Personalised support of brain tumour patients during radiotherapy based on psychological profile and quality of life.

PURPOSE: Psychological distress in primary malignant brain tumour (PMBT) patients is associated with poorer outcomes. Radiotherapy (RT) often induces side effects that significantly influence patients' quality of life (QoL), with potential impact on survival. We evaluated distress, anxiety, depression, and QoL over time to identify patients with difficulties in these areas who required more intense psychological support. METHODS: Psychological questionnaires-Distress Thermometer (DT), Hospital Anxiety and Depression Scale (HADS), and Functional Assessment of Cancer Therapy (FACT-G and FACT-Br)-were completed at the beginning (T0), in the middle (T1), directly after RT (T2), and 3 months after RT (T3). We personalised the psychological support provided for each patient with a minimum of three sessions ('typical' schedule) and a maximum of eight sessions ('intensive' schedule), depending on the patients' psychological profiles, clinical evaluations, and requests. Patients' survival was evaluated in the glioblastoma multiforme (GBM) patients, with an explorative intent. RESULTS: Fifty-nine consecutive PMBT patients receiving post-operative RT were included. For patients who were reported as 'not distressed' at T0, no statistically significant changes were noted. In contrast, patients who were 'distressed' at T0 showed statistically significant improvements in DT, HADS, FACT-G, and FACT-Br scores over time. 'Not distressed' patients required less psychological sessions over the study duration than 'distressed' patients. Interestingly, 'not distressed' GBM patients survived longer than 'distressed' GBM patients. CONCLUSIONS: Increased psychological support improved distress, mood, and QoL for patients identified as 'distressed', whereas psychological well-being was maintained with typical psychological support in patients who were identified as being 'not distressed'. These results encourage a standardisation of psychological support for all RT patients.

All-cause mortality among Japanese whose cohabiting partners are diagnosed with cancer: the Ohsaki Cohort 2006 study.

BACKGROUND: It has been noted that not only adverse psychosocial health effects but also mortality might increase for a person living with a spouse with cancer. This study examined the association between a partner's cancer diagnosis and mortality among a Japanese population. METHODS: In December 2006, a survey was conducted on participants aged 40 years or older who were residing in northeastern Japan. We identified couples using municipality-specific household ID numbers by searching public records and confirmed partner's cancer diagnosis after the baseline measurement using regional cancer registration information. After following up for a maximum of 4.0 years with the participants regarding mortality and emigration by reviewing the Residential Registry Record, we used Cox's proportional hazards regression to estimate the hazard ratio (HR) of all-cause mortality. RESULTS: We identified 25,938 participants (12,969 pairs) and included them in the analyses. A total of 1,308 (5.0%) participants had partners with a cancer diagnosis after baseline. The study found no association between a partner's cancer diagnosis and all-cause mortality; multivariable HRs of all-cause mortality for individuals in exposed subjects compared with those in unexposed subjects were 1.35 (95% confidence interval [CI] = 0.99-1.83; p = .055). Contrarily, sensitivity analyses of mortality attributed to having partners diagnosed with cancer based on the time since entry showed that all-cause mortality significantly increased only within one year from spouse cancer diagnosis; HR = 2.18 (95% CI = 1.44-3.30; p < .01). CONCLUSIONS: Our findings reveal that the mortality rate from partner's cancer diagnosis was significantly high during the early period of diagnosis and multidisciplinary teams for cancer treatment might be important for preventing death among the partner.

[Psychological distress and caregiving burden among spouses of women with breast cancer]. / Niveau de détresse psychologique et de fardeau perçu chez les conjoints de femmes atteintes d'un cancer du sein.

Breast cancer is a chronic disease that affects both patients and their caregivers. Spouses, in particular, will generally assume the role of primary caregiver and experience significant physical, social, economic and emotional stress. In the face of cancer, being the spouse of a patient is synonymous with unmet psychosocial needs and a new role assignment, that of a primary caregiver. In addition, cancer confronts spouses with fear of partner loss. This leads to a set of adverse consequences such as depression, anxiety, uncertainty, stress, etc. Several studies have shown that breast cancer reduces the quality of life of patients' spouses and increases their emotional distress, their psychosocial needs, and their responsibilities within the family. Spouses may live a complex powerful emotional experience, which is equal to or greater than that experienced by patients during the diagnosis and treatment process. These multiple solicitations contribute to the heavy symptom burden. Therefore, in the context of breast cancer, identifying vulnerable spouses and providing them with appropriate support would help ensure better adherence to the care of their wives at different stages of the disease.

