A single-arm pilot of MyInspiration: a novel digital resource to support spiritual needs of patients undergoing cancer-directed surgery

PURPOSE

This study aimed to assess the feasibility, acceptability, and satisfaction associated with the MyInspiration intervention, a digital spiritual support tool for patients undergoing cancer surgery. Additionally, we evaluated changes in spiritual well-being and the ability to find meaning in their experience with cancer before and after the intervention.

METHODS

This was a prospective, single-arm pilot study. Feasibility and acceptability were assessed by ratio of participants who completed all assessments among individuals who had signed consent forms. Satisfaction was assessed with 5 Likert-style questions around user experience. Patient spiritual well-being and finding meaning in their experience with cancer were measured at baseline and post-intervention.

RESULTS

Forty patients were enrolled, the majority of whom were female (80.0%) and diagnosed with breast cancer (52.5%), with an average age of 54.4 years (SD = 13.7, range 29.0-82.0). Regarding feasibility and acceptability, 76.9% of patients who consented to participate completed the full study protocol. In assessing satisfaction, 59% of patients were satisfied with the overall experience of MyInspiration. There was no difference in spiritual well-being pre-/post-intervention. There was a difference in pre (M = 1.95, SD = .95) and post (M = 2.23, SD = .86) scores relative to "finding meaning in the cancer experience" with a mean difference of 0.28 (p = 0.008).

CONCLUSION

MyInspiration was feasible and acceptable to patients, and the majority were satisfied with the tool. The intervention was associated with changes in patients' ability to find meaning within their cancer experience. A randomized control trial is needed to evaluate the efficacy of the tool in a broader population of patients with cancer.

Gaps in Patient-Centered Decision-Making Related to Complex Surgery: A Mixed-Methods Study

INTRODUCTION

We sought to understand the perceptions of surgeons around patient preferred roles in decision-making and their approaches to patient-centered decision-making (PCDM).

METHODS

A concurrent embedded mixed-methods design was utilized among a cohort of surgeons performing complex surgical procedures. Data were collected through online surveys. Associations between perceptions and PCDM approaches were examined.

RESULTS

Among 241 participants, most respondents were male (67.2%) with an average age of 47.6 y (standard deviation = 10.3); roughly half (52.4%) had practiced medicine for 10 or more years. Surgeons most frequently agreed (94.2%) with the statement, "Patients prefer to make health decisions on their own after seriously considering their physician's opinion." Conversely, surgeons most frequently disagreed (73.0%) with the statement, "Patients prefer that their physician make health decisions for them." Nearly one-third (30.4%) of surgeon qualitative responses (n = 115) indicated that clinical/biological information would help them tailor their approach to PCDM. Only 12.2% of respondents indicated that they assess patient preferences regarding both decision-making and information needs.

CONCLUSIONS

Surgeons most frequently agree that patients want to make their own health decisions after seriously considering their physicians opinion. A greater focus on what information surgeons should know before treatment decision-making may help optimize patient experience and outcomes related to complex surgical procedures.

Which factors influence the approach to shared decision-making among surgeons performing complex operations?

BACKGROUND

Shared decision-making (SDM) aims to create a context in which patients and surgeons work together to explore treatment options and goals of care. The objective of the current study was to characterize demographic factors, behaviors, and perceptions of patient involvement among surgeons relative to SDM.

METHODS

Using a cross-sectional survey methodology, surgeon demographics, behaviors, and perceptions of patient involvement were assessed. Surgeon approaches to SDM were measured using a 100-point scale ranging from 'patient-led' (0) to 'surgeon-led' (100).

RESULTS

Among 241 respondents, most were male (n = 123, 67.2%) and White (n = 124, 69.3%); roughly one-half of surgeons had been in practice ≥10 years (n = 120, 52.4%). Surgeon approaches to SDM ranged from 0 to 81.0, with a median rating of 50.0 (IQR: 35.5, 62.0). Reported approaches to SDM were associated with years in practice, sharing information, and perceptions of patient involvement. Surgeons in practice 10 + years most frequently utilized a 'Shared, Patient-led' approach to SDM (27.5%), while individuals with less experience more often employed a 'Shared, Surgeon-led' approach (33.3%, p = 0.031). Surgeons with a 'Patient-led' approach perceived patient involvement as most important (M = 3.82, SD = 0.16), while respondents who had a 'Surgeon-led' approach considered this less important (M = 3.57, SD = 0.38; p < 0.001).

CONCLUSION

Surgeon factors including demographics, behaviors, and perceptions of patient involvement influenced SDM approaches. SDM between patients and surgeons should strive to be more dynamic and tailored to each specific patient's needs to promote optimal patient-centered care.

The Use of Brief Mindfulness Interventions in the Context of Perioperative Care

The purpose of this review was to synthesize and categorize the literature on the use of brief mindfulness interventions for both patients and physicians across the spectrum of perioperative care. Web-based discovery services and discipline-specific databases were queried. Brief mindfulness interventions were defined as sessions lasting 30 min or less on any single occasion, with a total practice accumulation not exceeding 100 min per week, and a duration of up to 4 weeks. Study screening and data extraction were facilitated through the Covidence software platform. After screening 1047 potential studies, 201 articles were identified based on initial abstract and title screening; 10 studies ultimately met inclusion criteria. All ten studies were published between 2019 and 2023; most (n = 9) reports focused on patients (total joint arthroplasty, n = 3; stereotactic breast biopsy, n = 2; minimally invasive foregut surgery, n = 1; septorhinoplasty, n = 1; cardiac surgery, n = 1; and other/multiple procedures, n = 1); one studied investigated mindfulness interventions among surgeons. The duration of the interventions varied (3 min to 29 min). The most common issue that the mindfulness intervention aimed to address was pain (n = 6), followed by narcotic use (n = 3), anxiety (n = 2), delirium (n = 1), or patient satisfaction (n = 1). While most studies included a small sample size and had inconclusive results, brief mindfulness interventions were noted to impact various health-related outcomes, including mental health outcomes, anxiety, and pain perception. Mindfulness interventions may be a scalable, low-cost, time-limited intervention that has the potential to optimize well-being and surgical outcomes broadly construed.

