A preliminary investigation on the acute pharmacodynamic effects of hypericum on cognitive and psychomotor performance

Research has indicated that the herb St John's Wort (Hypericum perforatum) has comparable efficacy to conventional antidepressants in the treatment of depression. Although clinical studies have demonstrated that hypericum has a superior side-effect profile compared to standard antidepressants, no study has directly compared the cognitive and psychomotor effects of hypericum with those of other antidepressants. The aim of the current study was to examine the acute effects of hypericum on cognitive and psychomotor function, and to compare its effects with those of amitriptyline. Thirteen healthy volunteers received an acute dose of placebo, amitriptyline (25 mg, positive control) or hypericum (900 mg or 1800 mg) in a double-blind, placebo-controlled design. Cognitive and psychomotor tests and subjective measures of sedation were administered before and 1, 2 and 4 hours after drug administration. Amitriptyline impaired performance on a battery of psychological tests, which included critical flicker fusion (CFF), choice reaction time (CRT), digit symbol substitution test (DSST), profile of mood states (POMS) and the line analogue rating scale (LARS), while hypericum had neutral effects on performance in these tests. However, hypericum induced a dose-related impairment on DSST. Current findings suggest that clinical doses of hypericum do not impair attention, sensorimotor function or information processing.

Clinical outcomes in terminally ill patients admitted to hospice care: diagnostic and therapeutic interventions

This study's aim was to determine the impact of medical technologies on patient comfort and survival time, through retrospective review of the clinical course, symptom profile, and illness trajectory in 102 consecutive patients (50 males and 52 females), and of diagnostic and therapeutic interventions delivered to them. The average age of males was 72.3 years and of females 73.1 years. Ninety-four patients were admitted for palliation of symptoms due to malignant disease and eight other patients for non-malignant diseases. The median survival time was 12 days. On admission, higher univariate hazard risks for survival were significantly associated with male gender, metastatic disease, and dyspnea. Higher adjusted Charlson comorbidity scores were associated with significantly decreased survival time, while de novo symptoms and diagnostic interventions were associated with lower univariate risk rates and increased survival times. Palliative therapeutic interventions were not significantly associated with increased patient survival. A multivariate analysis showed that pain, dyspnea, immobility, and adjusted Charlson comorbidity scores were independent risks for shorter patient survival times. Diagnostic interventions were significant for increased patient survival. No requests for euthanasia had been recorded, which may, in part, reflect the significant family support most of these patients had received.

An investigation into the acute nootropic effects of Hypericum perforatum L. (St. John's Wort) in healthy human volunteers

Hypericum perforatum L. (St. John's Wort) is a complex herb that has been used for centuries for its putative medicinal properties, and has current therapeutic relevance as a treatment of mild to moderate depression. Recently, two studies in rodents have suggested that hypericum may also have memory-enhancing effects. It has a complex pharmacology, in that acute administration modulates numerous neurotransmitter systems that have previously been observed to either augment or impair a variety of memory processes in humans. This study aimed to examine whether acute administration of standardized hypericum extract could exert a nootropic effect in normal human subjects. The study employed a double-blind, crossover, repeated-measures design. Twelve healthy young subjects completed the Cognitive Drug Research (CDR) memory battery, following administration of placebo, 900 mg and 1800 mg hypericum (Blackmore's Hyperiforte). The findings suggested that hypericum does not have an acute nootropic effect in healthy humans at these doses. However, there was some evidence for an impairing effect on accuracy of numeric working memory and delayed picture recognition at the higher dose. This observed impairment could be due to a sensitivity of these specific tasks to modulation by neurotransmitters that have been noted to have memory-impairing effects (e.g. y-aminobutyric acid (GABA), serotonin).

Psychosocial interventions and cancer patients: psychological and immune responses may depend on cancer type

Psychological and immunological responses of cancer patients to a psychosocial intervention program will be assessed over time. Previously it has been proposed that there are two large divisions in cancer histology (type I and II) and that the psychobiology of patients will vary accordingly.

