Association between psychological distress and cancer type in patients referred to a psycho-oncology service.

Psychological distress is common in patients with cancer and psychological well-being is increasingly seen as an important component of cancer care. The aim of this study was to examine the relationship between cancer type and subjective distress. The following data were collected from a database of consecutive psycho-oncology referrals to the Liaison Psychiatry service in Cork University Hospital from 2006 to 2015: demographics, cancer diagnosis, Distress Thermometer (DT) score. 2102 out of 2384 referrals were assessed. Of those assessed, the most common cancer diagnoses were breast (23%, n=486) followed by haematological (21%, n=445). There were significant difference in DT score between the different cancer types, (?2(13)=33.685, p=0.001, Kruskal-Wallis test). When adjusted for age, gender and whether or not the cancer was recently diagnosed, there was no significant association between cancer type and psychological distress. In conclusion, cancer type is not associated with level of distress in cancer.

Defective plasma clearance of chylomicron-like lipid emulsions in Watanabe heritable hyperlipidemic rabbits.

Human patients with familial hypercholesterolemia (FH) and Watanabe heritable hyperlipidemic rabbits (WHHL), while lacking normal receptors recognizing low-density lipoproteins (LDL), are said to have normal clearance of chylomicrons. In the present study, emulsions with a similar lipid composition to chylomicrons were injected intravenously in homozygous WHHL rabbits and normal control rabbits fed diet with low or high cholesterol. Radioactive labels tracing emulsion triolein and cholesteryl oleate were both removed rapidly from the bloodstream, with the removal rate of triolein always faster than that of cholesteryl oleate. This pattern was similar to the clearance of normal chylomicrons in rabbits or rats, and was consistent with the formation of remnant lipoproteins after hydrolysis of emulsion triolein by lipoprotein lipase, followed by hepatic uptake of the remnants. The removal of cholesteryl oleate was significantly slower in WHHL rabbits than in normal controls, suggesting that the absence of LDL receptor function led to impaired remnant clearance. Measured in post-heparin plasma, the activity of lipoprotein lipase was decreased in WHHL rabbits, but this was not associated with clear evidence of defective lipolysis of emulsion triolein. Apolipoprotein E did not appear to be deficient in WHHL rabbits. Plasma devoid of lipoproteins less than 1.006 g/ml from WHHL and normal control rabbits transferred similar amounts of apolipoprotein E to chylomicron-like emulsions after incubation. Impaired clearance of chylomicron remnants possibly contributes to the hypertriglyceridemia of WHHL rabbits and to accelerated atherogenesis when the function of LDL receptors is defective.

Discrepancies between patient recall and the medical record. Potential impact on diagnosis and clinical assessment of chronic disease.

BACKGROUND: During a case-control study, data necessary for fulfilling diagnostic and classification criteria for spondyloarthropathy were collected from 121 patients. OBJECTIVE: To study the potential impact of differences between patient recall and the medical record on diagnosis and clinical characterization of spondyloarthropathy as a model of chronic disease. METHODS: The study was conducted among four Alaskan Eskimo populations served by the Alaska Native Health Service. Two sets of historical data were compiled for each subject, one acquired during the interview and the other derived from the medical record. Paired items from the interview and the medical record were analyzed to determine discrepancies and consequent effects on diagnosis, classification, and disease characterization. RESULTS: Significant differences were observed in the reporting of genitourinary or diarrheal illnesses preceding or associated with arthritis, the occurrence of eye inflammation in association with joint pain, the occurrence of joint pain and back pain together, and the age at onset of back pain all of which are important to the diagnosis and classification of spondyloarthropathy. In contrast, for information needed to establish the probable inflammatory nature of back pain, patient interview was more helpful than the medical records, which did not provide adequate details to differentiate inflammatory from mechanical back pain. CONCLUSIONS: Patient recall bias can substantially affect diagnosis and clinical assessment of chronic disease, as exemplified by spondyloarthropathy. Reliance on records alone, however, may lead to underestimation of features that require subjective appraisal by the patient.

A comparison of patients with spondyloarthropathy seen in specialty clinics with those identified in a communitywide epidemiologic study. Has the classic case misled us?

