Associations between adjuvant endocrine therapy and onset of physical and emotional concerns among breast cancer survivors.

BACKGROUND: Breast cancer survivors often receive long-term adjuvant endocrine therapy (AET) to reduce recurrence risk. Adherence to AET is suboptimal, which may be due to the experience of symptoms and/or concerns. Few studies have comprehensively assessed self-reported concerns between those who currently, previously or have never received AET. The study objective is to describe self-reported physical and emotional concerns of breast cancer survivors who are current, prior, or never-recipients of AET. METHODS: Secondary analysis was performed on a subset of survey data collected in the 2010 LIVESTRONG Survey. Breast cancer survivors (n = 1,013, mean 5.4 years post-diagnosis) reported on 14 physical and eight emotional concerns that began after diagnosis and were experienced within 6 months of participation in the survey. Bivariate analyses examined the prevalence of each concern by AET status. The relationships between AET and burden of physical or emotional concerns were modeled with logistic regression. RESULTS: More than 50% of the participants reported currently experiencing cognitive issues, fatigue, fear of recurrence, emotional distress, and identity/grief issues. Thyroid dysfunction and stigma concerns were more common among participants with prior AET (p < 0.01), while fear of recurrence, emotional distress, and concern about appearance were more common among those currently receiving AET (p < 0.01). Fatigue, sexual dysfunction, and pain were more common among prior and current AET recipients (p < 0.01). In adjusted models, receipt of AET was associated with a higher number of physical, but not emotional concerns. A higher number of concerns was associated with younger age, having children, receipt of chemotherapy, longer duration of cancer treatment, and shorter time since diagnosis (p < 0.01). CONCLUSIONS: Breast cancer survivors who received AET were at risk of developing a variety of physical and emotional concerns, many of which persisted after treatment. These findings suggest the importance of developing individualized, supportive resources for breast cancer survivors.

Early trajectories of depressive symptoms after liver transplantation for alcoholic liver disease predicts long-term survival.

Although it is well known that depression is associated with poorer medical outcomes, the association between depression- and liver transplant (LTX)-specific outcomes has not been investigated. We identified three trajectories of depressive symptoms evolving within the first post-LTX year in a cohort of 167 patients transplanted for alcoholic cirrhosis: a group with consistently low depression levels at all time points (group 1, n = 95), a group with initially low depression levels that rose over time (group 2, n = 41), and a group with consistently high depression levels (group 3, n = 31). Controlling for medical factors associated with poorer survival, recipients with increasing depression or persisting depression were more than twice as likely to die (all cause mortality) within the subsequent years. At 10 years post-LTX the survival rate was 66% for the low depression group, but only 46% and 43%, respectively, for the increasing depression and high depression groups. Except for a paradoxically higher percentage of malignancies in the low depression group, the causes of death and other specific LTX outcomes were not different between groups. Whether treatment of depression will improve survival rates is an area for research.

Donating stimulated peripheral blood stem cells vs bone marrow: do donors experience the procedures differently?

As the demand for undifferentiated stem cells for the treatment of leukemia and other cancers has increased, new methods for their collection have been developed. One of these new methods, allogeneic peripheral blood stem cell (PBSC) donation, involves the administration of a granulocyte colony-stimulating factor (G-CSF, filgrastim), and a 1-2 day apheresis collection procedure. Our goal in the current study was to examine donors' psychosocial and physical experiences of PBSC vs marrow donation. Potential participants included 80 donors from the National Marrow Donor Program (NMDP) who donated a second time between 1991 and 1997. All of these donors had previously donated marrow. A final cohort of 70 donors (25 PBSC and 45 marrow) participated in a retrospective questionnaire study of their donation experiences. In general, all second-time donors reported low levels of concern about the physical consequences of donation. However, PBSC donors were more likely to have postponed the decision to donate a second time. Despite their reservations, PBSC donors reported fewer donation-related side-effects than did marrow donors. Finally, PBSC donors reported that marrow donation was more physically difficult, time-consuming, and inconvenient, and that they preferred PBSC to marrow donation.