Effect of acute restraint stress in a polytrauma rat model.

INTRODUCTION: A stressful environment may contribute to poor outcomes after TBI. The current study evaluates the impact of acute stress in a polytrauma rat model. METHODS: Rats were stressed by a 45-minute immobilization period before instrumentation under ketamine (t1). Polytrauma was produced by blast overpressure and controlled hemorrhage (t2). Rats were euthanized immediately after a 3 h simulated Medevac-transport time (t3) or after 72 h post-trauma (t4). Corticosterone, ACTH, and ACTH receptor gene expression were measured at these time points. Physiological parameters were monitored throughout the study. RESULTS: HR was higher in stressed compared to unstressed animals at t1. Corticosterone and ACTH levels were similar for all conditions at t1 and t2; ACTH and corticosterone became elevated in all groups at t3 and at t4, respectively. The ACTH receptor gene expression trended towards higher values at t4 for the stressed animals whether being injured or not. Survival after injury was 83% in both unstressed and stressed animals. CONCLUSION: Overall, corticosterone was not significantly affected following acute stress in ketamine-anesthetized rats. Early mortality was primarily due to polytrauma and change in the animal's biochemical parameters appeared at t4 post trauma. The findings indicate that ketamine-anesthesia and/or surgery may have overshadowed the effect of the initial stress.

Association between psychological distress and mortality: the case of Israel.

BACKGROUND: Previous studies have demonstrated the association between psychological distress (measured by the 12-item General Health Questionnaire, GHQ-12) and risks of all-cause mortality and deaths from cardiovascular, cancer and other causes. We hypothesised that in the Israeli population permanently exposed to war/terror stressors, this relationship is absent. METHODS: We performed an analysis of data from participants in the Israel National Health Survey conducted in 2003-2004, who died during the follow-up decade. Subjects were assigned to groups based on GHQ-12 score: 0-10 (asymptomatic), 11-14 (subclinically symptomatic), 15-19 (symptomatic) and 20-36 (highly symptomatic). Data were weighted to the total population. RESULTS: We analysed data from 4843 individuals, median age 40.5 (IQR 28-54); 473 participants died during the follow-up. We found a significant increase in total mortality, cardiovascular and other causes of mortality (but not cancer deaths) with increase in GHQ-12 score (P for linear trend of ungrouped GHQ scores <0.0001, 0.0015 and <0.0001, respectively). The age-sex-adjusted HR for the highest GHQ-12 compared with the lowest asymptomatic category was 2.1 (95% CI 1.6 to 2.7) for all-cause deaths, 2.3 (95% CI 1.3 to 4.1) for cardiovascular disease deaths and 2.7 (95% CI 1.9 to 3.9) for other deaths. The HR remained significant after adjustment for education, smoking, alcohol consumption and diabetes. The HR even increased after excluding participants with baseline cardiovascular diseases and cancer. CONCLUSION: Contrary to our hypothesis, psychological distress was associated with all-cause and cardiovascular but not cancer mortality. The absence of reverse causality provides evidence for the direct deleterious effects of psychological distress on mortality outcomes.

Association of Stress Biomarkers With 30-Day Unplanned Readmission and Death.

