Impact of fatigue on outcome of selective serotonin reuptake inhibitor treatment: secondary analysis of STAR*D

OBJECTIVE

To explore relationships between baseline and changes in fatigue during treatment with outcomes in patients with major depressive disorder (MDD) receiving citalopram monotherapy.

RESEARCH DESIGN AND METHODS

Secondary analyses of data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Level 1 treatment phase (≤14 weeks citalopram monotherapy). Fatigue was assessed with item 14 on energy level from the 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16; scored 0-3: 0 = no fatigue, 3 = maximal fatigue); prospective fatigue: assessment of fatigue at Level 1 entry and exit (no fatigue, treatment-emergent fatigue, remitted fatigue, or residual fatigue).

CLINICAL TRIAL REGISTRATION

Http://clinicaltrials.gov, NCT00021528.

MAIN OUTCOME MEASURES

Remission of depressive symptoms (17-item Hamilton Rating Scale for Depression ≤7 or QIDS-SR16 ≤5); Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form; Short-Form Health Survey Mental and Physical subscales; and Work and Social Adjustment Scale (WSAS).

RESULTS

At baseline, of 2868 patients included in the analyses, 5.5% had a QIDS-SR16 item 14 score of 0; 22.9%, a score of 1; 53.6%, a score of 2; and 18.0%, a score of 3. During Level 1 treatment, 3.5% of patients had no prospective fatigue, 2.1% had treatment-emergent fatigue, 33.6% had fatigue remitting during treatment, and 60.8% had residual fatigue. Female gender, unemployment, fewer years of education, and lower monthly income were significantly associated with higher rates of baseline fatigue (all P < 0.0001). Higher levels of baseline or prospective fatigue were associated with reduced likelihood of remission, decreased overall satisfaction (P < 0.0001), and reduced mental and physical function at outcome (P ≤ 0.05). Patients with higher baseline or prospective fatigue reported higher WSAS total scores (P < 0.0001), indicative of more severe functional impairment.

CONCLUSIONS

Lower baseline fatigue and remission of fatigue during antidepressant treatment in patients with MDD are associated with higher rates of remission of depressive symptoms and better function and quality of life. Study limitations include use of the STAR*D Level 1 sample (citalopram as only antidepressant), use of a proxy measure of energy/fatigue (item 14 from the QIDS-SR16), and the secondary post-hoc analysis design.

Rhinosinusitis in oral medicine and dentistry

Rhinosinusitis is a very common condition which is normally readily recognizable. Given the intimate anatomic relationship between the antrum and the posterior maxillary teeth, maxillary sinusitis can present as odontalgia. Distinguishing between odontogenic orofacial pain and pain associated with maxillary sinusitis is important to prevent unnecessary dental intervention and to direct patients to medical colleagues. Conversely, odontogenic infection can spread to involve the antrum, termed odontogenic sinusitis, or maxillary sinusitis of dental origin. Odontogenic sinusitis accounts for about 10-40% of all cases of sinusitis, and usually requires combined dental and medical treatment. Maxillary sinusitis can also be a complication of exodontia, resulting from tuberosity fractures, displaced teeth or root fragments and the creation of oroantral communications and fistulae. Dental implants and endodontic materials can also impinge on the maxillary sinus, and are rare causes of sinusitis. Often it is stated that rhinosinusitis may contribute to a halitosis complaint, and widely used diagnostic protocols for rhinosinusitis sometimes list halitosis as a minor criterion. However, gold standards in halitotosis research such as organoleptic assessment or gas chromatography have not been used to validate a correlation between objective (genuine) halitosis and sinusitis. The pathophysiology of this mechanism is unclear, and the relative importance of this alongside other causes of extraoral halitosis is debated.

The sonopartogram: a novel method for recording progress of labor by ultrasound

OBJECTIVES

Progress of labor has hitherto been assessed by digital vaginal examination (VE). We introduce the concept of a non-intrusive ultrasound (US)-based assessment of labor progress (the 'sonopartogram') and investigate its feasibility for assessing cervical dilatation and fetal head descent and rotation.

METHODS

This was a prospective study performed in 20 women in the first stage of labor in two European maternity units. Almost simultaneous assessment of cervical dilatation and fetal head descent and rotation were made by US and digital VE.

