The social-cognitive clinician: On the implications of social cognitive theory for psychotherapy and assessment.

We review Bandura's contributions to cognitive-behavioural theory, research and practice. His basic research on the causal role of cognitive processes in social learning was a major factor in the emergence of cognitive-behavioural therapies in the 1970s. His investigations on observational learning and self-efficacy beliefs led to the development of guided mastery therapy, a specific cognitive-behavioural intervention for anxiety disorders. His research on self-regulatory processes provided an empirical basis for the emergence of numerous therapies targeting self-regulation. We conclude by discussing how Bandura's social cognitive theory, as well as more recent advances in social cognitive theorising, might be further applied to innovative approaches to therapeutic interventions, assessment and clinical case conceptualization.

The Relational Self-Schema Measure: Assessing Psychological Needs in Multiple Self-with-Other Representations.

Modern self-schema theory posits multiple representations in memory of the self, with each individual self-schema possessing associative connections to relational contexts (i.e., self-with-other). However, existing self-schema measures typically assess a generalized self unmoored from context. In two studies, we present a new instrument-the Relational Self-Schema Measure (RSSM)-designed to represent the self-schema construct with greater content validity. In Study 1, 512 adults completed an initial version of the RSSM that was subjected to exploratory factor analyses. Support emerged for a reduced four-factor model that included relatedness satisfaction, control satisfaction, self-esteem/status frustration, and autonomy frustration psychological need themes. In Study 2, 516 adults completed a revised RSSM along with measures of self-esteem, attachment, and mood and anxiety symptoms. A separate sample of 191 college students completed the revised RSSM and a measure of dysfunctional attitudes. Confirmatory factor analyses supported the same four-factor model. Moreover, the RSSM exhibited good convergent and discriminant validity as well as incremental validity in predicting positive affect, distress, and anxiety symptoms. Finally, significant within-person variability was apparent across relational schemata that accounted for additional variance in positive affect, distress, and anxiety symptoms.

Racial Disparities in Rates of Surgery for Esophageal Cancer: a Study from the National Cancer Database.

BACKGROUND: Treatment guidelines for stage I-III esophageal cancer indicate that management should include surgery in appropriate patients. Variations in utilization of surgery may contribute to racial differences observed in survival. We sought to identify factors associated with racial disparities in surgical resection of esophageal cancer and evaluate associated survival differences. METHODS: Patients diagnosed with stage I-III esophageal cancer from 2004 to 2015 were identified using the National Cancer Database. Matched patient cohorts were created to reduce confounding. Multivariate logistic regression was used to identify factors associated with receipt of surgery. Multi-level modeling was performed to control for random effects of individual hospitals on surgical utilization. RESULTS: A total of 60,041 patients were included (4402 black; 55,639 white). After 1:1 matching, there were 5858 patients evenly distributed across race. For all stages, significantly fewer black than white patients received surgery. Black race independently conferred lower likelihood of receiving surgery in single-level multivariable analysis (OR (95% CI); stage I, 0.67 (0.48-0.94); stage II, 0.76 (0.60-0.96); stage III, 0.62 (0.50-0.76)) and after controlling for hospital random effects. Hospital-level random effects accounted for one third of the unexplained variance in receipt of surgery. Risk-adjusted 1-, 3-, and 5-year mortality was higher for patients who did not undergo surgery. CONCLUSION: Black patients with esophageal cancer are at higher risk of mortality compared to white patients. This increased risk may be influenced by decreased likelihood of receiving surgical intervention for resectable disease, in part because of between-hospital differences. Improving access to surgical care may improve disparities in esophageal cancer survival.

Nucleocapsid Protein Precursors NCp9 and NCp15 Suppress ATP-Mediated Rescue of AZT-Terminated Primers by HIV-1 Reverse Transcriptase.

