Interval to biochemical recurrence following radical prostatectomy does not affect survival in men with low-risk prostate cancer.

OBJECTIVES: To evaluate the temporal relationship between interval to biochemical recurrence (BCR) following radical prostatectomy (RP) and prostate cancer-specific mortality (PCSM). PATIENTS AND METHODS: The study comprised of 2,116 men from the Victorian Radical Prostatectomy Register, a whole-of-population database of all RPs performed between 1995 and 2000 in Victoria, Australia. Follow-up prostate-specific antigen and death data were obtained via record linkage to pathology laboratories and the Victorian Registry of Births, Deaths and Marriages. Poisson regression models with PCSM as the outcome were fit to the data. Models included age at surgery, Gleason score and tumour stage as covariates. RESULTS: Median post-surgery and post-BCR follow-up was 10.3 and 7.5 years, respectively. 695 men (33 %) experienced BCR during follow-up, of which 82 % occurred within 5 years of RP; 66 men died from prostate cancer. Men with combined high Gleason sum (≥4 + 3) and extra-prostatic (≥pT3a) disease had substantially increased mortality rate with early BCR, while those experiencing BCR after a longer interval had significantly lower mortality. Men with combined low Gleason sum (≤3 + 4) and organ-confined disease (≤pT2c) risk disease were not at any substantial risk of death in this time frame regardless of timing of BCR following RP. CONCLUSIONS: This study evaluates the temporal relationship between BCR and PCSM using a whole-of-population cohort of men treated with RP. Men with low-risk features of prostate cancer at time of RP have low mortality even if they experience early BCR. This subgroup may be counselled regarding their favourable long-term prognosis.

Two pedigrees with restless legs syndrome in Brazil.

Numerous studies have suggested a substantial genetic contribution in the etiology of the primary form of restless legs syndrome (RLS) and periodic leg movements (PLM). We describe the symptoms, the sleep profiles and physiological parameters of two families in which several members present RLS/PLM. The proband of family 1 is a 70-year-old woman and the proband of family 2 is a 57-year-old woman; both have exhibited the symptoms since the age of 20 years. All patients in both families were diagnosed with RLS according to the criteria of the International RLS Study Group. Polysomnographic recordings were performed to quantify and to describe PLM during sleep. Sleep parameters showed decreased sleep efficiency, increased sleep latency in the arousal index and the presence of PLM in all subjects. One of the families showed an exact profile of dominant inheritance with anticipation of age at onset. In the other family, the founders were blood relatives and there was no affected member in the third generation suggesting a recessive mode of inheritance. RLS/PLM is a prevalent sleep disorder affecting about 5 to 15% of the population and one that substantially impairs healthy sleep patterns. Efforts to understand the underlying pathophysiology will contribute to improve the sleep and life quality of these patients.

Two pedigrees with restless legs syndrome in Brazil

Numerous studies have suggested a substantial genetic contribution in the etiology of the primary form of restless legs syndrome (RLS) and periodic leg movements (PLM). We describe the symptoms, the sleep profiles and physiological parameters of two families in which several members present RLS/PLM. The proband of family 1 is a 70-year-old woman and the proband of family 2 is a 57-year-old woman; both have exhibited the symptoms since the age of 20 years. All patients in both families were diagnosed with RLS according to the criteria of the International RLS Study Group. Polysomnographic recordings were performed to quantify and to describe PLM during sleep. Sleep parameters showed decreased sleep efficiency, increased sleep latency in the arousal index and the presence of PLM in all subjects. One of the families showed an exact profile of dominant inheritance with anticipation of age at onset. In the other family, the founders were blood relatives and there was no affected member in the third generation suggesting a recessive mode of inheritance. RLS/PLM is a prevalent sleep disorder affecting about 5 to 15 percent of the population and one that substantially impairs healthy sleep patterns. Efforts to understand the underlying pathophysiology will contribute to improve the sleep and life quality of these patients.

Epidemiological surveillance of bluetongue in Sicily.