Factors associated with attrition from a national bone marrow registry.

During its 10-year existence, the National Marrow Donor Program (NMDP) has been extremely successful at recruiting potential bone marrow donors to join the volunteer registry. Due in part to successful recruitment and the longevity of the registry, the focus of the NMDP has now shifted to decreasing potential attrition when volunteers are recontacted for additional testing to determine whether they would be the optimal donor for a specific patient. Our own interest in the bone marrow donation process led us to examine four domains of variables - demographic characteristics, volunteer history, recruitment-related characteristics and donation-related concerns - that we hypothesized would be associated with increased likelihood of donor attrition at a key donor decision-point (DR-stage blood typing). Questionnaires were mailed to potential donors after they were contacted at the DR-stage, and had made the decision of whether or not to continue with blood typing. Our final sample included 756 volunteers who decided to continue with typing, and 258 individuals who declined further participation in the registry. In the bivariate analyses, factors in three of the four domains (all except demographic characteristics) were found to be substantially correlated with likelihood of attrition. Logistic regression indicated that nine central variables across the three domains produced the majority of increased attrition likelihood. Finally, a dose-response analysis suggested that as the number of attrition-related factors endorsed by an individual increased, his/her likelihood of dropping out of the registry also increased. Implications for future research and interventions to reduce potential donor attrition are discussed.

Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation.

BACKGROUND: Poor medical compliance has been held responsible for a large proportion of deaths occurring subsequent to initial postoperative recovery. However, beyond clinical reports, there has been little empirical examination of this issue, or of the extent to which major psychiatric disorder and failure to adjust to the transplant predict long-term physical morbidity and mortality. We prospectively examined whether a full range of compliance behaviors and psychiatric outcomes during the first year post-transplant predicted subsequent mortality and physical morbidity through 3 years post-transplant. METHODS: A total of 145 heart recipients who had received detailed compliance and mental health assessments during the first year post-transplant were followed up at 3 years post-transplant. Interview data and corroborative information from family members were used to determine compliance in multiple domains, psychiatric diagnoses, and psychiatric symptomatology during the first year post-surgery. Medical record reviews were performed to abstract data on acute graft rejection episodes, incident cardiac allograft disease (CAD) and mortality from 1 to 3 years post-transplant. RESULTS: After controlling for known transplant-related predictors of outcome, multivariate analyses yielded the following significant (p < 0.05) results: (a) risk of acute graft rejection was 4.17 times greater among recipients who were not compliant with medications; (b) risk of incident CAD was elevated by persistent depression (Odds Ratio, OR = 4.67), persistent anger-hostility (OR = 8.00), medication noncompliance (OR = 6.91), and obesity (OR = 9.92); and (c) risk of mortality was increased if recipients met criteria for Post-Traumatic Stress Disorder related to the transplant (OR = 13.74). CONCLUSIONS: The findings, plus data we have previously reported that showed which patients are most likely to have compliance and psychiatric problems early post-transplant, suggest that interventions focused on maximizing patients' psychosocial status in these areas may further improve long-term physical health outcomes in this population.

The effects of bereavement on adult sibling bone marrow donors' psychological well-being and reactions to donation.

As living organ, tissue, and bone marrow donation become increasingly prevalent treatments for a variety of diseases, better understanding of living donors' experiences, especially when the recipient does not survive after the transplant, also becomes more critical. Although some psychological outcome data exist concerning living donation, there have been no systematic prospective investigations, to date, of the psychological impact of bereavement among sibling bone marrow donors. Studies of bereavement effects in other donation settings such as unrelated bone marrow donation and related kidney donation, suggest that bereavement may have a significant impact on donors' reactions. The present investigation studied a panel of sibling bone marrow donors at three key points in the donation process in order to (1) examine donor psychological well-being across time, and (2) investigate the effect of the sibling recipient's death on donor well-being. We surveyed sibling donors by mail 1-2 weeks prior to donation, 1-2 weeks following donation, and again 1 year after their donation. In general, all donors reported high levels of predonation self-esteem, mastery, happiness and life satisfaction. As might be expected, bereaved donors felt less as if their donation had really helped their sibling as time passed. However, despite such donation-specific perceptions, bereaved donors experienced global psychological gains following bereavement including enhanced self-esteem, happiness, and life satisfaction compared to donors whose siblings were still living. These findings suggest that physicians and mental health practitioners should monitor donors' psychological well-being for extended periods post-donation, and should consider clinical interventions for bereaved and nonbereaved sibling donors.