BACKGROUND: The theory that posthospitalization stress might increase the risk of postdischarge complications has never been investigated. OBJECTIVE: To assess whether serum levels of stress biomarkers at discharge are associated with readmission and death after an acute-care hospitalization. DESIGN: We prospectively included 346 patients aged ≥50 years admitted to the department of general internal medicine at a large community hospital between April 8, 2013 and September 23, 2013. We measured the serum levels of several biomarkers at discharge: midregional pro-adrenomedullin, copeptin, cortisol, and prolactin. All patients were followed for up to 90 days after discharge (none was lost to follow-up). The main outcome was first unplanned readmission or death within 30 days after hospital discharge. We assessed the additional value of biomarkers to 2 validated readmission prediction scores: the LACE index (Length of stay, Admission Acuity, Charlson Comorbidity Index, and number of Emergency department visits within preceding 6 months) and the HOSPITAL score (Hemoglobin level at discharge, discharge from Oncology service, Sodium level at discharge, any Procedure performed during index hospitalization, Index admission Type, number of Admissions within preceding 12 months, and Length of stay). RESULTS: Forty patients (11.6%) had a 30-day unplanned readmission or death. High serum copeptin and cortisol levels were associated with an increase in the odds of unplanned readmission or death (odds ratios [95% confidence interval] 2.69 [1.29-5.64] and 3.43 [1.36, 8.65], respectively). We found no significant association with midregional pro-adrenomedullin or prolactin. Furthermore, these stress biomarkers increased the performance of two readmission prediction scores (LACE index and HOSPITAL score). CONCLUSION: High serum levels of copeptin and cortisol at discharge were independently associated with 30-day unplanned readmission or death, supporting a possible negative effect of hospitalization stress during the postdischarge period. Stress biomarkers improved the performance of prediction models and therefore could help better identify high-risk patients.

Perspectivas dos estudos sobre violência na adolescência e cortisol: revisão bibliográfica sistemática / Prospects of studies on violence, adolescence and cortisol: a systematic literature review

Resumo A violência afeta negativamente a saúde de crianças e adolescentes, impactando sua qualidade de vida. Provoca estresse e exige da vítima uma capacidade adaptativa, o que pode acarretar mudanças psicológicas e biológicas. Os níveis do hormônio cortisol têm sido utilizados como biomarcador de estresse em vários estudos. Este artigo se propõe a realizar uma revisão bibliográfica sistemática das publicações sobre cortisol e violência envolvendo adolescentes no período de 2000 a 2013. Os seguintes descritores foram usados: "violência", "adolescente" e "cortisol", "violence, "adolescent", cortisol", que incluiu as bases bibliográficas PubMed/Medline, Lilacs, BVS e SciELO. Foram analisados 12 artigos. A maior parte dos estudos envolve participantes dos Estados Unidos, de ambos os sexos e sem grupo controle. Diferentes tipos de violência são estudados, destacando-se a familiar, vitimização ou testemunho. Todos utilizaram a saliva para medição do cortisol. Não existe uma padronização metodológica para a análise. A maior parte dos estudos (83,3%) encontrou associação estatisticamente significativa entre o nível de cortisol e a exposição à violência. Ainda não existe uniformidade nos resultados encontrados, seja quanto ao sexo, tipo de violência, condição socioeconômica ou forma de análise de cortisol.

Abstract Violence has a negative impact on adolescents and affects their quality of life. It causes stress and requires the victim's adaptive capacity, which can cause psychological and biological changes. Hormone cortisol levels have been used as stress biomarker in several studies. This paper aims to perform a systematic literature review of publications on cortisol and violence involving teenagers from 2000 to 2013. Descriptors "cortisol", "violence" and "adolescent" were used in both English and Portuguese in this review, which included bibliographic databases PubMed/Medline, Lilacs, BVS and SciELO. Twelve papers were analyzed. Most studies involve participants from the United States, of both genders and without a control group. Different types of violence are studied, especially family violence, victimization or testimony. All studies used saliva to measure cortisol and no standard methodology was used for the analysis. Most studies (83.3%) found a statistically significant association between cortisol levels and exposure to violence. Results regarding gender, type of violence, socioeconomic status or cortisol analysis methods are not yet uniform.

Do multiple health events reduce resilience when compared with single events?

