Chemotherapy-induced nausea, vomiting, and fatigue--the role of individual differences related to sensory perception and autonomic reactivity

BACKGROUND

In spite of antiemetics, postchemotherapy side effects continue to be common and may affect compliance to cancer treatment. Among the known factors associated with increased symptom severity are: younger age, treatment toxicity, expected severity, and distress, but little is still known about the role of other factors. The aim of our study was to investigate the role of individual differences related to sensory perception for posttreatment side effects.

METHODS

Hundred and twenty-five women receiving adjuvant chemotherapy for breast cancer completed measures of absorption, autonomic perception, somatosensory amplification, trait anxiety, and expected severity at baseline. Pretreatment distress and posttreatment nausea, vomiting, and fatigue were assessed at the 1st, 4th, 6th and last cycles of chemotherapy.

RESULTS

While univariate analyses showed several factors to be associated with side effects, only absorption and pretreatment distress remained independent predictors of nausea and fatigue when controlling for the remaining factors. Posttreatment vomiting was only predicted by expected severity of vomiting.

CONCLUSION

Chemotherapy-induced side effects are related to increased autonomic nervous system activity, and absorption has been associated with increased autonomic nervous system reactivity to stress. The results suggest that individuals with high absorption may be at greater risk for developing side effects. Improved precision in identifying patients at risk of experiencing more severe side effects after cancer treatment will increase the ability to target treatments aimed at reducing these side effects.

Anticipatory Nausea: The Role of Individual Differences Related to Sensory Perception and Autonomic Reactivity

BACKGROUND

Anticipatory nausea (AN) during chemotherapy has been difficult to control with conventional antiemetics. AN can lead cancer patients to delay or discontinue chemotherapy, possibly compromising the treatment.

PURPOSE

The aim is to investigate the possible influence on the development of AN of individual differences in absorption, somato-sensory amplification, and autonomic perception-measures theorized to be related to sensory perception and autonomic reactivity.

METHODS

Prior to treatment, 125 women (M age = 48.5 years) undergoing adjuvant chemotherapy for breast cancer rated their expected severity of side effects and completed the Tellegen Absorption Scale, the Somato-Sensory Amplification Scale, and the Autonomic Perception Questionnaire. AN, as well as anticipatory vomiting (AV), distress, and worry/anxiety, were measured prior to the fourth, sixth, and last cycle of chemotherapy. Posttreatment nausea (PN), vomiting, and fatigue were measured after the first, fourth, sixth, and last cycle.

RESULTS

34% of the women reported AN before 1 or more cycles. When controlling for treatment characteristics and other known predictors, AN was significantly associated with high absorption in addition to severity of PN, pretreatment worry/anxiety, and not receiving radiotherapy between chemotherapy sessions. AV was not associated with any of the variables investigated. Our data suggest that the association is strongest in the early phases of treatment.

CONCLUSIONS

Our results partly confirm the results of a previous study showing absorption and autonomic perception as predictors of anticipatory side effects in cancer patients receiving chemotherapy. Individuals high in absorption may be more autonomically reactive to aversive stimuli and, subsequently, more conditionable. Additional radiotherapy could be a competing stimulus, reducing the conditioning of chemotherapy-related nausea. Further studies investigating possible psycho-physiological mechanisms in the development of AN are needed.

Randomised controlled trial of a shared care programme for newly referred cancer patients: bridging the gap between general practice and hospital

OBJECTIVE

To determine the effect of a shared care programme on the attitudes of newly referred cancer patients towards the healthcare system and their health related quality of life and performance status, and to assess patients' reports on contacts with their general practitioner (GP).

SETTING

Department of Oncology at Aarhus University Hospital and general practices.

DESIGN

Randomised controlled trial in which patients completed questionnaires at three time points. The shared care programme included transfer of knowledge from the oncologist to the GP, improved communication between the parties, and active patient involvement.

PARTICIPANTS

248 consecutive cancer patients recently referred to the department.

MAIN OUTCOME MEASURES

Patients' attitudes towards the healthcare services, their health related quality of life, performance status, and reports on contacts with their GPs.

