Painful and non-painful chemotherapy-induced peripheral neuropathy and quality of life in colorectal cancer survivors: results from the population-based PROFILES registry.

PURPOSE: This study aims to (1) examine the prevalence of painful versus non-painful chemotherapy-induced peripheral neuropathy (CIPN) among long-term colorectal cancer (CRC) survivors, (2) identify sociodemographic, clinical, and psychological factors associated with painful and non-painful CIPN, and (3) examine the associations of painful CIPN with health-related quality of life (HRQoL) in comparison with non-painful CIPN, i.e., numbness/tingling. METHODS: All CRC survivors diagnosed between 2000 and 2009 as registered by the population-based Netherlands Cancer Registry (Eindhoven region) were eligible for participation. Chemotherapy-treated survivors (n = 477) completed questions on CIPN (EORTC QLQ-CIPN20) and HRQoL (EORTC QLQ-C30). RESULTS: Painful CIPN was reported by 9% (n = 45) of survivors and non-painful CIPN was reported by 22% (n = 103). Time since diagnosis was related to painful CIPN, and time since diagnosis, a higher disease stage, osteoarthritis, and more anxiety symptoms were related to non-painful CIPN. Finally, survivors with painful CIPN reported a worse global quality of life and worse physical, role, cognitive, and social functioning compared to survivors with non-painful CIPN and those without any sensory CIPN. No differences were found between survivors with non-painful CIPN and those without sensory CIPN. CONCLUSIONS: It seems that painful CIPN must be distinguished from non-painful CIPN, as only painful CIPN was related to a worse HRQoL. Future research is needed to examine whether painful CIPN must be distinguished from non-painful CIPN regarding predictors, mechanisms, and treatment.

Fear of pain and cortisol reactivity predict the strength of stress-induced hypoalgesia.

BACKGROUND: Acute stress can have an effect on pain sensitivity, yet the direction of the effect - whether it is hypoalgesic or hyperalgesic - is mixed across studies. Moreover, which part of the stress response influences pain sensitivity is still unclear. In the current experimental study, we aim to examine the effect of acute stress on heat pain thresholds and pain tolerance levels in healthy participants, while taking into account individual differences in stress responses. METHODS: Forty-two healthy participants were randomly assigned to either a well-validated stress paradigm: the Maastricht Acute Stress Task (MAST; combining physical and psychological stressors) or to a nonstressful version of the task. Heat pain thresholds and tolerance levels were assessed at three times: prior to the MAST, immediately after the MAST during the presumed sympatho-adrenal medullary (SAM) response, and 15 min after MAST to cover the presumed hypothalamus-pituitary-adrenal (HPA) axis response. Stress responses were assessed both subjectively and physiologically. RESULTS: We observed that the acute stress induction led to increased heat pain thresholds, an effect that was present only in participants showing a cortisol response following stress induction and only in the presumed HPA axis time window. The strength of this hypoalgesic effect was further predicted by the change in cortisol and by fear of pain levels. CONCLUSIONS: Our findings indicate that the HPA axis - and not the autonomic - stress response specifically underlies this stress-induced hypoalgesic effect, having important implications for clinical states with HPA axis dysfunctions. SIGNIFICANCE: This experimental study shows that an acute stress induction - that combines physical and psychological stressors - increases heat pain thresholds, but not tolerance in healthy participants. Furthermore, the magnitude of this stress-induced hypoalgesic effect is predicted by cortisol reactivity and fear of pain, revealing specific involvement of the HPA axis stress system and interactions with pain-related psychosocial aspects.

Hurst revisited: Are symptoms and signs of functional motor and sensory disorders "dependent on idea"?