BACKGROUND: Undiagnosed cases of seronegative spondyloarthropathy (Spa) are often observed during epidemiologic studies. OBJECTIVE: To determine the extent of and the reasons for the underdiagnosis of Spa. METHODS: We studied 2 groups of Alaskan native patients with Spa using a standardized protocol that included an interview, physical examination, medical record review, and radiographic and laboratory examinations. One group consisted of patients identified in a communitywide epidemiologic study; the other group consisted of patients from related but geographically separate populations who had been diagnosed by a specialist in the hospital or a specialty clinic. All cases met the current classification criteria for Spa. The clinical and demographic features of the cases in the 2 groups were compared. RESULTS: Fifty-five (72%) of the 76 community cases that we identified in the epidemiologic study had not been diagnosed previously as Spa. Among the undiagnosed patients were 34 (94%) of the 36 women, 11 (65%) of the 17 patients with ankylosing spondylitis, 12 (36%) of the 33 patients with reactive arthritis, and 24 (100%) of those with undifferentiated Spa. The community and specialty clinic patient groups were similar in age of onset of joint and back pain and in overall symptoms. The specialty clinic group had a higher proportion of men, more severe disease, and a higher frequency of iritis. CONCLUSIONS: The diagnosis of Spa was missed more often than not in the primary care setting, probably because most of the cases were of mild or moderate severity and did not fit the classic descriptions of spondyloarthropathic disorders. The higher proportion of men among the specialty clinic cases probably reflects provider expectation as well as a slightly milder disease course in women.

ß-Catenin is required for intrinsic but not extrinsic BCR-ABL1 kinase-independent resistance to tyrosine kinase inhibitors in chronic myeloid leukemia.

Activation of nuclear ß-catenin and expression of its transcriptional targets promotes chronic myeloid leukemia (CML) progression, tyrosine kinase inhibitor (TKI) resistance, and leukemic stem cell self-renewal. We report that nuclear ß-catenin has a role in leukemia cell-intrinsic but not -extrinsic BCR-ABL1 kinase-independent TKI resistance. Upon imatinib inhibition of BCR-ABL1 kinase activity, ß-catenin expression was maintained in intrinsically resistant cells grown in suspension culture and sensitive cells cultured in direct contact (DC) with bone marrow (BM) stromal cells. Thus, TKI resistance uncouples ß-catenin expression from BCR-ABL1 kinase activity. In ß-catenin reporter assays, intrinsically resistant cells showed increased transcriptional activity versus parental TKI-sensitive controls, and this was associated with restored expression of ß-catenin target genes. In contrast, DC with BM stromal cells promoted TKI resistance, but had little effects on Lef/Tcf reporter activity and no consistent effects on cytoplasmic ß-catenin levels, arguing against a role for ß-catenin in extrinsic TKI resistance. N-cadherin or H-cadherin blocking antibodies abrogated DC-based resistance despite increasing Lef/Tcf reporter activity, suggesting that factors other than ß-catenin contribute to extrinsic, BM-derived TKI resistance. Our data indicate that, while nuclear ß-catenin enhances survival of intrinsically TKI-resistant CML progenitors, it is not required for extrinsic resistance mediated by the BM microenvironment.

Link between pregnancy complications and minor physical anomalies in monozygotic twins discordant for schizophrenia.

OBJECTIVE: The aim of the current study was to explore the relevancy of early pregnancy complications for the development of minor physical anomalies in monozygotic twins discordant and concordant for schizophrenia. METHOD: Pregnancy complications and minor physical anomalies were independently assessed in 22 discordant, 10 concordant, and six normal comparison monozygotic twin pairs. RESULTS: Complications occurring during early pregnancy were associated with a higher frequency of minor physical anomalies in the total group and in the discordant twin pairs particularly. While no significant differences in anomaly rates were observed among the discordant, concordant, and normal comparison groups, the discordant ill twins showed a trend toward having more anomalies than their well co-twins. CONCLUSIONS: Complications occurring early in pregnancy are relevant for the development of minor physical anomalies and may be of particular importance for the development of these anomalies in twin pairs discordant for schizophrenia.

Urban birth and residence as risk factors for psychoses: an analysis of 1880 data.