Assessing the Impact of Provider Training and Perceived Barriers on the Provision of Spiritual Care: a Mixed Methods Study

The current study evaluated formal training around spiritual care for healthcare providers and the relationships between that training, perceived barriers to spiritual care, and frequency of inquiry around spiritual topics. A mixed methods explanatory sequential design was used. Quantitative methods included an online survey administered to providers at The Ohio State University Comprehensive Cancer Center. Main and interactive effects of formal training and barriers to spiritual care on frequency of inquiry around spiritual topics were assessed with two-way ANOVA. Qualitative follow-up explored provider strategies to engage spiritual topics. Among 340 quantitative participants, most were female (82.1%) or White (82.6%) with over one-half identifying as religious (57.5%). The majority were nurses (64.7%) and less than 10% of all providers (n = 26) indicated formal training around spiritual care. There were main effects on frequency of inquiry around spiritual topics for providers who indicated "personal discomfort" as a barrier (p < 0.001), but not formal training (p = 0.526). Providers who indicated "personal discomfort" as a barrier inquired about spirituality less frequently, regardless of receiving formal training (M = 8.0, SD = 1.41) or not (M = 8.76, SD = 2.96). There were no interactive effects between training and "may offend patients" or "personal discomfort" (p = 0.258 and 0.125, respectively). Qualitative analysis revealed four strategies with direct and indirect approaches: (1) permission-giving, (2) self-awareness/use-of-self, (3) formal assessment, and (4) informal assessment. Training for providers should emphasize self-awareness to address intrapersonal barriers to improve the frequency and quality of spiritual care for cancer patients.

Surgeon Strategies to Patient-Centered Decision-making in Cancer Care: Validation and Applications of a Conceptual Model

We sought to construct and validate a model of cancer surgeon approaches to patient-centered decision-making (PCDM) and compare applications of that model relative to surgical specialties. Ten PCDM strategies were assessed using a cross-sectional survey administered online to 295 board-certified cancer surgeons. Structural equation modeling was used to empirically validate and compare approaches to PCDM. Within the full sample, 7 strategies comprised a latent construct labeled, "physical & emotional accessibility," associated with surgeon approaches to PCDM (β = 0.37, p < .05). Three individual strategies were included: "expectations (Q4)" (β = 0.52, p < .05), "decision preferences (Q5) (β = 0.47, p < .05), and "access medical information (Q3)" (β = 0.75). Surgical specialties for subgroup analysis were classified as general/other (67.6%) or hepato-pancreato-biliary and upper gastrointestinal (HPB/UGI) (34.2%). For general/other surgeons, 7 individual strategies composed the model of surgeon approaches to PCDM, with "time (Q6) (β = 0.70, p < .001) and "therapeutic relationship building (Q9)" (β = 0.69, p < .001) being the strongest predictors. The HPB/UGI model included 2 latent constructs labeled "physical accessibility" (β = 0.72, p < .05) and "creating a decision-making dialogue" (β = 0.62) as well as the individual strategy, "effective communication (Q8)" (β = 0.51, p < .05). Although models of surgeon PCDM varied, there were 4 overlapping strategies, including effective communication. Tailoring models of PCDM may improve surgeon uptake and thus, overall patient satisfaction with their cancer care.

Burnout Assessment Among Surgeons and Surgical Trainees During the COVID-19 Pandemic: A Systematic Review

BACKGROUND

The objective of the current study was to summarize current research on burnout among surgical trainees and surgeons during the COVID-19 pandemic.

METHODS

PubMed, SCOPUS, Embase, and Psych INFO were systematically searched for studies that evaluated burnout during the COVID-19 pandemic among surgical trainees and surgeons.

RESULTS

A total of 29 articles met inclusion criteria, most of which originated from the United States (n = 18, 62.1%). Rates of burnout ranged from 6.0% to 86.0%. Personal factors responsible for burnout were fear of contracting/transmitting COVID-19 (8 studies, 27.6%), female gender (8, 27.6%), and younger age (5, 17.2%). Professional factors contributing to burnout included increased COVID-19 patient clinical load (6, 20.7%), limited work experience (6, 20.7%), reduction in operative cases (5, 17.2%) and redeployment to COVID-19 wards (4, 13.8%). The COVID-19 pandemic negatively impacted surgical education due to reduced number of operative cases (11, 37.9%), decreased hands-on experience (4, 13.8%), and not being able to complete case requirements (3, 10.34%). The shift of didactics to virtual formats (3, 10.3%), increased use of telemedicine (2, 6.9%), and improved camaraderie among residents (1, 3.4%) were viewed as positive consequences.

CONCLUSION

COVID-19 related burnout was reported in as many as 1 in 2 surgical trainees and attending surgeons. Intrinsic- (i.e., gender, age), family- (i.e., family/being married/having children or being single/not having children), as well as work-related extrinsic- (i.e., work-force deployment, risk of infection/spread, changes in educational format) factors were strongly associated with risk of burnout. These factors should be considered when designing interventions to ameliorate burnout among surgical trainees and surgeons.

Intersectionality in cancer care: A systematic review of current research and future directions

OBJECTIVES

The objective of the current review was to synthesize the literature on intersectionality relative to disparities across the cancer care continuum. A model to support future intersectional cancer research was proposed.

METHODS

Web-based discovery services and discipline-specific databases were queried for both peer-reviewed and gray literature. Study screening and data extraction were facilitated through the Covidence software platform.

RESULTS

Among 497 screened studies, 28 met study inclusion criteria. Most articles were peer-reviewed empirical studies (n = 22) that focused on pre-diagnosis/screening (n = 19) and included marginalized racial/ethnic (n = 22) identities. Pre-cancer diagnosis, sexual orientation and race influenced women's screening and vaccine behaviors. Sexual minority women, particularly individuals of color, were less likely to engage in cancer prevention behaviors prior to diagnosis. Race and socioeconomic status (SES) were important factors in patient care/survivorship with worse outcomes among non-white women of low SES. Emergent themes in qualitative results emphasized the importance of patient intersectional identities, as well as feelings of marginalization, fears of discrimination, and general discomfort with providers as barriers to seeking cancer care.

CONCLUSIONS

Patients with intersectional identities often experience barriers to cancer care that adversely impact screening, diagnosis, treatment, as well as survivorship. The use of an "intersectional lens" as a future clinical and research framework will facilitate a more multidimensional and holistic approach to the care of cancer patients.

Spiritual Motivations to Practice Medicine: A Survey of Cancer Care Providers

BACKGROUND

There is increased interest in the role of spirituality in the cancer care context, but how it may inspire individuals to pursue a career as a healthcare provider is unknown. We sought to determine the relationship between intrinsic religiosity, religious identity, provider role, and spiritual motivations to practice medicine.

METHODS

A cross-sectional survey was administered to healthcare providers at a large, Midwest Comprehensive Cancer Center. The relationship between provider type, intrinsic religiosity, religious identity, and spiritual motivations to practice medicine was assessed with binary logistic regression.