Single and multiple cholesterol gallstones and the influence of bacteria

Single and multiple cholesterol gallstones constitute at least 80% of the gallstone population observed at cholecystectomy in Western countries. While supersaturation of bile with cholesterol is necessary for gallstone growth, the kinetic determinant of crystal nucleation is perhaps the critical factor leading to the incidence of gallstones. Nucleation involves aggregation of nidus-forming materials like pigment precipitates and mucus proteins. In combination with cholesterol precipitates and crystal formation, gallstone propagation is enhanced. Bacterial species may augment the process of nucleation and gallstone growth by contributing specific enzyme activities resulting in the formation of insoluble precipitates in bile, or by acting as a nidus upon which the deposition of cholesterol crystals may initiate gallstone formation. The utilization of Raman microscopic techniques permits detailed mapping of the distribution of the gallstone components leading to identification and characterization of the site of nucleation. This, when coupled to molecular genetic tools such as PCR DNA amplification, would permit elucidation of the role of bacteria in vivo gallstone propagation mechanisms.

Bacterial infections in terminally ill hospice patients

Terminally ill patients are very susceptible to infections, which are the result of disease-related processes and/or therapy-induced mechanisms. These patients are already subject to multiple severe symptoms and associated comorbid conditions, with much resultant distress. Infection increases this symptom burden and further reduces quality of life. We have retrospectively investigated the prevalence of infection and clinical course in 102 consecutive patients who died after admission to a tertiary palliative care unit and assessed the site-specific frequency of infection, pathogenic organisms involved, and the pattern of antibiotic agents used. The prevalence of symptoms and comorbid conditions on admission and during the progress phase of care were noted. Median overall survival of the total cohort was 12 days. The median survival of patients with infections was 22 days. Thirty-seven patients (36.3%) were diagnosed with 42 separate infections. The sites of infections were the urinary tract (42.5%), the respiratory tract (22.9%), blood (12.5%), skin and subcutaneous tissues (12.5%), and the eyes (10.0%). There were 20 separate positive cultures isolated from specimens obtained from 13 individual patients. Three isolates were obtained from 1 patient, 2 isolates obtained from 5 patients, and 1 isolate was obtained from each of the 7 remaining patients. Escherichia coli was the most common pathogen isolated. Eleven patients with infections (31.4%) were diagnosed on admission, and antibiotic treatment was commenced within 48 hours of admission in 21 patients (60%). Overall antibiotic response and symptom control of infections was observed to be a minimum of 40%. Psychological distress was common in this group of patients (P = 0.001) as were disabling symptoms on admission, such as pain, immobility, and weakness. Symptoms indicating poor survival, such as severe pain and dyspnea, were not significantly associated with infection. Decreased patient survival in this cohort was not significantly associated with the presence of bacterial infection (P = 0.07), irrespective of whether or not a positive culture isolate was obtained. We conclude that appropriate management of infection resulted in enhanced palliative symptom control.

Gallstones and gall bladder carcinoma

BACKGROUND

The present study reviewed the occurrence of gall bladder carcinoma in patients who underwent a cholecystectomy for gallstone disease.

METHODS

A retrospective study of demographical and clinical information for patients who underwent a cholecystectomy and operative cholangiogram for gallstones predominantly in three major hospitals located in the northern area of Melbourne was carried out.

RESULTS

Gall bladder carcinomas were observed in 14 patients (3.2%; 95% confidence interval (CI): 1.8-5.3%) consisting of 11 women and three men of median age 78.5 years (interquartile range: 77-81) from a series of 439 patients with a male-to-female ratio of 1-2. The results of the present study show that primary carcinoma of the gall bladder in this descriptive retrospective cohort was always associated with single or multiple cholesterol gallstones that were impacting on the gall bladder wall. Cholesterol 'solitaire' gallstones were ovoid in shape with diameters > 3 cm along their longest axis, whereas multiple cholesterol gallstones varied in size and number from two or three large stones (1-2 cm), to numerous smaller stones (variable size to 0.5 cm). No patient with gall bladder carcinoma had either brown or black pigment gallstones.