INTRODUCTION: Symptoms and signs of functional (psychogenic) motor and sensory disorder are often said to be dependent on the patients' idea of what symptoms should be, rather than anatomy and physiology. This hypothesis has however rarely been tested. MATERIALS AND METHODS: Inspired by a brief experiment carried out in 1919 by neurologist Arthur Hurst we aimed to assess the views of healthy non-medical adults towards paralysis and numbness and their response to tests for functional disorders when asked to pretend to have motor and sensory symptoms. RESULTS: When subjects were asked to pretend they had a paralysed arm 80% thought there would be sensory loss. Of these 60% thought it would have a circumferential (functional) distribution at the wrist, elbow or shoulder. Hoover's sign of functional weakness was only positive in 75% of patients pretending to have leg paralysis with 23% maintaining weakness of hip extension in the feigned weak leg, a rare finding in neurological practice. 20% of subjects managed to continue having their feigned tremor during the entrainment test. 52% of subjects thought there was asymmetry of a tuning fork across their forehead even when no prior instruction had been given. CONCLUSIONS: The study confirmed Hurst's finding that non-medical people generally expect sensory loss to go along with paralysis, especially if the examiner suggests it. When present, it usually conforms to functional patterns of sensory loss. Clinical tests for functional and motor disorders appear to behave somewhat differently in patients asked to pretend to have symptoms suggesting that larger more detailed studies would be worthwhile.

"Lacking warmth": Alexithymia trait is related to warm-specific thermal somatosensory processing.

Alexithymia is a personality trait involving deficits in emotional processing. The personality construct has been extensively validated, but the underlying neural and physiological systems remain controversial. One theory suggests that low-level somatosensory mechanisms act as somatic markers of emotion, underpinning cognitive and affective impairments in alexithymia. In two separate samples (total N=100), we used an established Quantitative Sensory Testing (QST) battery to probe multiple neurophysiological submodalities of somatosensation, and investigated their associations with the widely-used Toronto Alexithymia Scale (TAS-20). Experiment one found reduced sensitivity to warmth in people with higher alexithymia scores, compared to individuals with lower scores, without deficits in other somatosensory submodalities. Experiment two replicated this result in a new group of participants using a full-sample correlation between threshold for warm detection and TAS-20 scores. We discuss the relations between low-level thermoceptive function and cognitive processing of emotion.

The effect of numbness on outcome from total knee replacement.

INTRODUCTION Some patients report continuing pain and functional limitations after total knee replacement (TKR). While numbness around the TKR scar is common, the impact of numbness is less clear. One particular activity that could be influenced by numbness is kneeling. The aim of this study was to explore the impact of numbness around TKR scars on health related quality of life and kneeling ability. METHODS Fifty-six patients were recruited one year after primary TKR. Sensation around the knee was assessed through patient self-reporting, monofilament testing and vibration, and patients' distress was measured on a visual analogue scale. Patient reported outcome measures (PROMs) including the Western Ontario and McMaster Universities (WOMAC®) index, the Knee injury and Osteoarthritis Outcome Score (KOOS), the painDETECT® (Pfizer, Berlin, Germany) questionnaire and the EQ-5D™ (EuroQol, Rotterdam, Netherlands) questionnaire were used. Participants were also asked about kneeling ability. RESULTS While 68% of patients reported numbness around their TKR scar, there was no statistically significant correlation between numbness and distress at numbness (self-report: 0.23, p=0.08; monofilament: 0.15, p=0.27). Furthermore, numbness did not correlate significantly with joint specific PROMs (WOMAC®: 0.21, p=0.13; KOOS: 0.18, p=0.19). However, difficulty with kneeling did correlate with both self-reported numbness (0.36, p=0.020) and worse PROM scores (WOMAC® pain subscale: 0.62, p<0.001; KOOS: 0.64, p<0.001). CONCLUSIONS Numbness after knee replacement is common but is not associated with worse patient reported outcomes.

Neuropsychiatric factors in sensitive skin.

Sensitive skin is a syndrome defined by the occurrence of unpleasant sensations (stinging, burning, pain, pruritus, and tingling sensations) in response to stimuli that normally should not provoke such sensations. The worldwide prevalence of sensitive skin is approximately 40%. Clinical, histologic, biochemical, and therapeutic data show that this condition is related to changes in epidermal nerve endings with subsequent hyperreactivity and neurogenic inflammation; hence, sensitive skin is not a psychosomatic disorder, although psychologic consequences are possible.