RESULTS

Among 340 participants, most were female (82.1%) or Caucasian (82.6%) and identified as being religious (57.5%); median age was 35 years (IQR: 31-48). Providers included nurses (64.7%), physicians (17.9%), and "other" (17.4%). Compared with physicians, nurses were less likely to agree that they felt responsible for reducing pain and suffering in the world (OR: 0.12, p = 0.03). Similarly, "other" providers were less likely than physicians to believe that the practice of medicine was a calling (OR: 0.28, p = 0.02). Providers with a high self-reported intrinsic religiosity demonstrated a much greater likelihood to believe that the practice of medicine is a calling (OR:1.75, p = 0.001), as well as believe that personal R&S beliefs influence the practice of medicine (OR:3.57, p < 0.001). Provider religious identity was not associated with spiritual motivations to practice medicine (all p > 0.05).

CONCLUSION

Intrinsic religiosity had the strongest relationship with spiritual motivations to practice medicine. Understanding these motivations may inform interventions to avoid symptoms of provider burnout in cancer care.

Provision of supportive spiritual care for hepatopancreatic cancer patients: an unmet need?

BACKGROUND

Among patients with a serious cancer diagnosis, like hepatopancreatic (HP) cancer, spiritual distress needs to be addressed, as these psychosocial-spiritual symptoms are often more burdensome than some physical symptoms. The objective of the current study was to characterize supportive spiritual care utilization among patients with HP cancers.

METHODS

Patients with HP cancer were identified from the electronic medical record at a large comprehensive cancer center; data on patients with breast/prostate cancer (non-HP) were collected for comparison. Associations between patient characteristics and receipt of supportive spiritual care were evaluated within the overall sample and end-of-life subsample.

RESULTS

Among 8,961 individuals (n_HP=1,419, n_non-HP =7,542), 51.7% of HP patients utilized supportive spiritual care versus 19.8% of non-HP patients (p<0.001). Younger age and religious identity were associated with receiving spiritual care (p<0.001). HP patients had higher odds of receiving spiritual care versus non-HP patients (OR 2.41, 95%CI: 2.10, 2.78). Within the end-of-life subsample, HP patients more frequently received spiritual care to "accept their illness" (39.5% vs. 22.5%, p<0.001), while non-HP patients needed support to "define their purpose in life" (13.1% vs. 4.5%, p=0.001).

DISCUSSION

Supportive spiritual care was important to a large subset of HP patients and should be integrated into their care.

Marginalized patient identities and the patient-physician relationship in the cancer care context: a systematic scoping review

PURPOSE

We sought to examine and categorize the current evidence on patient-physician relationships among marginalized patient populations within the context of cancer care using a systemic scoping review approach.

METHODS

Web-based discovery services (e.g., Google Scholar) and discipline-specific databases (e.g., PubMed) were queried for articles on the patient-physician relationship among marginalized cancer patients. The marginalized populations of interest included (1) race and ethnicity, (2) gender, (3) sexual orientation and gender identity, (4) age, (5) disability, (6) socioeconomic status, and (7) geography (rural/urban). Study screening and data extraction were facilitated through the Covidence software platform.

RESULTS

Of the 397 screened studies, 37 met study criteria-most articles utilized quantitative methodologies (n = 28). The majority of studies focused on racial and ethnic cancer disparities (n = 27) with breast cancer (n = 20) as the most common cancer site. Trust and satisfaction with the provider were the most prevalent issues cited in the patient-physician relationship. Differences in patient-physician communication practices and quality were also frequently discussed. Overall, studies highlighted the need for increased culturally congruent care among providers.

CONCLUSION

Results from this review suggest marginalized cancer patients face significant barriers in establishing culturally and linguistically congruent patient-physician relationships. Future studies should focus on the intersectionality of multiple marginalized identities and optimization of the patient-physician relationship.

The Influence of Patient and Provider Religious and Spiritual Beliefs on Treatment Decision Making in the Cancer Care Context

BACKGROUND

Providers often underestimate the influence of patient religious and spiritual (R&S) needs. The current study sought to determine the influence of R&S beliefs on treatment decision making among patients and providers in the context of cancer care.

METHODS

We conducted a systematic review of the literature using web-based search engines and discipline-specific databases. Search terms included a combination of the following Medical Subject Headings and key terms: "cancer,""spirituality,""religion," and "decision making." We used Covidence to screen relevant studies and extracted data into Microsoft Excel.

RESULTS

Among 311 screened studies, 32 met inclusion/exclusion criteria. Most studies evaluated the patient perspective (n = 29), while 2 studies evaluated the provider perspective and 1 study examined both. In assessing patient R&S relative to treatment decision making, we thematically characterized articles according to decision-making contexts, including general (n = 11), end-of-life/advance care planning (n = 13), and other: specific (n = 8). Specific contexts included, but were not limited to, clinical trial participation (n = 2) and use of complementary and alternative medicine (n = 4). Within end-of-life/advance care planning, there was a discrepancy regarding how R&S influenced treatment decision making. The influence of R&S on general treatment decision making was both active and passive, with some patients wanting more direct integration of their R&S beliefs in treatment decision making. In contrast, other patients were less aware of indirect R&S influences. Patient perception of the impact of R&S on treatment decision making varied relative to race/ethnicity, being more pronounced among Black patients.

CONCLUSION

Most articles focused on R&S relative to treatment decision making at the end of life, even though R&S appeared important across the care continuum. To improve patient-centered cancer care, providers need to be more aware of the impact of R&S on treatment decision making.

Comparing Surgeon Approaches to Patient-Centered Cancer Care Using Vignette Methodology

BACKGROUND

We sought to characterize surgeon perceptions of patient attachment-related behaviors relative to patient-centered approaches during treatment decision-making within the clinical encounter.

METHODS

An online survey including clinical vignettes was sent to board-certified surgeons to assess their approach to patient-centered treatment decision-making. Within these vignettes, patient behaviors associated with attachment styles (secure vs 3 insecure subtypes: avoidant, anxious, and fearful) were fixed and patient factors (age, race, occupation, and gender) were randomized. Analysis included repeated measures mixed-effects linear regression.

RESULTS

Among the 208 respondents, the majority were male (65.4%) and White/Caucasian (84.5%) with an average age of 51.6 years (SD = 9.9). Most surgeons had been in practice for more than 10 years (66.8%) and treated adult patients (77.4%). Surgical specializations included breast (27.2%), HPB (35.0%), and broad-based/general (21.8%). Patient race, age, and gender did not impact surgeons' patient-centered approach to treatment decision-making (all ps > 0.05). However, when the "patient" had a white collar occupation and were securely attached, surgeons reported a greater likeliness to spend equal time presenting all treatment options (p = 0.02 and p < 0.001, respectively) and believe the patient wanted an active role in decision-making (p = 0.01 and p < 0.001, respectively). Surgeons reported being least likely to agree with a patient's treatment decision (p < 0.001) and an increased likelihood of being directive (p = 0.002) when patients exhibited behaviors associated with avoidant attachment.