The authors describe the status of bluetongue (BT) since 13 October 2000, when the first outbreak was reported in Sicily. The results of the epidemiological surveillance programme, based on sentinel animals distributed over the entire region, are also given. In Sicily, the incidence of the disease is relatively low compared to some other areas in the Mediterranean Basin. Seventy-five outbreaks of the disease were recorded in the first three epidemics (October 2000 to May 2003). Overall morbidity was 13.25%, mortality 5.36% and the case fatality rate 41.49%. The Province of Catania seems to have been the worst affected; the incidence rate in August 2002 was 0.8%. The monthly incidence rate was calculated for sentinel animals of which the estimated total was 3 654, distributed in 63 areas. It is important to underline that in the period under consideration, a total of 2 382 animals was examined. During the surveillance period, which extended from September 2001 to May 2003, the incidence of BT peaked in September 2002, at 5.91% -/+ 0.979. The cumulative incidence rate from September 2001 to August 2002 and September 2002 to March 2003 was 4.53% -/+ 0.76 and 20.03% -/+ 1.85, respectively. The circulation of BT virus serotypes 2, 4, 9 and 16 is described, as revealed by seroconversion in sentinel animals.

The variability of the apnoea-hypopnoea index.

This study was designed to evaluate the variability of the apnoea-hypopnoea index (AHI) in 20 patients with obstructive sleep apnoea-hypopnoea syndrome (OSAHS) and to determine possible relationships of this variability with other polysomnographic parameters. The subjects were recorded on four consecutive nights. The mean AHI values were not significantly altered throughout the four recording nights (P=0.67). The intraclass correlation coefficient of the AHI on the four nights was 0.92. However, the Bland and Altman plot showed that, individually, the AHI presented an important variability, which was not related to its initial value. In regard to the OSAHS severity, 50% of the patients changed the classification from the first to the subsequent nights. Thirteen of the 20 patients (65%) presented a variation in the AHI value equal or higher than 10 events h(-1). When we evaluated the AHI mean values for a specific body position and sleep stage, no difference was observed among the nights. In both supine and lateral-ventral decubitus, higher AHI was observed during Stages 1 and 2 than the other stages. Additionally, the AHI during Stages 1 and 2 and REM sleep was higher on the supine than on the lateral-ventral decubitus. The AHI in OSAHS patients presented a good correlation among the four recording nights; however, a significant individual variability should be considered, especially when AHI is applied in OSAHS classification or as a criterion of therapeutic success.

Temperament, character, and attachment patterns in borderline personality disorder.

The aim of this study was to assess the specificity of the association between temperamental vulnerability, character deficits, and Borderline personality disorder (BPD), controlling for the effects of attachment patterns. A total of 44 BPD patients were compared with 98 non-BPD patients with other cluster B Personality Disorder (PD) diagnoses, 39 patients with any cluster A or cluster C PD diagnoses, 70 patients with no PD diagnosis, and 206 nonclinical patients. All patients were administered the Temperament and Character Inventory, the Parental Bonding Instrument, and the Attachment Style Questionnaire. Multivariate and univariate tests showed that BPD patients differed significantly from all control groups on Novelty Seeking and Cooperativeness. These differences remained significant when controlling for the effect of attachment.

Acute effect of nasal continuous positive air pressure on the ventilatory control of patients with obstructive sleep apnea.