RESULTS

The shared care programme had a positive effect on patient evaluation of cooperation between the primary and secondary healthcare sectors. The effect was particularly significant in men and in younger patients (18-49 years) who felt they received more care from the GP and were left less in limbo. Young patients in the intervention group rated the GP's knowledge of disease and treatment significantly higher than young patients in the control group. The number of contacts with the GP was significantly higher in the intervention group. The EORTC quality of life questionnaire and performance status showed no significant differences between the two groups.

CONCLUSIONS

An intersectoral shared care programme in which GPs and patients are actively involved has a positive influence on patients' attitudes towards the healthcare system. Young patients and men particularly benefit from the programme.

Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease

The aim of the study was to investigate the association of physician communication behaviours as perceived by the patient with patient reported satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease in cancer patients. Questionnaires measuring distress, self-efficacy, and perceived control were completed prior to and after the consultation by 454 patients attending an oncology outpatient clinic. After the consultation, the patients also rated the physicians' communicative behaviours by completing a patient-physician relationship inventory (PPRI), and the physicians were asked to estimate patient satisfaction. The overall results showed that higher PPRI scores of physician attentiveness and empathy were associated with greater patient satisfaction, increased self-efficacy, and reduced emotional distress following the consultation. In contrast, lower PPRI scores were associated with reduced ability of the physician to estimate patient satisfaction. The results confirm and expand previous findings, suggesting that communication is a core clinical skill in oncology.

Isolation and in vitro cultivation of the aphid pathogenic fungus Entomophthora planchoniana

Entomophthora planchoniana is an important fungal pathogen of aphids. Although Entomophthora chromaphidis has been considered a synonym for E. planchoniana, the two species are now separated, and E. planchoniana is reported not to grow in vitro. In this paper, we describe for the first time the isolation and cultivation of this species. Entomophthora planchoniana was isolated from a population of Ovatus crataegarius (Homoptera, Aphididae), which was infected by E. planchoniana only. The isolates did not sporulate, but the sequence of the small subunit rDNA and the restriction fragment length polymorphism patterns of the first part of the large subunit rDNA and the ITS II region confirm that the isolates were E. planchoniana. The isolated fungus grew in a medium consisting of Grace's insect cell culture medium supplemented with lactalbumin hydrolysate, yeastolate, and 10% fetal bovine serum or in GLEN medium with 10% fetal bovine serum. Vegetative cells of E. planchoniana were long and club-shaped and did not stain with Calcofluor, thus suggesting that they were protoplasts.

Intraspecific variation and host specificity of Entomophthora muscae sensu stricto isolates revealed by random amplified polymorphic DNA, universal primed PCR, PCR-restriction fragment length polymorphism, and conidial morphology

The intraspecific variations of Entomophthora muscae s. str. associated with particular host species, Musca domestica and Delia radicum, sampled from different localities and different years in Denmark and the variation of E. muscae s. str. originating from different host taxa were investigated. The isolates were compared both by primary spore morphology and by three molecular methods: random amplified polymorphic DNA, universal primed PCR, and PCR-restriction fragment length polymorphism. Analyses of the different molecular data showed the same overall picture and separated E. muscae s. str. into two main groups with all the M. domestica isolates in one group and isolates from D. radicum, Coenosia tigrina, and Pegoplata infirma in the second group. E. muscae s. str. isolates from M. domestica also differ significantly from the rest of the E. muscae s. str. isolates with regard to the morphology of the primary conidia, which were bigger and contained significantly more nuclei per conidium. Several different E. muscae s. str. genotypes were documented and each type was restricted to a single host species, indicating a very high degree of host specificity at or below the level of the subfamily.

Arabidopsis map kinase 4 negatively regulates systemic acquired resistance

Transposon inactivation of Arabidopsis MAP kinase 4 produced the mpk4 mutant exhibiting constitutive systemic acquired resistance (SAR) including elevated salicylic acid (SA) levels, increased resistance to virulent pathogens, and constitutive pathogenesis-related gene expression shown by Northern and microarray hybridizations. MPK4 kinase activity is required to repress SAR, as an inactive MPK4 form failed to complement mpk4. Analysis of mpk4 expressing the SA hydroxylase NahG and of mpk4/npr1 double mutants indicated that SAR expression in mpk4 is dependent upon elevated SA levels but is independent of NPR1. PDF1.2 and THI2.1 gene induction by jasmonate was blocked in mpk4 expressing NahG, suggesting that MPK4 is required for jasmonic acid-responsive gene expression.