CONCLUSION

Attachment-related behaviors were associated with differences in surgeon approaches to patient-centered decision-making. Attachment styles may offer a framework for providers to understand patient behaviors and needs, thereby providing insight on how to tailor their approach and provide optimal patient-centered care.

Healthcare provider self-reported observations and behaviors regarding their role in the spiritual care of cancer patients

PURPOSE

The provision of spiritual care by an interprofessional healthcare team is an important, yet frequently neglected, component of patient-centered cancer care. The current study aimed to assess the relationship between individual and occupational factors of healthcare providers and their self-reported observations and behaviors regarding spiritual care in the oncologic encounter.

METHODS

A cross-sectional survey was administered to healthcare providers employed at a large Comprehensive Cancer Center. Pearson's chi-square test and logistic regression were used to determine potential associations between provider factors and their observations and behaviors regarding spiritual care.

RESULTS

Among the participants emailed, 420 followed the survey link, with 340 (80.8%) participants completing the survey. Most participants were female (82.1%) and Caucasian (82.6%) with a median age was 35 years (IQR: 31-48). Providers included nurses (64.7%), physicians (17.9%), and "other" providers (17.4%). There was a difference in provider observations about discussing patient issues around religion and spirituality (R&S). Specifically, nurses more frequently inquired about R&S (60.3%), while physicians were less likely (41.4%) (p = 0.028). Also, nurses more frequently referred to chaplaincy/clergy (71.8%), while physicians and other providers more often consulted psychology/psychiatry (62.7%, p < 0.001). Perceived barriers to not discussing R&S topics included potentially offending patients (56.5%) and time limitations (47.7%).

CONCLUSION

Removing extrinsic barriers and understanding intrinsic influences can improve the provision of spiritual care by healthcare providers.

A mixed-methods approach to comparing perceptions of cancer patients' and cancer care providers' religious and spiritual beliefs, behaviours, and attitudes

OBJECTIVES

To compare the perceptions of cancer patients' and cancer care providers' religious and spiritual (R&S) beliefs, behaviours, and attitudes.

METHODS

A concurrent, nested, quantitative dominant, mixed-methods design was utilised. Data were collected from patient and provider groups via online survey. Analyses include chi-square tests of independence and independent t-tests for quantitative data and content analysis for qualitative data.

RESULTS

The final analytic cohort for the study included 576 participants (n_patients  = 236, n_providers  = 340) with an average age of 47.4 years (SD = 15.0). Over half of participants were partnered (n = 386, 70.1%), female (n = 317, 57.3%) and had an advanced degree (n = 284, 51.2%). The most common diagnosis for patients was breast cancer (n = 103, 43.2%). The most common provider role was nurse (n = 220; 64.7%), while a smaller subset included physicians (n = 61; 17.9%) and "other" providers (n = 59; 17.4%). There was no difference between patients and providers in relation to R&S identity (p = 0.49) or behaviour (p = 0.28). Providers more frequently indicated that patients should receive R&S resources in the hospital (n = 281, 89.7% vs. n = 111, 49.6%, p < 0.001). For resource type, patients most frequently endorsed written resources (n = 93, 83.8%) while providers endorsed relational resources (n = 281, 97.9%).

CONCLUSION

Aligning patient and provider expectations of spiritual care will contribute to provision of optimal patient-centred cancer care.

Mental illness is associated with increased risk of suicidal ideation among cancer surgical patients

BACKGROUND

Mental illness and depression can be associated with increased risk of suicidal ideation (SI). We sought to determine the association between mental illness and SI among cancer surgical patients.

METHODS

Medicare beneficiaries who underwent resection of lung, esophageal, pancreatic, colon, or rectal cancer were analyzed. Patients were categorized as no mental illness, anxiety and/or depression disorders or bipolar/schizophrenic disorders.

RESULTS

Among 211,092 Medicare beneficiaries who underwent surgery for cancer, the rate of suicidal ideation was 270/100,000 patients. Antecedent mental health diagnosis resulted in a marked increased SI. On multivariable analysis, patients with anxiety alone (OR 1.49, 95%CI 1.04-2.14), depression alone (OR 2.60, 95%CI 1.92-3.38), anxiety + depression (OR 4.50, 95%CI 3.48-5.86), and bipolar/schizophrenia (OR 7.30, 95%CI 5.27-10.30) had increased odds of SI.

CONCLUSIONS

Roughly 1 in 370 Medicare beneficiaries with cancer who underwent a wide range of surgical procedures had SI. An antecedent mental health diagnosis was a strong risk factor for SI.

Intrapersonal Factors Impact Advance Care Planning Among Cancer Patients

BACKGROUND

Cancer patients infrequently engage in advance care planning processes. Establishing preferences for future medical treatment without advance care planning may not be patient-centered, as it fails to consider important factors that influence these important decisions.

OBJECTIVE

The purpose of this study was to assess the influence of patient intrapersonal factors including race, religion, level of depression, and cancer stage on overall preferences for future medical treatment, including the presence of a (DNR), power of attorney, and advance directive.

DESIGN

A retrospective chart review design was used. Patients were included who were diagnosed with cancer at The Ohio State University James Comprehensive Cancer Center from 01/2015 to 08/2019.

RESULTS

A total of 3,463 patients were included. Median age was 59 years (IQR: 49, 67) and the majority of the patients was female (88.7%). Compared with no religious preference, patients who identified as religious had 61% higher odds (95%CI: 1.08-2.40) of having a DNR and approximately 30% higher odds of having a power of attorney (95%CI: 1.08-1.62) or advance directive (95%CI: 1.02-1.64). Patients with clinically relevant depression had more than twice the odds of having a DNR versus patients with no/lower levels of clinical depression (OR: 2.08; 95%CI: 1.40-3.10). White patients had higher odds of having a power of attorney (OR: 1.57; 95%CI: 1.16-2.13) and an advance directive (OR: 3.10; 95% CI: 1.95-4.93) than African-American/Black patients.

CONCLUSIONS

Understanding the factors that affect preferences for future medical treatment is necessary for medical professionals to provide proper care and support to patients diagnosed with cancer and their families.