In HIV-1, development of resistance to AZT (3'-azido-3'-deoxythymidine) is mediated by the acquisition of thymidine analogue resistance mutations (TAMs) (i.e., M41L, D67N, K70R, L210W, T215F/Y, and K219E/Q) in the viral reverse transcriptase (RT). Clinically relevant combinations of TAMs, such as M41L/T215Y or D67N/K70R/T215F/K219Q, enhance the ATP-mediated excision of AZT monophosphate (AZTMP) from the 3' end of the primer, allowing DNA synthesis to continue. Additionally, during HIV-1 maturation, the Gag polyprotein is cleaved to release a mature nucleocapsid protein (NCp7) and two intermediate precursors (NCp9 and NCp15). NC proteins interact with the viral genome and facilitate the reverse transcription process. Using wild-type and TAM-containing RTs, we showed that both NCp9 and NCp15 inhibited ATP-mediated rescue of AZTMP-terminated primers annealed to RNA templates but not DNA templates, while NCp7 had no effect on rescue activity. RNase H inactivation by introducing the active-site mutation E478Q led to the loss of the inhibitory effect shown by NCp9. NCp15 had a stimulatory effect on the RT's RNase H activity not observed with NCp7 and NCp9. However, analysis of RNase H cleavage patterns revealed that in the presence of NCp9, RNA/DNA complexes containing duplexes of 12 bp had reduced stability in comparison with those obtained in the absence of NC or with NCp7 or NCp15. These effects are expected to have a strong influence on the inhibitory action of NCp9 and NCp15 by affecting the efficiency of RNA-dependent DNA polymerization after unblocking DNA primers terminated with AZTMP and other nucleotide analogues.

Robotic approach to a subcarinal functional paraganglioma.

INTRO: Functional mediastinal paragangliomas arise from extra-adrenal tissues and are rare. These cases create challenges related to diagnosis, peri-operative management, and surgical management. We present a case that demonstrates a planned robot-assisted thoracoscopic resection of a mediastinal paraganglioma that ultimately required a trans-sternal resection of the tumor off the left atrium. CASE REPORT: Our patient is a 42-year-old male with a prolonged history of refractory hypertension, palpitations, headaches, and diaphoresis, which led to the discovery of a subcarinal functional mediastinal paraganglioma. The patient was brought to the operating room for a right robotic-assisted thoracoscopic subcarinal dissection with attempted resection of the mass. Subsequently, the patient's paraganglioma was successfully resected off the left atrium using a trans-sternal approach, cardiopulmonary bypass, and cardioplegic arrest. He was successfully transitioned to minimal anti-hypertensive medication post-operatively. DISCUSSION: Pheochromocytomas are neural-crest derived tumors that typically arise from the adrenal medulla. Rarely, paragangliomas arise in the thoracic cavity, at an approximate incidence of 2%. Our sequential approach offered the potential for a minimally invasive resection, and though initially unsuccessful, safely elucidated the feasibility of resection using cardiopulmonary bypass after confirming no invasion of the airway, esophagus, or other mediastinal structures.

Age-related differences in the goals and concerns that motivate real-life prospective memory tasks.

Prospective memory tasks are tasks that one must remember to perform in the future, such as keeping a dentist appointment or locking the door when leaving home. There has been little research to date on the question of what motivates real-life prospective memory tasks, and this is true both generally and within the subfield of aging and prospective memory. In the current study, we investigated whether the prospective memory tasks of younger and older adults were motivated by different personal goals and concerns, a question that has not been addressed in past research. Participants completed a questionnaire on current prospective memory tasks and the higher level goals and concerns that motivated these tasks. In general, younger and older adults reported prospective memory tasks motivated by different goals and concerns that reflected different social age systems or developmental tasks. Specifically, younger adults were more likely to report prospective memory tasks related to goals for education, profession, property, self, and leisure, and related to concerns about education and profession. In contrast, older adults were more likely to report prospective memory tasks related to concerns about world issues and war/terrorism. We also examined prospective memory task motivation more generally as approach motivation (goal-relatedness) and avoidance motivation (concern-relatedness). Both measures showed a gender by age group interaction. That is, older males showed especially low approach motivation and especially high avoidance motivation for their real-life prospective memory tasks. We suggest that a new approach to prospective memory research that incorporates motivational influences would enhance the ecological validity of prospective memory and aging research and may inform more effective memory interventions.

Lung Cancer Invading a Coronary Graft: Role of Coronary Intervention and Robotic Surgery.