Validity and reliability of Symptom Checklist '90 (SCL90) in an Argentine population sample.

Quantitative models to explore behavioural disorders are being used increasingly often for health care decision making. Unfortunately, there is a dearth of instruments in Argentina specifically designed for our population, and few researchers have focused on adapting and re-establishing psychometric criteria for instruments proven to be useful in other countries. The aims of this study were to assess the psychometric properties and to develop normative samples for a psychological status symptom inventory, the Symptom Checklist 90 (SCL90). We sought to determine the psychological symptom patterns both in physically healthy community-residing respondents and in physically ill patients in Argentina. The nonpatient sample was a random stratified one, made up of 484 individuals from the general population and representative with regard to gender, age, income and educational level. We also analysed a patient sample that included 105 persons with breast cancer. Results indicated acceptable reliability and validity levels as well as adequate sensitivity to detect differences between patients and nonpatients. We concluded that the SCL90 can be used to measure psychological status in Argentina, and the data presented in this paper can be utilized for comparisons with other similar instruments and with other populations.

Understanding donors' motivations: a study of unrelated bone marrow donors.

Medical advances in bone marrow transplantation techniques and immunosuppressive medications have dramatically increased the number of such transplants performed each year, and consequently, the demand for bone marrow from unrelated donors. Although physiological aspects of bone marrow donation have been thoroughly investigated, very few studies have examined psychosocial factors that may impact individuals' donation decisions and outcomes. To examine one particular set of donor psychosocial issues, this study investigated motives for bone marrow donation among 343 unrelated bone marrow donors who donated through the National Marrow Donor Program. Six distinct types of donor motives were identified from open-ended questionnaire responses. Donors most frequently reported motives reflecting some awareness of both the costs (to themselves) and potential benefits (to themselves and the recipient) of donation. A desire to act in accordance with social or religious precepts, expected positive feelings about donating, empathy for the recipient, and the simple desire to help another person were also commonly cited reasons for donating. Among a series of donor background characteristics, donors' gender was the variable most strongly associated with motive type; women were most likely to cite expected positive feelings, empathy, and the desire to help someone. Central study findings indicated that donor motives predicted donors reactions to donation even after the effects of donor background characteristics (including gender) were controlled. Donors who reported exchange motives (weighing costs and benefits) and donors who reported simple (or idealized) helping motives experienced the donation as less positive in terms of higher predonation ambivalence and negative postdonation psychological reactions than did remaining donors. Donors who reported positive feeling and empathy motives had the most positive donation reactions in terms of lower ambivalence, and feeling like better persons postdonation. These finding add substantially to the body of work concerning medical volunteerism generally, and also have important practical implications for the recruitment and education of potential bone marrow donors.

Changes in depressive symptoms as AIDS develops. The Multicenter AIDS Cohort Study.