RESULTS

The total number of paired US and digital VE assessments was 52, with a median of three per woman. Overall, 5% of sonopartogram parameters were not obtained compared with 18% of conventional digital VE parameters (P < 0.001). Assessment of cervical dilatation was possible in 86.5% of US examinations and 100% of digital VEs (P = 0.02), and dilatation was assessed as being greater by digital VE than by US (mean difference, 1.16 (95% limits of agreement, -0.76, 3.08) cm, r(2) = 0.68, P = 0.01). Fetal head descent was measured in all 52 cases by both methods (r(2) = 0.33, P < 0.001), but correlation between the two was only moderate. Head rotation was obtainable in 98% of US examinations and 46% of digital VEs (P < 0.001), with a mean difference of -3.9° (95% limits of agreement, -144.1°, 136.3°).

CONCLUSION

In this proof-of-concept study, the acquisition of data regarding progress of labor was more successful for the sonopartogram than the conventional partogram. The agreement between digital VE and US was good for cervical dilatation and head rotation but less so for head descent. US assessment of the progress of labor is feasible in most cases.

An exploratory study to evaluate whether medical nutrition therapy can improve dietary intake in hospital patients who eat poorly

BACKGROUND

The Australasian Nutrition Care Day Survey (ANCDS) reported that two-fifths of patients consume ≤50% of the offered food in Australian and New Zealand hospitals. After controlling for confounders (nutritional status, age, disease type and severity), the ANCDS also established an independent association between poor food intake and increased in-hospital mortality. The present study aimed to evaluate whether medical nutrition therapy (MNT) could improve dietary intake in hospital patients eating poorly.

METHODS

An exploratory pilot study was conducted in the respiratory, neurology and orthopaedic wards of an Australian hospital. At baseline, percentage food intake (0%, 25%, 50%, 75% and 100%) was evaluated for each main meal and snack for a 24-h period in patients hospitalised for ≥2 days and not under dietetic review. Patients consuming ≤50% of offered meals as a result of nutrition-impact symptoms were referred to ward dietitians for MNT. Food intake was re-evaluated on the seventh day after recruitment (post-MNT).

RESULTS

One hundred and eighty-four patients were observed over 4 weeks; 32 patients were referred for MNT. Although baseline and post-MNT data for 20 participants [mean (SD) age 68 (17) years, 65% females] indicated a significant increase in median energy and protein intake post-MNT (3600 kJ day(-1) ; 40 g day(-1) ) versus baseline (2250 kJ day(-1) ; 25 g day(-1) ) (P < 0.05), the increased intake met only 50% of dietary requirements. Persistent nutrition impact symptoms affected intake.

CONCLUSIONS

In the present pilot study, although dietary intake improved, it remained inadequate to meet participants' estimated requirements as a result of ongoing nutrition-impact symptoms. Appropriate medical management and early enteral feeding could be a possible solution for such patients.

Sustained adrenergic stimulation is required for the nuclear retention of TORC1 in male rat pinealocytes

The process involved in relocation of the coactivator, transducer of regulated cAMP-regulated element-binding protein (TORC) to the cytoplasm, unlike its activation, is not well understood. Using cultured pineal cells prepared from male rats, we found that although both α- and β-adrenergic stimulation could cause TORC1 dephosphorylation, only α-adrenergic stimulation was effective in the norepinephrine (NE)-mediated translocation of TORC1 into the nucleus. In contrast, blockade of either the α- or the β-adrenergic receptor after NE stimulation was effective in causing the rephosphorylation and rapid relocation of TORC1 into the cytoplasm. Studies with phosphoprotein phosphatase (PP) inhibitors indicated that although both PP2A and PP2B could dephosphorylate TORC1, only PP2B could cause translocation into the nucleus. However, after NE stimulation, treatment with either PP2A or PP2B inhibitors could cause the rephosphorylation and cytoplasmic relocation of TORC1. These results indicate a requirement of continuous activation of both α- and β-adrenergic receptors as well as PP2A and PP2B activities for the nuclear retention of TORC1 during NE stimulation. Knockdown of salt-inducible kinase 1 (SIK1) had no effect on the phosphorylation or localization of TORC1. Although overexpressing SIK1 could induce TORC1 phosphorylation in the nucleus, it did not reduce TORC1 level in the nucleus, indicating that SIK1-mediated TORC1 phosphorylation may not be sufficient for its relocation into the cytoplasm. Together, these results demonstrate that, in the rat pineal gland, different mechanisms are involved in regulating the nuclear entry and exit of TORC1 and that the SIK1-mediated phosphorylation of TORC1 may not lead to its nuclear exit.