The treatment of primary lung cancer of the left upper lobe in those patients with prior coronary artery bypass graft is difficult to plan and execute due to the potential for invasion into coronary grafts, particularly the left internal mammary artery. We present a patient with squamous cell carcinoma invading into coronary artery bypass grafts, but which is successfully treated by a combination of percutaneous coronary intervention followed by video-assisted thoracoscopic surgery.

Lung Resection in the Postpneumonectomy Patient.

Pulmonary resection after pneumonectomy is a reasonable option in selected patients. Wedge resection for single peripheral metachronous disease has the best outcome with 5-year survival as high as 63%. Current and predicted postoperative cardiopulmonary reserve should be evaluated carefully. Stereotactic body radiotherapy is a promising alternative for inoperable patients.

Benefits of Supplemental Jejunostomy Tube Feeding During Neoadjuvant Therapy in Patients with Locally Advanced, Potentially Resectable Esophageal Cancer.

BACKGROUND: Standard treatment for locally advanced esophageal cancer includes neoadjuvant therapy followed by surgical resection. However, many patients experience a period of decreased oral intake during neoadjuvant treatment and are at risk for malnutrition. We hypothesize that use of jejunostomy tube (j-tube) feedings during neoadjuvant therapy in selected patients may be associated with better perioperative outcomes. METHODS: A prospectively collected database at a single institution was retrospectively analyzed. The study period was from 2005 to 2015. Patients who underwent j-tube placement before neoadjuvant therapy before definitive resection for esophageal cancer were included in the analysis. Perioperative outcomes were compared between patients who adhered to recommended tube feeds during neoadjuvant therapy (users) and patients who did not adhere (nonusers). RESULTS: During the study period, 94/301 patients received a j-tube before or during neoadjuvant therapy for esophageal cancer. Seventy-three patients utilized tube feeds regularly during the neoadjuvant phase, while 21 patients did not. The groups did not differ significantly with respect to clinical factors such as dysphagia on presentation, postneoadjuvant therapy performance status, or Charlson Comorbidity Index. Perioperative pneumonia rates were lower in j-tube users compared to nonusers (6.8% [5 of 73] versus 23.8% [5 of 21]), respectively, P = .036); this difference remained significant with adjustment for type of surgery (odds ratio = 0.16, P = .018). CONCLUSIONS: j-Tube users had a significantly lower incidence of pneumonia within 30 days of curative resection when compared to nonusers. j-Tube feedings during neoadjuvant therapy for selected patients with locally advanced esophageal cancer should be encouraged.

On the quest for the elusive mechanism of action of daptomycin: Binding, fusion, and oligomerization.

Daptomycin, sold under the trade name CUBICIN, is the first lipopeptide antibiotic to be approved for use against Gram-positive organisms, including a number of highly resistant species. Over the last few decades, a number of studies have tried to pinpoint the mechanism of action of daptomycin. These proposed modes of action often have points in common (e.g. the requirement for Ca2+ and lipid membranes containing a high proportion of phosphatidylglycerol (PG) headgroups), but also points of divergence (e.g. oligomerization in solution and in membranes, membrane perturbation vs. inhibition of cell envelope synthesis). In this study, we investigate how concentration effects may have an impact on the interpretation of the biophysical data used to support a given mechanism of action. Results obtained from small angle neutron scattering (SANS) experiments and molecular dynamics (MD) simulations show that daptomycin oligomerizes at high concentrations (both with and without Ca2+) in solution, but that this oligomer readily falls apart. Photon correlation spectroscopy (PCS) experiments demonstrate that daptomycin causes fusion more readily in DMPC/PG membranes than in POPC/PG, suggesting that the latter may be a better model system. Finally, fluorescence and Förster resonance energy transfer (FRET) experiments reveal that daptomycin binds strongly to the lipid membrane and that oligomerization occurs in a concentration-dependent manner. The combined experiments provide an improved framework for more general and rigorous biophysical studies toward understanding the elusive mechanism of action of daptomycin. This article is part of a Special Issue entitled: Biophysics in Canada, edited by Lewis Kay, John Baenziger, Albert Berghuis and Peter Tieleman.