Olfactory processing in adults with autism spectrum disorders.

BACKGROUND: As evidenced in the DSM-V, autism spectrum disorders (ASD) are often characterized by atypical sensory behavior (hyper- or hypo-reactivity), but very few studies have evaluated olfactory abilities in individuals with ASD. METHODS: Fifteen adults with ASD and 15 typically developing participants underwent olfactory tests focused on superficial (suprathreshold detection task), perceptual (intensity and pleasantness judgment tasks), and semantic (identification task) odor processing. RESULTS: In terms of suprathreshold detection performance, decreased discrimination scores and increased bias scores were observed in the ASD group. Furthermore, the participants with ASD exhibited increased intensity judgment scores and impaired scores for pleasantness judgments of unpleasant odorants. Decreased identification performance was also observed in the participants with ASD compared with the typically developing participants. This decrease was partly attributed to a higher number of near misses (a category close to veridical labels) among the participants with ASD than was observed among the typically developing participants. CONCLUSIONS: The changes in discrimination and bias scores were the result of a high number of false alarms among the participants with ASD, which suggests the adoption of a liberal attitude in their responses. Atypical intensity and pleasantness ratings were associated with hyperresponsiveness and flattened emotional reactions, respectively, which are typical of participants with ASD. The high number of near misses as non-veridical labels suggested that categorical processing is functional in individuals with ASD and could be explained by attention-deficit/hyperactivity disorder. These findings are discussed in terms of dysfunction of the olfactory system.

Assessment of olfactory detection thresholds in children with autism spectrum disorders using a pulse ejection system.

BACKGROUND: Atypical responsiveness to olfactory stimuli has been reported as the strongest predictor of social impairment in children with autism spectrum disorders (ASD). However, previous laboratory-based sensory psychophysical studies that have aimed to investigate olfactory sensitivity in children with ASD have produced inconsistent results. The methodology of these studies is limited by several factors, and more sophisticated approaches are required to produce consistent results. METHODS: We measured olfactory detection thresholds in children with ASD and typical development (TD) using a pulse ejection system-a newly developed methodology designed to resolve problems encountered in previous studies. The two odorants used as stimuli were isoamyl acetate and allyl caproate. RESULTS: Forty-three participants took part in this study: 23 (6 females, 17 males) children with ASD and 20 with TD (6 females, 14 males). Olfactory detection thresholds of children with ASD were significantly higher than those of TD children with both isoamyl acetate (2.85 ± 0.28 vs 1.57 ± 0.15; p < 0.001) and allyl caproate ( 3.30 ± 0.23 vs 1.17 ± 0.08; p < 0.001). CONCLUSIONS: We found impaired olfactory detection thresholds in children with ASD. Our results contribute to a better understanding of the olfactory abnormalities that children with ASD experience. Considering the role and effect that odors play in our daily lives, insensitivity to some odorants might have a tremendous impact on children with ASD. Future studies of olfactory processing in ASD may reveal important links between brain function, clinically relevant behavior, and treatment.

Individual oral symptoms in burning mouth syndrome may be associated differentially with depression and anxiety.