BACKGROUND: Sleep fragmentation can decrease the awake ventilatory control. Since patients with obstructive sleep apnea (OSA) patients exhibit sleep fragmentation linked to respiratory events, their ventilatory control could be impaired. However, most of these patients are also obese, which could conversely increase the ventilatory control. The effect of nasal continuous positive airway pressure (CPAP) on the awake ventilatory control in normocapnic OSA patients is unclear. OBJECTIVES: To study the acute effect of nasal CPAP on the awake ventilatory control in normocapnic OSA patients. METHODS: 12 normocapnic OSA patients, with an apnea/hypopnea index (AHI) >15 with moderate obesity (body mass index: 33.5 kg/m2) and normal pulmonary function tests were submitted to two polysomnography studies (diagnostic and for CPAP titration). Before and after 3 consecutive nights of nasal CPAP we analyzed the hypersomnia score and the ventilatory and the mouth occlusion pressure (P.1) responses at rest (breathing room air and a mixture of 8% CO2 + 40% O2). RESULTS: The respiratory drive of OSA patients as evaluated by P.1 was in the range of the controls of our laboratory. After nasal CPAP, a significant decrease in AHI (mean: 51.9-9.4/h) and arousal (mean: 88.7-43/h) occurred, as well as improvement in nocturnal oxyhemoglobin. There was a marginal increase in DeltaV(E)/DeltaP(ET)CO2 (mean: 1.41-1.87 liters/min/ mm Hg, p = 0.09) and a significant rise in P.1/DeltaP(ET)CO2 (mean: 0.29-0.43 cm H2O/mm Hg), a better indicator of ventilatory drive. CONCLUSIONS: Normocapnic OSA patients increased their awake ventilatory drive response to a hypercapnic and hyperoxic mixture with the use of 3 consecutive nights of nasal CPAP.

Latent class analysis of DSM-IV schizotypal personality disorder criteria in psychiatric patients.

The aim of the study was to evaluate the latent structure of DSM-IV schizotypal personality disorder (SPD) diagnostic criteria. The sample consisted of 564 consecutively admitted inpatients and outpatients. Exploratory latent class analysis identified a four-class model as the best fitting model for DSM-IV SPD criteria. The first of the SPD latent classes was mainly characterized by odd thinking, inappropriate affect, and interpersonal features; the second class by cognitive/perceptual difficulties; the third class by paranoid features; and the fourth class by absence of SPD features. The conditional probability pattern of the fourclass solution could be safely replicated across confounder strata. Unlike previous findings, oddness, aloofness, and social withdrawal, rather than positive symptoms, best characterized SPD even in clinical samples.

Patterns of covariation of DSM-IV personality disorders in a mixed psychiatric sample.

The covariation patterns of DSM-IV personality disorders (PDs) were studied in 431 consecutively admitted psychiatric patients. The co-occurrence rate was greater than 50% for all DSM-IV PDs. Both bivariate association tests and loglinear models showed distinct significant covariation patterns among PDs which were stable across confounder strata. DSM-IV PD clusters were not replicated, with the exception of cluster A. Principal-component analysis (PCA) showed the presence of 3 latent dimensions, thus explaining the DSM-IV PD covariation patterns. These results seem to stress the inadequacy of the DSM-IV categorical model of PD assessment. The need for a reduction of axis II categories and the inclusion of a dimensional model in the diagnostic assessment of DSM-IV PDs are discussed.

Comparison of AutoSet TM and polysomnography for the detection of apnea-hypopnea events

The use of the flow vs time relationship obtained with the nasal prongs of the AutoSet TM (AS) system (diagnosis mode) has been proposed to detect apneas and hypopneas in patients with reasonable nasal patency. Our aim was to compare the accuracy of AS to that of a computerized polysomnographic (PSG) system. The study was conducted on 56 individuals (45 men) with clinical characteristics of obstructive sleep apnea (OSA). Their mean (+/- SD) age was 44.6 +/- 12 years and their body mass index was 31.3 +/- 7 kg/m2. Data were submitted to parametric analysis to determine the agreement between methods and the intraclass correlation coefficient was calculated. The Student t-test and Bland and Altman plots were also used. Twelve patients had an apnea-hypopnea index (AHI) < 10 in bed and 20 had values > 40. The mean (+/- SD) AHI PSG index of 37.6 (28.8) was significantly lower (P = 0.0003) than AHI AS (41.8 (25.3)), but there was a high intraclass correlation coefficient (0.93), with 0.016 variance. For a threshold of AHI of 20, AS showed 73.0 percent accuracy, 97 percent sensitivity and 60 percent specificity, with positive and negative predictive values of 78 percent and 93 percent, respectively. Sensitivity, specificity and negative predictive values increased in parallel to the increase in AHI threshold for detecting OSA. However, when the differences of AHI PSG-AS were plotted against their means, the limits of agreement between the methods (95 percent of the differences) were +13 and -22, showing the discrepancy between the AHI values obtained with PSG and AS. Finally, cubic regression analysis was used to better predict the result of AHI PSG as a function of the method proposed, i.e., AHI AS. We conclude that, despite these differences, AHI measured by AutoSetä can be useful for the assessment of patients with high pre-test clinical probability of OSA, for whom standard PSG is not possible as an initial step in diagnosis.