U24 from Roseolovirus interacts strongly with Nedd4 WW Domains.

U24 is a protein found in both roseoloviruses Human Herpes Virus type 6 and 7 (HHV-6 and HHV-7), with an N-terminus that is rich in prolines (PY motif in both HHV-6A and 7; PxxP motif in HHV-6A). Previous work has shown that the interaction between U24 and WW domains is important for endocytic recycling of T-cell receptors, but a cognate ligand was never identified. In this contribution, data was obtained from pull-downs, ITC, NMR and molecular dynamics simulations to show that a specific interaction exists between U24 and Nedd4 WW domains. ITC experiments were also carried out for U24 from HHV-6A phosphorylated at Thr6 (pU24-6A) and a peptide containing the PY motif from Nogo-A, a protein implicated in both the initial inflammatory and the neurodegenerative phases of multiple sclerosis (MS). The results suggest that phosphorylation of U24 from HHV-6A may be crucial for its potential role in MS.

Induction Therapy for Locally Advanced, Resectable Esophagogastric Cancer: A Phase I Trial of Vandetanib (ZD6474), Paclitaxel, Carboplatin, 5-Fluorouracil, and Radiotherapy Followed by Resection.

OBJECTIVES: Preoperative chemotherapy and radiation for localized esophageal cancer produces cure rates near 30% when combined with surgical resection. Vandetanib, a small molecule receptor tyrosine kinase inhibitor of VEGFR-2, VEGFR-3, RET, and EGFR, demonstrated synergy with radiation and chemotherapy in preclinical models. We conducted a phase I study to assess the safety and tolerability of vandetanib when combined with preoperative chemoradiation in patients with localized esophageal carcinoma who were surgical candidates. METHODS: Patients with stage II-III esophageal and gastroesophageal junction carcinoma without prior therapy were enrolled in a 3+3 phase I design. Patients received once-daily vandetanib (planned dosing levels of 100, 200, and 300 mg) with concomitant daily radiotherapy (1.8 Gy/d, 45 Gy total) and chemotherapy, consisting of infusional 5-FU (225 mg/m/d over 96 h, weekly), paclitaxel (50 mg/m, days 1, 8, 15, 22, 29) and carboplatin (AUC of 5, days 1, 29). RESULTS: A total 9 patients were enrolled with 8 having either distal esophageal or gastroesophageal junction carcinomas. All patients completed the planned preoperative chemoradiation and underwent esophagectomy. Nausea (44%) and anorexia (44%) were the most common acute toxicities of any grade. One grade 4 nonhematologic toxicity was observed (gastrobronchial fistula). One additional patient suffered a late complication, a fatal aortoenteric hemorrhage, not definitively related to the investigational regimen. Five (56%) patients achieved a pathologic complete response. Three (33%) additional patients had only microscopic residual disease. Five (56%) patients remain alive and disease free with a median follow-up of 3.7 years and median overall survival of 3.2 years. The maximum tolerated dose was vandetanib 100 mg/d. CONCLUSIONS: Vandetanib at 100 mg daily is tolerable in combination with preoperative chemotherapy (5-FU, paclitaxel, carboplatin) and radiation therapy with encouraging efficacy worthy of future study.

Esophageal Cancer: Associations With (pN+) Lymph Node Metastases.

OBJECTIVES: To identify the associations of lymph node metastases (pN+), number of positive nodes, and pN subclassification with cancer, treatment, patient, geographic, and institutional variables, and to recommend extent of lymphadenectomy needed to accurately detect pN+ for esophageal cancer. SUMMARY BACKGROUND DATA: Limited data and traditional analytic techniques have precluded identifying intricate associations of pN+ with other cancer, treatment, and patient characteristics. METHODS: Data on 5806 esophagectomy patients from the Worldwide Esophageal Cancer Collaboration were analyzed by Random Forest machine learning techniques. RESULTS: pN+, number of positive nodes, and pN subclassification were associated with increasing depth of cancer invasion (pT), increasing cancer length, decreasing cancer differentiation (G), and more regional lymph nodes resected. Lymphadenectomy necessary to accurately detect pN+ is 60 for shorter, well-differentiated cancers (<2.5 cm) and 20 for longer, poorly differentiated ones. CONCLUSIONS: In esophageal cancer, pN+, increasing number of positive nodes, and increasing pN classification are associated with deeper invading, longer, and poorly differentiated cancers. Consequently, if the goal of lymphadenectomy is to accurately define pN+ status of such cancers, few nodes need to be removed. Conversely, superficial, shorter, and well-differentiated cancers require a more extensive lymphadenectomy to accurately define pN+ status.