BACKGROUND: Burning mouth syndrome (BMS) is an idiopathic disease characterized by the feeling of burning in the oral cavity. Ten per cent of patients presenting to oral medicine clinics have BMS. Anxiety and depression are common co-morbidities in BMS, but it is not known if they are associated with specific BMS symptoms. OBJECTIVE: In an exploratory analysis, this study examined the association of generalized anxiety and depression with individual BMS symptoms. METHODS: Forty-one patients were recruited from a dental outpatient clinic (30 with BMS and 11 with other oral conditions), evaluating specific BMS symptoms and their intensity. Anxiety and depression symptoms were assessed using a standardized measure (Clinical Interview Schedule-Revised). RESULTS: Taste change (p = 0.007), fear of serious illness (p = 0.011), metallic taste (p = 0.018) and sensation of a film on the gums (p = 0.047) were associated with an excess of psychiatric symptoms. More specifically, metallic taste (coefficient = 0.497, 95% CI = 0.149-0.845; p = 0.006) and sensation of film on gums (coefficient = 0.625, 95% CI = 0.148-1.103; p = 0.012) were associated significantly with higher scores for depressive symptoms; taste change (coefficient = 0.269, 95% CI = 0.077-0.461; p = 0.007), bad breath (coefficient = 0.273, 95% CI = 0.065-0.482; p = 0.012) and fear of serious illness (coefficient = 0.242, 95% CI = 0.036-0.448; p = 0.023) were associated with higher anxiety scores. CONCLUSION: Specific BMS symptoms are associated differentially with generalized anxiety and depression. Dental practitioners should ascertain which BMS symptoms are predominant and be mindful of the association of certain symptoms with anxiety or depression and, where necessary, consider medical consultation.

The Relationship Between Catastrophic Thinking and Hand Diagram Areas.

PURPOSE: To evaluate the relationship between the total area marked on pain and numbness diagrams and psychosocial factors (depression, pain catastrophic thinking, and health anxiety). METHODS: A total of 155 patients marked painful and numb areas on separate hand diagrams. Patients also completed demographic, condition-related, and psychosocial (Pain Catastrophizing Scale, Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test, and Short Health Anxiety Inventory) questionnaires. Bivariate and multivariable analyses were used to determine factors associated with total area marked on the pain and numbness diagrams. RESULTS: The total area marked on the pain diagram correlated with catastrophic thinking, symptoms of depression, and health anxiety. In multivariable analysis, catastrophic thinking was the sole predictor of marked pain area, accounting for 10% of variance in the hand pain diagram. The total area marked on the numbness diagram correlated with the interval between onset and visit, diagnosis, catastrophic thinking, and symptoms of depression. In multivariable analysis, the interval between onset and visit, a diagnosis of carpal tunnel syndrome, and catastrophic thinking were independently associated with total area marked on the hand numbness diagram. CONCLUSIONS: Catastrophic thinking was independently associated with larger pain and numbness areas on a hand diagram. This suggests that larger symptom markings on hand diagrams may indicate less effective coping strategies. Hand diagrams might be used as a basis for discussion of coping strategies and illness behavior in patients with upper extremity conditions. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

National women's knowledge of stroke warning signs, overall and by race/ethnic group.

BACKGROUND AND PURPOSE: Recognition of stroke warning signs may reduce treatment delays. The purpose of this study was to evaluate contemporary knowledge of stroke warning signs and knowledge to call 9-1-1, among a nationally representative sample of women, overall and by race/ethnic group. METHODS: A study of cardiovascular disease awareness was conducted by the American Heart Association in 2012 among English-speaking US women ≥25 years identified through random-digit dialing (n=1205; 54% white, 17% black, 17% Hispanic, and 12% other). Knowledge of stroke warning signs, and what to do first if experiencing stroke warning signs, was assessed by standardized open-ended questions. RESULTS: Half of women surveyed (51%) identified sudden weakness/numbness of face/limb on one side as a stroke warning sign; this did not vary by race/ethnic group. Loss of/trouble talking/understanding speech was identified by 44% of women, more frequently among white versus Hispanic women (48% versus 36%; P<0.05). Fewer than 1 in 4 women identified sudden severe headache (23%), unexplained dizziness (20%), or sudden dimness/loss of vision (18%) as warning signs, and 1 in 5 (20%) did not know 1 stroke warning sign. The majority of women said that they would call 9-1-1 first if they thought they were experiencing signs of a stroke (84%), and this did not vary among black (86%), Hispanic (79%), or white/other (85%) women. CONCLUSIONS: Knowledge of stroke warning signs was low among a nationally representative sample of women, especially among Hispanics. In contrast, knowledge to call 9-1-1 when experiencing signs of stroke was high.