Patient Perceptions About the Role of Religion and Spirituality During Cancer Care

We sought to assess the perspectives of cancer patients relative to their spiritual well-being, as well as examine the impact of religion/spirituality during cancer care. A mixed-methods concurrent embedded online survey design was used. While 86% of participants indicated a religious/spiritual belief, respondents also reported lower overall spiritual well-being than population norms (t(73) = - 5.30, p < 0.01). Open-ended responses revealed that 22% of participants desired the healthcare team to address the topic of religion/spirituality, but the majority preferred to discuss with a family member or friend (48%). Religion/spirituality might play a central role for a subset of patients across the cancer journey.

Characterizing Perceptions Around the Patient-Oncologist Relationship: a Qualitative Focus Group Analysis

The purpose of the current study was to characterize the experiences of cancer patients and their caregiver/family members around their relationship with their oncologist, health care team, and the hospital environment. Participants were recruited from The Ohio State University Comprehensive Cancer Center. Participant sociodemographic factors were assessed. Focus groups were moderated and recorded by two members of the research team using a semi-structured interview format. The audio recordings were transcribed and uploaded to NViVO 11 for analyses. Four focus groups were conducted with 25 participants. The mean age of participants was 58.4 years (SD = 15.1, range 26.0-76.0). Participants who were identified as patients (84%) reported different malignancy types including breast (56%), gynecologic (16%), skin (6%) oral (6%), and non-Hodgkin's lymphoma (6%). Three major themes that emerged around the patient-oncologist relationship, include (1) choosing a physician and health care location, (2) relationship with the physician, health care team, and hospital environment; and (3) patient engagement and decision-making. Subthemes highlighted the importance of the flexible communication behaviors and trustworthiness of the oncologist, and the impact of other health care team members. Patients also reported the desire to be engaged in making treatment-related decisions and to include the caregiver/spouse in all stages of cancer care. Understanding the experience of cancer patients in a relationship with their oncologist in the context of the health care team and health care environment will be an important area of future research to provide optimal, tailored patient-centered cancer care.

The role of religion and spirituality in cancer care: An umbrella review of the literature

Although some studies have suggested a strong relationship between religion and spirituality (R&S) and patient outcomes in cancer care, other data have been mixed or even noted adverse effects associated with R&S in the healthcare setting. We sought to perform an umbrella review to systematically appraise and synthesize the current body of literature on the role of patient R&S in cancer care. A systematic search of the literature was conducted that focused on "cancer" (neoplasm, malignant neoplasm, malignancy), "spirituality" (beliefs, divine), and "religion" (specific practices like Christianity, faith, faith healing, prayer, Theology). A total of 41 review articles published from 1995 to 2019 were included: 8 systematic reviews, 6 meta-analyses, 4 systematic reviews and meta-analysis, and 23 other general reviews. The number of studies included in each review ranged from 7 to 148, while 10 studies did not indicate sample size. Most articles did not focus on a specific cancer diagnosis (n = 36), stage of cancer (n = 32), or patient population (n = 34). Many articles noted that R&S had a positive impact on cancer care, yet some reviews reported inconclusive or negative results. Marked variation in methodological approaches to studying R&S among cancer patients, including operational definitions and measurement, were identified. Resolving these issues will be an important step to understanding how patients seek to have R&S integrated into their patient-centered cancer care experience.

Do Religious/Spiritual Preferences and Needs of Cancer Patients Vary Based on Clinical- and Treatment-Level Factors?

BACKGROUND

The objective of this study is to characterize the religion and spiritual (R&S) needs of patients who undergo cancer-directed surgery. In addition, we seek to examine how R&S needs vary based on R&S identity and clinical and surgical treatment characteristics.

PATIENTS AND METHODS

A cross-sectional survey was administered to potential participants who were recruited through outpatient clinics and online. Respondent desires for R&S resources and engagement with the healthcare team  around R&S topics were assessed.

RESULTS

Among 383 potential participants who were identified, 236 respondents were included in the analytic cohort. Mean age was 58.8 (SD 12.10) years, and most participants were female (75.8%) and White/Caucasian (94.1%). The majority (78.4%) identified as currently cancer free. Commonly treated malignancies included breast (43.2%), male reproductive (8.9%), skin (8.5%), and gastrointestinal (GI) (7.2%). Two-thirds of the respondents indicated a desire to have R&S incorporated into their cancer treatment (63.3%). Patients who identified as highly/moderately religious reported wanting R&S more often (highly religious: 95.2% versus moderately religious: 71.4% vs. nonreligious but spiritual: 4.5%). On multivariable analysis, patients who believed their health would improve in the future were more likely to report wanting R&S service (OR 2.2, 95% CI 1.0-4.7) as well as wanting to engage their healthcare providers on R&S topics (OR 2.4, 95% CI 1.2-4.7). In contrast, perception of current or future health status was not associated with patient desire for the actual surgeon/doctor him/herself to be involved in R&S activities (OR 1.83, 95% CI 0.97-3.45).

CONCLUSIONS

Two-thirds of patients undergoing cancer-directed surgery expressed a desire to have R&S incorporated into their cancer treatment. Incorporating R&S into cancer treatment can help a subset of patients throughout their cancer experience.

Assessing Differences in Cancer Surgeon Approaches to Patient-Centered Decision-Making Using Vignette-Based Methodology

BACKGROUND

The objective of this study is to assess surgeon-patient-centered decision-making (PCDM) strategies relative to surgeon and patient factors.

METHODS

Approaches to PCDM were evaluated using a cross-sectional survey based on clinical vignettes assessing surgeon likeliness (0 = not at all likely, 100 = very likely) to utilize PCDM strategies. Data were analyzed using repeated-measures mixed-effects linear regression. Adjusted estimates are provided as least-squares mean (LSM) values.

RESULTS

The final analytic sample consisted of 208 respondents (58.5% response rate); the majority of respondents were male (67.7%) and Caucasian (82.0%) with an average age of 51.6 years (standard deviation, SD = 9.9 years, range 34.0-78.0 years). Specialties included breast (18.9%), hepatopancreatobiliary (21.4%), and other (59.7%). Surgeons practicing at academic (versus nonacademic) hospitals were less likely to be directive (LSM: 66.2 vs. 70.3, p = 0.004), spend equal time discussing all treatment options (LSM: 77.9 vs. 82.3, p = 0.001), and make explicit treatment recommendations (LSM: 67.7 vs. 71.7, p = 0.005). Surgeons who specialized in breast cancer (versus other specialties), in practice 10+ years (versus < 10 years), and female (versus male) were more likely to spend time discussing all treatment options (LSM: 82.8 vs. 77.3; 81.6 vs. 78.6; and 82.1 vs. 78.0, all p < 0.05). Surgeons perceived patients who had blue-collar (versus white-collar) jobs as less likely to want active participation in decision-making (LSM: 62.9 vs. 65.6, p = 0.02).