OBJECTIVE: The impact of multiple major life stressors is hypothesized to reduce the probability of resilience and increase rates of mortality. However, this hypothesis lacks strong empirical support because of the lack of prospective evidence. This study investigated whether experiencing multiple major health events diminishes rates of resilience and increases rates of mortality using a large population-based prospective cohort. METHOD: There were n = 1,395 individuals sampled from the Health and Retirement Study (HRS) and examined prospectively from 2 years before 4 years after either single or multiple health events (lung disease, heart disease, stroke, or cancer). Distinct depression and resilience trajectories were identified using latent growth mixture modeling (LGMM). These trajectories were compared on rates of mortality 4 years after the health events. RESULTS: Findings indicated that 4 trajectories best fit the data including resilience, emergent postevent depression, chronic pre-to-post depression, and depressed prior followed by improvement. Analyses demonstrate that multiple health events do not decrease rates of resilience but do increase the severity of symptoms among those on the emergent depression trajectory. Emergent depression increased mortality compared with all others but among those in this class, rates were not different in response to single versus multiple health events. CONCLUSIONS: Multiple major stressors do not reduce rates of resilience. The emergence of depression after health events does significantly increase risk for mortality regardless of the number of events. (PsycINFO Database Record

Association of psychological distress late in life and dementia-related mortality.

OBJECTIVE: It is not fully understood how subjective feelings of psychological distress prognosticate dementia. Our aim was to investigate the association between self-reported psychological distress and risk of dementia-related mortality. METHOD: We included 31,043 eligible individuals between the ages of 60 and 80 years, at time of examination, from the CONOR (Cohort of Norway) database. They were followed for a period of 17.4 years (mean 11.5 years). The CONOR Mental Health Index, a seven-item self-report scale was used. A cut-off score equal to or above 2.15 on the scale denoted psychological distress. Cox regression was used to assess the association between psychological distress and risk of dementia-related mortality. RESULTS: Total number of registered deaths was 11,762 and 1118 (9.5%) were classified as cases of dementia-related mortality. We found that 2501 individuals (8.1%) had psychological distress, of these, 119 (10.6%) had concomitant dementia-related mortality. Individuals with psychological distress had an increased risk of dementia-related mortality HR = 1.52 (95% confidence interval (CI) 1.25-1.85) after adjusting for age, gender and education. The association remained significant although attenuated when implemented in a full adjusted model, including general health status, smoking, obesity, hypertension, diabetes and history of cardiovascular disease; hazard ratio, HR = 1.30 (95% CI 1.06-1.59). CONCLUSION: Our results indicate that psychological distress in elderly individuals is associated with increased risk of dementia-related mortality. Individuals at increased risk of dementia may benefit from treatments or interventions that lessen psychological distress, but this needs to be confirmed in future clinical studies.

Managing Cancer And Living Meaningfully: study protocol for a randomized controlled trial.

BACKGROUND: We have developed a novel and brief semi-structured psychotherapeutic intervention for patients with advanced or metastatic cancer, called Managing Cancer And Living Meaningfully. We describe here the methodology of a randomized controlled trial to test the efficacy of this treatment to alleviate distress and promote well-being in this population. METHODS/DESIGN: The study is an unblinded randomized controlled trial with 2 conditions (intervention plus usual care versus usual care alone) and assessments at baseline, 3 and 6 months. The site is the Princess Margaret Cancer Centre, part of the University Health Network, in Toronto, Canada. Eligibility criteria include: ≥ 18 years of age; English fluency; no cognitive impairment; and diagnosis of advanced cancer. The 3-6 session intervention is manualized and allows for flexibility to meet individual patients' needs. It is delivered over a 3-6 month period and provides reflective space for patients (and their primary caregivers) to address 4 main domains: symptom management and communication with health care providers; changes in self and relations with close others; sense of meaning and purpose; and the future and mortality. Usual care at the Princess Margaret Cancer Centre includes distress screening and referral as required to in-hospital psychosocial and palliative care services. The primary outcome is frequency of depressive symptoms and the primary endpoint is at 3 months. Secondary outcomes include diagnosis of major or minor depression, generalized anxiety, death anxiety, spiritual well-being, quality of life, demoralization, attachment security, posttraumatic growth, communication with partners, and satisfaction with clinical interactions. DISCUSSION: Managing Cancer And Living Meaningfully has the potential to relieve distress and promote psychological well-being in patients with advanced cancer and their primary caregivers. This trial is being conducted to determine its benefit and inform its dissemination. The intervention has cross-national relevance and training workshops have been held thus far with clinicians from North and South America, Europe, the Middle East, Asia and Africa. TRIAL REGISTRATION: ClinicalTrials.gov NCT01506492 4 January 2012.