CONCLUSION

It is postulated that gall bladder carcinoma may be intimately associated with large or numerous cholesterol gallstones that in the first instance may interfere with the mechanical functioning of the gall bladder. The size as well as the number of gallstones present in the gall bladder may contribute significantly to the promotion of a gallstone filling defect of the gall bladder that may cause chronic mechanical damage to the gall bladder mucosa. The present report supports the hypothesis that gall bladder carcinoma is an age-dependent malignancy, present mostly in women, that may be intimately associated with long-standing benign gallstone disease of the gall bladder.

Psychological morbidity and quality of life in Australian women with early-stage breast cancer: a cross-sectional survey

OBJECTIVE

To determine the prevalence of psychological morbidity and describe quality of life in women with early-stage breast cancer.

DESIGN

Cross-sectional descriptive study (3 months after conservative breast surgery or mastectomy) of patients from nine general hospitals in Melbourne, Victoria, October 1994 to March 1997.

PARTICIPANTS

303 women with early-stage breast cancer entering a randomised trial of adjuvant psychological group therapy; mean age, 46 years (SD, 8).

MAIN OUTCOME MEASURES

Diagnostic and Statistical Manual of Mental Health (DSM)-IV psychiatric diagnoses generated by the Monash Interview for Liaison Psychiatry; quality-of-life data based on the the European Organization for Research and Treatment of Cancer quality-of-life questionnaire (QLQ)-C30 (core) and QLQ-BR23 (breast module) instruments.

RESULTS

45% of the women (135/303) had a psychiatric disorder; 42% (127) of the sample had depression or anxiety, or both; there was minor depression in 82 (27.1%), an anxiety disorder in 26 (8.6%), major depression in 29 (9.6%) and a phobic disorder in 21 (6.9%). 20% of women (61) had more than one disorder. On quality-of-life measures nearly one-third of the women felt less attractive and most had lost interest in sexual activity. There was substantial distress about hair loss. Symptoms of lymphoedema were described by 13 women (4.3%). Breast conservation surgery was associated with a better body image (P<0.01).

CONCLUSION

Women recently diagnosed with early-stage breast cancer have high rates of psychiatric and psychological disturbance. Quality of life is substantially affected. Clinicians should actively explore their patients' psychological adjustment to enable early recognition and treatment of these disorders.

Oral and pharyngeal cancer, diet, smoking, alcohol, and serum vitamin A and beta-carotene levels: a case-control study in men

A case-control study was conducted in Melbourne, Australia. Forty-one men with histologically confirmed squamous cell oral or pharyngeal cancer were compared with 398 male community controls. A statistically significant increase in risk was found for alcohol (ethanol) consumption and for smoking, and there was a synergistic effect for these two exposures. Statistically significant protection was noted with increasing intake of dietary vitamin C, dietary beta-carotene, fruit, vegetables, and dietary fiber. The mean serum levels of beta-carotene and vitamin A were statistically significantly lower when the cases were compared with another set of 88 male controls of a similar age who were hospitalized for minor surgical operations. This study confirms a causal effect of smoking and alcohol and a protective role for a high dietary intake of fruit, vegetables, cereals, and, particularly, beta-carotene- and vitamin C-containing foods.

Smoking and colorectal cancer risk: data from the Melbourne Colorectal Cancer Study and brief review of literature

Lifetime smoking data were obtained from 715 colorectal cancer cases and 727 age/sex matched community controls as one part of a large, comprehensive, population-based study of colorectal cancer aetiology and survival in Melbourne, Australia, The Melbourne Colorectal Cancer Study. Statistically significant associations were found for those males smoking handrolled cigarettes and for cigar-/pipe-smoking males with colon cancer. Review of 18 previous case control studies of colorectal cancer showed an elevated risk for cigar-smoking black males in one study, a statistically non-significant increased risk for current smokers in one of 3 cohort studies and a statistically significant elevation of risk for smokers in 2 of 3 studies of adenomatous large-bowel polyps. Although at present there is insufficient evidence to link smoking with large-bowel cancer, the possibility that ingested tobacco is in some way carcinogenic for the colorectal mucosa may be worth further study.