It is known that social drift to cities increases the urban prevalence for severe mental illnesses. Recent studies in England and Sweden have reported that being born in, or raised in, an urban area is also a risk factor for later developing schizophrenia. The present study utilized 1880 census data, the most complete enumeration of severely mentally ill individuals ever done in the United States, to examine the association of urban residence and severe mental illnesses. Individuals identified as having one of seven forms of 'insanity' (n = 91959) were allocated to their county of origin (n = 2661) in the census. Rates of 'insane' persons per 1000 population were calculated for each county. The counties were then divided by degree of urbanization based on the largest cities and the percentage of population living in towns of 4000 or more. The point prevalence of 'insanity' in the United States as a whole in 1880 was 1.8 per 1000. There was a significant association between 'insanity' by county and degree of urbanization, with odds ratios of 1.66 for urban, 1.46 for semi-urban, and 1.44 for semi-rural, and 1.37 for rural, using completely rural counties as a baseline. Most completely rural counties with high rates included mining camps, lumbering camps, or fishing villages, and not farming areas. In addition to urban drift, urban birth and residence appear to be risk factors for developing severe mental illnesses. Psychological and biological explanations have both been proposed. However, recent studies reporting winter birth and urban birth or residence as synergistic risk factors favor the latter.

Handedness in twins with schizophrenia: was Boklage correct?

Boklage's report of increased non-right handedness among monozygotic twins with schizophrenia has been cited as evidence to support an association of abnormal brain lateralization with the development of schizophrenia. The present study found no such association. Two previous attempts to replicate Boklage's findings (Luchins et al. 1980; Lewis et al. 1989) also reported little support. Studies of twin handedness do not appear to support an association of brain lateralization and schizophrenia.

The seasonality of schizophrenic births: a reply to Marc S. Lewis.

Lewis contends that the previously demonstrated finding of seasonality of schizophrenic births is a statistical artifact due to the age-incidence effect. If Lewis is correct, then (1) January should have the highest schizophrenic birthrate, (2) December should have the lowest schizophrenic birthrate, (3) the Southern Hemisphere should show the same pattern as the Northern Hemisphere, and (4) the age-incidence effect should be more marked in younger age cohorts. None of these findings have been borne out by studies to date. It is concluded that the seasonality of schizophrenic birthrates is a replicable finding, and should be considered one of the more intriguing clues to the etiology of this disease.

Geographical distribution of insanity in America: evidence for an urban factor.

The geographic distribution of insanity and schizophrenia in the United States is examined for 9 separate years between 1880 and 1963. A concentration of these conditions in Northeastern and Pacific Coast States was remarkably consistent over the 83 years. States with a high prevalence rate had approximately three times more insanity and schizophrenia than those with a low prevalence rate. There is a direct regional correlation of insanity/schizophrenia with urbanization, which is consistent with previous studies. There is also a direct regional correlation of schizophrenia with socioeconomic status, which contradicts previous studies carried out in large cities in which the schizophrenic rates were inversely correlated with socioeconomic status. The apparent discrepancy can be explained by postulating that the direct regional correlations are due to correlations of urbanization and socioeconomic status (cities have higher mean incomes than rural areas) whereas, within a particular city, schizophrenia is more prevalent among lower socioeconomic groups because of drift and other factors. Social, stress and crowding, genetic, and biological factors are discussed as possible explanations for the urban factor associated with insanity/schizophrenia.

Seasonality of schizophrenia and stillbirths.

A study of the birth pattern of 30,467 patients with schizophrenia and 428,406 stillbirths in New York State showed a significant winter-month excess in both schizophrenia births (p = 0.0000) and stillbirths (p = 0.0000). Excess births of individuals with schizophrenia in November and December provided additional evidence to refute the age-incidence explanation for the observed seasonality. Time series spectral analysis showed coherence in the pattern of schizophrenia births and stillbirths of 0.898 (p < 0.003) with schizophrenia births preceding stillbirths by 13 days. These results suggest that a common etiological seasonal factor affects a subgroup of births of individuals who later develop schizophrenia and a subgroup of stillbirths. Nutritional factors, temperature, and infectious agents known to cause both central nervous system disease and stillbirths are possible candidates.

Prenatal origin of schizophrenia in a subgroup of discordant monozygotic twins.