Determinants of Complete Resection of Thymoma by Minimally Invasive and Open Thymectomy: Analysis of an International Registry.

INTRODUCTION: Minimally invasive thymectomy (MIT) is a surgical approach to thymectomy that has more favorable short-term outcomes for myasthenia gravis than open thymectomy (OT). The oncologic outcomes of MIT performed for thymoma have not been rigorously evaluated. We analyzed determinants of complete (R0) resection among patients undergoing MIT and OT in a large international database. METHODS: The retrospective database of the International Thymic Malignancy Interest Group was queried. Chi-square and Wilcoxon rank sum tests, multivariate logistic regression models, and propensity matching were performed. RESULTS: A total of 2514 patients underwent thymectomy for thymoma between 1997 and 2012; 2053 of them (82%) underwent OT and 461 (18%) underwent MIT, with the use of MIT increasing significantly in recent years. The rate of R0 resection among patients undergoing OT was 86%, and among those undergoing MIT it was 94% (p < 0.0001). In propensity-matched MIT and OT groups (n = 266 in each group); however, the rate of R0 resection did not differ significantly (96% in both the MIT and OT groups, p = 0.7). Multivariate analyses were performed to identify determinants of R0 resection. Factors independently associated with R0 resection were geographical region, later time period, less advanced Masaoka stage, total thymectomy, and the absence of radiotherapy. Surgical approach, whether minimally invasive or open, was not associated with completeness of resection. CONCLUSIONS: The use of MIT for resection of thymoma has been increasing substantially over time, and MIT can achieve rates of R0 resection for thymoma similar to those achieved with OT.

Gastric Cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology.

Gastric cancer is the fifth most frequently diagnosed cancer and the third leading cause of death from cancer in the world. Several advances have been made in the staging procedures, imaging techniques, and treatment approaches. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Gastric Cancer provide an evidence- and consensus-based treatment approach for the management of patients with gastric cancer. This manuscript discusses the recommendations outlined in the NCCN Guidelines for staging, assessment of HER2 overexpression, systemic therapy for locally advanced or metastatic disease, and best supportive care for the prevention and management of symptoms due to advanced disease.

Biology is Destiny: A Case of Adrenocortical Carcinoma Diagnosed and Resected at Inception in a Patient Under Close Surveillance for Lung Cancer.

Adrenocortical carcinoma (ACC) is a rare malignancy that is generally associated with a poor prognosis whose existence dictates the management of incidental renal masses. We report a case of ACC diagnosed and treated at its apparent inception in a patient undergoing close surveillance imaging of a prior malignancy. Despite timely detection and resection of a localized ACC this patient rapidly progressed to systemic disease. This case highlights the rapid growth kinetics of ACC and puts into perspective the challenges associated with the established treatment paradigm for patients diagnosed with an adrenal mass.

Recurrent Spontaneous Esophageal Rupture Managed With Esophageal Stenting.

Recurrent spontaneous esophageal ruptures are rare, found in only a few case reports. They are treated mostly by thoracotomy and repair, but none through stenting alone. We present a patient with recurrent spontaneous esophageal rupture who was successfully treated through stenting and made a speedy and complete recovery.

Risk of radiation pneumonitis in patients receiving taxane-based trimodality therapy for locally advanced esophageal cancer.