OBJECTIVE: The authors sought to determine whether rates of depressive symptoms change from early- to late-stage HIV-1 infection and to determine the predictors of depressive symptoms as AIDS develops. METHOD: The data for this study were from 911 HIV-seropositive men-community volunteers from four U.S. cities-who entered the 10-year Multicenter AIDS Cohort Study without a diagnosis of AIDS and subsequently developed AIDS. The subjects underwent semiannual follow-ups during the study period. The outcome measures-overall depressive symptoms, nonsomatic depressive symptoms, syndromal depression, and severe depression-were assessed over the 5 years before and the 2 years after AIDS diagnosis from responses on the Center for Epidemiologic Studies Depression Scale (CES-D Scale). RESULTS: Depressive symptoms were stable over time from month 60 to month 18 before AIDS developed. However, beginning 12-18 months before AIDS diagnosis, there was a significant rise in all measures of depression, which reached a plateau within 6 months before AIDS developed. At this plateau, there was a 45% increase in mean CES-D Scale scores above baseline. An elevated CES-D Scale score in the earlier stages of infection, a self-report of AIDS-related symptoms (such as rash and lymphadenopathy), concurrent unemployment, cigarette smoking, and limited social supports were consistent predictors of higher rates of depression as AIDS developed. CONCLUSIONS: There is a dramatic, sustained rise in depressive symptoms as AIDS develops, beginning as early as 18 months before clinical AIDS is diagnosed. Prior depression, HIV-disease-related factors, and psychological stressors contribute to this rise. This robust phenomenon invites further characterization.

Medical compliance and its predictors in the first year after heart transplantation.

BACKGROUND: Although poor medical compliance is a major risk factor for morbidity and mortality after heart transplantation, no prospective data are available on rates of noncompliance with each component of the posttransplantation regimen. Little is known about the impact of health history, sociodemographic, or perioperative psychosocial variables on long-term compliance. METHODS: Compliance in eight domains was examined in a cohort of 101 heart recipients followed through the first year after transplantation. Patients received detailed interviews at 2, 7, and 12 months after transplantation. Additional corroborative information was obtained from family member interviews and nurse evaluations. Potential predictors of noncompliance were obtained from medical record reviews and from initial patient interviews. Predictors pertained to cardiac-related history, psychiatric history, sociodemographic variables, and perioperative psychosocial status (psychologic adaptation, social supports, coping strategies). RESULTS: Although degree of noncompliance varied across timepoints, rates of persistent noncompliance during the year were as follows: 37% (exercise); 34% (monitoring blood pressure); 20% (medications); 19% (smoking); 18% (diet); 15% (having blood work completed); 9% (clinic attendance); and 6% (heavy drinking). Compliance in most areas worsened significantly (p < 0.05) over time. Background health-related and sociodemographic characteristics showed no significant influence on any area of posttransplantation compliance. Perioperative psychosocial characteristics were strong and significant predictors of noncompliance. CONCLUSIONS: Pretransplantation screening for background and demographic variables may have limited utility for compliance outcomes. Strategies to improve compliance should focus on psychosocial risk factors pertaining to early psychologic reactions to transplantation, the quality of family relationships, and patients' styles of coping. These risk factors are each potentially modifiable through appropriate educational and supportive interventions.

Qualitative features of the memory deficit associated with HIV infection and AIDS: cross-validation of a discriminant function classification scheme.

The neuropsychological defects associated with late stage HIV infection and AIDS have been characterized as being similar to those seen in patients with dementia syndromes of subcortical etiologies. The purpose of this paper is to report on the cross-center replication of the classification of HIV-infected subjects' neuropsychological status based on a discriminant function generated from other HIV-related and unrelated cognitively impaired subjects. Of the HIV-control subjects, 42/46 (91.3%) were classified as "Normal", with only two subjects in each of two "dementia" groups: subcortical and cortical. However, similar to other HIV+ samples, a large proportion (36%) of our HIV-infected subjects were classified as "Subcortical", with 61% classified as "Normal", and one (3%) in the "Cortical" group. These data demonstrate that not only does the cognitive performance of some HIV+ subjects have distinct features relative to that of HIV-control subjects, but that the features are consistent with previous suggestions that such patients have a "Subcortical" pattern of impairment.

Chronic mechanical circulatory support: rehabilitation, low morbidity, and superior survival.