Neuropathological, obstetrical, and epidemiological evidence increasingly suggest that some cases of adult-onset schizophrenia have prenatal or neonatal etiological roots. We evaluated the developmental histories of 23 monozygotic twin pairs discordant for schizophrenia to determine when they markedly and permanently began diverging from each other in motor skills or unusual behavior. Seven of the twins (30%) who later developed schizophrenia had become permanently different from their cotwins by age 5 years. The early divergence group differed from the others by multivariate tests (p = 0.002) for within-twin pair effects and by univariate tests for physical anomaly scores (p = 0.01), total finger ridge counts (p = 0.001), family history of psychosis (p = 0.004), and serious perinatal complications or low birth weight (p = 0.05). It is concluded that some cases of adult-onset schizophrenia are associated with prenatal events, which may include neurodevelopmental abnormalities or specific insults such as anoxia or infectious agents.

Epidemiologic considerations in defining hypertension.

Definitions of hypertension have historically been based on at least one of three concepts. The first approach identifies thresholds of hypertension based on the frequency of occurrence in the population. The statistical approach designates a point in the distribution (e.g., the 95th percentile), as the threshold for hypertension. This distribution method identifies different limits for hypertension depending on the age, sex, and race, of the population, all of which affect the average pressure. Although distribution curves do not by themselves identify thresholds for intervention, they are useful for examining changes in population groups over time. The second approach to defining hypertension relates pressures to the risk of morbidity and mortality and is characterized by a continuously graded curve with no clear categorical thresholds. Studies correlating both diastolic and systolic pressures with cardiovascular complications demonstrate continuous risks from lowest to highest values for both sexes, all ages, and both blacks and whites in the United States. The blood pressure-risk relationship provides a compelling rationale for treatment but does not by itself define thresholds for the initiation of therapy. The third approach uses data from clinical intervention trials to identify thresholds where the benefits of therapy outweigh the costs and side effects of long-term treatment. Although results of large randomized trials have clearly demonstrated reductions in morbidity and mortality by lowering blood pressures, consensus on the lowest threshold within the mild range for which antihypertensive drug treatment is recommended has not been reached. Because an optimal definition of hypertension must encompass all three approaches and the resultant classification scheme must be sufficient for all purposes, attempts to refine and improve upon the presently recommended thresholds will undoubtedly continue.

Hypertension knowledge, attitudes, and behavior: 1985 NHIS findings.

Data from the Health Promotion/Disease Prevention Supplement to the 1985 National Health Interview Survey provide an indication of progress made toward achieving the 1990 objectives for the nation. Survey results showed remarkably high levels of knowledge concerning the increased risks associated with uncontrolled high blood pressure. Nine of 10 adults in the United States knew that high blood pressure increases the risk of heart disease, and 3 of 4 knew that high blood pressure is the most significant risk factor for stroke. The majority of both the general public and the subgroup of the population identified as hypertensives reported knowing the results of their last blood pressure measurement; and, most importantly, almost two-thirds of the identified hypertensives reported that their pressures were under control at last measurement. Data examining professional advice, given and acted upon to achieve blood pressure goals, show that almost two-thirds of the hypertensives currently report taking antihypertensive medication. Results also suggest a degree of willingness by both professionals and hypertensives to attempt nondrug approaches to controlling pressures. The large majority of hypertensives who were advised by a health professional to cut down on sodium, lose weight, and exercise reported they were following this advice. These findings will be used to further refine high blood pressure education strategies and advance the progress toward meeting the 1990 hypertension objectives.

Hypertension as a risk factor.

Hypertension has been demonstrated to be a clear risk factor for CHD. The finding that hypertension is a risk factor has been demonstrated in observation studies, actuarial data and clinical trials. The relationship between blood pressure and CHD is strong. As blood pressure rises, risk for cardiovascular events increases. This is true for both sexes, for blacks and whites, and for all age categories. Clinical trials, both large and small, have demonstrated that lowering blood pressure can reverse the risk and reduce morbidity and mortality. This cause-and-effect relationship has been replicated consistently, and there is not one well-controlled trial of adequate size that has failed to show this finding. It is important to know which concept of risk to use in developing hypertensive programs. The concept of relative risk is useful to determine whether a public health program is needed within a population, but it has less value in identifying which subset of the population in which to intervene. In essence, relative risk is used to mandate a program but cannot determine where the program should be directed. Hypertension attributable risk describes which individuals are at greatest risk and serves to guide planners as to which groups have the greatest mortality once blood pressure becomes elevated. Population attributable risk becomes the most useful tool in identifying or locating those communities of highest-risk individuals.