Illusory touch temporarily improves sensation in areas of chronic numbness: a brief communication.

BACKGROUND: Creating the visual illusion of touch can improve tactile perception in healthy subjects. OBJECTIVE: We were interested in seeing if creating the illusion of touch in an insensate area could improve sensation in that area. METHODS: Fourteen people with chronic numbness participated in a randomized crossover experiment. The 4 conditions were the following: (a) stimulation over the unaffected limb with mirror visual feedback (experimental condition), (b) stimulation over the affected limb with mirror visual feedback, (c) stimulation over the unaffected limb without mirror visual feedback, and (d) stimulation over the affected limb without mirror visual feedback. Participants were assessed before and after each condition using the Ten-Test and mechanical detection thresholds. Data were analyzed using linear mixed models. RESULT: Only the experimental condition produced a change in the Ten-Test (mean difference = -1.1; 95% confidence interval = -1.8 to -0.4; P = .003), corresponding to a 24% improvement in sensation. No differences were observed for any condition in mechanical detection thresholds. CONCLUSION: Creating the illusion of touch may improve sensory function in areas of chronic numbness. This preliminary finding adds to the growing body of evidence supporting the use of techniques that directly target cortical function in people with peripheral nerve injury.

C2 nerve root transection during C1 lateral mass screw fixation: does it affect functionality and quality of life?

BACKGROUND: Sectioning of the C2 nerve root allows for direct visualization of the C1-2 joint and may facilitate arthrodesis. OBJECTIVE: To determine the clinical and functional consequences of C2 nerve root sectioning during placement of C1 lateral mass screws. METHODS: All patients undergoing C1 lateral mass screw fixation were included in this prospective study. A standard questionnaire was used to determine the severity of occipital numbness/pain and its effect on quality of life (QOL). Domains of the neck disability index were used to assess the disability related to C2 symptoms. RESULTS: A total of 28 patients were included (C2 transection, 8; C2 preservation, 20). A trend of decreased blood loss and length of surgery was observed in the C2 transection cohort. Occipital numbness was reported by 4 (50.0%) patients after C2 transection. Occipital neuralgia was reported by 7 (35.0%) patients with C2 preservation. None of the patients with numbness after C2 transection reported being "bothered" by it. All patients with occipital neuralgia after C2 sparing reported being "bothered" by it, and 57.1% reported a moderate to severe effect on QOL. The use of medication was reported by 5 (71.4%) patients with neuralgia vs none with numbness. Mean disability was significantly higher with neuralgia vs numbness (P = .016). CONCLUSION: C2 nerve root transection is associated with increased occipital numbness but this has no effect on patient-reported outcomes and QOL. C2 nerve root preservation can be associated with occipital neuralgia, which has a negative impact on patient disability and QOL. C2 nerve root transection has no negative consequences during C1-2 stabilization.

[Delusional disorder, autoaggression und suicide]. / Wahnerkrankung, Autoaggression und Suizid.

The authors report on the suicide of a 27-year-old woman with extreme self-inflicted injuries. The victim suffered from schizophrenic psychosis with several stays in mental institutions and one previous suicide attempt. Autopsy revealed multiple cut and stab injuries in various body regions (51 stabs to the chest, cutting off parts of ears and nose, stab to the eye and transection of the scalp). Death was caused by exsanguination.

Predicting dental avoidance among dentally fearful Australian adults.