Fusion genetic analysis of gibberellin signaling mutants

A fusion genetic strategy was used to identify gibberellin (GA) signaling mutants in transgenic Arabidopsis expressing the beta-glucuronidase (GUS) and firefly luciferase (LUC) reporter genes under control of the GA-responsive GASA1 promoter. Initial analyses determined the spatial and temporal patterns of reporter expression, and showed that reporter induction by GA was antagonized by ABA. gamma-Irradiated M2 progeny with altered reporter activities were identified by LUC bioimaging followed by GUS assays and northern hybridization of the endogenous GASA1 mRNA. Genetic analysis showed that three mutants, which overexpressed both reporters and endogenous GASA1, were caused by recessive (goe1 and goe2, for GASA over-expressed) and semi-dominant (goe3) mutations at different loci. These mutants are altered in their sensitivity to GA and the GA biosynthetic inhibitor paclobutrazol, and in the expression of several GA signaling related genes.

Tropisetron reduces postoperative vomiting in children undergoing tonsillectomy

In this patient, parent and investigator blinded, randomized, placebo-controlled study, children undergoing tonsillectomy (mean age 6.4 years) received either intravenous placebo (n=36) or tropisetron 0.2 mg.kg-1 up to 5 mg (n=35) at induction of anaesthesia with halothane, nitrous oxide and oxygen. Morphine and paracetamol were given in theatre for postoperative pain. Episodes of vomiting were recorded during the first 24 h after surgery. Intravenous tropisetron was significantly (P<0.001, chi-squared) more effective than placebo in controlling the incidence and frequency of emesis during the first 24 h: vomiting was reduced from 89% to 46% and the mean number of vomits from 4.6 to 2.4. Minor side-effects occurred equally in both the placebo and active groups. Intravenous tropisetron is an effective and safe antiemetic for reducing postoperative vomiting in children undergoing tonsillectomy or adenotonsillectomy.

Characterization, subcellular localization and nuclear targeting of casein kinase 2 from Zea mays

We have isolated and characterized the genomic clone of maize casein kinase 2 (CK2) alpha subunit using the previously described alphaCK2-1 cDNA clone as a probe. The genomic clone is 7.5 kb long and contains 10 exons, separated by 9 introns of different size, two larger than 1.5 kb and the others around 100-150 bp. The sequence of the exons is 100% homologous to the sequence of the alphaCK2-1 cDNA. Southern hybridization of total genomic DNA from maize embryos with aCK2 cDNA indicated that the alphaCK2-1 gene is part of a multigenic family. We also isolated a new embryo cDNA clone coding for an alphaCK2-2 subunit. We studied the regulation of the enzyme in embryos at the mRNA level, at the protein level and by activity testing. By using immunocytochemistry the CK2 protein was localized in several types of cells of mature embryos. Particularly strong signals were visible in the cytoplasm of epidermis and meristematic cells. Decoration of nuclei of root cortex and scutellum cells was also observed suggesting that CK2 can shift from the cytoplasm into nuclei in specific cell types. We examined whether CK2 contained specific protein domains which actively target the protein to the nucleus by using in-frame fusions of the maize CK2alpha subunit to the reporter gene encoding beta-glucuronidase (GUS) which were assayed in transiently transformed onion epidermal cells. Analysis of chimeric constructs identified one region containing a nuclear localization signal (NLS) that is highly conserved in other alphaCK2 proteins.

Nurses' attitudes to the use of alternative medicine in cancer patients

This study reports results from a questionnaire study on nurses' attitudes to and experiences with alternative medicine, especially related to cancer patients' use of alternative medicine. Sixty nurses from a department of oncology and haematology participated in the study. The response rate was 62%. The nurses primarily perceived the use of alternative medicine as an individual choice which the nurses wanted to support. Sixty-three percent of the nurses indicated that alternative medicine could be useful in the treatment of cancer patients, 32% would sometimes suggest alternative medicine to the patients, and 20% used alternative medicine in their nursing. One-third of the nurses had experienced conflict in connection with alternative medicine and their patients, mostly when established treatment was delayed or refused in favour of alternative medicine. Fifty-three percent of the nurses had tried alternative medicine themselves. This study reveals that nurses are in an ambiguous and complex situation: they are simultaneously professionals in the established health care system, caregivers supporting the patients, and individuals using alternative medicine.