CONCLUSION

Surgeon approaches to PCDM varied based on a number of surgeon and patient characteristics. Further studies are needed to understand how surgeon PCDM strategies can be tailored to specific care contexts and patient needs.

Understanding the use of attachment theory applied to the patient-provider relationship in cancer care: Recommendations for future research and clinical practice

Patient attachment styles may inform how patients react differently to the stress of being diagnosed with cancer, as well as how patients may desire to interact and be supported by their provider. The objectives of this study were two-fold: 1) to conduct a systematic scoping review to clarify how attachment theory is utilized and applied within the current body of research on the patient-provider relationship within cancer care, and 2) add to the existing body of literature by introducing an integrated model of patient attachment styles and patient-provider relationships for use in clinical and scholarly work. A systematic search of multiple databases including PubMed, Google Scholar, PsychInfo, and WorldCat was conducted using variations and combinations of keywords related to patient-provider relationship, attachment style, and cancer. The nine studies included in the review were published from 2011 to 2019. The majority of studies had participant samples with multiple cancer diagnoses (n = 5) and examined attachment as an independent or predictor variable (n = 6). Results suggest that a secure attachment was predictive of a better working alliance, more perceived support, less general distress, higher levels of trust and satisfaction with healthcare providers when compared to patients with an insecure attachment style. Data from the current review suggest that using an attachment theory framework can improve the understanding of the patient-provider relationship. We propose a conceptual model that aligns patient attachment style and patient-provider relationship types to be utilized in clinical practice in future research to tailor patient-centered cancer care.

Understanding the Type of Support Offered Within the Caregiver, Family, and Spiritual/Religious Contexts of Cancer Patients

CONTEXT/OBJECTIVES

We sought to characterize patterns of social support types (i.e., emotional, informational, appraisal, and instrumental) within the caregiver/spouse, family, and spiritual/religious contexts for patients diagnosed with cancer.

METHODS

Focus groups were conducted with mixed groups of patients with cancer and caregiver/family members at a Midwestern comprehensive cancer center. Participants completed brief demographic questionnaires. Focus groups were moderated using semistructured interviews. The 90-minute discussions were audio-recorded, transcribed, and uploaded into NVivo for analysis using a deductive approach based on four social support types and the constant comparative method.

RESULTS

Four focus groups were conducted (n = 25). The average age was 58.4 years (SD = 15.1, range 26.0-76.0). Patient participants reported different malignancy types, including breast, gynecologic, skin, oral, and Non-Hodgkin's lymphoma. Participants acknowledged changes within their social network across the cancer journey. Overall, the caregiver/spouse fulfilled all types of social support. Spirituality/religion was often discussed as a form of appraisal social support. Fellow survivors were sources of informational support. Across groups, nondirective/emotional support was most frequently mentioned.

CONCLUSION

Cancer is a unique experience, and understanding the importance of social support, including types of social support needed from different contexts to best meet the needs of the patient, may promote optimal, patient-centered care across the cancer trajectory.

Identifying subgroups of well-being among patients with cancer: Differences in attitudes and preferences around surveillance after curative-intent surgery

BACKGROUND

Patient perceptions and preferences related to postoperative surveillance are not yet well defined.

METHODS

A cross-sectional analysis of the surveillance practice preferences and attitudes was undertaken based on subgroups derived from clustering participants for measures of well-being, including financial toxicity, emotional, family/social, and functional well-being.

RESULTS

Among 212 participants, the average age was 58.1 years and most patients were female (57.1%) and white (90.2%). Common malignancies included melanoma/sarcoma (26.4%), thyroid (25.5%), breast (18.9%), gastrointestinal (18.4%), and lung (7.5%) cancer. Respondents within the highest well-being subgroup rated their perception of communication as being the highest more consistently compared with the other well-being subgroups (P = .005). Participants with the highest level of well-being felt more reassured by follow-up appointments (Subgroup 1, Med = 4.00, interquartile range (IQR) = 0.25 vs subgroup 4, Med = 3.75, IQR = 0.73, P = .023). In contrast, patients with the lowest sense of well-being had the highest level of nervousness related to surveillance (subgroup 1, Med = 1.60, IQR = 1.00 vs subgroup 4, Med = 2.20, IQR = 1.15, P < .001). There were no differences in surveillance frequency preferences among different well-being subgroups.

CONCLUSION

Attitudes towards postoperative surveillance varied with regard to perception of provider communication, nervous anticipation, and assuredness depending on overall patient well-being. Providers should attempt to assess patient well-being as part of a tailored approach to postcancer surgery surveillance.

Patient preferences on the use of technology in cancer surveillance after curative surgery: A cross-sectional analysis

BACKGROUND

Advances in communication technology have enabled new methods of delivering test results to cancer survivors. We sought to determine patient preferences regarding the use of newer technology in delivering test results during cancer surveillance.

METHODS

A single institutional, cross-sectional analysis of the preferences of adult cancer survivors regarding the means (secure digital communication versus phone call or office visit) to receive surveillance test results was undertaken.

RESULTS

Among 257 respondents, the average age was 59.1 years (SD 13.5) and 61.8% were female. Common malignancies included melanoma/sarcoma (29.5%), thyroid (25.7%), breast (22.8%), and gastrointestinal (22.0%) cancer. Although patients expressed a relative preference to receive normal surveillance results via MyChart or secure e-mail, the majority preferred abnormal imaging (87.2%) or blood results (85.9%) to be communicated by in-office appointments or phone calls irrespective of age or cancer type. Patients with a college degree or higher were more likely to prefer electronic means of communication of abnormal blood results compared with a telephone call or in-person visit (odds ratio 2.18, 95% confidence interval: 1.01-4.73, P < .05). In contrast, patients >65 years were more likely to express a preference for telephone or in-person communication of normal imaging results (odds ratio: 2.03, 95% CI: 1.16-3.56, P < .05) versus patients ≤65 years. Preference also varied according to malignancy type.

CONCLUSION

Although many cancer patients preferred to receive "normal" surveillance results electronically, the majority preferred receiving abnormal results via direct conversation with their provider. Shifting routine communication of normal surveillance results to technology-based applications may improve patient satisfaction and decrease health care system costs.

A systematic review of the methods utilised to measure the relationship between cancer patients and oncologists: Implications for future research and practice

INTRODUCTION

The patient-physician relationship is a critical component of patient-centred health care. The patient-oncologist relationship is particularly important due to the uncertainties that surround treatment of cancer. The goal of the current review was to summarise current methodological approaches to studying the relationship between cancer patients and oncologists.