Occupational exposure to maternal death: psychological outcomes and coping methods used by midwives working in rural areas.

AIM: to explore the psychological outcomes of occupational exposure to maternal death and the coping methods used by midwives working in rural areas. BACKGROUND: maternal deaths are common in rural areas of developing countries because of the shortages of human and other resources needed for maternity services. When maternal deaths occur, midwives often experience emotional distress while striving to perform their work. This may have a negative impact on their well-being. METHODS: Descriptive design. A self-administered questionnaire in the English language, comprising the Death Distress Scale and Brief COPE Scale, was used to collect data from 238 midwives working in two rural districts of Uganda. FINDINGS: the majority of participants were female (81%) and had a diploma in midwifery (36%). Mean age and years of professional experience were 34 [standard deviation (SD) 6.3] years and three (SD 1.3) years, respectively. The majority of participants (94%) had witnessed a maternal death. The results from the Death Distress Scale showed that the majority of midwives who had witnessed a maternal death had moderate to high death anxiety (93%), mild to moderate death obsession (71%) and mild death depression (53%). Most midwives coped with their distress using methods such as active coping, venting, positive reframing, self-distraction and planning. CONCLUSION: midwifery educational programmes and work settings need to understand the importance of maternal death from the midwives' perspective and their ability to cope with this detrimental experience. IMPLICATIONS FOR PRACTICE: there is a need for midwifery practice settings to provide respite care, education on coping with death experiences and counselling after traumatic experiences in order to maintain the well-being of midwives. As occupational exposure to maternal death can have a negative effect on the well-being of midwives, this can affect their professional quality of life and clinical practice.

The association between psychosocial stress and mortality is mediated by lifestyle and chronic diseases: the Hoorn Study.

Psychosocial stress is associated with chronic disease. We evaluated whether in the general population the number of stressful life events is associated with risk of mortality and whether this association is mediated by behavioral factors and morbidities. We conducted this study in the Hoorn cohort; a population-based cohort study among older men and women. Our main variable of interest was the number of stressful life events experienced during the previous 5 years, which were assessed by questionnaire. We calculated Cox proportional hazard ratios (HRs) for all-cause and cause-specific mortality during follow-up for those who experienced stressful life events compared to those who did not. We included 2385 participants (46% male; 62 ± 7 years). During 20 years of follow-up 834 (35%) participants died, of whom 239 (28.6%) died of cardiovascular disease. Compared to the group with no stressful life events, the age, sex and socioeconomic status adjusted HRs (with 95% confidence intervals) for all-cause mortality, for the groups who had 1 event, 2 events, 3 events and ≥4 events were 0.89 (0.72-1.09), 1.01 (0.81-1.24), 1.29 (1.00-1.66) and 1.44 (1.08-1.92), respectively. Similar results were observed for cardiovascular mortality. Mediation analysis showed that smoking, prevalent type 2 diabetes and cardiovascular disease were statistically significant mediators of the association between the number of stressful life events and mortality. Having 3 or more stressful life events is associated with a significantly increased risk for mortality in an elderly population-based cohort. This association is mediated by smoking, type 2 diabetes and cardiovascular disease.

Percepção dos sintomas e sofrimento no fim da vida das crianças com câncer e repercussões nos cuidadores / Symptom perception and end of life suffering of cancer children and the repercussion on caregivers