Because of donor scarcity, 12 (39%) of a series of 31 Novacor left ventricular assist system recipients required mechanical circulatory support for an average of 125 days before transplantation (range, 61 to 303 days). Ten received a heart transplant and all survived to discharge. Two died of infection before transplantation after 93 and 303 days of support. Significant reductions were noted from preimplantation values of right and left cardiac filling pressures. Right ventricular ejection fraction and cardiac index increased. The 4-month actuarial freedom from infection during support was 75%. Three patients benefited from chronic outpatient housing for 5, 18, and 131 days, respectively, with improvements in quality of life measures. Ten chronically supported patients participated in an intensive rehabilitative exercise program resulting in an improvement of New York Heart Association class from IV to I in 9 patients. Mean oxygen consumption, which was 10 mL.kg-1.min-1 30 days after implantation (mean exercise time, 10 minutes) had risen to 15 mL.kg-1.min-1 before transplantation (mean exercise time, 16 minutes). This series suggests that long-term circulatory support is compatible with low morbidity, significant physical and hemodynamic rehabilitation, and an outpatient setting.

Behavioral, health and psychosocial factors and risk for HIV infection among sexually active homosexual men: the Multicenter AIDS Cohort Study.

We examined whether 644 homosexual men who engaged in receptive anal intercourse were at particularly elevated risk for seroconversion if they also possessed specific behavioral, health or psychosocial vulnerability characteristics. Of 11 potential factors examined, heavy drinking, moderate to heavy drug use, and younger age were significantly related to seroconversion. These variables were also associated with an increased number of sexual partners, anonymous sex, and failure to use condoms.

Health effects of long-term solvent exposure among women in blue-collar occupations.

The relationship of solvent exposure to self-reported neurologic and somatic symptoms as well as neuropsychological performance was examined in a sample of 567 female blue collar workers who were members of the International Brotherhood of Electrical Workers (IBEW). Structured interviews were conducted at IBEW offices. Five solvent exposure categories were derived--never exposed, exposed prior to but not during the past year, exposed during the past year but not currently, currently exposed less than 50% of the time, and currently exposed more than 50% of the time. No differences among the groups on neuropsychological performance were found. On the other hand, heightened exposure was significantly related to depression, severe headaches, light-headedness, room spinning, appetite difficulties, funny taste in mouth, weakness/fatigue, rashes, and abdominal pain after controlling for the effects of seven risk factors (age, smoking, moderate-heavy alcohol consumption, severe obesity, history of physician-diagnosed chronic illness, working in a clean room, and exposure to other chemicals). These findings are consistent with Scandinavian studies of solvent-exposed male workers and point to the need for careful prospective research.

Effectiveness of the United Steel Workers of America Coke Oven Intervention Program.

This paper describes the implementation and evaluation of the Coke Oven Intervention Program developed jointly by the United Steel Workers of America and the University of Pittsburgh. The program was offered on four occasions at each of seven coke oven plants over a 2-year period. Participants were compared with nonparticipating co-workers and controls from matched plants on knowledge of the Coke Oven Standard and workplace behaviors. Few baseline differences were found among participants, nonparticipants, and controls. Participants improved significantly as a result of the program, with those attending multiple programs accruing the greatest benefits. Panel controls interviewed on six occasions throughout the 2-year period showed little improvement. Reasons for and implications of the effectiveness of the program are discussed.

Occupational lead exposure and blood pressure.

Recent community studies have suggested that low level lead exposure is significantly associated with blood pressure in the general population. This finding is inconsistent with the results of recent occupational studies of lead exposed workers, although the occupational studies contained serious methodological weaknesses. The present study examined the relation between occupational lead exposure and diastolic and systolic blood pressure in randomly selected samples of 270 exposed and 158 non-exposed workers. Four exposure indicators were examined: employment at a lead battery plant nu a control plant, current blood lead value, current zinc protoporphyrin value, and time weighted average blood lead value. After controlling for other known risk factors such as age, education, income, cigarette usage, alcohol consumption, and exercise, the associations between exposure and blood pressure were small and non-significant. In the absence of a biologically feasible hypothesis regarding the mechanism by which low level lead exposure would influence blood pressure the present findings challenge the validity of the general population association.