METHODS

A systematic review using PsychInfo, Ebsco, PubMed and Google Scholar was performed using combinations and variations of the MESH terms: "relationship," "doctor-patient," and "oncology." The included studies explicitly measured the "relationship" as an independent or dependent variable. Data were extracted and analysed.

RESULTS

The 13 studies included in the review were published from 2004 to 2018. There was little agreement between studies on the definition of the patient-oncologist relationship. Trust was most frequently measured, but methods varied. Most studies evaluated the patient perspective (n = 10). The few studies that considered the oncologist perspective did not measure their perception of the relationship.

CONCLUSIONS

The current review demonstrates that current approaches used to assess the patient-oncologist relationship are inconsistent. These differences may limit our understanding of patient needs in current research and practice. Future research should focus on the use of a relational lens as a theoretical framework to assess the patient-oncologist relationship.

Patient-reported outcomes after Silastic replacement of the trapezium for osteoarthritis

This retrospective study evaluated 69 Swanson trapezium replacements performed between 1990 and 2009 for trapeziometacarpal osteoarthritis in 58 patients. Pain and function were assessed using the Michigan Hand Questionnaire and the Disability of the Arm, Shoulder and Hand questionnaire. Patients had a mean age of 62 years at the time of surgery, with a mean time of 7.7 years (range 9 months to 19 years) from surgery to follow-up interview. There was no association between outcome scores and the length of follow-up, suggesting that the results are maintained over time (Spearman's rank correlation test < ±0.2). Scores for activities of daily living and work-related activities were higher when surgery was on the dominant hand (p < 0.05). Silicone trapezium replacement remains a good option for patients with painful trapeziometacarpal osteoarthritis that has not responded to nonoperative management.

"S" Quattro external fixation for complex intra-articular thumb fractures

PURPOSE

To report outcomes in 10 patients who underwent dynamic "S" Quattro external fixation for complex fractures of the base of the thumb.

METHODS

Nine men and one woman aged 18 to 69 (mean, 31) years underwent "S" Quattro external fixation for complex fractures of the base of the thumb. The dominant hand was involved in 8 patients. Three patients had Bennett fractures, 5 had Rolando fractures, one had an open multi-fragmented fracture, and one had a fracture-subluxation. Four of them had had prior (failed) treatment with splints and/or Kirschner wires. The "S" Quattro external fixator was applied for a mean of 4.9 weeks. Patients were followed up in an out-patient setting for a mean of 10.7 months until bone union and removal of the external fixator. Finger flexor function was assessed based on total active movement (TAM). Functional outcomes were assessed using the Disability of Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

No pin-site infection, malunion, or non-union was encountered. Mean loss of TAM was 7.5 degrees. Five patients lost 10 degrees or more, 2 of whom lost 20 degrees (one with an open comminuted fracture and one was elderly). Four patients regained full TAM and 6 attained more than 75% TAM compared to the contralateral thumb. At the 3-year follow-up, the mean DASH score was 3.4. Four patients reported no functional disability. Poorer outcomes were reported in the 2 patients who once had lost 20 degrees of TAM.

CONCLUSION

The "S" Quattro external fixator is recommended as a primary and definitive treatment modality for complex intra-articular thumb fractures when conservative and other surgical interventions have failed.

Posterior compartment syndrome associated with clopidogrel therapy following trivial trauma

Haematomata caused by blunt trauma may potentially induce a compartment syndrome by raising intra-compartmental pressure. We report a case of acute posterior compartment syndrome following minimal trauma to the leg of an elderly patient on the antiplatelet agent clopidogrel. This case highlights the high index of clinical suspicion required to detect compartment syndrome in those on long term antiplatelet therapy and prompt surgical decompression is recommended.

Outcome measures following metacarpophalangeal joint replacement

We used the Jebsen-Taylor hand function assessment system to prospectively study the effect of metacarpophalangeal joint replacement on overall hand function in 29 hands. In addition pain relief, subjective improvement in hand function, appearance and overall patient satisfaction were assessed. There was modest improvement in the number of Jebsen-Taylor tasks performed (1.8 to 3. 1), and pain relief was good or excellent in 18 of 24 patients. Eleven patients felt their hand function had improved by more than 50%, and the majority of patients (22 of 24) were very satisfied with the procedure. This study demonstrates that despite limited improvements in objective outcome measures, this procedure is reliable in producing a very high rate of patient satisfaction.

Purified dengue 2 virus envelope glycoprotein aggregates produced by baculovirus are immunogenic in mice

The full-length dengue 2 virus envelope glycoprotein (Egp) was expressed in insect cells by recombinant (r) baculovirus and found to form multimeric aggregates that were recovered in the void volume of gel filtration columns and by ultracentrifugation. An immunoblot confirmed that rEgp aggregrates disrupted with SDS sample buffer released a monomeric form that migrated with a molecular weight similar to native dengue 2 virus Egp on polyacrylamide gels. The rEgp aggregates reacted strongly with a panel of monoclonal antibodies specific for the native Egp and which identify critical structural and functional epitopes. The rEgp aggregates were purified by ultracentrifugation through 30% sucrose, and were shown to be the major protein band on a polyacrylamide gel and corresponding immunoblot. Purified rEgp aggregates in combination with aluminum hydroxide induced high titer neutralizing antibodies in adult mice. The generation of full-length dengue 2 rEgp aggregates in insect cells facilitated development of a simple, effective procedure for purification of the recombinant protein, and represents a good approach for producing highly immunogenic dengue 2 rEgp as a component of a subunit vaccine.

Use of the "S" Quattro dynamic external fixator in the treatment of difficult hand fractures

Thirty-seven patients were treated over a 7-year period using the "S" Quattro dynamic external fixator. There were 30 intra-articular and nine extra-articular fractures. Patients were reviewed at an average of 22.5 months. The average total range of motion for the affected digit at follow-up was 232 degrees for intra-articular and 241 degrees for extra-articular fractures. We believe that this device is a simple, reliable technique in the treatment of these difficult fractures.

A comparative genetic analysis of the Irish greyhound population using multilocus DNA fingerprinting, canine single locus minisatellites and canine microsatellites

Pairwise analysis of HinfI/33.6 DNA fingerprints from a total of one hundred and fifty-three Irish greyhounds of known pedigree were used to determine band-share estimates of unrelated, first-degree and second-degree relationships. Forty-eight unrelated Irish greyhounds were used to determine allele frequencies for three single-locus minisatellites, and following a preliminary screen, eight of the most polymorphic tetra-nucleotide microsatellites from a panel of 15. The results indicated that both band-share estimates by DNA fingerprinting and microsatellite allele frequencies are highly effective in resolving parentage in this greyhound population, while single-locus minisatellites showed limited polymorphism and could not be used alone for routine parentage testing in this breed. The present study also demonstrated that, to obtain optimal resolution of parentage, sample sets of known pedigree status are required to determine the band-share distribution and/or microsatellite allele frequencies.