PURPOSE: There are limited data regarding clinical and treatment factors associated with radiation pneumonitis (RP) in patients receiving taxane-based trimodality therapy for esophageal cancer. The purpose of this study was to identify predictors of RP in patients undergoing trimodality therapy. METHODS AND MATERIALS: We retrospectively reviewed patients undergoing chemoradiation followed by esophagectomy between 2006 and 2011. The association between clinical and dosimetric factors with RP was assessed using χ2 test and Mann-Whitney U test. Multivariable regression was used to assess the relationship between grade 2+ RP and clinical/dosimetric factors. Receiver operator curves were generated to identify threshold doses for RP. RESULTS: A total of 139 patients were included; 19 (13.7%) patients experienced grade 2+ RP. Patients with upper/middle thoracic tumors (P = .038) and receiving higher radiation doses (P = .038) were more likely to develop grade 2+ RP. There was no association between taxane-based therapy and grade 2+ RP (P = .728). The percent volume of lung receiving 5 Gy (V5; P < .001), 10 Gy (P < .001), 20 Gy (V20; P < .001), and 30 Gy (P < .001) was associated with an increased risk of grade 2+ RP. On multivariable regression, the lung V5 (odds ratio, 1.101; 95% confidence interval, 1.1014-1.195) and V20 (odds ratio, 1.149; 95% confidence interval, 1.1015-1.301) remained associated with grade 2+ RP. A V5 ≤65% and V20 ≤25% were identified as optimal thresholds for increased grade 2+ RP. CONCLUSIONS: Dosimetric parameters are strong predictors of symptomatic RP in patients undergoing trimodality therapy for esophageal cancer. Mitigating the risk of RP in these patients should be an important consideration during treatment planning.

Minimally Invasive versus Open Thymectomy for Thymic Malignancies: Systematic Review and Meta-Analysis.

Complete resection is the standard of care for treatment of thymic malignancies. The use of minimally invasive surgery remains controversial. We searched online databases and identified studies from 1995 to 2014 that compared minimally invasive to open thymectomy for thymic malignancies. Study end points included operative blood loss, operative time, respiratory complications, cardiac complications, length of hospital stay, R0 resection, and recurrence. We summarized outcomes across studies using random-effects meta-analysis to account for study heterogeneity. We calculated ORs for binary outcomes and standardized mean differences for continuous outcomes. We calculated incidence rate ratios for the number of recurrences, accounting for total person-time observed in each study. Of 516 potential reference studies, 30 with a total of 2038 patients met the inclusion criteria. Patients with Masaoka stage I or II thymic malignancy constituted 94.89% of those in the minimally invasive surgery (MIS) group and 78.62% of those in open thymectomy (open) group. Mean tumor size was 4.09 cm (MIS) versus 4.80 (open). Of the 1355 MIS cases, 32 were converted to open cases. Patients in the MIS group had significantly less blood loss; however, no significant differences in operating time, respiratory complications, cardiac complications, or overall complications were identified. Length of stay was shorter for patients in the MIS group. When patients with Masaoka stage I and II thymic malignancy only were analyzed, there was no difference in rate of R0 resection or overall recurrence rate. One postoperative death occurred in the open group. The results of this unadjusted meta-analysis of published reports comparing minimally invasive with open thymectomy suggest that in selected patients with thymic malignancy, minimally invasive thymectomy is safe and can achieve oncologic outcomes similar to those of open thymectomy.

Children's Depression Inventory: A unidimensional factor structure for American Indian and Alaskan native youth.

Given that American Indian and Alaskan Native (AI/AN) youth are at increased risk for a variety of depression-related outcomes and may experience depression uniquely, the fact that the factor structure of the Children's Depression Inventory (CDI; Kovacs, 1992) is unknown for these populations represents a significant obstacle. In Study 1 with an AI youth sample, we conducted confirmatory factor analyses and failed to find support for either of the 2 predominant CDI multifactor models (Craighead, Smucker, Craighead, & Ilardi, 1998; Kovacs, 1992). In subsequent exploratory structural equation modeling, we found the most support for a unidimensional factor structure. In Study 2, using confirmatory modeling with independent AI/AN youth samples, we found further support for this unidimensional model. Finally, in Study 3, we found support across AI/AN groups varying in gender and age for measurement invariance with respect to both factor structure and factor loadings. Overall, for these AI/AN youth populations, our findings support the practice of calculating total CDI scores, and they suggest a unique construction of the depression experience.