Introdução: Apesar do progresso da oncologia pediátrica, ainda existem pacientes que não atingem a cura. Estudos mostram que estes recebem tratamento agressivo no fim da vida, sem controle efetivo dos sintomas, com sofrimento significativo. O cuidador familiar é fonte preciosa de informações conforme a morte da criança se aproxima. No entanto, as impressões parentais podem não refletir precisamente a experiência da criança, pois presenciar sofrimento pressupõe sofrimento. Talvez isso explique a discordância entre o relato dos pais e os registros médicos. A convivência com o sofrimento do filho morrendo permanece gravado na memória dos pais. Acreditar que o filho morreu sofrendo pode levar a morbidade psicológica e interferir no futuro deles. Avaliou-se a percepção dos pais sobre os sintomas que afetaram o bem estar dos seus filhos no fim da vida, comparou-se com os dados da equipe médica e relacionaram-se as circunstâncias em que a morte ocorreu com transtornos de humor e presença de luto complicado. Material e métodos: em 2012 entramos em contato com 250 famílias que perderam o filho no período de 2000 a 2010, em um Hospital especializado, no interior do Brasil, que realiza atendimento através do sistema governamental. A pesquisa foi conduzida através de questionários auto-aplicáveis enviados pelos correios. Resultados: tivemos a participação de 60 cuidadores com tempo de luto variando entre 14 e 80 meses. Esses relataram média de 12 sintomas que afetaram o bem estar dos filhos na última semana de vida, sem concordância quando comparado com os dados registrados pela equipe médica, até mesmo para o sintoma dor. Esses pais apresentam altos níveis de ansiedade e depressão (74,0% e 81,0% respectivamente) e altos níveis de luto complicado (38,0% com luto baixo/ausente, 12,0% com luto adiado e 34,0% como luto prolongado). Os maiores escores de luto atual foram evidenciados entre os cuidadores casados, com idade variando entre 30-39 anos, analfabetos, assalariados,...

Introduction: Despite all the progress in pediatric oncology, there are still patients who cannot achieve cure. Studies show that they receive aggressive treatment in the end of life, with no effective control of symptoms, and endure considerable suffering. The family caregiver is a precious source of information as the death of the child approaches. Parental impressions may not reflect accurately the child's experience due to the fact that witnessing suffering implies in suffering. This may explain the discrepancy between the parents' reports and the medical records. Living with a dying child remains engraved in the parents' memories. Believing that their child died in pain may lead to psychological morbidity and interfere in their future. Parental perception on the symptoms that affected the well- being of the child in the end of life was evaluated and compared with medical data, and the circumstances in which death occurred were related with mood swings and the presence of complicated grief. Material and methods: In 2012, 250 families that had lost a child between the years of 2000 and 2010, in a specialized, public hospital in Brazil, were contacted. A survey was carried out through self- applied questionnaires sent by mail. Results: 60 caregivers with time of mourning ranging between 14 and 80 months reported, on average, 12 symptoms that affected the well-being of their children on their last week of life, and these reports did not agree with the data recorded by the medical team. These parents present with high levels of anxiety and depression (74.0% and 81.0% respectively), as well as complicated grief (38.0% absent/ low grief, 12.0% delayed grief and 34.0% prolonged grief). The highest grief scores were seen among the caregivers who met the following parameters: married, age range between 30 and 39, illiterate, minimum wage and social class C/D/E. They had also been mourning the loss of their only child, who was between 12 and 18 years old...

Age-related differences in the effect of psychological distress on mortality: Type D personality in younger versus older patients with cardiac arrhythmias.

BACKGROUND: Mixed findings in biobehavioral research on heart disease may partly be attributed to age-related differences in the prognostic value of psychological distress. This study sought to test the hypothesis that Type D (distressed) personality contributes to an increased mortality risk following implantable cardioverter defibrillator (ICD) treatment in younger patients but not in older patients. METHODS: The Type D Scale (DS14) was used to assess general psychological distress in 455 younger (≤70 y, m = 59.1) and 134 older (>70 y, m = 74.3) ICD patients. End points were all-cause mortality and cardiac death after a median follow-up of 3.2 years. RESULTS: Older patients had more advanced heart failure and a higher mortality rate (n = 34/25%) than younger patients (n = 60/13%), P = 0.001. Cardiac resynchronization therapy (CRT), but not Type D personality, was associated with increased mortality in older patients. Among younger patients, however, Type D personality was associated with an adjusted hazard ratio = 1.91 (95% CI 1.09-3.34) and 2.26 (95% CI 1.16-4.41) for all-cause and cardiac mortality; other predictors were increasing age, CRT, appropriate shocks, ACE-inhibitors, and smoking. CONCLUSION: Type D personality was independently associated with all-cause and cardiac mortality in younger ICD patients but not in older patients. Cardiovascular research needs to further explore age-related differences in psychosocial risk.