Linear assessment of the thoroughbred horse: an approach to conformation evaluation

A linear assessment trait evaluation system is proposed to allow quantitative description of the static conformation of the horse. Measurements were made on 27 selected traits. The system was tested initially for repeatability of measurements on 4 horses. Twenty-one of the selected traits were satisfactory and 6 proved unsatisfactory in terms of reproducibility. A population of 101, superior 2- and 3-year-old Thoroughbreds and 19 premium Thoroughbred stallions were similarly assessed. More than 65% of the traits exhibited large (CV > 10%) phenotypic variation within the sampled population. It is proposed that such a system of static conformation assessment, in conjunction with a similar system for dynamic linear assessment, would provide useful quantitative selection criteria in the description and breeding of horses.

Murine immunoglobulin G subclass responses following immunization with live dengue virus or a recombinant dengue envelope protein

Murine immunoglobulin G (IgG) subclass responses to immunization are restricted to certain subclasses depending on the nature of the immunogen. Immunization with live viruses generally leads to a predominant IgG2a response, which may be the most effective at resisting future challenge due to the unique effector functions of IgG2a. Knowledge of subclass responses following immunization with dengue vaccine candidates may be helpful in determining which candidates are most efficacious. We measured the dengue-specific IgG subclass responses of BALB/c mice following immunization with live dengue-2 virus or with a partially purified recombinant dengue-2 envelope (E) protein. Subclass responses following immunization with live virus were IgG2a > IgG1 > IgG2b > IgG3, as opposed to IgG1 > IgG2a > IgG2b > IgG3 after immunization with recombinant protein. Responses of all subclasses except IgG1 were greater following immunization with live dengue than with the recombinant E protein. Neutralizing antibody titers were also higher after immunization with live virus than with E protein and were positively correlated with dengue-specific IgG2a responses in mice immunized with recombinant E protein. Following separation of the four IgG subclasses by chromatography, the IgG2a fraction exhibited the greatest neutralizing activity. The results seen after immunization with live dengue virus or recombinant E protein in this study are in concordance with studies involving other viruses and viral proteins and may have implications for the development of an effective vaccine for dengue.

Elbow fractures with carpal injuries

We report four cases with six episodes of concurrent carpal and elbow fractures or dislocations. Few such combinations of injuries have been reported in the literature. We discuss the mechanism and management of such injuries and conclude that elbow injuries should be suspected in severe carpal injuries. Surgical treatment may be required in their management.

A new method of paternity testing for dogs, based on microsatellite sequences

Microsatellite sequences, like minisatellites, belong to a class of polymorphic DNA that is commonly found in mammalian DNA. Although they vary significantly less in a population of animals than minisatellites, they have potential for use in paternity disputes. However, their inherently lower variability together with the more genetically homogeneous nature of pedigree dogs due to inbreeding (line breeding), raised doubts about their effectiveness for paternity tests. This paper demonstrates that canine microsatellites provide an adequate basis for assigning paternity in pedigree breeds. The system presented is more straightforward to perform and interpret than that based on canine minisatellites (DNA 'fingerprinting') and requires as little as 0.1 ml of blood.

Reversal of advanced liver fibrosis in rabbits with Schistosomiasis japonica

Advanced liver fibrosis is generally considered to be irreversible. We studied the reversibility of marked liver fibrosis in rabbits infected with Schistosoma japonicum. We determined liver collagen content, collagen biosynthesis, and collagenase activity using serial biopsy specimens obtained 20, 40, and 60 weeks after infection. Reversibility of this process was investigated in rabbits cured of infection at 21 weeks; control rabbits not cured of infection were also studied. At 20 weeks, liver collagen content was 16-fold greater than normal, with accumulation of collagen types I, III, and V. Synthesis of collagen within fibrotic liver slices was 10-fold greater than normal. Liver collagenolytic activity for a type I substrate was 19-fold greater than normal. After parasitologic cure, a striking morphologic reversal of fibrosis occurred during the subsequent 40 weeks, with the return of liver collagen content to three-fold greater than normal and a 75% decrease in synthetic rates compared with those at 20 weeks (P < 0.01). Collagenolytic activity remained elevated to the same degree noted at 20 weeks. A similar but lesser resolution of fibrosis also occurred in untreated control rabbits, coincident with a spontaneous decrease in new egg deposition known to occur in this model system. We conclude that advanced liver fibrosis in S. japonicum-infected rabbits is slowly reversible after cure or senescence of the infection. A possible mechanism for this reversal is persistently increased collagenolysis as collagen synthesis diminishes.

Baclofen: effects on evoked field potentials and amino acid neurotransmitter release in the rat olfactory cortex slice

A study has been made of the in vitro effects of (+/-)- and (-)-baclofen on the evoked field potentials and release of endogenous amino acid neurotransmitter candidates (aspartate, glutamate, GABA and possibly taurine) which accompany electrical stimulation of the excitatory input to the olfactory cortex slice, the lateral olfactory tract. Baclofen appears to reduce the excitatory input to the GABA-utilizing inhibitory interneurones; this action was manifest as a drug-induced abolition of the field potential known as the P-wave (IC50 for (-)-baclofen, 1.7 +/- 0.4 microM) together with a simultaneous reduction in the synaptically evoked release of aspartase and glutamate from the cut surface of slices. Both these actions of baclofen exhibited concentration dependence and stereospecificity and were not antagonized by picrotoxin (25 microM) thereby suggesting that they are directly related. The consequence of this action of baclofen was the abolition of GABA-mediated presynaptic and postsynaptic inhibition together with their respective field potential correlates, the late N- and I-waves. (+/-)-Baclofen (5 and 25 microM) also inhibited the potassium-evoked release of aspartate and glutamate from small cubes of tissue but, except at a high concentration (1 mM), had no effect on GABA release. Baclofen (up to 1 mM) did not affect transmission either at the lateral olfactory tract-superficial pyramidal cell synapse, a site where aspartate is the likely neurotransmitter, or at the superficial pyramidal cell collateral-deep pyramidal cell excitatory synapse. It is proposed that: (i) the actions of baclofen on the olfactory cortex are the result of inhibition of aspartate and glutamate release, probably from deep pyramidal cell collaterals; and (ii) not all neurones utilizing excitatory amino acids as their neurotransmitters are subject to the inhibitory action of baclofen.