Dental fear is related to poorer oral health outcomes, and this might be explained by the less frequent dental visiting of many fearful people. The objectives of this study were to investigate differences between dentally fearful people who regularly attend the dentist and fearful people who infrequently visit the dentist. A random sample of 1,082 Australians ≥ 15 yr of age completed a mailed questionnaire (response rate = 71.6%), and 191 dentate, high-fear adults (≥ 18 yr of age) were selected for further analysis. Dental avoidance was recorded if a person was currently avoiding or delaying dental care and if he/she had not been to a dentist in the previous 2 yr. Among the selected dentally fearful adults, dental avoidance was predicted by smoking status, toothbrushing frequency, coping strategy use, perceptions of dental visits as uncontrollable and unpredictable, and by anxiety relating to numbness, not knowing what the dentist is going to do, and cost. In a multivariate logistic regression model, smoking, toothbrushing, coping, and anxiety about numbness and cost remained as statistically significant predictors, with the model accounting for 30% of the variance. While several variables were associated with dental avoidance among fearful adults, the nature and causal directions of these associations remain to be established.

Subclinical pretreatment sensory deficits appear to predict the development of pain and numbness in patients with multiple myeloma undergoing chemotherapy.

PURPOSE: Chemotherapy-induced peripheral neuropathy is a major complication in the treatment for cancer, including multiple myeloma (MM). Patients may develop painful and non-painful (e.g., numbness) neuropathy symptoms that impair function and often persist after therapy is terminated. This study tested the hypothesis that baseline subclinical neuropathy, as assessed by sensory thresholds, is related to the development of neuropathy symptoms (e.g., pain and numbness) in patients with MM undergoing treatment with chemotherapy. METHODS: Patients (n = 56) who had undergone two or fewer cycles of induction therapy and who had no evident neuropathy were assessed using quantitative sensory tests to determine multiple-modality sensory thresholds. Patient-reported pain and numbness were assessed through induction therapy (16 weeks) via the MD Anderson Symptom Inventory. A subset of participants (n = 15) continued reporting on their symptoms for an additional 16 weeks ("maintenance phase"). RESULTS: Patients with sharpness detection deficits at baseline (n = 11, 20 % of sample) reported less severe pain and numbness during induction therapy and less numbness during maintenance therapy (P < 0.05). During the maintenance phase, patients with warmth detection deficits (n = 5, 38 % of sample) reported more severe pain and numbness, and those with skin temperature deficits (n = 7, 47 % of maintenance sample) reported more severe pain (P < 0.05). These deficits were related to patient reported difficulty walking, a common symptom of peripheral neuropathy. CONCLUSION: Our results suggest that baseline subclinical sensory deficits may be related to a patient's risk for developing chemotherapy-induced peripheral neuropathy.

Clomipramine reverses hypoalgesia/hypoesthesia and improved depressive-like behaviors induced by inescapable shock in rats.

An increased vulnerability to pain complaints, along with a simultaneous increase in experimental pain thresholds, shows the paradoxical phenomenon of pain perception in depressive patients. Clomipramine, a tricyclic antidepressant, could also ameliorate syndromes in chronic pain patients. However, few studies have focused on the effect of antidepressants on experimental pain thresholds. By using a rat model, the learned helplessness paradigm, the present study explored the effect of clomipramine on behavioral deficits and experimental pain thresholds to different stimuli in "helpless" rats. Helpless rats were administered clomipramine (10mg/kg, i.p, b.i.d.) for 5 consecutive days. The depressive-like and anxiety-like behaviors were detected by shuttle box, open field and elevated plus maze test before and after inescapable shock and after medication. The sensitivity to the thermal and mechanical stimuli was also measured by the von Frey hair and Hargreaves test at the indicated time points. Helpless rats displayed shorter total travel distance and fewer rearing times in the open field test and decreased percentage of time spent in the open arms in the elevated plus maze test. In addition, they exhibited significant hypoalgesia/hypoesthesia to mechanical and thermal stimuli. Clomipramine alleviate depressive-like and anxiety-like behaviors and increased the sensitivity to von Frey filament stimuli with no effect on the sensitivity to radiant heat stimuli in helpless rats. These suggested that clomipramine could reverse mechanical but not thermal hypoalgesia/hypoesthesia and simultaneously improved behavioral deficits.

Nipple-sparing mastectomy in modern breast practice.

