visits in the intervention and usual care groups respectively at 6 months (88.4% versus 65.8% respectively; p < 0.01) and 1 year (72.1% versus 46.3% respectively; p < 0.01). The median (IQR) scores for HADS-Depression over 1 year were significantly better in the interventional group than usual care (p < 0.049). The differences in SIBDQ, BDI-II, BAI, HADS-Anxiety and compliance to drug therapy between the groups did not reach statistical significance. CONCLUSION: Video assisted patient education improved compliance to follow up visits and depression scores in IBD. Further modifications in the educational video content and delivery might improve compliance to drug therapy, QOL and anxiety scores.

Prevalence and Factors Associated With Clozapine-Related Constipation: An Observational Study.

BACKGROUND: Despite being a very effective treatment for resistant schizophrenia and bipolar disorder, use of clozapine is limited by adverse effects. Constipation is a common but potentially life-threatening adverse effect of clozapine that is understudied. The objective was to study the prevalence and factors associated with constipation in those receiving clozapine compared with control subjects. METHODS: Fifty patients in age group of 18 to 55 years receiving clozapine were compared with 50 patients in the same age group receiving medications other than clozapine. Presence of constipation was ascertained using the World Gastroenterology Organization Practice Guidelines definition. The severity of constipation was assessed using Constipation Assessment Scale and Bristol Stool Form Scale, and anticholinergic burden was assessed using Anticholinergic Burden Scale. RESULTS: Among clozapine-treated patients, 28 (56%) had constipation as compared with 11 (22%) in the control subjects (P < 0.001); the odds of developing constipation was 4.5 (95% confidence interval, 1.9-10.8). Kaplan-Meier survival analysis showed median time to onset of constipation in clozapine-treated patients was 60 days (SE, 13.1 days; 95% confidence interval, 34.3-85.7 days) and median dose of clozapine was 300 mg/d (interquartile range, 312 mg/d). Clozapine group had high Constipation Assessment Scale scores (P = 0.005, Cohen d = 1.17) and higher prevalence of types 1 and 2 Bristol stool types (Fisher exact P = 0.005, Cramer V = 0.59). CONCLUSIONS: Constipation was prevalent in more than half of patients receiving clozapine, which was severe and took longer time for recovery. Limitations include using a hospital-based sample and that dietary habits and lifestyle factors were not studied.

Psychosocial Aspects of Therapeutic Donor Insemination.

The experience of delays in conception or possibility of remaining childless has the potential to create considerable psychological discomfort. In couples with severe male factor infertility, therapeutic intrauterine insemination using donor sperms (TDI) is offered as a treatment, second to in vitro fertilization using donor sperms. TDI is lucrative, less invasive, and a hopeful treatment. However, there are intricacies associated with it. Its immediate outcomes involve limited success rates, nonresponse, and chances of implantation failures, miscarriages, and multifetal pregnancies. Due to this, couples experience distress when they are advised to undergo three to six cycles of TDI in order to meet the expectations of having a baby. TDI has long-term issues on the triad comprising the "recipients," the "donors," and the "the children born out of TDI." Nevertheless, managing psychosocial needs for couples undergoing TDI and other treatments in Indian clinics are grey areas of the conventional treatment pathway. The present review expands on the psychological issues and needs in couples opting for TDI.

"In Cycles of Dreams, Despair, and Desperation:" Research Perspectives on Infertility Specific Distress in Patients Undergoing Fertility Treatments.

"Emotional distress in infertility" is a broad expression that loosely denotes anxiety, depression, grief, crisis, depleting psychological well-being, and all forms of affective and interpersonal disturbances faced by individuals with infertility. The distress is usually associated with involuntary childlessness as it is an unwelcoming event. The developmental crisis associated with childlessness poses a threat to one's sense of self at all levels (individual, family and social). Distress may begin before or during treatments as a person experiences the loss of control over attaining parenthood, anxiety or dejection after the diagnosis, treatments, its complications particularly its limited success rates. This paper reviews the basic concepts, theoretical models related to infertility specific distress (ISD). It elaborates on the effects of individual and treatment-specific variables on ISD with special highlights gathered from the national and international research.

Expression of HSP70 genes in skin of zebu (Tharparkar) and crossbred (Karan Fries) cattle during different seasons under tropical climatic conditions.