Involvement in research activities and factors influencing research capacity among dietitians

BACKGROUND

A healthcare professional's aptitude to develop research skills and actively engage in research is necessary to optimise healthcare efficacy. The present study investigated the factors that contribute to research capacity within the Australian dietetic workforce.

METHODS

Queensland-based dietitians scored their department and individual skill or success in research on a 10-point scale using an anonymous online survey that incorporated the validated Research Capacity in Context tool. Descriptive statistics were assessed against geographical setting, dietetic experience and the proportion of role (Full Time Equivalent; FTE) designated to research. Research activities were defined by the number of items currently involved in or completed in the past 6 months (n = 11). Factors associated with research activities were assessed by multivariable linear regression.

RESULTS

Dietitians (n = 130) identified having a moderate skill or success in 14 research items [mean (SD) 5.1 (1.7)] and perceived that their departments provided a moderate level of research support in 19 research items [mean (SD) 6.1 (2.5)]. Geographical setting, the proportion of role designated to research (FTE) and participation in research activities were associated with individual and department ratings of research skill or success. Research involvement was predicted by the proportion of role (FTE) designated to research (β = 0.34, t = 4.16, P < 0.001) and years of experience in dietetics (β = 0.32, t = 2.67, P < 0.009).

CONCLUSIONS

A dietitian's capacity for research is related to professional experience and the designation of research in the role description. The findings of the present study will provide a baseline of research capacity and expertise among dietitians, and also inform the strategic development of building research capacity.

Simple two-dimensional ultrasound technique to assess intrapartum cervical dilatation: a pilot study

OBJECTIVES

To describe a two-dimensional (2D) ultrasound technique to measure cervical dilatation in labor, and to compare ultrasound with digital measurements.

METHODS

2D transperineal ultrasound was performed in 21 nulliparous women in labor with a singleton fetus in cephalic presentation and cervical dilatation measured before or after a digital vaginal examination. The absolute difference was calculated and Bland-Altman analysis was used to assess the mean difference between digital vaginal examination and ultrasound examination of cervical dilatation. Pearson analysis was used to determine the correlation between digital and ultrasound measurements. Intraclass correlation coefficients (ICCs) with 95% CI were used to evaluate the reliability of the two methods.

RESULTS

Satisfactory quality images of the cervix were obtained in 19 of 21 cases. There was positive correlation between 2D ultrasound measurement of cervical dilatation and digital vaginal examination (Pearson coefficient r = 0.821, n = 19, P < 0.001). Bland-Altman analysis showed a mean difference between digital and ultrasound measurements of 0.08 cm (95% limits of agreement: -1.83 to 2.00) and the mean absolute difference was 1.24 cm. The ICC between the two methods was 0.81 (95% CI, 0.58-0.92).

CONCLUSIONS

Assessment and measurement of cervical dilatation by 2D transperineal ultrasound is feasible, with close agreement shown between the technique and digital vaginal examination. The technique that we describe could represent an important component of a 'sonopartogram' for ultrasound assessment of labor progress.

Aorto-mesenteric and renal allograft transplant: a novel treatment for midaortic syndrome

Midaortic syndrome (MAS) is a rare condition characterized by stenosis of the aorta and often involving renal and visceral arteries. Current therapies include medical management of associated hypertension, and interventional procedures such as angioplasty or surgical bypass. We report a 2-year-old female with severe MAS who was initially treated with angioplasty and stents in both her aorta and superior mesenteric artery (SMA). Due to the presence of long segment stenoses, her renal arteries were not amenable to surgical reconstruction and she rapidly progressed to Stage V chronic kidney disease. The patient underwent bilateral nephrectomy and renal transplantation using a donor thoracoabdominal aorta allograft to provide inflow for the kidney as well as to bypass the nearly occluded aorta. The donor SMA was used to bypass the native SMA stenosis. Postoperatively, the patient had normalization of four limb blood pressures. She weaned from five anti-hypertensive agents to monotherapy with excellent renal function. This is the first reported case of thoracoabdominal aortic bypass using allograft aorta to address MAS. This approach allowed for successful kidney transplantation with revascularization of the mesenteric, and distal aortic circulation using allograft conduit that will grow with the child, obviating the need for repeated interventional or surgical procedures.