Breast cancer management has evolved from the conventional radical Halsted to a fully integrated multidisciplinary approach. Nipple sparing mastectomy (NSM) is an innovative technique that preserves native breast envelope without mutilation of nipple-areola complex (NAC), thus providing a reasonable alternative for early cancers without NAC involvement and prophylactic high risk patients and avoids multiple surgical procedures required for reconstruction. This article aims to critically review indications, intra-operative protocols, radiotherapy planning and limitations of NSM. Patient selection should be based on study of breast duct anatomy by Magnetic Resonance Imaging, mammographic tumor-nipple distance and obligatory intra-operative frozen section from retro-areolar tissue. Tumor size, axillary lymph node status, lymphovascular invasion and/or degree of intraductal component are factors used to include NSM candidates based on institutional practice. Given the heterogeneity of patients and lack of standardization of preoperative investigations, surgical technique and pathologic sampling of retro-areola tissue so far, mandates a multi-institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis is an important NSM complication which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra-operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation.

Assessing DSM-IV symptoms of panic attack in the general population: an item response analysis.

BACKGROUND: Unexpected panic attacks may represent a non-specific risk factor for future depression and anxiety disorders. The examination of panic symptoms and associated latent severity levels may lead to improvements in the identification, prevention, and treatment of panic attacks and subsequent psychopathology for 'at risk' individuals in the general population. METHODS: The current study utilised item response theory to assess the DSM-IV symptoms of panic in relation to the latent severity level of the panic attack construct in a sample of 5913 respondents from the National Epidemiologic Survey on Alcohol and Related conditions. Additionally, differential item functioning (DIF) was assessed to determine if each symptom of panic targets the same level of latent severity between different sociodemographic groups (male/female, young/old). RESULTS: Symptoms indexing 'choking', 'fear of dying', and 'tingling/numbness' are some of the more severe symptoms of panic whilst 'heart racing', 'short of breath', 'tremble/shake', 'dizzy/faint', and 'perspire' are some of the least severe symptoms. Significant levels of DIF were detected in the 'perspire' symptom between males and females and the 'fear of dying' symptom between young and old respondents. LIMITATIONS: The current study was limited to examining cross-sectional data from respondents who had experienced at least one panic attack across their lifetime. CONCLUSIONS: The findings of the current study provide additional information regarding panic symptoms in the general population that may enable researchers and clinicians to further refine the detection of 'at-risk' individuals who experience threshold and sub-threshold levels of panic.

Quality of life outcomes after isolated limb infusion.

BACKGROUND: Isolated limb infusion (ILI) for the treatment of in-transit melanoma was originally described more than 10 years ago. Response rates of 45-53% have been reported in U.S. series. Long-term quality of life outcomes after this procedure have not been described. We hypothesized that ILI is rarely associated with long-term limb morbidity. METHODS: ILIs performed at our institution between July 2005 and June 2009 were reviewed. Patients were contacted cross-sectionally at 2 time points. During these interviews, response to treatment and postoperative limb function were assessed. RESULTS: Thirty-two ILIs were performed during the time period. Twenty-seven patients were treated for in-transit melanoma; 5 were treated for recurrent Merkel cell carcinoma. The 30-day mortality was 0%. Three patients (9%) required fasciotomy. Durable complete responses were achieved in 41% of patients, with mean follow-up time of 19.4 ± 9.6 months after infusion; after this period, 53% reported progression of disease. The most common postprocedure symptoms were edema (88%), numbness (59%), and pain (59%). By 3 months and at the time of last follow-up, the most common symptoms were edema (82%), numbness (65%), and stiffness (35%). No patients reported impaired limb function at the time of last follow-up compared to baseline. Median survival was 19.2 ± 4.2 months after infusion. CONCLUSIONS: ILI for melanoma and Merkel cell carcinoma is associated with postprocedure symptoms in most patients, most commonly edema, color change, and numbness. At last follow-up, no ILI patients had residual functional impairment in the treated limb.