[Decisions about life and death. An empirical study of the position of Danish physicians concerning end-of-life decisions]

In a postal questionnaire investigation of experiences and attitudes concerning end-of-life decisions among Danish physicians, most of the respondents reported having made decisions involving the hastening of a patient's death, and considered this acceptable. Such decisions were more frequent, and were considered ethically more acceptable, when made with the patient's informed consent than without. Of the respondents, two per cent had participated in assisted suicide, and five per cent had administered a lethal injection at the patient's request, practices considered ethically acceptable by 37 per cent and 34 per cent, respectively, of the respondents. The most frequently cited reasons for opposing such practices were double effect principle, the active killing/allowed-death distinction, and the sanctity of life; and the most frequently cited justifications were respect for the patient's autonomy, the avoidance of unnecessary suffering, and the patient's right to a death with dignity.

Relationships of the insect-pathogenic order Entomophthorales (Zygomycota, Fungi) based on phylogenetic analyses of nuclear small subunit ribosomal DNA sequences (SSU rDNA)

We sequenced the nuclear small subunit of ribosomal DNA (SSU rDNA) from seven species within the insect-pathogenic order Entomophthorales. These sequences were aligned with other published SSU rDNA sequences and phylogenies were inferred using phenetic and cladistic methods. Based on three different phylogenetic methods the Entomophthorales (excluding Basidiobolus ranarum) is monophyletic; B. ranarum was more closely related to chytrids from Chytridiales and Neocallimasticales than to Entomophthorales, as was proposed by Nagahama et al. (Mycologia 87: 203-209, 1995). Nuclear characters (large nuclei containing conspicuous condensed chromatin and lack of a prominent nucleolus) were of predictive value for the monophyly of the family Entomophthoraceae. Conidial characters separate the Entomophthoraceae, which only includes obligate pathogens, into at least two lineages: one lineage with uninucleate conidia and another with multinucleate conidia. The two species of Conidiobolus studied were paraphyletic in our analyses and only distantly related to each other. This information may prove to be important in the use of these fungi as biocontrol agents.

Phosphorylation mediates the nuclear targeting of the maize Rab17 protein

The maize abscisic acid-responsive Rab17 protein localizes to the nucleus and cytoplasm in maize cells. In-frame fusion of Rab17 to the reporter protein beta-glucuronidase (GUS) directed GUS to the nucleus and cytoplasm in transgenic Arabidopsis thaliana and in transiently transformed onion cells. Analysis of chimeric constructs identified one region between amino acid positions 66-96, which was necessary for targeting GUS to the nucleus. This region contains a serine cluster followed by a putative consensus site for protein kinase CK2 phosphorylation, and a stretch of basic amino acids resembling the simian virus 40 large T antigen-type nuclear localization signal (NLS). Mutation of two basic amino acids in the putative NLS had a weak effect on nuclear targeting in the onion cell system and did not modify the percentage of nuclear fusion protein in the Arabidopsis cells. The mutation of three amino acids in the consensus site for CK2 recognition resulted in the absence of in vitro phosphorylated forms of Rab17 and in a strong decrease of GUS enzymatic activity in isolated nuclei of transgenic Arabidopsis. These results suggest that phosphorylation of Rab17 by protein kinase CK2 is the relevant step for its nuclear location, either by facilitating binding to specific proteins or as a direct part of the nuclear targeting apparatus.

Regulatory elements in vivo in the promoter of the abscisic acid responsive gene rab17 from maize

The rab17 gene from maize is transcribed in late embryonic development and is responsive to abscisic acid and water stress in embryo and vegetative tissues. In vivo footprinting and transient transformation of rab17 were performed in embryos and vegetative tissues to characterize the cis-elements involved in regulation of the gene. By in vivo footprinting, protein binding was observed to nine elements in the promoter, which correspond to five putative ABREs (abscisic acid responsive elements) and four other sequences. The footprints indicated that distinct proteins interact with these elements in the two developmental stages. In transient transformation, six of the elements were important for high level expression of the rab17 promoter in embryos, whereas only three elements were important in leaves. The cis-acting sequences can be divided in embryo-specific, ABA-specific and leaf-specific elements on the basis of protein binding and the ability to confer expression of rab17. We found one positive, new element, called GRA, with the sequence CACTGGCCGCCC. This element was important for transcription in leaves but not in embryos. Two other non-ABRE elements that stimulated transcription from the rab17 promoter resemble previously described abscisic acid and drought-inducible elements. There were differences in protein binding and function of the five ABREs in the rab17 promoter. The possible reasons for these differences are discussed. The in vivo data obtained suggest that an embryo-specific pathway regulates transcription of the rab genes during development, whereas another pathway is responsible for induction in response to ABA and drought in vegetative tissues.