Alcohol consumption and the etiology of colorectal cancer: a review of the scientific evidence from 1957 to 1991

The relationship between alcohol consumption and colorectal cancer in humans has been examined in 52 major studies in the past 35 years. An association was found in five of the seven correlational studies. An elevated risk was found in about half of the 31 case-control studies and, of these, in 9 of the 10 studies using community controls but in only 5 of the 17 studies using hospital controls (p = 0.008), suggesting that the absence of association when hospital controls are used is due to a high prevalence of alcohol consumption/alcohol-related illness in the hospital controls. Of the 14 cohort studies, an association with alcohol was found in 10, while in 3 of the 4 cohort studies in which an association was not found the alcohol data obtained were somewhat restricted. A positive dose-response effect was found in two of three cohort studies and in all four case-control studies with community controls in which this effect was examined. In both case-control and cohort studies, the association was found for females and males and for colon and rectal cancer. When the type of alcohol consumed was examined separately, beer was the principal type of at-risk alcoholic beverage, with much less risk for spirits and least risk for wine. Statistically significant elevations of risk were more often found in males than in females and slightly more frequently for rectal than for colon cancer and were related almost entirely to beer, rather than to wine or spirit, consumption. The alcohol risk was independent of the dietary risk in those studies that controlled for this factor. There was some confirmatory evidence for alcohol augmentation in rodent models of chemically induced carcinogenesis in six of nine studies. The hypotheses of alcohol as a direct and specific colorectal carcinogen include increased mucosal cell proliferation, the activation of intestinal procarcinogens, and the role of unabsorbed carcinogens, particularly in beer. Also, five of six other human studies showed an association between alcohol/beer consumption and adenomatous polyps, consistent with the hypothesis that alcohol stimulates the colorectal mucosa. General or indirect carcinogenic effects of alcohol include immunodepression, activation of liver procarcinogens, and changes in bile composition, as well as nitrosamine content of alcoholic beverages and increased tissue nitrosamine levels. With alcohol/beer consumption, the overall conclusion on present evidence is that alcohol, particularly beer consumption, is an etiologic factor for colon and rectal cancer for females and males.(ABSTRACT TRUNCATED AT 400 WORDS)

Primary bile duct stones and bacterial activity

The results of this study suggest that infection with beta-glucuronidase active bacteria is the initial event in the nucleation of primary bile duct stones (PBDS). PBDS from five patients were morphologically fragile and "earthy" with alternating light and dark brown pigment layers with no evidence of a distinct central nucleus that may have been reminiscent of a different structure. Chemically, calcium bilirubinate and calcium palmitate were prominent throughout their structure. All bile duct biles had a positive culture and were always associated with at least one bacterial species which was beta-glucuronidase active. Moreover, fragments of PBDS nuclear areas had positive cultures that were comparable with those present in their individual bile duct bile. Microscopic examination of bile showed abundant precipitation of calcium bilirubinate granules in all samples. Thus, bile duct bile infection with beta-glucuronidase active bacteria (e.g. E. coli, C. perfringens) appears to be a key factor in PBDS pathogenesis, having a precursor role, rather than being a consequence. Bile stasis is likely to be a co-factor which must have a supportive role in subsequent stone growth.