Chylomicron-remnant clearance in homozygote and heterozygote Watanabe-heritable-hyperlipidaemic rabbits is defective. Lack of evidence for an independent chylomicron-remnant receptor.

Lymph chylomicrons radiolabelled in triacylglycerol and cholesteryl ester were injected into control and Watanabe heritable-hyperlipidaemic (WHHL) rabbits. Clearance of chylomicrons was slower in heterozygote and homozygote WHHL rabbits. Slower remnant clearance in WHHL rabbits was confirmed by monitoring the clearance from plasma of preformed chylomicron remnants. Use of chylomicron-like lipid emulsions injected into control and WHHL rabbits also confirmed the defect in remnant clearance in heterozygote WHHL and homozygote WHHL groups. Clearance from plasma of emulsion triolein was delayed in both WHHL groups compared with controls, owing to slower remnant clearance. The clearance from plasma of radioiodinated rabbit low-density lipoproteins (LDL) in heterozygote WHHL rabbits was the same as control rabbits. Defective chylomicron-remnant removal but normal LDL clearance in the heterozygote WHHL corresponded to elevated concentrations of plasma triacylglycerol and normal concentrations of plasma cholesterol. Receptor versus non-receptor clearances of chylomicron remnants were studied by comparing the clearance of emulsions with and without unesterified cholesterol respectively. Unlike control rabbits, there were no significant differences in the clearances of the two emulsion types in either the homozygote or heterozygote WHHL rabbits, indicating that the apolipoprotein-B100/E receptor is the primary route for clearance of chylomicron remnants from plasma.

Clearance of chylomicron-like lipid emulsions is increased in normal rabbits but not in heterozygous Watanabe heritable hyperlipidaemic rabbits following treatment with cholestyramine or pravastatin.

1. Cholestyramine and pravastatin are two potent hypocholesterolaemic drugs which lower plasma cholesterol by increasing the clearance of low density lipoproteins by high affinity uptake mechanisms. 2. We gave heterozygous Watanabe heritable hyperlipidaemic rabbits (hz-WHHL) cholestyramine and/or pravastatin for a two week period to try and ameliorate slow clearance of chylomicron remnants, which occurs because of reduced expression of the apolipoprotein B100/E receptor. 3. In hz-WHHL rabbits the clearance of chylomicron-like lipid emulsions, traced by the decrease in plasma cholesteryl oleate radioactivity was not improved following treatment with either of the cholesterol lowering drugs. 4. In contrast, control rabbits had significantly less chylomicron-like emulsion cholesteryl-ester radioactivity remaining at each time of blood sampling. 5. Similarly, the clearance of chylomicron-like emulsion triolein was enhanced in normal rabbits receiving cholestyramine or pravastatin, whereas there was no detectable increase in clearance in hz-WHHL rabbits. 6. Combined treatment with cholestyramine and pravastatin increased the rate of receptor-mediated uptake in vivo in control rabbits but not in hz-WHHL rabbits. 7. The plasma lipid profiles of control and hz-WHHL rabbits paralleled the patterns of chylomicron-like emulsion clearance. Moderate hypertriglyceridaemia was identified in hz-WHHL rabbits compared to controls and there was no change in plasma triglyceride or cholesterol following drug therapy. In contrast, control rabbits had decreased plasma lipids following cholestyramine or pravastatin treatment. 8. It appears that therapy with lipid lowering drugs increased chylomicron remnant clearance in control rabbits by up-regulation of the apolipoprotein B100/E receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving the quality of emergency department documentation using the voice-activated word processor: interim results.

We examined whether voice-activated word processors provide an acceptable means for emergency physicians to create medical records. Our study addressed three areas of inquiry: whether physicians can be induced to try this new technology, whether they will continue to use it after outside technical support is withdrawn, and the factors contributing to adoption and substantial use of voice-activated computers by practicing emergency physicians. This paper presents findings from the first half of the study, reflecting physicians' reported experiences while receiving onsite training followed by technical support for three months after system installation. Based on preliminary assessments, the keys to successful use appear to include physician and group commitment, acceptance of a steep learning curve, and flexibility in adapting the computer software and/or practice habits.