Molecular characterization of L2 lipoxygenase from maize embryos

We investigated the expression and accumulation pattern of lipoxygenase isoforms throughout the maize plant life. Two forms of lipoxygenase L1 and L2 have been identified as acidic proteins of 100 kDa (pI 6.4) and 90 kDa (pI 5.5-5.7) which accumulate in dry embryos and in various organs of maize seedlings. In young embryos, only the L2 form was detected and accumulation of L2 mRNA decreased during embryo development. Identification of lipoxygenases from in vivo and in vitro synthesized proteins indicates that similar levels of both L1 and L2 forms accumulated during treatment with abscisic acid, (ABA) gibberellic acid (GA3) and jasmonic acid (JA). However, differences in the activity of both enzymes were detected. By using an antiserum directed against purified L2 we isolated and characterized a partial cDNA clone of maize embryos encoding a lipoxygenase. The deduced amino acid sequence of L2 cDNA shares 78% identity with the rice L2 protein, and 51-56% identity with lipoxygenases from the dicotyledonous plants soybean and Arabidopsis. DNA blot analysis indicated that maize contains a family of lipoxygenase genes which are presently being characterized.

Prognostic value of interleukin-8 in AIDS-associated Pneumocystis carinii pneumonia

Interleukin-8 (IL-8) is a potent neutrophil chemoattractant and activator. Pneumocystis carinii pneumonia is associated with an accumulation of neutrophils in bronchoalveolar lavage (BAL) fluid. Thus, we hypothesized that IL-8 is involved in the pathogenesis of P. carinii pneumonia. BAL fluid and serum were prospectively collected in 76 consecutive HIV-infected patients with a primary episode of P. carinii pneumonia, as well as in 10 healthy control subjects. Patients were found to have elevated levels of IL-8 in BAL fluid compared with control subjects (p < 0.01). Nine patients died during the course of P. carinii pneumonia. Comparing survivors with nonsurvivors, the median IL-8 level in BAL fluid was 127 (0 to 3,900) versus 584 (127 to 6,100) pg/ml (p < 0.05). Furthermore, patients with levels of IL-8 in BAL fluid greater than 90 pg/ml (i.e., greater than control subjects) had significantly worse vital prognosis (log rank test, p < 0.05). Thirteen percent required mechanical ventilation (MV). Patients requiring MV had a median IL-8 level of 396 (25 to 6,100) versus 129 (0 to 3,900) pg/ml for patients not requiring MV (p < 0.05).

IN CONCLUSION

i) IL-8 in BAL fluid correlates to the clinical severity of the pneumonia, and ii) is a predictor of mortality and severe respiratory compromise.

Irradiation of bone metastases in breast cancer patients: a randomized study with 1 year follow-up

The results from a prospective randomized trial comparing two different radiation schedules for treatment of painful bone metastases in women with recurrent breast cancer are presented. A total of 217 patients with painful bone metastases were randomized to either 30 Grey (Gy) in ten fractions, five fractions a week (5F/W) or 15 Gy in three fractions 2F/W. The effect of treatment was evaluated by pain assessment, the radiological response and the degree of side-effects. The patients were rated at start of treatment and after 1, 3, 6 and 12 months. No difference between the two radiation regimes was found, neither in achieved pain relief, improvement in level of activity and medication, nor was there any difference in radiological response and side-effects from treatment. Both regimes resulted in a significant improvement in both pain score and level of activity 1 month after treatment, an improvement which persisted during the follow-up period. We conclude that 15 Gy given in three fractions 2F/W is as effective as 30 Gy in ten fractions 5F/W, but more convenient to the patient and of less cost to society.