Lifetime trauma exposure and prospective cardiovascular events and all-cause mortality: findings from the Heart and Soul Study.

OBJECTIVE: Little is known about the effect of cumulative psychological trauma on health outcomes in patients with cardiovascular disease. The objective of this study was to prospectively examine the association between lifetime trauma exposure and recurrent cardiovascular events or all-cause mortality in patients with existing cardiovascular disease. METHODS: A total of 1021 men and women with cardiovascular disease were recruited in 2000 to 2002 and followed annually. Trauma history and psychiatric comorbidities were assessed at baseline using the Computerized Diagnostic Interview Schedule for DSM-IV. Health behaviors were assessed using standardized questionnaires. Outcome data were collected annually, and all medical records were reviewed by two independent, blinded physician adjudicators. We used Cox proportional hazards models to evaluate the association between lifetime trauma exposure and the composite outcome of cardiovascular events and all-cause mortality. RESULTS: During an average of 7.5 years of follow-up, there were 503 cardiovascular events and deaths. Compared with the 251 participants in the lowest trauma exposure quartile, the 256 participants in the highest exposure quartile had a 38% greater risk of adverse outcomes (hazard ratio = 1.38, 95% confidence interval = 1.06-1.81), adjusted for age, sex, race, income, education, depression, posttraumatic stress disorder, generalized anxiety disorder, smoking, physical inactivity, and illicit drug abuse. CONCLUSIONS: Cumulative exposure to psychological trauma was associated with an increased risk of recurrent cardiovascular events and mortality, independent of psychiatric comorbidities and health behaviors. These data add to a growing literature showing enduring effects of repeated trauma exposure on health that are independent of trauma-related psychiatric disorders such as depression and posttraumatic stress disorder.

Suicide and suicide attempt after a cancer diagnosis among young individuals.

BACKGROUND: Data are scarce on the potential change in suicidal behavior among adolescents and young adults after receiving a cancer diagnosis. PATIENTS AND METHODS: We conducted a population-based cohort study including 7 860 629 Swedes at the age of ≥15 during 1987-2009. Among the cohort participants, 12 669 received a first diagnosis of primary cancer between the age of 15 and 30. We measured the relative risks (RRs) of suicidal behavior (defined as completed suicides or suicide attempts) after cancer diagnosis. We also carried out a case-crossover study nested within the cohort to adjust for unmeasured confounders. RESULTS: Twenty-two completed suicides (versus 14 expected) and 136 suicide attempts (versus 80 expected) were identified among the cancer patients. The RR of suicidal behavior was 1.6 [95% confidence interval (CI), 1.4-1.9] after a cancer diagnosis, compared with cancer-free individuals. Risk increase was greatest immediately after diagnosis; the RR was 2.5 (95% CI 1.7-3.5) during the first year after diagnosis and was 1.5 (95% CI 1.2-1.8) thereafter. This pattern was similar for completed suicide and suicide attempts. The elevated risks were evident for majority of the main cancer types, except for cancer in thyroid, testis and melanoma. The case-crossover analysis of suicidal behavior during the first year after cancer diagnosis revealed similar results. CONCLUSIONS: Adolescents and young adults receiving a cancer diagnosis are at substantially increased risk of suicidal behavior, particularly during the first year after diagnosis. Although the absolute excess risk is modest, these findings emphasize the need to support and carefully monitor this vulnerable population.

Perceived stress and mortality in a Taiwanese older adult population.