Diet, alcohol, smoking, serum beta-carotene, and vitamin A in male nonmelanocytic skin cancer patients and controls

A case-control study was conducted in Melbourne, Australia of 88 consecutive males admitted for the surgical removal of a nonmelanocytic skin cancer (histologically confirmed basal cell carcinoma and squamous cell carcinoma) and of 88 male control patients admitted for small elective surgical procedures. In both cases and controls, previous diet, alcohol consumption, and smoking habit were investigated and serum beta-carotene and vitamin A levels were measured. A statistically significant inverse relationship was found between the risk of skin cancer and a high intake of fish (p = 0.05); vegetables in general (p < 0.001); beans, lentils, or peas (p < 0.001), carrots, silverbeet (Swiss chard), or pumpkin (p < 0.001); cruciferous vegetables (cabbage, brussel sprouts, or broccoli) (p < 0.001); and beta-carotene- and vitamin C-containing foods (p = 0.004). Cases had a lower mean serum level of beta-carotene (p < 0.001) and vitamin A (p = 0.02) than controls. The incidence of skin cancer in the study was inversely related to the level of serum beta-carotene (p < 0.0001). The correlation coefficient between dietary beta-carotene/vitamin C and serum beta-carotene was 0.22 (p = 0.04). Smoking and alcohol consumption showed no statistically significant association with the risk of nonmelanocytic skin cancer. The results were similar for both cell types. A high intake of vegetables including cruciferous vegetables, beta-carotene- and vitamin C-containing foods, and fish appears to be protective for nonmelanocytic skin cancer, and this deserves further study, as does the possible etiologic relevance of the low serum levels of beta-carotene and vitamin A.

Primary "brown pigment" bile duct stones

Bile duct stones from 42 patients were morphologically and chemically analysed. The calculi from 27 patients had important primary bile duct stone (PBDS) features, consisting of a general ovoid shape and fragile structure, with alternating light and dark brown pigmented layers on cross-section. Chemically these stones contained low levels of cholesterol, with high levels of bilirubin and calcium. Subsequent infrared spectroscopy analysis showed that calcium bilirubinate and calcium palmitate were the only calcium salts present. Calcium palmitate was prominent in the light brown layers. A morphological and chemical comparison with gallbladder stones showed that bile duct "stasis stones" were similar in morphological and chemical composition to the brown pigment gallbladder calculi. However, they were distinct from most gallbladder stones, indicating that primary bile duct calculi have an aetiology that is different to 90% of gallbladder calculi. Primary bile duct calculi were observed to occur with or without the presence of a gallbladder, and more interestingly, in the bile duct of two patients with cholesterol gallbladder stones. Bile duct bile of patients with primary choledocholithiasis were always moderately to profusely infected and with abundant calcium bilirubinate precipitation. Moreover, this study has shown that PBDS chemical analyses profiles were consistent and correlated well with their defined morphology. Consequently, PBDS may be accurately identified at the time of operation by morphology. An important aetiological factor would appear to be infection, which would seem to promote bile duct bile stasis and eventual stone growth.

Limy bile cholecystitis: an in vitro study and a case report

Limy bile is a rare condition characterized by excessive precipitation of calcium carbonate in the gall-bladder. It has been found to cause cholecystitis without obstruction at the neck of the gall-bladder. A patient with the appearance of limy bile on ultrasound films which was consistent with a large gallstone is described. An in vitro study with gall-bladders filled with lime utilizing ultrasonography is also presented for the first time.

Gallstone decalcification and dissolution using chenodeoxycholate and citrate

Gallstone dissolution may be possible only in selected patients. Patients with calcified or large gallstones are not suitable for dissolution. Citrate is normally present in bile and an oral citrate load can increase biliary citrate. A combination of chenodeoxycholic acid (C.D.C.A.) and citrate has been shown to dissolve calcified cholesterol gallstones in vitro. Patients with calcified or large gallstones were treated with a combination of C.D.C.A. and citrate. Partial decalcification was achieved in seven out of twenty patients with calcified stones (35%) and complete decalcification in four patients (20%). One of the patients with large stones had complete dissolution. Five patients who were suitable for C.D.C.A. treatment but did not respond were also treated with C.D.C.A. and citrate. One of the patients in this latter group had complete dissolution. Oral citrate can decalcify some calcified gallstones.