Longitudinal assessment of cardiac diastolic function in HIV-infected patients

Asymptomatic isolated diastolic dysfunction (DD), with normal left ventricular systolic function, may be the first indication of underlying cardiac disease in HIV-negative populations. We previously reported a high prevalence (37%) of DD among asymptomatic HIV-infected patients at low risk for AIDS and cardiovascular disease (CVD). We performed a longitudinal assessment of interval echocardiographic changes in this cohort over a four-year period. Repeat transthoracic echocardiograms (TTEs) utilized standard techniques. Sixty (of the original 91) HIV-infected patients, predominately men, underwent repeat TTE (median follow-up 3.7 years, interquartile range [IQR] 3.5, 4.0). Cohort characteristics (median; IQR) include age 42.0 (36.5, 46.0) years, HIV duration 16.4 years (8.1, 18.9), current CD4 count 572.0 cells/mm(3) (436.5, 839.0), antiretroviral therapy (ART) duration 8.1 years (4.8, 13.4) and Framingham risk score 1.0 (0.0, 2.0). DD was observed in 28/60 patients on re-evaluation (47%, 95% confidence interval [CI] 34%, 60%); 31% (11/36) of patients had new onset DD for an overall incidence of 8.2/100 person-years. On follow-up, subjects with DD were older, had a trend towards higher body mass index, hypertension and longer duration of HIV infection compared with subjects without DD. We confirmed a high prevalence of DD (47%) in asymptomatic HIV-infected patients at low risk for AIDS and CVD.

Different signaling mechanisms are involved in the norepinephrine-stimulated TORC1 and TORC2 nuclear translocation in rat pinealocytes

The distribution of transducers of regulated cAMP-response element-binding protein activity (TORC) between the cytoplasm and the nucleus is tightly regulated and represents one of the main mechanisms whereby the cAMP response element activation activities of TORC are controlled. Whereas both cAMP and Ca(2+) pathways can cause translocation of TORC, the relative importance of these two pathways in regulating different TORC within the same cell is unclear. In this study, we determined the mechanism that regulated TORC1 translocation and compared it with that of TORC2 in rat pinealocytes. Stimulation of pinealocytes with norepinephrine (NE), although having no effect on Torc1 transcription, caused rapid dephosphorylation of TORC1. Although NE also caused rapid dephosphorylation of TORC2, pharmacological studies revealed that TORC1 dephosphorylation could be induced by both β-adrenoceptor/cAMP and α-adrenoceptor/intracellular Ca(2+) pathways contrasting with TORC2 dephosphorylation being induced mainly through the β-adrenoceptor/cAMP pathway. PhosTag gel indicated a different pattern of TORC1 desphosphorylation resulting from the selective activation of α- or β-adrenoceptors. Interestingly, only the α-adrenoceptor/intracellular Ca(2+)-mediated dephosphorylation could translocate TORC1 to the nucleus, whereas the β-adrenoceptor/cAMP-mediated dephosphorylation of TORC1 was ineffective. In comparison, translocation of TORC2 was induced predominantly by the β-adrenoceptor/cAMP pathway. Studies with different protein phosphatase (PP) inhibitors indicated that the NE-mediated translocation of TORC1 was blocked by cyclosporine A, a PP2B inhibitor, but that of TORC2 was blocked by okadaic acid, a PP2A inhibitor. Together these results highlight different intracellular signaling pathways that are involved in the NE-stimulated dephosphorylation and translocation of TORC1 and TORC2 in rat pinealocytes.

When peer support may be most beneficial: the relationship between upward comparison and perceived threat

OBJECTIVE

Currently, the mechanism by which dyadic peer support programs may facilitate positive psychological adjustment for cancer patients is unclear. This study utilized social comparison theory to examine the effects of peer support on the psychological adjustment of women with breast cancer.

METHODS

A cross-sectional survey of 251 recently diagnosed breast cancer patients (52% response), who had received a dyadic peer support intervention, was undertaken assessing anxiety, depression, perceived threat, and upward comparison.

RESULTS

Perceived cancer threat significantly moderated the relationship between positive upward comparison and depression levels (p = 0.017). Women who engaged in upward comparisons and who perceived their diagnosis to be more threatening had lower depression levels than women who were less threatened.

CONCLUSIONS

Peer support services that provide support from cancer survivors may be especially beneficial for people who appraise their cancer diagnosis as more threatening. The application of theoretical models to future evaluation designs will further increase understanding of the psychological mechanisms involved in the effects of peer support and inform program development.