Skin is most important environmental interface providing a protective envelope to animals. It's always under the influence of both internal and external stressors. Heat shock proteins (HSP) are highly conserved stress proteins which play crucial roles in environmental stress tolerance and thermal adaptation. Present study was planned to observe the relative mRNA expression of inducible (HSP70.1 and HSP70.2) and constitutive (HSP70.8) HSP in skin of zebu (Tharparkar) and crossbred (Karan Fries) cattle during different seasons. Skin biopsies were collected from rump region of each animal, aseptically during winter, spring and summer season. Quantitative real time polymerase chain reaction was performed to examine the gene expression of constitutive (HSP70.8) and inducible (HSP70.1 and HSP70.2) HSP in skin of both the breeds during different seasons. Present study observed higher expression of both constitutive and inducible HSP genes in both the breeds during summer and winter than spring season, but magnitude of increase was higher during summer than winter. During summer season, expression pattern of HSPs in skin showed breed differences, where constitutive HSP expression was higher in Tharparkar than Karan Fries and that of inducible HSP was higher in Karan Fries than Tharparkar. Hence, present study suggested that HSP may be conveniently used as biomarkers for assessing protective response of skin against heat stress in zebu and crossbred cattle. Variation in expression between breeds is associated with their heat tolerance and thermal adaptability. In summary, skin of zebu cattle (Tharparkar) is more resistant to summer stress than crossbred (Karan Fries), providing greater protection against heat stress during summer season. Superior skin protective mechanism of zebu (Tharparkar) than crossbred (Karan-Fries) cattle against heat stress may contribute to superior adaptability of zebu cattle to tropical climatic conditions than crossbreed.

Prevalence and predictors of infertility-specific stress in women diagnosed with primary infertility: A clinic-based study.

BACKGROUND: According to the existing literature on infertility, stress appears to be inevitably associated with infertility diagnosis and treatment in sub-fertile individuals. The epidemiological data on the prevalence and predictors of infertility-specific stress in cultural specific scenario are scarce. The objective of the present study was to estimate the prevalence of infertility-specific stress and identify predictors of infertility-specific stress in women diagnosed with primary infertility. MATERIALS AND METHODS: This cross-sectional study was conducted on 300 infertile married women, diagnosed with primary infertility. The tools used for the assessment were "semi-structured questionnaire" compiled by the authors, "ICD-10 Classification of Mental and Behavioral Disorders (Clinical Descriptions and Diagnostic Guidelines)," and "Psychological Evaluation Test for infertility." STATISTICAL ANALYSIS: Data were analyzed using SPSS (version 15). Chi-square test was used for univariate analysis followed by multiple logistic regressions between stress and the predictor variables. RESULTS AND DISCUSSION: The prevalence of stress among women was 80%. Univariate analysis revealed that predictors of stress were years of marital life, duration of infertility, infertility type, history of gynecological surgery, cycles of ovulation induction with timed intercourse and intra-uterine inseminations, present and past psychiatric morbidity, coping difficulties, gynecological diagnosis, and severity of premenstrual dysphoria. Multivariate analysis showed leading associations of stress with infertility type and coping difficulties.

Factors Affecting Well-being and Socio-occupational Functioning in Schizophrenia Patients Following an Acute Exacerbation: A Hospital Based Observational Study.

BACKGROUND: Improving functioning levels are an important goal of treatment in schizophrenia. Most studies have described long-term course and outcome in schizophrenia. However, understanding factors influencing functioning in the immediate recovery period following an acute exacerbation may be of important clinical relevance. AIM: The aim of this study is to assess the factors that influence well-being and socio-occupational functioning following an acute exacerbation in schizophrenia patients. MATERIALS AND METHODS: The study included 40 patients during the period from June 2013 to June 2014. The possible effect of gender, duration of illness, duration of untreated psychosis, premorbid adjustment, cognitive impairment, facial affect perception and treatment compliance on well-being, and socio-occupational functioning was examined. RESULTS: About 45% of the individuals experienced below average well-being. On logistic regression analysis poor compliance with medication and poorer cognitive functioning significantly differentiated the patient group with below average well-being from those with an above average well-being. Male gender, poor premorbid adjustment, poor compliance to treatment, poor cognitive functioning, and greater duration of untreated psychosis were found to be associated with a poorer socio-occupational functioning. CONCLUSION: Clinical interventions focusing on improving cognitive impairment and compliance to treatment could play a role in improving well-being, and socio-occupational functioning in schizophrenia patients following an acute exacerbation.

Outcome of mood stabilizer discontinuation in bipolar disorder after 5 years of euthymia.

OBJECTIVE: The objective was to study the outcome of mood stabilizer discontinuation on recurrence in patients with bipolar disorder after at least 5 years of euthymia. METHODS: Twenty-three patients diagnosed with bipolar affective disorder according to the International Classification of Diseases, 10th Revision Diagnostic Criteria for Research, receiving mood stabilizer prophylaxis for at least 5 years, had undergone planned discontinuation, and the rates and time to recurrence were studied. RESULTS: Twenty (87%) of 23 patients had recurrence, and all of the episodes were manic. Kaplan-Meier survival analysis showed median time to recurrence following discontinuation of mood stabilizer prophylaxis was 10 months (SE, 6.06 months; 95% confidence interval, 0 to 21.89 months). CONCLUSION: Four fifths of our patients had recurrence following discontinuation of mood stabilizer prophylaxis within 10 months.