A psychometric study of DSM-IV passive-aggressive (negativistic) personality disorder criteria.

The passive-aggressive (negativistic) personality disorder (PAPD) is one of the most controversial personality disorders. In order to assess DSM-IV PAPD psychometric properties and comorbidity pattern in a mixed psychiatric sample, 379 consecutively admitted in- and outpatients were administered SCID-II, Version 2.0. Confirmatory factor analysis showed that DSM-IV PAPD is a unidimensional construct with adequate internal consistency (K-R 20 = .85). A strong, specific association (odds ratio = 10.38, 95% CI = 4.83-22.30) was observed between DSM-IV PAPD and narcissistic personality disorder (NPD). Confirmatory factor analysis showed that DSM-IV PAPD should be considered as a subtype of a broader narcissistic disorder.

Comparison of AutoSet and polysomnography for the detection of apnea-hypopnea events.

The use of the flow vs time relationship obtained with the nasal prongs of the AutoSettrade mark (AS) system (diagnosis mode) has been proposed to detect apneas and hypopneas in patients with reasonable nasal patency. Our aim was to compare the accuracy of AS to that of a computerized polysomnographic (PSG) system. The study was conducted on 56 individuals (45 men) with clinical characteristics of obstructive sleep apnea (OSA). Their mean (+/- SD) age was 44.6 +/- 12 years and their body mass index was 31.3 +/- 7 kg/m2. Data were submitted to parametric analysis to determine the agreement between methods and the intraclass correlation coefficient was calculated. The Student t-test and Bland and Altman plots were also used. Twelve patients had an apnea-hypopnea index (AHI) <10 in bed and 20 had values >40. The mean (+/- SD) AHI PSG index of 37.6 (28.8) was significantly lower (P = 0.0003) than AHI AS (41.8 (25. 3)), but there was a high intraclass correlation coefficient (0.93), with 0.016 variance. For a threshold of AHI of 20, AS showed 73.0% accuracy, 97% sensitivity and 60% specificity, with positive and negative predictive values of 78% and 93%, respectively. Sensitivity, specificity and negative predictive values increased in parallel to the increase in AHI threshold for detecting OSA. However, when the differences of AHI PSG-AS were plotted against their means, the limits of agreement between the methods (95% of the differences) were +13 and -22, showing the discrepancy between the AHI values obtained with PSG and AS. Finally, cubic regression analysis was used to better predict the result of AHI PSG as a function of the method proposed, i.e., AHI AS. We conclude that, despite these differences, AHI measured by AutoSettrade mark can be useful for the assessment of patients with high pre-test clinical probability of OSA, for whom standard PSG is not possible as an initial step in diagnosis.

Latent structure analysis of DSM-IV borderline personality disorder criteria.

The aim of this study was to evaluate the structure of DSM-IV borderline personality disorder (BPD) criteria. The study group consisted of 564 consecutively admitted inpatients and outpatients. BPD criteria discriminatory power was tested by using corrected item-to-total and item-to-diagnosis correlations. Weighted least-squares (WLS) confirmatory factor analysis (CFA) was used to assess the fit of DSM-IV BPD unidimensional model. The categorical model of BPD was tested by exploratory latent class analysis (LCA). Item analysis suggested a hierarchy in BPD criteria discriminatory power, even if with different rank order with respect to the DSM-IV model. CFA showed a unifactorial structure with congeneric items as the best fitting model for DSM-IV BPD criteria (chi2 = 18.89, df= 27, P > .87). LCA showed evidence for three latent classes; heterogeneity was observed only among subjects falling below DSM-IV diagnostic threshold for BPD. These results support the categorical model of BPD, even if with several differences with respect to DSM-IV.