Effect on pregnancy on gallstone formation

An ultrasound study was carried out to determine the incidence of gallstone formation during pregnancy. One hundred and thirty seven pregnant women attending antenatal clinics were studied; 70 women were primigravidas and 67 were 1 para or more. An ultrasound of the gallbladder was carried out at 20 weeks or less of gestation and a repeat of ultrasound examination was performed soon after delivery. Five women had gallstones diagnosed before pregnancy; 1 of these was a primigravida, the other 4 were para 1 or more. None of the women developed gallstones during pregnancy. This finding suggests that pregnancy is unlikely to be an important factor in gallstone formation.

Bacteria and gallstone nucleation

This preliminary study reports for the first time that there might be a possible association between bacteria and the aetiology of some cholesterol calculi. The gall-bladder biles from 225 cholecystectomy patients underwent bacteriological and microscopic study. Cholesterol calculi from 13 patients (10.2%) were observed to be associated with gall-bladder bile profusely infected with at least one bacterial species that was shown to possess beta-glucuronidase activity, an enzyme that is thought to promote calcium bilirubinate precipitation in bile. Concomitantly, the associated gall-bladder bile was 'high' in calcium bilirubinate precipitation and the precipitate was also detected in the centre of the gallstones. Moreover, in approximately half of these patients (six of 13), the cholesterol gallstones' nuclear areas also contained calcium palmitate, which is also thought to be due to bacterial activity. The results also support the hypothesis that bacteria with active beta-glucuronidase (for example, Escherichia coli) can significantly influence the aetiology of brown pigment gallstones. In contrast, bacteria were observed to have no role in black pigment gallstone formation, as their associated gall-bladder biles were always observed to be sterile.

Serum levels of beta-carotene, vitamin A, and zinc in male lung cancer cases and controls

The mean serum levels of beta-carotene and vitamin A in a multivariate analysis of data from 64 histologically confirmed male lung cancer cases were statistically significantly lower than those from 63 randomly selected male hospital controls, who were admitted for small surgical operations (p values for both beta-carotene and vitamin A less than 0.001). The mean serum levels of zinc were not statistically significantly different between cases and controls (p = 0.10). The levels of beta-carotene, vitamin A, or zinc were not statistically significantly influenced by either the extent of the cancer (p = 0.45) or the cancer cell type (p = 0.06). The possible biological significance of these findings is discussed briefly.

Gallstones at autopsy and cholecystectomy: a comparative study

An examination of 613 post-mortems gave a prevalence of biliary disease at autopsy of 36.5%, higher than reported previously in Australia. This consisted of an asymptomatic gallstone prevalence of 18.9%, with a further 5.7% of the autopsies having granular biliary sludge and 11.9% having had a previous cholecystectomy. Although the rate of occurrence of cholesterol gallstones was approximately half that of the pigment gallstones and pigment biliary sludge combined, no significant association between the sex of the postmortems and stone type was observed at autopsy (chi 2(1) = 0.1: P greater than 0.05). The ratio of biliary disease between females and males was approximately 2:1. Gallstones and biliary sludge from 310 cholecystectomy patients showed that cholesterol gallstones were approximately twice as common in men, and approximately six times as common in women than pigment gallstones. In this group of patients there was a significant association between the sex of the patient and the rate of occurrence of stone type. The rate of occurrence of cholesterol gallstones was significantly higher than pigment gallstones in both the males and females at cholecystectomy (chi 1(2) = 18.97; P less than 0.0001). A female to male ratio of approximately 2:1 was also observed. A statistically significant higher rate of pigmented biliary disease was observed at autopsy than at cholecystectomy. (chi 2 = 101.0; P less than 0.0001). Analyses on biliary sludge, a filterable, fine granular pigmented material in bile, suggest that it may be the direct precursor for a number of different gallstone types.