Perceived stress is associated with poor health outcomes including negative affect, increased susceptibility to the common cold and cardiovascular disease; the consequences of perceived stress for mortality, however, have received less attention. This study characterizes the relationship between perceived stress and 11-year mortality in a population of Taiwanese adults aged 53+ years. Using the Survey of Health and Living Status of the Near Elderly and Elderly of Taiwan, we calculated a composite measure of perceived stress based on six items pertaining to the health, financial situation, and occupation of the respondents and their families. Proportional hazard models were used to determine whether perceived stress predicted mortality. After adjusting for sociodemographic factors only, we found that a one standard deviation increase in perceived stress was associated with a 19% increase in all-cause mortality risk during the 11-year follow-up period (hazard ratio, HR = 1.19, 95% confidence interval, CI 1.13-1.26). The relationship was greatly attenuated when perceptions of stress regarding health were excluded, and was not significant after adjusting for medical conditions, mobility limitations and depressive symptoms. We conclude that the association between perceived stress and mortality is explained by an individual's current health; however, our data do not allow us to distinguish between two possible interpretations of this conclusion: (a) the relationship between perceived stress and mortality is spurious, or (b) poor health acts as the mediator.

Vasovagal syncope related to emotional stress predicts coronary events in later life.

BACKGROUND: The aim of the study was to assess whether history of vasovagal syncope (VVS) mediated by emotional (emotional VVS) or orthostatic stress (orthostatic VVS) is associated with an increased risk of cardiovascular (CV) events in later life. METHODS: Retrospective analysis based on medical records of the consecutive 3,288 cardiologic outpatients (mean age, 61 ± 12 years; 43% men). RESULTS: A total of 254 patients (7.7%) reported emotional VVS, whereas 294 (9.0%) had history of orthostatic VVS. First-ever syncopal episode was reported at a median age of 16 years (interquartile range [IQR], 12 years to 28 years), and the median total number of episodes was two (IQR, 1 to 5). There were 779 patients (23.7%) with at least one CV event, and the median age for the first CV event was 59 years (IQR, 52 years to 67 years). In the fully adjusted model, history of emotional VVS was predictive of CV event (hazard ratio [95% confidence interval]: 1.63, [1.27-2.09]; P < 0.001), myocardial infarction (1.99, [1.49-2.66]; P < 0.001), and percutaneous coronary intervention (1.84, [1.31-2.60]; P = 0.001). There was one significant interaction (P = 0.07) between history of emotional VVS and gender. Emotional VVS was predictive of CV event in men (1.89 [1.41-2.53]; P < 0.001) but not in women (1.24 [0.79-1.94]; P = 0.35). CONCLUSIONS: History of emotional but not orthostatic VVS is independently associated with increased risk of coronary events in later life. The relationship between predisposition to emotional VVS in adolescence and development of cardiovascular disease requires further studies.

A prospective study of family conferences: effects of patient presence on emotional expression and end-of-life discussions.

CONTEXT: Limited research has taken place examining family conferences (FCs) with patients with advanced cancer and their caregivers in the palliative care setting. OBJECTIVES: To characterize the FCs involving cancer patients in a palliative care unit at a comprehensive cancer center and examine the effects of patient participation on emotional expression by the participants and end-of-life discussions. METHODS: A data collection sheet was completed immediately after 140 consecutive FCs that documented the number of participants, caregiver demographics, expressions of emotional distress, dissatisfaction with care, and the topics discussed. Patient demographics and discharge disposition also were collected. RESULTS: Seventy (50%) patients were female, 64 (46%) were white, and 127 (91%) had solid tumors. Median age of patients was 59 years. Patients participated in 68 of 140 FCs (49%). Primary caregivers (n = 140) were female (66%), white (49%), and the spouse/partner (59%). Patients verbalized distress frequently (73%). Primary caregivers' verbal expression of emotional distress was high (82%) but not significantly affected by patient presence (82% vs. 82%, P = 0.936). Verbal expressions of emotional distress by other family members were more common when patients were absent (87%) than when present (73%), P = 0.037. Questions concerning advance directives (21%), symptoms anticipated at death (31%), and caregiver well-being (29%) were infrequent. Patient presence was significantly associated with increased discussions regarding goals of care (P = 0.009) and decreased communication concerning prognosis (P = 0.004) and what symptoms dying patients may experience (P < 0.001). CONCLUSION: There was a high frequency of expression of emotional distress by patients and family members in FCs. Patient participation was significantly associated with decreased verbal emotional expression by family members but not the primary caregiver and was associated with fewer discussions regarding prognosis and what dying patients may experience.