Assessment of ventilatory neuromuscular drive in patients with obstructive sleep apnea.

The presence of abnormalities of the respiratory center in obstructive sleep apnea (OSA) patients and their correlation with polysomnographic data are still a matter of controversy. Moderately obese, sleep-deprived OSA patients presenting daytime hypersomnolence, with normocapnia and no clinical or spirometric evidence of pulmonary disease, were selected. We assessed the ventilatory control and correlated it with polysomnographic data. Ventilatory neuromuscular drive was evaluated in these patients by measuring the ventilatory response (VE), the inspiratory occlusion pressure (P.1) and the ventilatory pattern (VT/TI, TI/TTOT) at rest and during submaximal exercise, breathing room air. These analyses were also performed after inhalation of a hypercapnic mixture of CO2 (delta P.1/delta PETCO2, delta VE/delta PETCO2). Average rest and exercise ventilatory response (VE: 12.2 and 32.6 l/min, respectively), inspiratory occlusion pressure (P.1: 1.5 and 4.7 cmH2O, respectively), and ventilatory pattern (VT/TI: 0.42 and 1.09 l/s; TI/TTOT: 0.47 and 0.46 l/s, respectively) were within the normal range. In response to hypercapnia, the values of ventilatory response (delta VE/delta PETCO2: 1.51 l min-1 mmHg-1) and inspiratory occlusion pressure (delta P.1/delta PETCO2: 0.22 cmH2O) were normal or slightly reduced in the normocapnic OSA patients. No association or correlation between ventilatory neuromuscular drive and ventilatory pattern, hypersomnolence score and polysomnographic data was found; however a significant positive correlation was observed between P.1 and weight. Our results indicate the existence of a group of normocapnic OSA patients who have a normal awake neuromuscular ventilatory drive at rest or during exercise that is partially influenced by obesity.

Brief communication: criterion validity of the Personality Diagnostic Questionnaire-4+ (PDQ-4+) in a mixed psychiatric sample.

Three hundred consecutively admitted in- and outpatients were administered the Personality Diagnostic Questionnaire-4+ (PDQ-4+). The Structured Clinical Interview for DSM-IV Axis II Personality Disorders, Version 2.0 (SCID-II) was used as the external diagnostic standard for personality disorder (PD) assessment. SCID-II was administered blind to PDQ-4+ scores. Low agreement between PDQ-4+ and SCID-II was observed for both dimensional and categorical PD evaluations. Receiver operating characteristic (ROC) analysis showed a definitively satisfactory discriminatory capability only for two PDQ-4+ PD scales (dependent, and antisocial). In agreement with previous studies, these results showed that PDQ-4+ was not a substitute for a structured diagnostic interview.

[Subsidies in the critical-reflexive professional education in the field of health care: a challenge for the changing century]. / Subsídios para uma formação profissional crítico-reflexiva na área da saúde: o desafio da virada do século.

Change in the logic of health professional formation is a demanding challenge for the new world order. The present study searches the problematical bases of reflexive-critical teaching in the area and its contribution for placing the professional in the work market. This insertion must be regulated by the collective citizenship ethics and must also look forward to a confrontation, in an organized way, with the interests of the neoliberal project.

Assessment of ventilatory neuromuscular drive in patients with obstructive sleep apnea

The presence of abnormalities of the respiratory center in obstructive sleep apnea (OSA) patients and their correlation with polysomnographic data are still a matter of controversy. Moderately obese, sleep-deprived OSA patients presenting daytime hypersomnolence, with normocapnia and no clinical or spirometric evidence of pulmonary disease, were selected. We assessed the ventilatory control and correlated it with polysomnographic data. Ventilatory neuromuscular drive was evaluated in these patients by measuring the ventilatory response (VE) the inspiratory occlusion pressure (P.1) and the ventilatory pattern (VT/TI, TI/TTOT) at rest and during submaximal exercise, breathing room air. These analyses were also performed after inhalation of a hypercapnic mixture of CO2 (deltaP.11/deltaPETCO2, deltaVE/deltaPETCO2). Average rest and exercise ventilatory response (VE: 12.2 and 32.61/min, respectively), inspiratory occlusion pressure (P.1: 1.5 and 4.7 cmH2O, respectively), and ventilatory pattern (VT/TI: 0.42 and 1.09 1/s; TI/TTOT: 0.47 and 0.46 1/s, respectively) were within the normal range. In response to hypercapnia, the values of ventilatory response (deltaVE/deltaPETCO2: 1.51 lmin(-1) mmHg(-1)) and inspiratory occlusion pressure (deltaP.1/deltaPETCO2: 0.22 cmH2O) were normal or slightly reduced in the normocapnic OSA patients. No association or correlation between ventilatory neuromuscular drive and ventilatory pattern, hypersomnolence score and polymnographic data was found; however a significant positive correlation was observed between P.1 and weight. Our results indicate the existence of a group of normocapnic OSA patients who have a normal awake neuromuscular ventilatory drive at rest or during exercise that is partially influenced by obesity.

Interrater reliability and internal consistency of the structured clinical interview for DSM-IV axis II personality disorders (SCID-II), version 2.0.

Interrater reliability and internal consistency of the SCID-II 2.0 was assessed in a sample of 231 consecutively admitted in- and outpatients using a pairwise interview design, with randomized rater pairing and blind interview assessment. Interrater reliability coefficients ranged from .48 to .98 for categorical diagnosis (Cohen kappa), and from .90 to .98 for dimensional judgements (Intraclass correlation coefficient). Internal consistency coefficients were satisfactory (.71-.94). The results suggest that the SCID-II 2.0 has adequate interrater and internal consistency reliability.

Psychological stress in nurses' relationships with HIV-infected patients: the risk of burnout syndrome.

To assess the role played by psychological stress and sociodemographic factors as predictors of burnout in nurses, we administered the AIDS Impact Scale (AIS) and the Maslach Burnout Inventory (MBI) to nurses in the AIDS field. The sample was composed of 410 nurses from 19 departments for the treatment of infectious diseases. In these subjects we observed a low level of burnout in the MBI, but a small proportion had a high level of burnout We did not find significant associations between sociodemographic variables and the MBI scales. We found significant correlations between the MBI and three AIS scales that specifically assessed the emotional involvement of nurses in their relationships with patients. The results suggest that an empathic involved relationship seems to be protective towards burnout rather than a frustrating involved relationship. Moreover nurses tolerate stress better if they receive supportive social rewards. We found that the impact of working with HIV-infected patients causes psychological stress (measured with the AIS), but it is a weak predictor of burnout (measured with the MBI). The results indicated the incompatibility between the relational/defensive model of the AIS and the environmental/work performance model of the MBI.

An assessment of self-esteem in HIV-positive patients.

The objective of this research is to assess how self-esteem levels differ in HIV-infected subjects in three different risk behaviours: drug addicts, homosexuals, heterosexuals. The sample (n = 104) consisted of: drug addicts (n = 46); homosexual (n = 26); heterosexuals (n = 32). The Rosenberg Self-Esteem Scale (RSES) and the Eysenck Personality Inventory (EPI) were used. A covariance analysis was used to assess the effect of the different personality traits on the 'self-esteem variable' and to eliminate the variance caused by the personality variables. Bonferroni's T-test was used to assess which group contributed to confute the hypothesis of equivalence between the RSES means of the groups. A significant association between the HIV-infection risk behaviour and the level of self-esteem was shown; this association was assessed by eliminating the effect of personality traits. The risk behaviour as well as the personality traits were both indicative of the level of self-esteem. The assessment of each group revealed that the drug addicts had a relatively lower self-esteem level (mean = 35.251) than the homosexuals (mean = 38.698) and the heterosexuals (mean = 38.227). In conclusion the RSES enables clinicians to identify subjects with low levels of self-esteem who need to be psychologically assessed within a vast population of HIV-infected patients.